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SUTURE OF THE ABDOMINAL WALL.

1
BY CHARLES DAVISON, M.D.,
OF CHICAGO,
PROFESSOR OF SURGERY, CHICAGO CLINICAL SCHOOL; ADJUNCT PROFESSOR OF CLINICAL SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, MEDICAL COLLEGE OF THE UNIVERSITY OF ILLINOIS; ATTENDING SURGEON TO COOK COUNTY HOSPITAL AND THE WEST SIDE HOSPITAL.

IN suture of the abdominal wall after laparotomy, the ideal method of approximation is that of layer to layer apposition, uniting peritoneum to peritoneum, fascia to fascia, and skin to skin by independent planes of suture. The ideal suture material is one that can be rendered sterile by boiling in water that will remain sterile while in the tissues, and that will cease to exist in the tissues when- healing is complete and its function has been accomplished. These indications are not fulfilled by absorbable sutures, of which catgut is the type, for the reason that this material is of animal origin, already infected with germs, the sterilization of which is difficult and uncertain, and cannot be accomplished by prolonged boiling in water without disintegration of the suture. Absorbable sutures eventually break down and pulpify, liberating any imprisoned germs and making a line of culture material, a nidus for pyogenic germs, either local in the catgut orhbrQught to it by the blood current. Many times late infection of a wound after primary union has occurred is due to this action of catgut.
'Read before the Mississippi Valley Medical Association, September
I3, I90I.

Vol. XXXV, No. 3, 1902.

297

The closure of the peritoneum in a median laparotomy is illustrated by Fig. and the ends are left hanging out of the angles of the wound. the suture is shirred to take up all of the slack and to lessen the length of the wound. they become foreign bodies. the other end is grasped in an artery-forceps protected by a bit of gauze and wound up close to the skin. and has brought the perforations in the peritoneum into a straight line. one end of the stitch is cut short. the ends of which are left out at the angles of the wound to be removed by traction when healing is complete. so that it is very easy to remove by traction. Permanent buried sutures. but bv the end of a week. and traction is made on the forceps like the handle to a corkscrew. when the suture is removed. The silkworm gut is kinked in such a manner that it binds itself in the peritoneum and does not slip or pull apart. . and the peritoneum is closed by a continuous herring-bone suture of silkworm gut. the type of which is the twisted silver wire. and either are encysted in the tissues or are surrounded by granulation tissue. i. When the opening in the peritoneum is closed. After healing has occurred and their function has ceased. The suture in the strongest layer is tied in position at each end in the layer with knots that can be unlocked by traction on the exposed ends when the stitch is to be removed.298 CHARLES DAVISON. the patient relaxes the abdominal wall by elevation of the thighs and shoulders. In removing this suture. the elasticity of the silkworm gut has made the suture perfectly straight. are not the ideal sutures. and are gradually extruded from the tissues months or years after the operation. making a track around the stitch by pressure necrosis. The wounds are closed by suturing each layer with a continuous silkworm-gut suture. The edges of the peritoneum are caught with forceps and held up away from the intestines by an assistant. I wish to present the method of closure of abdominal sections that I am using in routine work.

. . ... :* . ....:.FXSX.. . .....!~ ~ ~ ~ . ..... . :~~~~~~~~~~~~~ ... . . .. :. .. : ...... S ..:... 4 FIG.!... ..-Suture of peritoneum.s. .' :'.. *~ ~ ~ ~ ~~~~~~~~~~~~~~..0.. . . . ... i.

tied in position. . 2.FIG.-Suture of linea alba.

-Diagram of knot. 3. .FIG.

:...:: .: :. . :..: .-Suture of the superficial layer..::'.. ::::. 4.m:!: :~'.i:':i: FIG..

5.FIG.-Suture of the sac. .

299 For identification at removal. this suture may be colored black with silver nitrate.SUTURE OF THE ABDOMINAL WALL. For this suture coarse selected Spanish silkworm gut thirteen inches long without flaw or defect is used. These sutures -act. This method of suture can be used in appendectomy or any laparotomy in which there is no provision for drainage and in which the incision is in a straight line. A small reverse bow-knot (a diagram of which tied and loose is shown in Fig. 3) is tied four or five inches from the end of the strand. This is the strong layer of the abdominal wall. grasped by a smooth pointed dissecting forceps at its exit from the fascia. This layer being securely fastened takes all of the tension from the other layers. Simultaneous traction on the free ends unties the knots. The skin is closed by the Halstead subcuticular stitch (Fig. With practice this can be done without a particle of slack being left in the suture. blue with an alcoholic solution of methylene blue. At the last stitch the suture is shirred up tightly. they may be constricted by loops of the nearest suture without making a knot. and another reverse bowknot tied below the point of the forceps. and if the tissues are fastened securely there can be no spreading of the wound. 2. when the suture is removed in the same manner as the peritoneal suture. This suture is removed in two or more weeks. The closure of the lineal alba in a median laparotomy is illustrated by Fig. and the wound is closed by the continuous herring-bone suture. 4) of silkworm gut colored red for identification by alcoholic solution of carbol-fuchsin. The ends are allowed to hang out at the angles of the wound.as capillary drains from each layer. If there are bleeding points which pressure or torsion do not control. . The edges of the fascia are caught with forceps and held up by an assistant. It can be tied in this manner as closely as in the ordinary method of tying a continuous suture. The suture is introduced in a firm place in the fascia back from the edge of wound and drawn tightly up to the knot. or the ends knotted to correspond.

The lower end'is marked by a knot for identification. The sac is closed by a continuous mattress suture (Fig. when completed. emerging on the peritoneal side of the conjoined-tendon.) The suturing of Poupart's ligament to the conjoined tendon by edge to edge apposition. and when sutured firmly takes the tension from the'other layers. This suture is removed at the end of a week by pulling up the'lower strand and cutting it short. 8) of black or blue silkworm gut.the ends are tied together and brought out of the upper angle of the wound. a simple continuous basting stitch (Fig. and'the free ends are allowed to extend out at 'the angles of the wound.The fascia of the. (Fig. close' to the cord. The same method of suture can be applied to any of the standard operations for the radical cure of inguinal hernia.300 CHARLES DAVISON. making a sort of double purse-string suture.:external'oblique muscle is sutured to the shelving edge of Poupart's ligament over'the cord with a continuous'herring-bone' stitch (Fig. the ends projecting from'the angles of the wound without being tied. The suture with the knot tied at one end is passed through'Poupart's ligament about one centimetre from its free edge. completing one unit of the continuous basting or sailor-stitch. penetrating the ligament from the outside' and emerging from its internal'surface. (Fig. is tied in position with the knot shown in detail in Fig. the ends'shirred up. which i usually do. 3. as in the typical Bassini opera- . . 6) tied at either end is used. The suture is next carried across the wound behind the cord and penetrates the conjoined tendon at the same level and distance from its edge. and then drawing out the upper fragment. one centimetre below the first perforation. The suture is -then returned through the same tissues in the opposite direction. 7. The skin layer is closed by the subcuticular suture of red silkworm gut already'described. 5) of silkworm gut. In the 'operation for'hernia in'which Poupart's ligament is imbricated over the conjoined tendon behind' the cord. and. 4. which.) This is the strong layer.

.-Basting suture uniting Poupart's ligament to conjoined tendon in the imbricating operation for hernia. 6.FIG.

..-Basting suture uniting Poupart's ligament to conjoined tendon tied in position... ~~~.-30 f- ............ .................... 7. FIG.....

1. FIG. 8. .-Suture of fascia of external oblique muscle to Poupart's ligament over the cord by continuous herring-bone suture.

-Suture of Poupart's ligament to conjoined tendon by continuous herring-bone suture. aO_N FIG. . 9. producing edge to edge apposition as in Bassini's operation.:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.

io.FIG. .-Suture of Poupart's ligament to conjoined tendon by continuous mattress suture. producing the same apposition of tissue as in Halstead's operation.

SUTURE OF THE ABDOMINAL WALL. In the seven months following January 3. and obtained sterile primary union in every case. The suturing of Poupart's ligament to the conjoined tendon by a continuous mattress suture (Fig. (5) Safety of intestines from injury during the application of the sutures. (g) All of the advantages of a permanent buried suture without the danger of future irritation and extrusion of the knot. in eight appendectomies. in four ventral herniotomies. (7) Minimum line of irritation on the peritoneal surface and consequent adhesions to the viscera. In general. all of my abdominal operations that were closed without drainage. I9OI. I have used this method in eleven median laparotomies. (3) Removal of the buried sutures when healing is complete. 9) of silkworm gut tied at each end in the ligament with the reverse bow-knot. the advantages of this method of suture are: (i) Certainty that all suture or ligature material placed in the wound has been made sterile by boiling in water. io) of silkworm gut tied at either end in the ligament produces the same apposition of tissues as in the Halstead operation with the buried interrupted mattress suture of silver wire. 30I tion. there being no perforation of the skin by sutures. (8) Slight scar in the skin. and without producing a nidus for septic germs from the blood current during absorp- tion. (4) Capillary drainage from each layer. and in seventeen inguinal herniotomies. The most recent . (6) Rapidity of application. can be accomplished by a continuous herring-bone suture (Fig. (io) The advantages of an absorbable suture without the danger of sepsis from the suture. (2) Accurate layer approximation of tissue. the date of the initial use of the knot.

302 CHARLES DAVISON. The claim for originality which is maintained is not in the use of a longitudinal suture. of these cases being now six weeks from operation and safe from suppuration. but in the tightly and securely tying of a buried longitudinal suture which can be easily removed when healing is complete. .