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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.




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



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FIG. i.-Suture of peritoneum.

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

FIG. 3.-Diagram of knot.

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FIG. 4.-Suture of the superficial layer.

FIG. 5.-Suture of the sac.



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



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

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




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


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



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


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



tion, can be accomplished by a continuous herring-bone suture (Fig. 9) of silkworm gut tied at each end in the ligament with the reverse bow-knot. The suturing of Poupart's ligament to the conjoined tendon by a continuous mattress suture (Fig. 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. In general, 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. (2) Accurate layer approximation of tissue. (3) Removal of the buried sutures when healing is complete. (4) Capillary drainage from each layer. (5) Safety of intestines from injury during the application of the sutures. (6) Rapidity of application. (7) Minimum line of irritation on the peritoneal surface and consequent adhesions to the viscera. (8) Slight scar in the skin, there being no perforation of the skin by sutures. (g) All of the advantages of a permanent buried suture without the danger of future irritation and extrusion of the knot. (io) The advantages of an absorbable suture without the danger of sepsis from the suture, and without producing a nidus for septic germs from the blood current during absorp-

In the seven months following January 3, I9OI, the date of the initial use of the knot, I have used this method in eleven median laparotomies, in eight appendectomies, in four ventral herniotomies, and in seventeen inguinal herniotomies, all of my abdominal operations that were closed without drainage, and obtained sterile primary union in every case. The most recent



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