SUTURES AND KNOTS.
Sutures.
—There are many varieties of sutures which have found favor. Until the surgeon becomes expert by long practice he should confine himself to few sutures and knots. Primary sutures include continuous, interrupted, plate or modified plate, quill or modified quill, chain, and transfixion sutures, and also certain forms of suture used in intestinal surgery. The above forms are illustrated in [Figs. 61] to [66]. Several of them may be used in making what are known as buried sutures, i. e., those which are tied deeply, whose ends are cut off below the surface and left either permanently or for later absorption.
The purpose of a suture is to bring the parts into accurate apposition and so maintain them. It is a mistake to employ a superficial suture alone, which may leave a “dead space” beneath it. If but one suture is used, as in closing an abdominal wound, it should pass through the tissue layers of the abdomen and bring each layer into contact with the corresponding layer on the other side. Unless this can be done a series of sutures should be used uniting the tissues layer by layer. If these be made of formalin or chromic gut they will remain in situ for a length of time sufficient to serve their purpose. Some prefer silk for this purpose, but it may work out later; if sterile and freshly boiled just before using it will rarely cause this trouble. In closing a thick and fat abdominal wall four or five tiers of buried sutures may be used and their effect may be reinforced by the addition of a modified plate or quill suture, as shown in [Figs. 63] and [64].
Fine wire is preferred by some operators, and horse-hair by others. Success pertains rather to the perfection of the method than to the material used. The primary feature of all wound sutures should be prevention of tension and protection against it. Further support in the same direction can be made by the use of adhesive plaster after fastening the dressing upon the wound, thus taking off strain.
Certain expedients have been resorted to in superficial wounds, some of which include the affixion of a strip of plaster on either side of the wound and then the application of the suture material through the plaster rather than through the skin. Plasters with small hooks have also been applied, and then a shoelace suture applied over the hooks, thus lacing the wound margins together. Such measures are convenient for certain cases, although they make the maintenance of strict asepsis difficult or impossible. Fine-wire clips have also been introduced, by which skin margins may be held together for three or four days, or until they have had time to unite with some firmness, after which they may be removed. These little implements can be sterilized and repeatedly used.
Fig. 61
Continuous suture.
Fig. 62