Fig. 69.—Loop method of passing sutures in palate operations. (Mason.)
The silver wire must next be substituted for these loops, and this is effected by taking a six-inch length of the former and doubling half an inch of one end into a hook over the loop; gentle traction on the free ends of the silk will easily draw the wire through into its place. A small piece of sponge lightly dabbed on the edges of the cleft at the point of suture removes any adherent blood-clot or mucus. The ends of the wire are crossed and the wire-twister ([Fig. 66]) applied, and in this way the suture is tightened until the margins of the cleft lie accurately in apposition, without undue mutual pressure or folding in of the edges; experience and practice can alone decide the requisite amount of tension. When this has been accomplished, the twisted ends are cut off with scissors, leaving a sufficient length visible to allow of easy removal when necessary. It is better to deal in this way with each wire separately, in order to prevent entanglement or confusion.
To stitch the uvula, a double-curved semicircular needle ([Fig. 63]) may be advantageously employed, and passed through both sides before withdrawing it; as previously stated, no substitution of wire is advisable ([p. 114]), but the silk is drawn tight by means of a slip-knot made fast in the usual way ([Fig. 70]). Two of these silk sutures may often with advantage be inserted in the uvula, but this should be accomplished with the greatest possible delicacy of manipulation, as any rough handling with the forceps may result in bruising, œdema, and subsequent non-union. The sutures, moreover, must be so placed that the circulation in the uvula is not interfered with when they are drawn tight, or strangulation and sloughing may follow.
Fig. 70.—Method of tying slip-knot for uvula stitch; formerly used in each suture. (Fergusson.)
Fig. 71.—T. Smith’s palate needle (Arnold).
Although the above detailed process appears very elaborate, it certainly seems to me the best. Other methods are used by many, and amongst these perhaps the most frequently employed is the “direct” method of Mr. T. Smith. In this the needle ([Fig. 71]) is double-curved and hollow, and the wire which is wound on a drum in the handle of the instrument can be projected at will from the aperture at the point by a movement of the thumb. Different shapes are used for different parts of the palate. The needle is passed from below upwards through one side of the cleft, and without withdrawing it through the other from above downwards; the wire is now protruded from the point of the needle, grasped by forceps, paid out from the drum, and the needle withdrawn as it entered. Mr. Smith’s usual practice is to stitch from the uvula upwards, tying each stitch as it is inserted, and making use of the ends of one stitch to steady the palate whilst introducing the next. The advantage claimed for this method, viz. the saving of time, is more than counterbalanced in my opinion by the following drawbacks; first, the strain exercised upon one of the palatal flaps in order to pass the needle through the other; second, the occasional and not infrequent hindrances to the smooth working of the wire by its kinking; and, thirdly, the difficulty often experienced in seizing the end of the wire.
Stage IV.—Relief of Lateral Tension.
The palate having been thus satisfactorily sutured, the relief of lateral tension and the division of the levator palati have now to be undertaken; for however well the parts may appear to lie, it is never safe to omit this. A narrow-bladed probe-pointed bistoury is introduced through the lateral aperture on either side, and carried directly backwards through the soft palate. It is useful to introduce the left index finger into the lateral opening to ascertain if any fibres of the muscle still remain undivided. This plan was first introduced and practised by Mr. Pollock in mild cases of cleft palate, where the fissure extended through the velum only.