Surgical Sutures

SURGICAL SUTURES are used for connecting tissues during operations and wounds, as well as for stopping parenchymal hemorrhage. Materials for sutures include silk, simple linen or Florentine thread, catgut, horse or human hair, silk-worm gut, and silver or bronze-aluminum wire. For closing skin wounds, Michel staples and serfins are used. Silk-worm gut, silk-worm gut, represents the hardened juice from the silk gland of the silkworm. The threads obtained in this way have an advantage over silk due to their smoothness, but they are expensive and due to their brittleness are not suitable for fine sutures. They are sterilized by boiling. Wire is currently used mainly for applying bone sutures and for skin sutures in not completely aseptic wounds. Due to their elasticity, bronze-aluminum wire is most often used. Despite aseptic healing of the wound, submerged wire sutures come apart significantly more often than sutures made of other materials. Additionally, the sharp ends of the wire sometimes cause the patient considerable discomfort. The wire suture is tied by twisting, the ends of the wire are cut short, grasped with tweezers, and bent inward. Thin bronze-aluminum wire is tied with ordinary knots. The wire is sterilized by boiling. For rapid closure of superficial wounds, Michel staples (Fig. 1) are used. They are applied and removed with special tweezers and hooks. Staples should be removed earlier than other types of sutures, especially on the face, because when left for a long time, pressure sores form, which affects the cosmetic aspect. For the same purposes as Michel staples, Vidal's serfins modified by Herff are used, which are small wire clamps with a spring (Fig. 2). Serfins are an inexpensive material, as they can be used up to 40 times. Serfins and staples are sterilized by boiling. Usually, wounds are closed in layers. In each individual case, when applying sutures, it is necessary to eliminate all pockets and cavities as much as possible, and the edges of the wound should be in contact with each other throughout their entire length. In order for the sutures to properly approximate the skin, certain rules must be observed. If sutures are placed too superficially and close to the edges from both sides, cavities remain under them, contributing to the formation of hematomas. Placing sutures too far from the edges and too superficially leads to the turning in of the wound edges inward or outward. In cases where, with an even wound, the suture is placed through one edge too far and through the other too close, the edge that was captured close turns inward and is covered by the other edge. For more correct application of sutures, it is better to sew each edge separately, but with superficial wounds, both edges of the wound can be pierced simultaneously, while an assistant approximates them with tweezers. In cases where one edge overlaps the other, a ligature should be placed through the lower edge farther from the edge, and through the upper edge closer to the edge. Proper approximation of wound edges can be achieved by applying preliminary situational sutures. The insertion of these sutures should be done at a greater distance from the edges of the wound, and the material for situational sutures should be of considerable strength. Good approximation of skin edges can be achieved by using hooks with which the wound is stretched in the longitudinal direction. For this purpose, sharp anatomical hooks can be used. The same can be achieved by stretching the wound with clamps or by applying preliminary nodal sutures along the edges of the wound, which are pulled. Esmarch advised making long incisions in a zigzag pattern at an obtuse angle. The corners of this pattern facilitate finding the corresponding edges of the wound. Kocher suggested marking corresponding points before making a skin incision, for which he made shallow notches transversely to the edges of the incision with a scalpel. When sewing skin, nodal sutures (Fig. 3) are most commonly used. They have the advantage that due to individual tying, the weakening of one thread does not lead to the weakening of other sutures. Nodal sutures are applied perpendicular to the edges of the wound, but in cases where it is necessary to shift the skin edges, as for example in plastic operations, sutures are applied obliquely. Usually, the insertion and exit of the needle are made at a distance of several millimeters from the edge of the wound, but in cases where it is necessary to reduce the tension of the sutures, the needle is inserted at a distance of 2 cm from the edge. Usually, nodal sutures are applied at a distance of 1 cm from each other. Where there is a danger of bleeding, larger intervals should be left. On the contrary, in cases where careful approximation of tissues is required, such as on the face, eyelids, lips, sutures are applied very close to each other and with the thinnest silk. This adaptability to various conditions must be seen as a great advantage of nodal sutures. The continuous, or tailor's suture (Fig. 4) has the advantage that it is much more economical and applied much faster than the nodal suture, but if one stitch is cut or removed due to suppuration, all the others weaken. This suture is most often used in operations on the intestine. When applying a continuous suture to the skin, each loop must be overlapped. The tailor's, or magic suture (Fig. 5) is used in cases where it is necessary to achieve the inversion of wound edges. This can be achieved if the needle continuously changes direction and alternately pierces each of the wound edges from inside out. At present, following Schmieden's proposal, this suture has become widely used in operations on the gastrointestinal tract. It is also used on the skin in cases where it is necessary to submerge the edges of the wound, for example for covering the separated anal opening during rectal amputations. The American suture, or Halsted suture (Fig. 6), the so-called cosmetic suture, is used to avoid traces left by needle insertions. In this suture, the thread is continuously passed under the epidermis alternately through both internal surfaces of the incision. This type of suture is best performed with wire, the removal of which is less difficult than the removal of silk or threads or catgut, which is not removed. The mattress suture (Fig. 7) is used in cases of excess skin or significant development of subcutaneous tissue. This suture promotes proper contact of the latter and eliminates all hollow spaces. It is applied with one thread, and on the side of the exit, an insertion is made immediately, after which the needle is brought out on the opposite side. After applying this suture on both sides of the incision line, something like a broken line is obtained. The principle of the mattress suture corresponds to the U-shaped suture (Fig. 8), or the four-stitch suture according to Lexer. In cases of great tension of the tissues, it is recommended to apply the so-called roller, or plate suture (Fig. 9). Sutures are tied with a surgical, reef, or granny knot (Fig. 10). The first type of knot is necessary in cases of tension. The reef knot has advantages with submerged sutures, as less material is submerged with it. The ordinary granny knot is flexible but is strong enough for sutures in the absence of tension. When removing sutures, the knot is grasped, after which it is pulled until a part of the suture that was in the canal appears. It differs by its pure white color. In this discolored part, the suture is cut, after which it is extracted. This precaution prevents the passage of the infected part of the thread through the entire canal.

f. Yanishevskii.