A CONSIDERATION OF THE SUTURE PROBLEM* JOHN BURKE, M.D. Attending Surgeon, BuffaIo City Hospital BUFFALO, NEW YORK T HE existence of the suture probIem is manifested by the variety of suture materiaIs at hand as we11 as by the Iack of uniformity in the methods of their utihzation. Yet, the suture and its appli- cation is such an integra1 part of the sur- geon’s, and for that matter, the general practitioner’s daiIy activities that it is too often taken for granted. Most of us, un- fortunately, acquire our suture technique rather bIindIy from our elders and with it many time-honored and often time-dis- proved prejudices. At present, the ideal suture materia1 does not exist, and the materiaIs avaiIabIe represent compromises. The absorbable sutures produce varying degrees of tissue reaction, and their rates of loss of strength and of absorption are far from constant. Some of the non-absorbabIe sutures are remarkably inert in tissue and they main- tain tensiIe strength far beyond any neces- sary time interva1, but, as the name implies, are of the nature of permanent guests. It is not too much to expect that the future wiI1 produce a material with the advan- tages of both and the disadvantages of neither. In the meantime, a knowIedge of the characteristics of both types is of con- siderabIe advantage to the surgeon. ABSORBABLE SUTURES AbsorbabIe sutures are now made excIu- siveIy from anima1 tissues. Catgut, kan- garoo tendon and preserved fascia comprise aImost the entire group, aIthough in Germany “ carnofi1” made from serum has had some cIinica1 acceptance. Catgut is far and away the predominant materia1, and is obtainabIe as “pIain,” chromicized, iodized, tanned, or processed by combina- tions of these methods. Huhne, in Ger- many, has introduced another form of processing invoIving certain aniline dyes, but this catgut is not avaiIabIe in America at present. According to its discoverer, it eIiminates most of the disadvantages in- herent in the use of catgut. Some of Huhne’s cIaims have been corroborated by other observers. Catgut’s soIe advantage Iies in its ab- sorbabiIity in the body tissues, which is necessariIy associated with a progressive loss of tensire strength. Chromicizing and the other processes are used in an attempt to control this Ioss of strength. PIain catgut Ioses about 90 per cent of its strength with- in six days, and the processed catguts within ten to twenty days, under idea1 wound conditions. Many investigators, incIuding Howes and Harvey, Jenkins, KraissI and Inman, have shown concIu- siveIy that the optimum ten, twenty and forty day absorption rates claimed by manufacturers are subject to wide varia- tions under cIinica1 as we11 as experimenta conditions. Inman, in this hospita1, demon- strated that pIain catgut, when pIaced sub- cutaneousIy in cIean herniorraphy wounds, Iost most of its strength within three to six days; forty day chromic 2 catgut simiIarIy placed was without measurable strength within ten to fifteen days, and frequently as earIy as the seventh day. This is in agreement with Jenkins’ work. The Iatter, however, found one type of chronic gut which seemed to approximate the manufacturer’s cIaims. It is generaIly recognized that wound infection markedIy accelerates the rate of digestion of a11 types of catgut and there is some reason to beIieve, as does Hinton, * From the SurgicaI Service, BuffaIo City Hospital, 303
Transcript
A CONSIDERATION OF THE SUTURE PROBLEM*
JOHN BURKE, M.D.
Attending Surgeon, BuffaIo City Hospital
BUFFALO, NEW YORK
T HE existence of the suture probIem is manifested by the variety of suture materiaIs at hand as we11 as by the
Iack of uniformity in the methods of their utihzation. Yet, the suture and its appli- cation is such an integra1 part of the sur- geon’s, and for that matter, the general practitioner’s daiIy activities that it is too often taken for granted. Most of us, un- fortunately, acquire our suture technique rather bIindIy from our elders and with it many time-honored and often time-dis- proved prejudices.
At present, the ideal suture materia1 does not exist, and the materiaIs avaiIabIe represent compromises. The absorbable sutures produce varying degrees of tissue reaction, and their rates of loss of strength and of absorption are far from constant. Some of the non-absorbabIe sutures are remarkably inert in tissue and they main- tain tensiIe strength far beyond any neces- sary time interva1, but, as the name implies, are of the nature of permanent guests. It is not too much to expect that the future wiI1 produce a material with the advan- tages of both and the disadvantages of neither. In the meantime, a knowIedge of the characteristics of both types is of con- siderabIe advantage to the surgeon.
ABSORBABLE SUTURES
AbsorbabIe sutures are now made excIu- siveIy from anima1 tissues. Catgut, kan- garoo tendon and preserved fascia comprise aImost the entire group, aIthough in Germany “ carnofi1” made from serum has had some cIinica1 acceptance. Catgut is far and away the predominant materia1, and is obtainabIe as “pIain,” chromicized, iodized, tanned, or processed by combina-
tions of these methods. Huhne, in Ger-
many, has introduced another form of processing invoIving certain aniline dyes, but this catgut is not avaiIabIe in America at present. According to its discoverer, it eIiminates most of the disadvantages in- herent in the use of catgut. Some of Huhne’s cIaims have been corroborated by other observers.
Catgut’s soIe advantage Iies in its ab- sorbabiIity in the body tissues, which is necessariIy associated with a progressive loss of tensire strength. Chromicizing and the other processes are used in an attempt to control this Ioss of strength. PIain catgut Ioses about 90 per cent of its strength with- in six days, and the processed catguts within ten to twenty days, under idea1 wound conditions. Many investigators, incIuding Howes and Harvey, Jenkins, KraissI and Inman, have shown concIu- siveIy that the optimum ten, twenty and forty day absorption rates claimed by manufacturers are subject to wide varia- tions under cIinica1 as we11 as experimenta conditions. Inman, in this hospita1, demon- strated that pIain catgut, when pIaced sub- cutaneousIy in cIean herniorraphy wounds, Iost most of its strength within three to six days; forty day chromic 2 catgut simiIarIy placed was without measurable strength within ten to fifteen days, and frequently as earIy as the seventh day. This is in agreement with Jenkins’ work. The Iatter, however, found one type of chronic gut which seemed to approximate the manufacturer’s cIaims.
It is generaIly recognized that wound infection markedIy accelerates the rate of digestion of a11 types of catgut and there is some reason to beIieve, as does Hinton,
* From the SurgicaI Service, BuffaIo City Hospital,
303
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that certain individuaIs are aIIergic to catgut and manifest this aIIergy by acceI- erated suture digestion. CIinicaIIy, the disappearance of absorbabIe sutures in many cases of wound disruption gives credence to this viewpoint, although the presence of subcIinica1 infection may aIso be a factor. There is a suggestion in the work of Ravdin and his coIIaborators that protein deficiency may influence the rate of catgut digestion. The experimenta and cIinica1 studies of the increment of strength in the heaIing wound together with the studies of the rate of absorption of catgut, however, give sufficient information to aIIow the rationa use of catgut under average circumstances.
Aside from inconstancy of Ioss of tensiIe strength there are severa other factors which make catgut a Iess than idea1 mate- ria1. A definite foreign body reaction is seen surrounding the strands, which is more evident when the more durabIe, chromicized varieties are used. This is ex- pressed cIinicaIIy by the increased indura- tion about the wound in which catgut has been used. Another disadvantage is the necessary reIiance upon the manufacturer for the contro1 of steririty. MeIeney and ChatfieId, CIock and the British commis- sion have shown that catgut purchased in the open market is not invariabIy steriIe when subjected to exhaustive test. It must be said, however, that the major American manufacturers have adopted the rigorous standards and testing techniques of MeI- eney and of CIock, so that the possibihty of purchasing contaminated catgut in the domestic market is practicaIIy ni1.
NON-ABSORBABLE SUTURES
There are aImost as many varieties of non-absorbabIe sutures as there are raw materiaIs avaiIabIe for their fabrication. To mention a few: siIk, Iinen, cotton, stain- Iess stee1, siIver, bronze, horsehair and siIkworm gut may be purchased in the average surgica1 suppIy house and are in use in one or more cIinics throughout the worId. Among the metals, stainIess stee1
and siIver are most frequentIy used. The other metaIs are used occasionaIIy, but possess the disadvantage of causing tissue necrosis in varying degree because of chemical interaction with the tissues. In this connection it is important to reahze that the term “stainIess stee1” incIudes a wide variety of aIIoys, many of which definiteIy interfere with heaIing. The aIIoy recommended by Babcock has been tested extensiveIy and shown to be inert in tissue.
SiIk is the favorite materia1 among the non-metaIIic sutures, combining as it does high tensiIe strength, pIiabiIity and Iack of tissue reaction. Many surgeons have great fear of infection in its use, but it is more sinned against than sinning. HaIsted had IittIe fear that siIk, properIy used, would contribute to infection. Shambaugh, re- porting the resuIts of the use of siIk and catgut in herniorraphy over a twenty-one year period, found that infection was Iess frequent when siIk was used, and further that infection persisted Ionger in the catgut series. In this study the nature of the suture materia1 was the onIy variabIe factor.
Horsehair is frequentIy used in faciaI surgery because it can be obtained in very smaI1 diameters. It has IittIe use eIsewhere and, even in the face, may be repIaced with siIk.
SiIkworm gut is mentioned onIy to con- demn it. SurgicaI siIkworm is a very poor reIation of the eIegant gut used for Ieaders, and is brittIe, hard to tie secureIy, and seems to be irritating. Its advantage, Iack of capiIIary action, is possessed by the metaIIic sutures and by processed siIk and Iinen. Every one who has used it for tension sutures has had the discomforting experi- ence of finding one or more siIkworms broken at the time of the first wound in- spection. However, its use is deep-seated in tradition and wiI1 probabIy continue for many years.
PRACTICAL CONSIDERATIONS
Hemostasis. As the primary purpose of any materia1 used for hemostasis is the
NEW SERIES VOL. XLIX, No. 2 Burke-Suture Problem American Journal of Surgery 305
closure of the vessel invoIved, the size of the suture required is dependent on the nature and caIiber of the vesse1. Either absorbabIe or non-absorbable sutures may be used in the non-infected wound, but catgut is usua1Iy chosen in the presence of infection. Kennedy, however, uses siIk excIusiveIy regardIess of the nature of the wound.
The common error in the seIection of “ties” is the use of unnecessariIy heavy materia1. This fauIt is IargeIy confined to the “catgut” schoo1, and the influence of the siIk advocates is perhaps chieff y respon- sible for the trend toward smaIIer sizes in absorbabIe materia1. Despite this, one frequentIy sees vesseIs tied off with sutures whose diameters are Iarger than the vessels. With the exception of major arteries, any vesse1 can be secureIy fastened with oo catgut, and even smaIIer sizes are adequate for most “breeders.” Those who are accus- tomed to the Iarger sizes compIain that the smaIIer ties break with great frequency and the complaint is not entireIy unreasonable. The answer Iies in the manner of tying and in the amount of tissue incIuded within the tie. If the vesse1 aIone is incIuded and the knot made without terrific tension there wiI1 be no troubIe. Too often we forget that the tension within the incIuded tissue is governed by the tension of the first throw, and that the second throw mereIy acts as a lock for the first. Observation wiI1 revea1 that most sutures are broken in an attempt to put unnecessary tension on the second knot. If extra security is needed, a trans- fixion suture wiI1 be adequate.
Wound Closure. The term covers a tremendous variety of situations, but in- testinal suture, abdomina1 waI1 cIosure and skin suture wiII serve to iIIustrate the basic probIems. After aII, sutures are empIoyed in any wound soIeIy as an artificia1 support unti1 the tissue union has attained sufh- cient tensiIe strength for norma activity. ConsequentIy, the requirements for suture tensire strength and durabiIity are gov- erned by the tissues and the forces which tend to distract them.
The suture par exceIIence for intestina1 work is siIk, as Harvey has recently pointed out. The fine interrupted suture provides a maximum of strength, and a minimum in- terference with heaIing. If catgut is to be used, ooo is Iarge enough and Bower’s work indicates that ooooo wiI1 give even better resuIts. In my experience a two Iayer suture is adequate, when interrupted bIack silk seromuscuIar sutures are used. The inner mucosa1 suture may be carried out with a fine running catgut stitch.
The conventiona abdominal waI1 cIosure is carried out by suture of the individua1 anatomic Iayers, aIthough Kennedy and more recently Hinton (upper abdominal incisions) advocate the “through-and- through” one Iayer cIosure. This type was abandoned generaIIy after BiIIroth demon- strated the markedIy Iessened incidence of postoperative hernia foIIowing anatomic reconstruction. Kennedy reports a gratify- ingIy Iow incidence of wound disruption and hernia foIIowing the singIe Iayer cIosure. It is highly probable that com- plications as a resuIt of “through-and- through” cIosure are Iess frequent than in BiIIroth’s era, but cIosure Iayer by Iayer appeaIs to the vast majority of surgeons.
If the wound is IikeIy to be infected, as after the incision of an abscess, or gen- eraIized peritonitis, or if there has been gross contamination intra operationem, it is advisabIe to use absorbabIe sutures. For cIean wounds absorbabIe or non- absorbabIe sutures may be used at the option of the surgeon. In either case, it is most important to recognize that the onIy layers with appreciabIe tensire strength are the fascia1 sheaths and aponeuroses. DoubIe zero plain catgut or very fine silk is strong enough if the peritoneum is cIosed as a separate layer. If the posterior rectus sheath is incIuded, o chromic or silk with the equivaIent tensiIe strength is adequate. During the past three years, I have used oo chromic without mishap. We have demonstrated that the fascia of the anterior rectus sheath, when sutured with o chromic gut and pIaced in a tension
306 American Journal of Surgery Burke-Suture ProbIem
dynamometer, tears beyond the suture line before suture breakage occurs. If muscIes are to be approximated, very fine sutures are advisabIe because muscIe wiI1 tear Iong before the breaking point of the suture is reached.
Skin cIosure may be carried out with any fine, non-irritant materia1.
WhiIe the decision for or against siIk is best Ieft in the hands of the individua1 operator, I have been impressed by the Iack of induration in the wound sutured with silk or stainIess stee1 and, as a resuIt, have Iargely abandoned the use of catgut.
The custom of using so-caIIed tension sutures to reIieve strain on the suture Iine has much in its favor. For this purpose, heavy processed siIk, stainIess steel or siIver wire shouId be used.
The suture of facia1 wounds, or wounds normaIIy visibIe is most satisfactorily per- formed with non-absorbabIe materiaIs. The advantages of high tensiIe strength in smaII diameter and Iack of reaction are nowhere more desirabIe. WhiIe horse hair is occasionaIIy used for this purpose, but it has IittIe superiority over fine processed siIk and its Iack of uniform strength is a disadvantage.
REFERENCES
BABCOCK, W. W. Ligature and sutures of aIIoy steel. J. A. M. A., 102: 1756, 1934.
CLOCK, R. 0. A reIiabIe method for testing the sterility of surgica1 catgut sutures. Surg., Gynec. 0 Obst.. 61:
789, 1935. HALSTEAD, W. S. The employment of fine silk in prefer-
ence to catgut and the advantage of transfixing tissues and vesseIs in controIling hemorrhage. J. A. M. A., 60: 1119, 1913.
HINTON, J. W. AIIergy as an explanation of dehiscence of a wound and incisiona hernia. Arch. Surg., 33:
197, 1936. HOWES, E. L., and HARVEY, S. C. The strength of the
heaIing wound in relation to the holding strength of the catgut suture. New England J. Med., 200: 1285,
1929. HUHNE, T. Neue Wege zu einem besseren Catgut. Arch.
f. klin. Cbir., 164: 131, 1931. INMAN, J. UnpubIished data. JENKINS, H. P. A cIinica1 study of catgut in relation to
KENNEDY, J. W. Tragedies of the abdominal incision. Am. J. Surg., 25: 512, 1934.
KRAISSL, C. J. Intrinsic factors aItering the absorption of catgut. Surg., Gynec. 0 Obst., 63: 561, 1936.
MELENEY. F.. and CHATFIELD. M. The steriIitv of catgut in relation to hospital infections; with an effective test for the sterility of catgut. Surg., Gynec. w Obst., 52: 430, 1931.
REID, M. R. Some considerations of the probIems of wound heaIing. New England J. Med., 215: 753.
1936. SHAMBAUGH, P. Postoperative wound complications.
