U.S. patent number 3,845,772 [Application Number 05/397,878] was granted by the patent office on 1974-11-05 for retention suture device and method.
Invention is credited to Dean B. Smith.
United States Patent |
3,845,772 |
Smith |
November 5, 1974 |
RETENTION SUTURE DEVICE AND METHOD
Abstract
A retention suture is looped around an incision in a deep tissue
layer such as the muscle layer, with the ends of the suture being
passed up through a tubular retention suture device. The device is
emplaced in the incision and the ends of the retention suture are
drawn up tightly and secured at the top end of the device. The
incision is closed between the retention suture devices by the
primary wound closure sutures, and these devices remain in the
incision until healing of the muscle tissue layer is adequate.
Inventors: |
Smith; Dean B. (Madison,
WI) |
Family
ID: |
23573037 |
Appl.
No.: |
05/397,878 |
Filed: |
September 17, 1973 |
Current U.S.
Class: |
606/232;
606/233 |
Current CPC
Class: |
A61B
17/04 (20130101); A61B 2017/0464 (20130101); A61B
2017/0458 (20130101); A61B 17/0487 (20130101); A61B
2017/0496 (20130101) |
Current International
Class: |
A61B
17/04 (20060101); A61b 017/04 () |
Field of
Search: |
;128/334R,335,335.5,336,337,339 |
References Cited
[Referenced By]
U.S. Patent Documents
Foreign Patent Documents
|
|
|
|
|
|
|
494,960 |
|
Jun 1919 |
|
FR |
|
116,594 |
|
Jun 1946 |
|
SW |
|
Primary Examiner: Laudenslager; Lucie H.
Attorney, Agent or Firm: Long; Theodore J. Winter; John M.
Engstrom; Harry C.
Claims
I claim:
1. A device insertable in a surgical incision for use with a
rentention suture which is looped around an incision in a deep
tissue layer comprising:
a. an elongate hollow tube adapted to be inserted into said
surgical incision above said deep tissue layer, said tube having a
bottom end and a top end, the bore of said tube being sufficiently
large to receive the two end portions of said suture therethrough;
and
b. means at the top end of said tube for retaining said end
portions of said suture and preventing same from being retracted
through said tube.
2. The device as specified in claim 1 wherein said means for
retaining said end portions of said suture comprises an element
extending across the bore of said tube at the top end of said tube
to allow said end portions of said suture to be tied together over
said element.
3. The device as specified in claim 2 wherein said element extends
substantially the length of said tube to divide the bore of said
tube into two passageways each sufficiently large to receive one
end portion of said suture therethrough.
4. The device as specified in claim 1 wherein said means for
retaining the end portions of said suture comprises a support
member placed transversely over the top end of said tube in
position to allow the end portions of said suture to be tied
together over said support member.
5. The device as specified in claim 4 wherein the top end of said
tube has flared portions in two opposed directions and grooved
portions substantially at right angles to said flared portions,
said support member fitting into said grooved portions.
6. The device as specified in claim 5 wherein said support member
has flared ends.
7. The device as specified in claim 1 wherein the bttom end of said
tube is flared out in two opposed directions.
8. The device as specified in claim 1 wherein the bottom end of
said tube is flared around the circumference thereof.
9. A method of suturing a surgical incision particularly that
portion of said incicsion in deep body tissue comprising the steps
of:
a. encircling the suture around said incision in said deep body
tissue;
b. passing the end portions of said suture through a hollow
tube;
c. inserting said tube into the incision above said deep body
tissue; and
d. securing said end portions of said suture at the top end of said
tube.
Description
BACKGROUND OF THE INVENTION
1. Field of the Invention
This invention pertains to methods of placing retention sutures
around an incision, and devices used to facilitate the placement of
retention sutures.
2. Description of the Prior Art
It is common practice in abdominal surgery to employ retention
sutures which support the primary wound closure by absorbing
lateral tension exerted on the several tissue layers in which an
incision has been made. The basic purpose of the retention sutures
is to absorb the lateral tension placed on the deeper tissue layers
of muscle and fascia since the strength of the primary incision
closures in these deeper layers may not be adequate to withstand
the strain on the incision. The sutures used in the primary
incision closure in deeper tissue layers are often made of
absorbable suture material, which contributes to the doubtful
strength of the closure.
Retention sutures are usually made of non-absorbable suture
material such as silk, cotton, or synthetic fibers. Very heavy
absorbable suture material is inappropriate for use as a retention
suture because of the questionable strength of this material, and
becuase of the marked tissue reaction that would occur with such a
large amount of absorbable suture being present. The use of
nonabsorbable retention sutures requires that they be removed when
healing of the wound is satisfactory, usually in two to three
weeks. To facilitate the removal of the suture, the common surgical
practice has been to pass the suture downwardly through the skin at
a point spaced several centimeters laterally from the incision, and
continue the passage of the suture through the fat layer, fascia,
muscle layer and the peritoneum. The suture is then brought to a
point spaced laterally away from the incision of the other side
thereof, and is passed up through the peritoneum and the respective
tissue layers to protrude from the skin. The retention suture,
having thus been looped around the incision in all tissue layers,
is tied tightly to draw the tissue layers together. When healing is
adequate, and the retention suture is to be removed, the suture is
simply lifted up, cut, and pulled out. Because sutures placed by
this technique have to be tied quite tightly to apply the proper
tension at the lateral aspect of the incision, they frequently will
cut into the skin, possibly producing necrosis, or at the minimum,
cross hatching of the skin. Distortion and compartmentalization of
the subcutaneous tissues often occurs, promoting the development of
serous fluid collections and secondary infections.
Several devices have been developed in attempts to mitigate the
problems associated with the usual retention suture technique
described above. A common device is a piece of hollow tubing
through which the suture is passed, which is placed transversely
across the incision, and which is intended to distribute the
pressure of the suture over a greater skin area. However, these
tubes, which may be telescoping, do not adequately protect the skin
if the suture is tied tightly. Various retention suture bridges
have been developed which are made of rigid material, and which
support the suture above the skin between the two exit points of
the suture. These bridges tend to be cumbersome and complicate the
nursing care of the patient. They may also produce some degree of
pressure injury to the skin where the feet of the apparatus are
placed. Since all of these devices are used with the usual
retention suture technique, the suture is still being brought
through the fat layers and the skin, even though the main purpose
of the retention suture is to support the deeper layers of
abdominal wall tissue that are primarily subject to stress. The
passage of the suture material through the subcutaneous tissue and
skin facilitates the removal of the suture, but does not serve any
other substantial purpose.
SUMMARY OF THE INVENTION
I have invented a method of placing retention sutures in a deep
tissue layer without passing the ends of the suture through the
subcutaneous tissue and across the skin. I have also invented a
device which enables the placement of a retention suture in this
manner.
A retention suture is first looped around an incision in only the
layers of muscle, fascia, and peritoneum. The end portions of the
suture are passed up through a tubular portion of my retention
suture device. This tube portion is inserted into the incision so
that the bottom end of the tube portion is adjacent to the upper
surface of the tissue layer being sutured. The end portions of the
retention suture are drawn up tightly and tied or otherwise joined
over a portion of the retention suture device, thus preventing
retraction of the suture into the device.
In different embodiments of my invention the portion of the device
over which the suture is tied may consist of an element or spindle
affixed across the top end of the tube portion, or a removable
support member which is placed transversely across the top end. The
bottom end of the tube portion may also be flared out, either in
two opposing directions or around its entire circumference, to
thereby allow the suture to be drawn into the tube portion with
minimal friction. The several retention sutures thus placed around
the incision in deep layers of tissue are capable of absorbing the
lateral tension applied to those tissue layers, thereby relieving
the primary wound closure of this tension.
The incision in the subcutaneous tissue layer and skin is closed by
the primary wound closure sutures at all points along the incision
except where the retention suture devices are located, and these
devices remain in the incision until healing of the tissue layer
having the retention sutures is adequate. The retention sutures are
then cut and pulled out and the retention suture devices are
removed. Clinical experience has shown that the areas where the
retention suture devices were emplaced heal rapidly and leave very
little scarring. In addition, when this method of placing retention
sutures is utilized, the possibility of skin damage and infection
is greatly reduced since the retention suture does not have to be
passed through the skin and higher subcutaneos tissue layers. It
has also been demonstrated that the use of my retention suture
devices has been more comfortable for the patient and less
cumbersome than devices intended for use with conventionally placed
retention sutures.
BRIEF DESCRIPTION OF THE DRAWING
In the drawing:
FIG. 1 is a front elevation view showing a preferred embodiment of
a retention suture device exemplifying the principles of my
invention.
FIG. 2 is a side elevation view of the retention suture device
shown in FIG. 1.
FIG. 3 is a side cross-sectional view of the retention suture
device shown in FIG. 1.
FIG. 4 is a side cross-sectional view of a modified embodiment of
the device of FIG. 1.
FIG. 5 is a top view of the device of FIG. 1, shown emplaced in an
incision.
FIG. 6 is a cross-sectional view taken along the line 6--6 of FIG.
5, showing the placement of the device of FIG. 1 in an
incision.
FIG. 7 is a front elevation view of another emobdiment of a
retention suture device.
FIG. 8 is a front elevation view of a modified embodiment of the
retention suture device of FIG. 7.
FIG. 9 is a side elevation view of the vertical tube portion of the
retention suture device of FIG. 8.
FIG. 10 is a top view of the device of FIG. 8, shown emplaced in an
incision.
FIG. 11 is a cross-sectional view taken along the line 11--11 of
FIG. 10, showing the placement of the device of FIG. 8 in an
incision.
DESCRIPTION OF THE PREFERRED EMBODIMENTS
Referring now more particularly to the drawing, wherein like
numerals refer to like parts throughout the several views, a
preferred embodiment of my retention suture device is shown
generally at 20 in FIGS. 1-3.
The retention suture device 20 has a generally cylindrical hollow
tube portion 21, a top end 22 which is flared out around its
circumference, and a bottom end 23 which is flared out in two
opposed directions to form curved flanges or reception portions 23a
for s suture. As best shown in FIG. 3, the two curved reception
portions 23a provide a smooth rounded edge for the two end portions
of a suture to be drawn over when the device 20 is emplaced in an
incision. A dividing wall 24 runs substantially the length of the
tube 21 and divides the bore of the tube into two passageways each
large enough to allow a standard retention suture to be passed
therethrough. The dividing wall 24 supports a rounded spindle
element 25 located at the top end 22 of the device 20, which, as
best shown in FIG. 1, is slightly bowed towards the middle of the
element.
A modified embodiment of the retention suture device 20 is shown
generally at 26 in FIG. 4. The device 26 has a hollow tube portion
27, a flared top end 28, and a bottom end 29 which is flared out in
two opposing directions to form suture reception portions 29a in
the same manner as described for the device 20. The retention
suture device 26 does not have a dividing wall, but does have a
rounded element or bar 30 narrower than the diameter of the bore of
the tube 27, which is affixed across the top end 28 of the
device.
The use of the retention suture device 20 in placing a retention
suture is best illustrated with reference to FIGS. 5 and 6. An
incision 31 is made surgically in the skin 32 and through a fat
layer 33 and a deep muscle layer 34. Depending on the surgical
technique employed, the retention suture may or may not traverse
the peritioneal cavity throughout its passage. The muscle and
fascial layers 34 are shown schematically in FIG. 6 as a single
layer for illustrative purposes, and this is intended to represent
any combination of layers of body tissue, or portions of a single
layer of body tissue, which a retention suture might be placed
around.
When using my retention suture device 20, a retention suture 35 is
passed down through only the muscle and fascial layers 34 on one
side of the incision 31, and is brought up through the layers on
the other side of the incision. Thus the retention suture 35 is
looped around the incision 31 only in the muscle and fascial layers
34 in contrast to the usual retention suture technique. The end
portions 35a and 35b of the suture 35 are then brought up through
the incision 31 and laid aside while the primary incision closure
is made on the muscle and fascial layers 34. When the primary
incision closure has been completed in the muscle and fascial
layers, the suture end portions 35a and 35b are passed up from the
bottom end 23 to the top end 22 of the suture device 20 on opposite
sides of the dividing wall 24. The dividing wall 24 allows the
suture end portions to be more easily passed through the tube 21 by
the surgeon, and ensures that the end portions will not become
twisted or otherwise entangled. The suture device 20 is then
inserted into the incision and positioned as shown in FIG. 6 so
that the two end portions of the suture are in contact with the
curved reception portions 23a. The curvature of these reception
portions allows the suture to be pulled over them with minimal
friction and little chance of damage to the suture.
The device 20 is held in place in the incision 31 while the end
portions 35a and 35b of the suture are drawn up tightly and tied in
a knot 36 over the spindle element 25. The slight bow in the
element 25 prevents the tied end portions of the suture from
slipping off the end of the spindle element, and the end portions
of the suture are thus retained above the top end 22 by the spindle
element. The suture 35 is now capable of absorbing the lateral
tension applied to the muscle and fascial layers 34, thus relieving
the primary wound closure at the incision 31 of this tension. The
length of the tube 21 is chosen to correspond to the distance
between the skin 32 and the upper surface of the muscle and fascial
layers 34 of the patient being operated on. With the bottom end 23
adjacent to the muscle and fascial layer, the top end 22 should
protrude slightly above the skin to facilitate removal of the
suture.
Several retention sutures must usually be placed around a typical
abdominal incision, with the number of sutures and therefore suture
devices required depending on the length of the incision. After all
of the sutures have been placed, the incision in the subcutaneous
tissue layers 33 and the skin 32 is closed by primary wound closure
sutures at all points except where the retention suture devices 20
are located. When healing of the muscle and fascial tissue layers
34 is adequate, the retention sutures 35 are cut and pulled out.
The retention suture devices 20 should be held firmly in place in
the incision with the bottom ends 23 just above the muscle and
fascial layers, to allow the sutures to be pulled out through the
devices without damage to the subcutaneous tissue. Experience has
shown that following the removal of the sutures 35, the retention
suture devices 20 can be easily removed, leaving narrow tracts
which are lined with granulation tissue. These tracts close rapidly
in a few days, with only minimal attention to the wound required to
prevent pocketing of serum in the tracts. The closure of the skin
over these tracts is usally so satisfactory that it is difficult to
identify the exit points of the retention suture devices in a few
weeks.
The modified retention suture device 26 shown in FIG. 4 is utilized
in the same manner as described above for the device 20, except
that the suture end portions are tied over and retained by the bar
30. The absence of the dividing wall in this device allows some
twisting of the suture end portions, but this is not a serious
problem if the length of the tube 27 is relatively short.
An alternative embodiment of a retention suture device is shown
generally at 37 in FIG. 7. The device 37 has a hollow tube 38 with
a top end 39 and a bottom end 40 which are both flared out around
their circumferences. A support member 41 is placed transversely
over the top end 39 of the tube 38 when the device 37 is being used
with a retention suture. The tube 38 is emplaced in an incision as
described above for the device 20, with the ends of the suture
being brought up through the bore of the tube and tied over the
support member 41. The support member may be tubular or solid, and
preferably has flared ends 41a and 41b, as shown in FIG. 7, to
prevent the tied suture from slipping off the ends of the support
member.
A modified embodiment of the device 37 is shown generally at 42 in
FIG. 8. The retention suture device 42 has a hollow tube 43 which
has a top end 44 with flared portions 44a which extend from the
tube in two opposed directions, and grooved portions 44b which are
substantially at right angles to the flared portions. The bottom
end 45 of the tube is flared out around its circumference to
provide a curved edge for a suture to be drawn over. The retention
suture device 42 also has a support member 46, which may be hollow
or solid and has flared ends 46a and 46b, and which fits into the
grooves 44b and is thus laterally restrained in this position by
the top end flared portions 44a.
Placement of a retention suture using the retention suture device
42 is shown in FIGS. 10 and 11, which will serve to illustrate the
use of both the device 42 and the device 37. As shown in FIG. 11, a
suture 47 is looped around the incision 31 only in the muscle and
fascial layers 34, in the same manner as indicated above wherein
the use of the device 20 was described. The end portions 47a and
47b of the suture are brought up through the incision 31 and laid
aside while the primary incision closure is made on the muscle and
fascial layers 34. The end portions 47a and 47b of the suture 47
are then passed up through the tube 43 and the tube is inserted
into the incision. The support member 46 is placed in the grooves
44b on the top end 44 of the tube, and the end portions of the
suture 47 are drawn up tightly and tied over the support member 46
in a knot 48. The primary closures of the subcutaneous tissue
layers and the skin 32 are carried out, and the suture devices 42
remain in the incision until healing is adequate. The tube 43 is
removed as described previously for the retention suture device 20,
and is similarly chosen to correspond in length to the distance
between the upper surface of the muscle layer and the skin of the
patient being operated on.
The retention suture devices described above are preferably made of
metals or plastics which will not react with body tissues and
liquids, and which can be sterilized as is usual with surgical
instruments. Although clinical experience has shown that the chance
of infection around these devices is slight, the use of a suitable
broad spectrum antibiotic ointment, instilled into the bore of the
tube portion and around its outer circumference at the skin line,
would be a useful adjunct to the surgical technique described.
It is understood that my invention is not confined to the
particular construction and arrangement of parts herein illustrated
and described, but embraces all such modified forms thereof as come
with the scope of the following claims.
* * * * *