Visceral and parietal suture in abdominal surgery

The effect of various modifications in suture technic on the healing of intestinal and other alimentary anastomoses is reviewed in the light mainly of controlled clinical comparisons by the author and other workers. (a) In small bowel anastomoses and in colonic and colorectal anastomoses in which both participating stumps have a peritoneal coat an inverting technic of suture has been found to be much more secure than an everting technic, but no significant difference has been demonstrated between the classic two-layer inverting technic and a one-layer inverting technic. However, for low anterior resections in which the distal stump is devoid of a peritoneal coat, the one-layer end-on slightly inverting technic has been shown to be followed by significantly fewer anastomotic dehiscences than the two-layer technic. (b) No controlled clinical studies are available regarding anastomoses in the upper gastrointestinal tract, but for anastomoses between the stomach and the intestine, the weight of surgical experience seems to be heavily in favor of a two-layer technic, whereas for esophago-gastric, -jejunal, or -colonic anastomoses there is one body of authoritative opinion in favor of a one-layer inverting technic. (2) The method of determining the relative merits of some of the many different ways of closing parietal abdominal wounds, by means of controlled clinical trails, is discussed. By one such trial, continuous layer suture with chromic catgut has been shown to be significantly inferior to catgut layer suture combined with tension, sutures or to figure-of-eight (Tom Jones) sutures of wire, as judged by the incidence of wound dehiscence or of subsequent incisional herniation. Reference is made to other trials in progress for evaluation of Prolene, Dexon, and other suture materials and comparison of median and paramedian incisions.