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A SIMPLIFIED TECHNIQUE FOR CLOSURE OF INTERVENTRICULAR SEPTAL DEFECTS
A SIMPLIFIED TECHNIQUE FOR CLOSURE OF INTERVENTRICULAR SEPTAL DEFECTS Benson B. Roe, M.D., San Francisco, Calif.
T
HE TECHNICAL difficulties of precisely placing sutures in interventricular septal defects are well known to cardiac surgeons. A right ventriculotomy which does not traverse major coronary vessels often does not provide ideal ex posure of the ventricular septum in the defect area, and the septal leaflet of the tricuspid valve often obscures the lower edge of the defect. Under these circumstances it is frequently awkward or impossible to place an ordinary suture needle in the ideal location and proper direction through the tissue. A large curved needle is difficult to manipulate in the limited exposure and a smaller needle may be impossible to grasp when placed through the septal edge. An ordinary needle holder can be manipulated only by rotation on its long axis, particularly when it is introduced into a confined space. Motion of the needle it grasps is thus necessarily limited to the plane at right angles, regard less of how it is mounted or the curvature in the jaws (Pig. 1). Directing the needle in any other plane is reflected by motion of the instrument handle as a long lever. This motion is manifestly awkward or impossible inside the ventri cle. Nevertheless, the desired needle direction is often in a plane parallel to, or at acute angles to, the axis of the needle holder. To solve this difficulty, a simple curved needle hook is used as described in the accompanying diagrams (Fig. 2). It is easily handled and directed; its total size is small and does not obscure the field. Its piercing arm is sufficiently long to be easily seen, and it has no tail to snare or pierce adjacent tissues. Its only drawback is the necessity of passing double thicknesses of suture ma terial adjacent to the needle through the septum; however, the size of this puncture hole is not significant and is doubtless smaller than some holes pro duced by the tearing action of misdirected needles. Furthermore, the direction Pig. 2.—Technical steps in placing a mattress suture through the septal edge. 1, The needle is mounted with the arm of suture through the inside of the needle grasped with the handle ; the short free end extends through the outside of the hook as it penetrates the tissue. B, The outside loop is snared to draw the a end through. S, With the a end secured, the needle tip is withdrawn and the b end is released from the operator's grip. i, The other side of the mattress suture is begun with the second needle pierce. 5, The outside loop is again snared to pull through the b end. 6, The hook needle is withdrawn, leaving the mattress suture in place. From the Department of Surgery, University of California School of Medicine, San Francisco, Calif. Received for publication Nov. 17, 1959. 232
Χί ut?' i9°'o2
CLOSURE OF VENTRICULAR S E P T A L D E F E C T S
A.
233
B.
^ί?·, V · - A cu.r.ved needle mounted on a needle holder (A) cannot be directed through (ko the septal tissue without obliquity. The hook needle (B), with the point parallel to the shaft can be drawn with a simple upward motion. ^
Fig. 2.—For legend see opposite page,
234
J. Thoracic and Cardiovas. Surg.
ROB
{ 1
'ί ■
^Mîa^«î Pig. 3. Fig. 4. Fig. 3.—Instruments used, left to right. Tonsil needle from which hooks were adapted. Hook needle used in this technique. Dura hook for snaring suture loop of needle eye. Crotchet needle. Fig. 4.—Result if wrong loop is snared from the needle holder in the second stage. Suture will have to be withdrawn if this occurs.
Fig. 5.—Special curved hollow needle with spool of suture material delivered through tip. The piercing arm of this needle is a No. 22 hypodermic size. In effect, the & arm of the suture loop in Fig. 2 is in the shaft of the instrument, rather than floating loose.
Vol. 40, No. 2 August, 1960
CLOSURE OF VENTRICULAR SEPTAL DEFECTS
235
Pig. 6.—The Figure shows the suture ring with 8 clips showing sutures in place, draped a special sheet which covers the rest of the operative field.
.4"
us -„* i.Fig^·—T1ie ? ° £ . t h e ""ochet hook to travel suture ends through the plastic qnnne-e Ä l u & Ä ^ ^ ^ P · * * - the delired e p o Ä C a n P d ° ^
236
ROE
J. Thoracic and Cardiovas. Surg.
of tension on the suture tends to be in a straight line through the septum; a curved needle travels through this thick tissue in a circular course which must be distorted or torn when straight tension is applied. This method of suturing can be accomplished as illustrated with a simple tonsil hook needle which has been rebent into a more suitable curve (Fig. 3). Practice is required to snare the correct side of the loop with a sharp pin hook so as not to tear the delicate septal tissue and not to have the loop left through the needle eye after both ends are through the tissue (Fig. 4). A new instru ment has been developed to facilitate this maneuver and to reduce the size of the needle puncture hole. It consists of a hollow shaft and needle tip (No. 22 hypodermic needle) which carries the suture and delivers a single end of suture from a spool on the handle (Fig. 5). The technique is rapid for several reasons: (1) the hook is easy to handle and simple to direct into the desired position; (2) both arms of the mattress suture are introduced with a single mounting in the needle, thus obviating the withdrawal of the needle holder and grasping a separate needle; (3) the absence of multiple needles around the incision and the use of a suture ring (Fig. 6) reduces the tangle in the operative field; and (4) the crochet hook facilitates bringing the sutures through the patch material with a simple straight down and up motion (Fig. 7) obviating the multiple maneuvers of mounting, grasp ing, and cutting 12 to 16 curved needles. Experience with this technique in the closure of ventricular septal defects, when patches have been used, has significantly reduced the operating time during cardiotomy and largely obviated the necessity of elective cardioplegia. SUMMARY
A simplified timesaving technique for introduction of sutures in confined areas is described. Its application for placing of mattress sutures for closure of interventricular septal defects with patches has significantly reduced operat ing time.
T
HE TECHNICAL difficulties of precisely placing sutures in interventricular septal defects are well known to cardiac surgeons. A right ventriculotomy which does not traverse major coronary vessels often does not provide ideal ex posure of the ventricular septum in the defect area, and the septal leaflet of the tricuspid valve often obscures the lower edge of the defect. Under these circumstances it is frequently awkward or impossible to place an ordinary suture needle in the ideal location and proper direction through the tissue. A large curved needle is difficult to manipulate in the limited exposure and a smaller needle may be impossible to grasp when placed through the septal edge. An ordinary needle holder can be manipulated only by rotation on its long axis, particularly when it is introduced into a confined space. Motion of the needle it grasps is thus necessarily limited to the plane at right angles, regard less of how it is mounted or the curvature in the jaws (Pig. 1). Directing the needle in any other plane is reflected by motion of the instrument handle as a long lever. This motion is manifestly awkward or impossible inside the ventri cle. Nevertheless, the desired needle direction is often in a plane parallel to, or at acute angles to, the axis of the needle holder. To solve this difficulty, a simple curved needle hook is used as described in the accompanying diagrams (Fig. 2). It is easily handled and directed; its total size is small and does not obscure the field. Its piercing arm is sufficiently long to be easily seen, and it has no tail to snare or pierce adjacent tissues. Its only drawback is the necessity of passing double thicknesses of suture ma terial adjacent to the needle through the septum; however, the size of this puncture hole is not significant and is doubtless smaller than some holes pro duced by the tearing action of misdirected needles. Furthermore, the direction Pig. 2.—Technical steps in placing a mattress suture through the septal edge. 1, The needle is mounted with the arm of suture through the inside of the needle grasped with the handle ; the short free end extends through the outside of the hook as it penetrates the tissue. B, The outside loop is snared to draw the a end through. S, With the a end secured, the needle tip is withdrawn and the b end is released from the operator's grip. i, The other side of the mattress suture is begun with the second needle pierce. 5, The outside loop is again snared to pull through the b end. 6, The hook needle is withdrawn, leaving the mattress suture in place. From the Department of Surgery, University of California School of Medicine, San Francisco, Calif. Received for publication Nov. 17, 1959. 232
Χί ut?' i9°'o2
CLOSURE OF VENTRICULAR S E P T A L D E F E C T S
A.
233
B.
^ί?·, V · - A cu.r.ved needle mounted on a needle holder (A) cannot be directed through (ko the septal tissue without obliquity. The hook needle (B), with the point parallel to the shaft can be drawn with a simple upward motion. ^
Fig. 2.—For legend see opposite page,
234
J. Thoracic and Cardiovas. Surg.
ROB
{ 1
'ί ■
^Mîa^«î Pig. 3. Fig. 4. Fig. 3.—Instruments used, left to right. Tonsil needle from which hooks were adapted. Hook needle used in this technique. Dura hook for snaring suture loop of needle eye. Crotchet needle. Fig. 4.—Result if wrong loop is snared from the needle holder in the second stage. Suture will have to be withdrawn if this occurs.
Fig. 5.—Special curved hollow needle with spool of suture material delivered through tip. The piercing arm of this needle is a No. 22 hypodermic size. In effect, the & arm of the suture loop in Fig. 2 is in the shaft of the instrument, rather than floating loose.
Vol. 40, No. 2 August, 1960
CLOSURE OF VENTRICULAR SEPTAL DEFECTS
235
Pig. 6.—The Figure shows the suture ring with 8 clips showing sutures in place, draped a special sheet which covers the rest of the operative field.
.4"
us -„* i.Fig^·—T1ie ? ° £ . t h e ""ochet hook to travel suture ends through the plastic qnnne-e Ä l u & Ä ^ ^ ^ P · * * - the delired e p o Ä C a n P d ° ^
236
ROE
J. Thoracic and Cardiovas. Surg.
of tension on the suture tends to be in a straight line through the septum; a curved needle travels through this thick tissue in a circular course which must be distorted or torn when straight tension is applied. This method of suturing can be accomplished as illustrated with a simple tonsil hook needle which has been rebent into a more suitable curve (Fig. 3). Practice is required to snare the correct side of the loop with a sharp pin hook so as not to tear the delicate septal tissue and not to have the loop left through the needle eye after both ends are through the tissue (Fig. 4). A new instru ment has been developed to facilitate this maneuver and to reduce the size of the needle puncture hole. It consists of a hollow shaft and needle tip (No. 22 hypodermic needle) which carries the suture and delivers a single end of suture from a spool on the handle (Fig. 5). The technique is rapid for several reasons: (1) the hook is easy to handle and simple to direct into the desired position; (2) both arms of the mattress suture are introduced with a single mounting in the needle, thus obviating the withdrawal of the needle holder and grasping a separate needle; (3) the absence of multiple needles around the incision and the use of a suture ring (Fig. 6) reduces the tangle in the operative field; and (4) the crochet hook facilitates bringing the sutures through the patch material with a simple straight down and up motion (Fig. 7) obviating the multiple maneuvers of mounting, grasp ing, and cutting 12 to 16 curved needles. Experience with this technique in the closure of ventricular septal defects, when patches have been used, has significantly reduced the operating time during cardiotomy and largely obviated the necessity of elective cardioplegia. SUMMARY
A simplified timesaving technique for introduction of sutures in confined areas is described. Its application for placing of mattress sutures for closure of interventricular septal defects with patches has significantly reduced operat ing time.