- Email: [email protected]
Operation to Shorten a Rectus Muscle with Buried Sutures
AMERICAN JOURNAL OF OPHTHALMOLOGY Volume 14
June, 1931
Number 6
OPERATION TO SHORTEN A RECTUS MUSCLE WITH BURIED SUTURES WALTER B. LANCASTER, M.D.,
F.A.C.S.
BOSTON
The operation now described differs from that recommended by the author in 1918, in that it omits the advancement stitch in the sclera near the cornea; the mattress "security stitch" through the tendon stump and muscle having been found sufficient. It was also found that the sutures did not need to be removed if they were buried. This operation may be regarded not so much as an addition to the many forms of muscle shortening, but rather as a simplification of some of the ap proved methods. Certainty, accuracy and ease of performance are the ad vantages claimed, just what every sur geon claims for his favorite method ! The muscle is exposed by a longi tudinal incision from limbus to canthus (figure 1), the conjunctiva is under mined and then dissected off the muscle as far as necessary (figure 2), and the capsule of Tenon is picked up at the margin of the muscle and incised (fig ure 3) ; this permits an easy introduc tion of the strabismus hook (figures 4, 5 and 6). The muscle is isolated by cutting the capsule along each side of the muscle as far backward as neces sary (figure 7). With two strabismus hooks the muscle is fully freed from surrounding tissues on both sides and underneath (figure 8). Prince's forceps are applied in such a position as to mark exactly the amount of shortening intended. One may measure off the distance, deter mined in advance, by a millimeter scale, by compasses, by the eye or in any other manner. The forceps are clamped to the muscle just in front of the point one wishes to attach to the original insertion. The tendon is cut off, but a one or two millimeter stump is left. If one prefers to fold, reef or tuck the muscle the tendon is not cut, in that case the sutures are introduced according to the 483
second or third method. There are several ways of introducing the sutures. I give them in what I regard as the order of preference. First method. A double-armed white silk suture, not too coarse, is introduced through the stump of the tendon close to the sclera from behind forward, and is brought out just in front of the ac tual insertion (figure 9A). The two needles are introduced in the same way, one near the center of the tendon and the other near the edge of the tendon; this makes the first stage of a mattress suture. A second double-armed suture is placed in exactly the same way in the other half of the tendon. These two mattress sutures are now completed by passing the needles from the scleral side through the muscle just back of the Prince's forceps (figure 10, 1). The conjunctiva is not included. One needle should be near the edge of the muscle, and the other about onethird of the width away from the first. At least one-third of the muscle is not included in the suture, and so the mus cle is not cut off as by a ligature which includes the whole muscle. Each mattress suture includes about one-third of the width of the muscle, which is sufficient for a safe hold (fig ure 9, B and C). In slender muscles one can use judgment; for instance take as much as three quarters in the two sutures and leave only one quarter. The two mattress sutures are slightly farther apart in the tendon stump than they are in the muscle; this tends to
484
WALTER B. LANCASTER
keep the muscle well spread out and not puckered. The width of a muscle is normally greater at its insertion than it is at a point five or ten millimeters back in the muscle.
ture in the muscle is directly over its corresponding portion in the stump of the tendon. The surgeon ties each suture; he is careful to draw the first half-knot
Fig. 1 (Lancaster). Fold of conjunctiva raised by forceps to make conjunctival incision.
Fig. 3 (Lancaster). Conjunctiva still held by assistant. Capsule of Tenon raised by surgeon's forceps to incise.
The assistant grasps the eyeball at the opposite side of the cornea with fixation forceps near the cornea or in the insertion of the muscle with one
tightly enough to take up all slack thread and fasten the muscle firmly to the tendon stump before he ties the second half of the knot. It is usually
Fig. 2 (Lancaster). Conjunctiva re tracted and undermined.
Fig. 4 (Lancaster). Surgeon's forceps laid aside. Hook introduced beneath the tendon, raising capsule at lower margin.
hand and holds the Prince's forceps with the other. The eyeball is rotated toward the muscle to be shortened, and that muscle is gently pulled forward until the portion of each mattress su
better not to use a surgeon's knot for the first half-knot because it is difficult to draw it tightly enough. Since the assistant is holding the muscle steadily in position there is no strain on the
OPERATION TO SHORTEN A RECTUS MUSCLE
485
thread to make it slip, after it has been pulled tight, while the surgeon is tying the other half of the knot (figure 9, D and E ) . Prince's forceps are removed. The threads are then cut off short,
suture which is not tied. The mattress sutures are buried; they do not have to be removed (figure 9, G). The antagonist is tenotomized, if necessary, either at this time or after
Fig. 5 (Lancaster). Capsule slit at lower margin of tendon, permitting hook to come through.
Fig. 7 (Lancaster). Method of isolat ing tendon by incision with scissors along each edge.
the field is irrigated and sponged and the work is inspected. If there has been only a small shortening the end of the muscle may be left intact. If
a few days when it will have become possible to estimate more accurately whether the shortening was sufficient. If one plans a rather large shortening
Fig. 6 (Lancaster). Hook fully intro duced, point emerging through lower opening in capsule.
Fig. 8 (Lancaster). Both hooks used to raise tendon ready to introduce the Prince's forceps.
there is too much redundant tissue some of it should be cut off (figure 9, F ) . The conjunctiva is drawn together and sutured with a running continuous
and intends to do a tenotomy anyway, perhaps with a regulating stitch, the best time to do it is after the first mus cle has been exposed and isolated, but
486
WALTER B. LANCASTER
before the stitches have been applied. This makes it easier to tie the sutures. The assistant can grasp the stump of the tenotomized muscle with fixation forceps, to roll the eye into position, more easily after a tenotomy has been
through the tendon stump from behind forward. If a fairly long quarter curved needle is used, it can be passed through both at a single introduction. It is better to pass the needle next to the middle of the muscle first, and the
Fig. 9 (Lancaster). A. Cross section through tendon insertion and sclera. Needles are introduced through the stump of the tendon close to the sclera. B. Muscle held up by Prince's forceps, showing how sutures are to be placed. C. Muscle held in normal position, showing position of sutures. D. Muscle pulled forward while eye is rotated toward it to facilitate tying the sutures. E. Cross section showing how muscle is lapped over tendon stump and securely tied down to it. F. Prince's forceps removed and redundant muscle cut off, conjunctiva ready to be sutured over the site of the operation. G. Conjunctiva closed by a running continuous suture which need not be tied. Dotted lines show site of buried sutures. If a tuck is made the fold also is buried.
done, because he can secure a better hold and has less resistance to over come. A second way to apply the two mat tress sutures is to start the needles first through the muscle just back of the Prince's forceps from the conjunctival surface to the scleral surface, and then
needle next to the border second. The other suture is passed in the same way (figure 10, 2). The first method described laps the muscle over the tendon and ties it down with mattress suture (figure 10, 1). The second method does not lap the muscle over the stump, but raises a
O P E R A T I O N TO SHORTEN A RECTUS MUSCLE
fold, or tuck, or reef, which may or may not be cut, and sutures the under sur face of the muscle to the under surface of the tendon (figure 10, 2). This is less advantageous as it does not produce as firm, secure and smooth an adhesion of muscle to stump. It is a good way to make a tuck or fold when only a small effect is desired. It is also the method to use when a very
487
muscle behind the Prince's forceps from the scleral to the conjunctival sur face; the knots are tied back of the Prince's forceps (figure 10, 3). This is a satisfactory way of making a tuck; it is not a good way for making a re section because it does not lap the ends to be fastened together. This is the method of Fromaget. I have not included the Reese meth
R E 3 E C T I C B SBEI1EH
1869
EWIHG
1915
LANCASTER 1918 DUVE3GEB
1919
BUTLER
1916
FHOMAOBU
1921
BOYES
1874
3EESE
1912
^
Fig. 10 (Lancaster). Four different ways of inserting the mattress suture through the tendon stump and the muscle in making a resection. Two of them become tucks when the muscle is not cut.
large tuck is wanted, one that is larger than can be secured with a tendon tucker. Personally, I like it better than a tucker for any size of tuck; one can measure the amount more accurately and it is almost as easy to insert the stiches as with a tucker. The third method of placing the mat tress sutures is to introduce the needles from before backward through the ten don stump and then out through the
od of passing the sutures among those that I approve, because it folds the end of the resected muscle under the stump in a way that seems less advantageous than the ones I have described, and be cause it involves removing the Prince's forceps before tying the sutures; con sequently the muscle must be pulled forward to its insertion by the suture only, a single mattress loop through its middle. This will not slip after it is
488
WALTER B. LANCASTER
securely tied, but it is not so safe against slipping during the critical moments of the tying as when held by a well clamped forceps. The best method of securing anes thesia is also a slight modification of the usual practice. Cocaine four per cent instilled four or five times and adrenalin once or twice will give ample anesthesia for incising and undermin ing the conjunctiva and exposing the muscle and tendon. If one is ready to begin and cocaine has been instilled twice only, time can be saved by apply ing a tiny wad of cotton, soaked in ten percent cocaine, just over the muscle and tendon and then closing the lids carefully over it for three minutes. After the muscle has been exposed and before it has been taken up on the hook, novocaine two percent and ad renalin 1 to 10,000 are injected along the muscle back of the tarso-orbital fascia. If this is done at the beginning of the operation some of the solution may unintentionally be placed in front of the fascia and so infiltrate the field of operation; this makes it slightly more difficult to isolate the muscle. Some surgeons have abandoned the deep in jections altogether on this account. By giving the deep injection after the mus cle has been exposed the objection is met and the patient is spared the very disagreeable sensations caused by pull
ing on the muscle with the hooks or Prince's forceps. It will be seen that this operation differs from the one I described in 1918, in omitting the advancement stitch in the sclera near the cornea. This was abandoned as unnecessary several years ago; the so-called security stitch, a mattress stitch through the tendon stump and muscle were sufficient. This still left me with the annoyance of having to remove the stitches which were tied outside the conjunctiva. Fi nally I realized that it was not neces sary to remove the sutures if they were buried, and so the operation here de scribed evolved. It has the advantage not only of eliminating the stitch re moval but of making the other steps in the operation easier and more exact. I believe that it is easier to remove these buried stitches than the old type tied outside the conjunctiva. One can secure good anesthesia and ischemia, incise and undermine the conjunctiva, and pick up and cut the sutures with less trouble than he can pick up a su ture imbedded in swollen conjunctiva and cut it in the right place. Often enough I have cut off the knot and left a piece of silk buried under the muscle. I have never seen it do harm. This, and the burying of sutures in the tuck ing operation, convinced me that the operation here described was practical and safe. 520 Commonwealth building.
June, 1931
Number 6
OPERATION TO SHORTEN A RECTUS MUSCLE WITH BURIED SUTURES WALTER B. LANCASTER, M.D.,
F.A.C.S.
BOSTON
The operation now described differs from that recommended by the author in 1918, in that it omits the advancement stitch in the sclera near the cornea; the mattress "security stitch" through the tendon stump and muscle having been found sufficient. It was also found that the sutures did not need to be removed if they were buried. This operation may be regarded not so much as an addition to the many forms of muscle shortening, but rather as a simplification of some of the ap proved methods. Certainty, accuracy and ease of performance are the ad vantages claimed, just what every sur geon claims for his favorite method ! The muscle is exposed by a longi tudinal incision from limbus to canthus (figure 1), the conjunctiva is under mined and then dissected off the muscle as far as necessary (figure 2), and the capsule of Tenon is picked up at the margin of the muscle and incised (fig ure 3) ; this permits an easy introduc tion of the strabismus hook (figures 4, 5 and 6). The muscle is isolated by cutting the capsule along each side of the muscle as far backward as neces sary (figure 7). With two strabismus hooks the muscle is fully freed from surrounding tissues on both sides and underneath (figure 8). Prince's forceps are applied in such a position as to mark exactly the amount of shortening intended. One may measure off the distance, deter mined in advance, by a millimeter scale, by compasses, by the eye or in any other manner. The forceps are clamped to the muscle just in front of the point one wishes to attach to the original insertion. The tendon is cut off, but a one or two millimeter stump is left. If one prefers to fold, reef or tuck the muscle the tendon is not cut, in that case the sutures are introduced according to the 483
second or third method. There are several ways of introducing the sutures. I give them in what I regard as the order of preference. First method. A double-armed white silk suture, not too coarse, is introduced through the stump of the tendon close to the sclera from behind forward, and is brought out just in front of the ac tual insertion (figure 9A). The two needles are introduced in the same way, one near the center of the tendon and the other near the edge of the tendon; this makes the first stage of a mattress suture. A second double-armed suture is placed in exactly the same way in the other half of the tendon. These two mattress sutures are now completed by passing the needles from the scleral side through the muscle just back of the Prince's forceps (figure 10, 1). The conjunctiva is not included. One needle should be near the edge of the muscle, and the other about onethird of the width away from the first. At least one-third of the muscle is not included in the suture, and so the mus cle is not cut off as by a ligature which includes the whole muscle. Each mattress suture includes about one-third of the width of the muscle, which is sufficient for a safe hold (fig ure 9, B and C). In slender muscles one can use judgment; for instance take as much as three quarters in the two sutures and leave only one quarter. The two mattress sutures are slightly farther apart in the tendon stump than they are in the muscle; this tends to
484
WALTER B. LANCASTER
keep the muscle well spread out and not puckered. The width of a muscle is normally greater at its insertion than it is at a point five or ten millimeters back in the muscle.
ture in the muscle is directly over its corresponding portion in the stump of the tendon. The surgeon ties each suture; he is careful to draw the first half-knot
Fig. 1 (Lancaster). Fold of conjunctiva raised by forceps to make conjunctival incision.
Fig. 3 (Lancaster). Conjunctiva still held by assistant. Capsule of Tenon raised by surgeon's forceps to incise.
The assistant grasps the eyeball at the opposite side of the cornea with fixation forceps near the cornea or in the insertion of the muscle with one
tightly enough to take up all slack thread and fasten the muscle firmly to the tendon stump before he ties the second half of the knot. It is usually
Fig. 2 (Lancaster). Conjunctiva re tracted and undermined.
Fig. 4 (Lancaster). Surgeon's forceps laid aside. Hook introduced beneath the tendon, raising capsule at lower margin.
hand and holds the Prince's forceps with the other. The eyeball is rotated toward the muscle to be shortened, and that muscle is gently pulled forward until the portion of each mattress su
better not to use a surgeon's knot for the first half-knot because it is difficult to draw it tightly enough. Since the assistant is holding the muscle steadily in position there is no strain on the
OPERATION TO SHORTEN A RECTUS MUSCLE
485
thread to make it slip, after it has been pulled tight, while the surgeon is tying the other half of the knot (figure 9, D and E ) . Prince's forceps are removed. The threads are then cut off short,
suture which is not tied. The mattress sutures are buried; they do not have to be removed (figure 9, G). The antagonist is tenotomized, if necessary, either at this time or after
Fig. 5 (Lancaster). Capsule slit at lower margin of tendon, permitting hook to come through.
Fig. 7 (Lancaster). Method of isolat ing tendon by incision with scissors along each edge.
the field is irrigated and sponged and the work is inspected. If there has been only a small shortening the end of the muscle may be left intact. If
a few days when it will have become possible to estimate more accurately whether the shortening was sufficient. If one plans a rather large shortening
Fig. 6 (Lancaster). Hook fully intro duced, point emerging through lower opening in capsule.
Fig. 8 (Lancaster). Both hooks used to raise tendon ready to introduce the Prince's forceps.
there is too much redundant tissue some of it should be cut off (figure 9, F ) . The conjunctiva is drawn together and sutured with a running continuous
and intends to do a tenotomy anyway, perhaps with a regulating stitch, the best time to do it is after the first mus cle has been exposed and isolated, but
486
WALTER B. LANCASTER
before the stitches have been applied. This makes it easier to tie the sutures. The assistant can grasp the stump of the tenotomized muscle with fixation forceps, to roll the eye into position, more easily after a tenotomy has been
through the tendon stump from behind forward. If a fairly long quarter curved needle is used, it can be passed through both at a single introduction. It is better to pass the needle next to the middle of the muscle first, and the
Fig. 9 (Lancaster). A. Cross section through tendon insertion and sclera. Needles are introduced through the stump of the tendon close to the sclera. B. Muscle held up by Prince's forceps, showing how sutures are to be placed. C. Muscle held in normal position, showing position of sutures. D. Muscle pulled forward while eye is rotated toward it to facilitate tying the sutures. E. Cross section showing how muscle is lapped over tendon stump and securely tied down to it. F. Prince's forceps removed and redundant muscle cut off, conjunctiva ready to be sutured over the site of the operation. G. Conjunctiva closed by a running continuous suture which need not be tied. Dotted lines show site of buried sutures. If a tuck is made the fold also is buried.
done, because he can secure a better hold and has less resistance to over come. A second way to apply the two mat tress sutures is to start the needles first through the muscle just back of the Prince's forceps from the conjunctival surface to the scleral surface, and then
needle next to the border second. The other suture is passed in the same way (figure 10, 2). The first method described laps the muscle over the tendon and ties it down with mattress suture (figure 10, 1). The second method does not lap the muscle over the stump, but raises a
O P E R A T I O N TO SHORTEN A RECTUS MUSCLE
fold, or tuck, or reef, which may or may not be cut, and sutures the under sur face of the muscle to the under surface of the tendon (figure 10, 2). This is less advantageous as it does not produce as firm, secure and smooth an adhesion of muscle to stump. It is a good way to make a tuck or fold when only a small effect is desired. It is also the method to use when a very
487
muscle behind the Prince's forceps from the scleral to the conjunctival sur face; the knots are tied back of the Prince's forceps (figure 10, 3). This is a satisfactory way of making a tuck; it is not a good way for making a re section because it does not lap the ends to be fastened together. This is the method of Fromaget. I have not included the Reese meth
R E 3 E C T I C B SBEI1EH
1869
EWIHG
1915
LANCASTER 1918 DUVE3GEB
1919
BUTLER
1916
FHOMAOBU
1921
BOYES
1874
3EESE
1912
^
Fig. 10 (Lancaster). Four different ways of inserting the mattress suture through the tendon stump and the muscle in making a resection. Two of them become tucks when the muscle is not cut.
large tuck is wanted, one that is larger than can be secured with a tendon tucker. Personally, I like it better than a tucker for any size of tuck; one can measure the amount more accurately and it is almost as easy to insert the stiches as with a tucker. The third method of placing the mat tress sutures is to introduce the needles from before backward through the ten don stump and then out through the
od of passing the sutures among those that I approve, because it folds the end of the resected muscle under the stump in a way that seems less advantageous than the ones I have described, and be cause it involves removing the Prince's forceps before tying the sutures; con sequently the muscle must be pulled forward to its insertion by the suture only, a single mattress loop through its middle. This will not slip after it is
488
WALTER B. LANCASTER
securely tied, but it is not so safe against slipping during the critical moments of the tying as when held by a well clamped forceps. The best method of securing anes thesia is also a slight modification of the usual practice. Cocaine four per cent instilled four or five times and adrenalin once or twice will give ample anesthesia for incising and undermin ing the conjunctiva and exposing the muscle and tendon. If one is ready to begin and cocaine has been instilled twice only, time can be saved by apply ing a tiny wad of cotton, soaked in ten percent cocaine, just over the muscle and tendon and then closing the lids carefully over it for three minutes. After the muscle has been exposed and before it has been taken up on the hook, novocaine two percent and ad renalin 1 to 10,000 are injected along the muscle back of the tarso-orbital fascia. If this is done at the beginning of the operation some of the solution may unintentionally be placed in front of the fascia and so infiltrate the field of operation; this makes it slightly more difficult to isolate the muscle. Some surgeons have abandoned the deep in jections altogether on this account. By giving the deep injection after the mus cle has been exposed the objection is met and the patient is spared the very disagreeable sensations caused by pull
ing on the muscle with the hooks or Prince's forceps. It will be seen that this operation differs from the one I described in 1918, in omitting the advancement stitch in the sclera near the cornea. This was abandoned as unnecessary several years ago; the so-called security stitch, a mattress stitch through the tendon stump and muscle were sufficient. This still left me with the annoyance of having to remove the stitches which were tied outside the conjunctiva. Fi nally I realized that it was not neces sary to remove the sutures if they were buried, and so the operation here de scribed evolved. It has the advantage not only of eliminating the stitch re moval but of making the other steps in the operation easier and more exact. I believe that it is easier to remove these buried stitches than the old type tied outside the conjunctiva. One can secure good anesthesia and ischemia, incise and undermine the conjunctiva, and pick up and cut the sutures with less trouble than he can pick up a su ture imbedded in swollen conjunctiva and cut it in the right place. Often enough I have cut off the knot and left a piece of silk buried under the muscle. I have never seen it do harm. This, and the burying of sutures in the tuck ing operation, convinced me that the operation here described was practical and safe. 520 Commonwealth building.