- Email: [email protected]
Surgical floatation retention button
NEW
INSTRUMENT
Surgical Floatation Retention Button
Richard F. Edlich, MD, Charlottesville,
Virginia
William C. Murphy, MD, Minneapolis,
Minnesota
Milton T. Edgerton, MD, Charlottesville,
Virginia
Despite the many advances in surgery, the incidence of disruption of abdominal wounds has been reported as high as 5.8 per cent [I]. Retention sutures have been found to have a distinct value in preventing wound .disruption. The success of retention sutures in surgical w,ounds appears to lie in their ability to protect the wound from stresses encountered in the early postoperative period. There are two general de!Ggns of retention sutures. One type of suture encircles the wound, whereas the other type crosses only the bottom of the wound. When encircling retention sutures are used, the inevitable swelling of the wound may lead to ischemia or cutting of the suture through the tissues. The use of a horizontal mattress suture extending through all abdominal layers except the peritoneum allows the edematous wound to expand in an anterior direction without the threat of necrosis. The holding base of the mattress suture is the skin underneath the suture. Any increase in intra-abdominal pressure is applied directly to the suture which allows it to erode through the underlying skin. Tying the retention sutures over a button lessens the amount of tissue necrosis. The major asset of buttons is that they provide a broad surface for holding the suture against the wound. A variety of buttons have been recommended for use with retention sutures [2]. Buttons varying in
From the Department of Plastic Surgery, University of Virginia Medical Center, Charlottesville. Virginia and the Department of Surgery, University of Minnesota Health Sciences Center, Minneapolis, Minnesota. Reprint requests should be addressed to Dr Edlich. Department of Plastic Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901.
794
size from 0.5 to 2.2 cm have been utilized in closure of abdominal wounds with retention sutures. These buttons are rigid and often have sharp edges. Their stiffness does not allow them to conform to the topography of the skin. When the position of the skin changes during the postoperative period, the rigid button rubs against the skin causing inflammation and eventual tissue necrosis. The sharp edges of the button often cut through the skin in a manner like that of an epidermal punch biopsy. When the button is removed, the underlying skin is erythematous and surrounded by a circular laceration that may lead to an unattractive scar. For this reason a retention button has been designed that is flexible enough to conform to the topography of the skin and that uniformly distributes the pressure of the suture to the underlying skin. In our initial attempts to solve this problem, a soft, liquid-filled microcell sponge was cut into 3 cm circular discs. The top of the disc was covered by a flexible polyurethane-Dacron@ backing to strengthen the disc so that the suture would not cut through the soft plastic gel. This prototype was utilized in thirty patients undergoing laparotomy. The results of the study were very encouraging. The underlying skin in twenty-six patients exhibited no visible inflammation or laceration. In the remaining patients, the flexible backing did not provide enough support and the disc buckled, tearing the soft gel. The torn sharp edges of the gel rubbed against the underlying skin causing considerable irritation. Placement of a rigid polyester disc, in place of the flexible backing, has prevented the buckling and subsequent tearing of the soft disc. The value of this new floatation retention button has recently been ex-
The American
Journal of Surgery
Floatation
Figure 1. The surgical
floatation
button.
Button
remains in contact with the underlying skin protecting it from the rigid disc. The efficacy of the floatation button was assessed in ten patients undergoing laparotomy in whom retention sutures were used. In each of these patients, horizontal mattress retention sutures were employed. The suture was threaded through a floatation disc on one side of the wound. On the opposite side, the retention suture was passed through a 14 mm rigid polypropylene button (Ethicon, Inc). (Figure 2.) Placement of the two different buttons on opposite ends of the mattress suture ensured that the pressure exerted on each button was equal. To further eliminate bias, the site for placement of the retention button was alternated. The retention sutures were removed on the fourteenth postoperative day. The skin underlying the button was examined for the presence of erythema or necrosis. Results and Comments
Figure 2. The experimental
design.
amined in ten patients in whom retention sutures were used for closure of abdominal wounds. In this study, the inflammatory responses of the skin to the floatation button and a commercially available rigid button were compared. The results of this study constitute the basis for this report. Material and Methods The surgical floatation button consists of two tightly adherent discs. (Figure 1.) The outer.disc is made of rigid, transparent polyester plastic that is molded with eight openings to facilitate threading the button with the suture needle. The diameter of the rigid backing (2.2 cm) is less than the diameter of the underlying soft floatation disc (3 cm). The material selected for construction of this soft disc was the liquid-filled microcell sponge (NB #30016-24, 3M Company, St. Paul, Minnesota). The mold for the sponge disc was designed so that the rigid polyester disc backing could be inset into the floatation disc. When these but.tons are used in surgery, the suture is threaded through the soft sponge disc and a hole in the rigid transparent disc. When the suture is tied down, the knot of the suture lies on the rigid backing, and the soft rubber disc
Volume 125. June 1973
The edges of the rigid polypropylene buttons cut circular lacerations in the skin of eight of ten patients. In addition, the skin underlying the rigid buttons was erythematous and indurated. These effects of the rigid plastic buttons on the skin were not apparent with the soft floatation disc. The skin underlying the floatation buttons had no demonstrable lacerations. Mild erythema of skin was encountered in only two of the ten patients. The results of this study lend support to the use of the surgical floatation button for closure of the wound with retention sutures. Summary
A surgical floatation button has been designed that protects the underlying skin from excessive pressure exerted by a retention suture. The floatation button consists of an outer rigid disc inset in a circular microcell sponge. The button uniformly distributes pressure to underlying skin, eliminating the skin necrosis that is commonly encountered after the use of rigid buttons. References 1. Marsh RL, Coxe JW, Ross WL, Stevens GA: Factors involving wound dehiscence. Studies of one thousand cases. JAMA 155: 1197,1954. 2. Hermann RE, Weckesser EC: Use of buttons in retention suture closure of abdominal incisions. Amer J Surg 116: 949, 1968.
795
INSTRUMENT
Surgical Floatation Retention Button
Richard F. Edlich, MD, Charlottesville,
Virginia
William C. Murphy, MD, Minneapolis,
Minnesota
Milton T. Edgerton, MD, Charlottesville,
Virginia
Despite the many advances in surgery, the incidence of disruption of abdominal wounds has been reported as high as 5.8 per cent [I]. Retention sutures have been found to have a distinct value in preventing wound .disruption. The success of retention sutures in surgical w,ounds appears to lie in their ability to protect the wound from stresses encountered in the early postoperative period. There are two general de!Ggns of retention sutures. One type of suture encircles the wound, whereas the other type crosses only the bottom of the wound. When encircling retention sutures are used, the inevitable swelling of the wound may lead to ischemia or cutting of the suture through the tissues. The use of a horizontal mattress suture extending through all abdominal layers except the peritoneum allows the edematous wound to expand in an anterior direction without the threat of necrosis. The holding base of the mattress suture is the skin underneath the suture. Any increase in intra-abdominal pressure is applied directly to the suture which allows it to erode through the underlying skin. Tying the retention sutures over a button lessens the amount of tissue necrosis. The major asset of buttons is that they provide a broad surface for holding the suture against the wound. A variety of buttons have been recommended for use with retention sutures [2]. Buttons varying in
From the Department of Plastic Surgery, University of Virginia Medical Center, Charlottesville. Virginia and the Department of Surgery, University of Minnesota Health Sciences Center, Minneapolis, Minnesota. Reprint requests should be addressed to Dr Edlich. Department of Plastic Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901.
794
size from 0.5 to 2.2 cm have been utilized in closure of abdominal wounds with retention sutures. These buttons are rigid and often have sharp edges. Their stiffness does not allow them to conform to the topography of the skin. When the position of the skin changes during the postoperative period, the rigid button rubs against the skin causing inflammation and eventual tissue necrosis. The sharp edges of the button often cut through the skin in a manner like that of an epidermal punch biopsy. When the button is removed, the underlying skin is erythematous and surrounded by a circular laceration that may lead to an unattractive scar. For this reason a retention button has been designed that is flexible enough to conform to the topography of the skin and that uniformly distributes the pressure of the suture to the underlying skin. In our initial attempts to solve this problem, a soft, liquid-filled microcell sponge was cut into 3 cm circular discs. The top of the disc was covered by a flexible polyurethane-Dacron@ backing to strengthen the disc so that the suture would not cut through the soft plastic gel. This prototype was utilized in thirty patients undergoing laparotomy. The results of the study were very encouraging. The underlying skin in twenty-six patients exhibited no visible inflammation or laceration. In the remaining patients, the flexible backing did not provide enough support and the disc buckled, tearing the soft gel. The torn sharp edges of the gel rubbed against the underlying skin causing considerable irritation. Placement of a rigid polyester disc, in place of the flexible backing, has prevented the buckling and subsequent tearing of the soft disc. The value of this new floatation retention button has recently been ex-
The American
Journal of Surgery
Floatation
Figure 1. The surgical
floatation
button.
Button
remains in contact with the underlying skin protecting it from the rigid disc. The efficacy of the floatation button was assessed in ten patients undergoing laparotomy in whom retention sutures were used. In each of these patients, horizontal mattress retention sutures were employed. The suture was threaded through a floatation disc on one side of the wound. On the opposite side, the retention suture was passed through a 14 mm rigid polypropylene button (Ethicon, Inc). (Figure 2.) Placement of the two different buttons on opposite ends of the mattress suture ensured that the pressure exerted on each button was equal. To further eliminate bias, the site for placement of the retention button was alternated. The retention sutures were removed on the fourteenth postoperative day. The skin underlying the button was examined for the presence of erythema or necrosis. Results and Comments
Figure 2. The experimental
design.
amined in ten patients in whom retention sutures were used for closure of abdominal wounds. In this study, the inflammatory responses of the skin to the floatation button and a commercially available rigid button were compared. The results of this study constitute the basis for this report. Material and Methods The surgical floatation button consists of two tightly adherent discs. (Figure 1.) The outer.disc is made of rigid, transparent polyester plastic that is molded with eight openings to facilitate threading the button with the suture needle. The diameter of the rigid backing (2.2 cm) is less than the diameter of the underlying soft floatation disc (3 cm). The material selected for construction of this soft disc was the liquid-filled microcell sponge (NB #30016-24, 3M Company, St. Paul, Minnesota). The mold for the sponge disc was designed so that the rigid polyester disc backing could be inset into the floatation disc. When these but.tons are used in surgery, the suture is threaded through the soft sponge disc and a hole in the rigid transparent disc. When the suture is tied down, the knot of the suture lies on the rigid backing, and the soft rubber disc
Volume 125. June 1973
The edges of the rigid polypropylene buttons cut circular lacerations in the skin of eight of ten patients. In addition, the skin underlying the rigid buttons was erythematous and indurated. These effects of the rigid plastic buttons on the skin were not apparent with the soft floatation disc. The skin underlying the floatation buttons had no demonstrable lacerations. Mild erythema of skin was encountered in only two of the ten patients. The results of this study lend support to the use of the surgical floatation button for closure of the wound with retention sutures. Summary
A surgical floatation button has been designed that protects the underlying skin from excessive pressure exerted by a retention suture. The floatation button consists of an outer rigid disc inset in a circular microcell sponge. The button uniformly distributes pressure to underlying skin, eliminating the skin necrosis that is commonly encountered after the use of rigid buttons. References 1. Marsh RL, Coxe JW, Ross WL, Stevens GA: Factors involving wound dehiscence. Studies of one thousand cases. JAMA 155: 1197,1954. 2. Hermann RE, Weckesser EC: Use of buttons in retention suture closure of abdominal incisions. Amer J Surg 116: 949, 1968.
795