Suture of a stab wound of the heart

Over many centuries, from the early writings of Galen, 'the father of Medicine', wounds of the heart were considered fatal and outside the remit of surgery. With the advent of anaesthesia, (ether was introduced by William Morton in 1846) and of antiseptic surgery, (Joseph Lister's first publication was in 1867), there was an explosion in the surgery of the abdominal cavity, the chest, the skull and the limbs, yet the heart was considered by the surgical fraternity to be the 'no-go' area of the body. Theodor Billroth, Professor of Surgery in Vienna and himself a pioneer of modern surgery, (he performed the first successful partial gastrectomy for carcinoma of the stomach in 1881), wrote "the surgeon who would attempt to suture a wound of the heart should lose the respect of his colleagues". In London, Stephen Paget, in 1896, wrote: "No new method and no new discovery can overcome the natural difficulties that attend a wound of the heart. It is true that suture has been vaguely proposed as a possible procedure and has been done in animals but I cannot find that it has ever been attempted in practice". (In fact, the heart is an amazingly tough and efficient pump that goes on working, year after year, without ever stopping for a service!).

Barbed sutures in breast reconstruction

Postoperative closure techniques in breast reconstruction have remained largely unchanged over the past 75 years, despite recent use of adhesives and subcuticular staples and the advent of self-anchoring barbed sutures. In this article, the author discusses the applications for barbed sutures in breast reconstruction and describes specific techniques. Innovations in barbed suture material are also described, and the author's personal experiences are presented in comparison with traditional suturing techniques.

The history of barbed sutures

Ligatures have been used for millennia to close wounds. Sterilization and synthetic polymers that degrade in a commensurate fashion with wound healing have been the most significant improvements in these age-old devices. However, the constricting loop of a traditional suture and subsequent ischemia ("approximate, don't strangulate") still account for the most common cause of wound dehiscence-necrosis. Inspired by the quill of the North American porcupine, I envisioned a bidirectional array of barbs that could secure tissue without relying on constricting loops. One set of barbs could anchor the other. In this article, I document the development process of these barbed sutures from concept to patent to manufacture and US Food and Drug Administration approval. Knotless, strong, and easy to place, barbed sutures could foreseeably supplant conventional sutures, particularly as endoscopic procedures become more common. They also offer the intriguing potential to suspend ptotic tissues without surgical intervention.

Suturing methods and materials with special emphasis on the jaws of giant ants (an old-new surgical instrument)

The historical development of surgical sutures, ligatures, and staples is discussed. The use of the jaws of giant ants, especially in the suturing of bowel injuries, is documented.

[Nephropexy in the course of time. Aspects of an historical surgical technique]

The first successful nephropexy was performed in the year 1881. From this time, surgical therapy of nephroptosis has always been a subject of discussion. A partly uncritical acceptance led to nephropexy being the most performed urological operation at the beginning of the 20th century, with up to 200 different surgical variations. As early as the 15th century, a first description of ren mobilis was made by Alessius de Pedemontanus. The first surgical intervention for the treatment of nephroptosis was performed by Gilmore in 1870. In 1877, the American Dowell from New Orleans tried a fixation of the kidney through a seton, however, this operation failed. Eventually in 1881, Eugen Hahn from Berlin was able to perform the first successful nephropexy, he named this method "nephroraphy". In 1882, the first modification was made by Bassini with sutures through the renal capsule. Finally, the gynaecologist George Edebohl led nephropexy into a great popularity and secured the method through numerous technical innovations. By 1936, approximately 170 different surgical methods existed for fixation of the kidney. An accurate diagnosis is imperative before performing nephropexy. There were times in which this operation was carried out much too often and, therefore, had a bad reputation. However, it is not correct to drop nephropexy altogether as some would prefer. The statement by Professor Voelcker from Halle in the year 1911 that for all those who have a urinary obstruction and those with a beginning dilation, nephropexy is still justified and may - when correctly performed provide many blessings". Nothing needs to be added to this.

Mario Donati and the vertical mattress suture of the skin

Mario Donati (1879-1946) was one of the foremost European surgeons of the early 20th century. During an impressive carrier as surgeon, teacher, and innovator he authored more than 200 scientific works. Already as a young teacher he won the admiration of his colleagues: "His lectures were models of clarity and conviction, his originality and brilliance as a surgeon have well earned [him] a place among the most famous of the clinical masters of surgery of all eras" (Mario Donati. J. Int. Coll. Surg. 1946;9:739). The present review offers a brief biographical sketch of Donati's life and career, presents an eyewitness account of the origin of the Donati stitch, and discusses a possible precursor of this suture technique in the Middle Ages. On the occasion of the 60th anniversary of the end of World War II, the authors would like to pay a special homage to Mario Donati, who due to his Jewish ancestry was removed from his office as Professor of Surgery at the University of Milan in 1938 and died shortly after his return from exile in Switzerland.

Intestinal anastomoses prior to 1882; a legacy of ingenuity, persistence, and research form a foundation for modern gastrointestinal surgery

This review describes some of the main intestinal suture and anastomosis techniques up to 1882. The disparity between the great variety of proposed techniques and the paucity of actual clinical application is highlighted. Additionally, the statistical reviews of Rydygier (1881) and Madelung (1882), sources originally written in German and only rarely cited, are compared and analyzed. Historical terminology regarding anastomoses is clarified, and the contribution made by experimental surgery toward the establishment of modern suture technique is discussed. The technique of Philipp Ramdohr (1727) is presented in greater detail.

[Microsurgery: History of instrumental vascular anastomoses, our experience with eversion-stapling using VCS forceps]

One century, after Carrel in 1906, technics of vascular surgery are the same. After two world wars, peace surgery has been improved by war surgery. Microscopy surgery gave a new way for vascular surgery which became microsurgery with specific instrumentation. We have move from the developing period of microsurgery in the 1970s, to the fully matured period of microsurgery in the 1980s and the the development of clinical free flaps. The 1990s must be the turning point from autogenous tissue transplantation to allogenic transplantation. Ethic comity keeps keys of future! About microvascular anastomoses, many instrumental technics are explored but no-one is better than the classic manual suture. For us, the best instrumental technic is the anastomose with titanium clips VCS((R)) but we only use it in good situation without difficulties.

The Pfannenstiel or so called "bikini cut": still effective more than 100 years after first description

The original Pfannenstiel incision is discussed including the technique, history, current indications, advantages, and disadvantages. Excellent cosmetic results, principles of less traumatic surgery, and a rare incisional hernia complication rate of about 0-2%, as well as long-time use characterise this access path to the pelvic organs first described by the German gynaecologist in 1900. Complications of nerve damage, however, should be recognised, especially when extending the incision too far laterally.

[Milestones in the history of intestinal anastomosis]

Description of the most important steps in the evolution of intestinal suture technique: The simple Lembert suture and its precursors, the two-layer suture, and the adapting one-layer suture. The contributions of Ph. F. Ramdohr. Wolfenbüttel, 1727, A. Lembert, Paris, 1826, F. Wydler, Aarau, 1865, and Th. Kocher, Bern, 1878-1907, are presented in more details.

Max Sänger - father of the modern caesarean section

The major turning point in the development of the caesarean section appeared in 1882, when the German gynaecologist Max Sänger (1853-1903) suggested closing the uterine wound. Until this point, the wound was not sutured and so haemorrhage was a common cause of maternal death. Sänger's method quickly became standard, leading to a spectacular drop in maternal mortality. Sänger was one of the most renowned German gynaecologists at the end of the 19th century. He contributed to the entire fields of obstetrics and gynaecology, in particular in founding Monatsschrift für Geburtshülfe und Gynaekologie, the predecessor of this journal.

[History of mechanical sutures in digestive system surgery]

The attempts to suture wounds with mechanical device are very old, and their history is lost in the night of times. But more recently--that means less than two century ago--already before the true initial beginning of the modern surgery, after the birth of anaesthesiology with the "ether day--16 october 1846" there have been many efforts to develop new methods to join the tissue of the gut avoiding the danger of peritoneal contamination. The primitive tools of these ancient stapler were founded on the principle to compress with mechanical devices the two sides of the tissue to join. Very early in the past century, well before the appearance of the antibiotics, in the heart of the old Europe were developed and perfectionated devices able to join the intestinal tissue with metallic stitches: the primitive staplers. But after the end of the second world war the development has become bursting, with the progress of the Sovietic Institute of experimental research on surgical tools of Moscow and then with the mighty initiatives of the industrial power in the USA. The more important progress in this field was founded on the standardization of tools designed to fix metallic stitches on the gut, but very recently there are new attempts to use the more old principle of compression-suture on new basis. The results of this development, essential for modern surgery, are the standardization of the surgical technique, the shortening of operative times, and an important support to the new mininvasive approach to digestive surgery.

[History of meniscus surgery. From excision of joint loose bodies to meniscus suture]

In comparison with other operative procedures, the history of meniscal-surgery offers some particular differences. Over a long period of time injuries of the semilunar-cartilages of the knee-joint were not generally recognised. In the 18th century only was the clinical picture roughly outlined. There is evidence, that parts of the meniscus were removed much earlier than we have historic proof of. These meniscal fragments were generally mistaken for "loose bodies" in the joints, not knowing the exact etiology. Operative interference with joints was afflicted with a very high incidence of infections and thus complications. Due to this reliable standards of sterility were imperative to obtain reproductive and satisfactory results in surgery of the knee-joint and this is why the discovery and implementation of antiseptic and aseptic principles play such an important role in joint- and, in particular, in meniscal-surgery. The development of meniscal-surgery is dominated by a lengthy discussion about the way in which the injuries of the semilunar cartilages should be dealt with operatively. Fundamental techniques such as fixation of the cartilage by sutures, limited or total removal of the meniscus were established as early as 1895. Over a long period they existed concurrently and their adequate application remained cause for a highly controversial discussion until the end of the 20th century. Not before more detailed knowledge was gained about the exact morphology of the meniscus and the rising of arthroscopic surgery offered new surgical perspectives, it was possible to establish a widely accepted standard of meniscal surgery.

[Ramdohr invagination operation and its significance for development of intestinal suture technique]

The development of the modern intestinal suture began with the invagination operation, performed by the German surgeon P.F. Ramdohr in Wolfenbüttel in 1727. Today this fact is largely forgotten. Yet this operation stimulated not only Jobert de Lamballe (1824) but also Lembert (1826) to perform their animal experiments on sutures in the intestine. Also all later modifications of these suture techniques took into consideration the principle of invagination.

[From Murphy's button to the Valtrac Ring. 100 years in search of a paradigm]

In the context of continuous development in the area of anastomotic sutures leading to exceptional results in surgical practice, the biofragmentable anastomosis ring (BAR) described in 1985 by Hardy et al. represents a breakthrough in a 100 years' search of a paradigm. The first anastomotic button created in 1892 by J.B. Murphy was at once accepted as a quick and safe method of intestinal anastomosis. In 1896 Czerny demanded the following: "The task of technology is ... to create buttons with material that is entirely or partly dissolved in the intestinal lumen." Polyglycolic acid--developed in the sixties and now in widespread use for resorbable surgical sutures--was the material to fulfill the requirements already stated in the relevant literature 100 years ago, namely in the form of Hardy's BAR, which represents a redesigned Murphy button exploiting the recent biotechnological developments of this century.

[History of healing; wound suturing]

The history of wound suturing reflects that of surgery itself. In wound treatment, which encloses the technique of suturing as well as suturing materials, wound suturing plays a prominent role. In ancient India, Egypt and the Greek and Roman societies wound treatments as well as suturing techniques and instruments were developed that strongly resemble those in our days. Catgut and silk are known since antiquity. Hardly any progress is noted up to the nineteenth century. The debate on closed or open wound treatment has never stopped. The improvement of catgut by Lister started in 1860. In the 19th century prototypes of mechanical suturing instruments (staplers) were developed. They were introduced into clinical practice in the early decades of the 20th century. The greatest progress in wound suturing started after World War II with the introduction of advanced semiautomatic stapler machinery and with the manufacture of synthetic non-resorbable and resorbable fibres. They have revolutionized surgery and were instrumental in developing new fields (microsurgery).

Cemil Topuzlu Pacha and his arterial suture technique

Cemil Topuzlu Pacha (1868-1958) is known to be one of the most famous surgeons in Turkey through the early decades of the twentieth century. Being a talented and courageous surgeon, he performed many of the avoided operations of that time. He presented his vascular suture techniques at the International Medical Congress in Moscow in August 1897 and at the annual Congress of the Societe de Chirurgie de Paris in July 1904. He reported 2 cases of arterial tear during breast carcinoma resection and repair within the same session. He also reported the removal of a pen cover from the right main bronchus of a 7-year-old girl through a tracheotomy in 1903. He worked for 3 years with the famous French surgeon Jules Pean and became a preferred surgeon of the Ottoman Imperial family in Istanbul. He was admired for his scientific studies in international congresses and was one of the first Turkish surgeons who became a member of important European surgical associations.

David R. Boyd Lecture in Trauma Care and Emergency Medical Systems: upper extremity injuries--past, present, and future

Since its recognition as a subspeciality soon after World War I, hand surgery has evolved into a highly specialized and sophisticated field of medicine. Enormous advances have been made in the diagnosis and treatment of disorders of the upper limb; primary tenorrhaphy and the application of microsurgical techniques for revascularization, replantation, and free tissue transfer are among the most important innovations. This article reviews the history of flexor tendon surgery and reconstructive microsurgery up to the present time, and makes some predictions for the future direction of these, and other, areas of hand surgery.