COMPLIMENTS OF THE AUTHOR. 
Reprinted from The New York Journal of Gyn/ecology and Obstetrics for January, 1893. 
THE PREVENTION OF HERNIA AFTER INCISION OF 
THE ABDOMINAL WALLS.1 
George M. Edebohls, A. M., M. D. 
On June 27, 1891, I saw, with Drs. A. Freeh and C. Nicolai, her 
attendant physicians, a stout lady suffering for many years past from a 
large umbilical hernia. The hernia had become irreducible four or five 
days previously, symptons of strangulation had manifested themselves, 
and the skin and fat overlying the hernial tumor were in a state of low 
phlegmonous inflammation. All attempts at reduction failed, the lady’s 
condition became critical and herniotomy was performed late at night on 
Jure 29th, with the kind assistance of Drs. Freeh, Nicolai and Torek. 
After opening the sac it was found to contain the stomach, omentum 
and gieater part of the small intestines, all adherent to each other and 
to the sac wall. After liberation of adhesions, reduction of the hernial 
contents, and ligation and removal of the sac, a large hernial aperture, 
circular in form, ten to twelve centimeters in diameter, with thin aponeu- 
rotic margins and situated in the median line just above the umbilicus, 
confronted us. The thin, sharp, fibrous margin was split all around by 
the knife to the depth of a little over a centimeter to obtain fresh sur- 
faces for union, and the margins of the ring were brought together by 
transverse sutures in such a manner as to form a longitudinal line of 
union when approximated. The intra-abdominal tension, however, 
was so great that it required all my strength, without exaggeration, to 
draw together and tie the sutures. I recognized that sutures embracing 
both the skin and the margins of the hernial aperture, if tight enough 
to close the latter, would inevitably strangulate the already inflamed 
'Read before The New York Obstetrical Society, November xBq2. George M. Edebohls, A. M., M. D. 
skin and fat. Buried sutures to close the hernial aperture were a 
necessity. Catgut was tried, but the great tension opened the knots 
of the slippery material as fast as I could tie them. Interrupted sutures 
of heavy pedicle silk were used until my supply gave out, when I closed 
the balance of the aperture with interrupted silkworm-gut sutures. 
Ten silk and nine silkworm-gut sutures were thus placed and buried 
by closing over them, with catgut sutures, the skin and fat. The 
patient unexpectedly recovered from the operation, or rather from the 
condition which necessitated it, and still more unexpectedly was radi- 
cally cured of her hernia, and remains so cured to this day. Now 
comes the part that is pertinent to the subject of this evening. Begin- 
ning with three and ending with seven months after operation, every 
one of the buried silk sutures, one by one, ulcerated to the surface and 
was removed. Not one of the silkworm-gut sutures came away, but 
all remain in situ to the present day. After the removal of the last silk 
suture the little sinuses closed and the wound healed definitely. 
This experience of a year and nearly a half ago induced me to 
employ the buried silkworm-gut suture in isolated cases of abdominal 
section where the tension upon the lips of the wound was exceptionally 
great. Meeting in each instance with the same favorable experience 
as in my first case, the idea finally dawned upon me : Why not suture 
every operative wound of the abdominal parietes with buried silkworm 
gut ? A better and. in view of the non-absorbability of silkworm gut, 
more permanent provision against the occurence of hernia could not be 
imagined. 
Acting upon this thought I have since May xst of the present year 
closed all wounds of the abdominal parietes, made by me, in the fash- 
ion presently to be detailed. That part of my work, during the months 
of May, June, July and October, to which the method was applicable, 
embraced sixteen cceliotomies, nine operations for shortening the round 
ligaments, five single and one double nephrorrhaphy. In all, forty-one 
incised wounds of the abdominal parietes, in which, at a low estimate, 
upward of two hundred and fifty silkworm-gut sutures were buried. 
The interrupted buried suture of silkworm gut, placed three or four 
to the inch, was invariably used. In closing coeliotomy wounds each 
buried suture included fascia, muscle and peritoneum, care being exer- 
cised, of course, that the cut edges of each of these tissues be accurately 
opposed to each other. In my modification of the operation for shorten- 
ing the round ligaments the anterior wall of the inguinal canal is slit 
open along its whole length (New York Medical Journal, October n, Preventio7i of Hernia After Incision of the Abdominal Walls. 
3 
1890). In sewing up, each buried suture embraces the lips of the 
wound of the aponeurosis of the external oblique and that portion of 
the drawn-out round ligament which comes to lie in the canal. In per- 
forming nephrorrhaphy the buried sutures pierce the muscles and fascia 
of the abdominal walls, the fatty capsule and capula propria of the 
kidney and the kidney itself. In tying each silkworm suture a double 
or friction-knot is first applied and on top of this two single knots. The 
ends are then cut as short as possible. Such a knot properly and 
tightly tied never slips nor opens. 
It will thus be seen that in each wound the buried silkworm suture 
embraces all the cut tissues except the skin and the subcutaneous fat.. 
In ventro-fixation, nephrorrhaphy and shortening of the round ligaments, 
the uterus, kidney and round ligaments respectively are likewise 
embraced in the loop of the suture. The skin and fat are united over 
the buried silkworm sutures by a running suture of catgut drawn just 
tight enough to gently approximate the cut edges. Of course, any other 
material may be used instead of catgut, to unite the skin. Catgut has 
the advantage of lasting long enough to insure firm union and of not 
requiring removal. 
We all know that, in closing wounds of the abdominal parietes, if 
all the tissues are embraced in one loop of whatsoever suture you 
please, the tension necessary to securely hold together the deeper parts, 
the muscles and fascia, is so great as to cause the suture to cut through 
the skin and subcutaneous fat. Often also to cause necrosis of parts 
of the fatty tissue embraced and thus interference with wound-healing. 
In line with good surgery, therefore, is the principle to apply separate 
sutures to tissues of different densities and under different degrees of 
tension. 
Why is silkworm gut preferable to silk, silver wire, kangaroo tendon 
and catgut for buried sutures of wounds of the abdominal walls ? With 
silk it shares the properties of ease of tying and of permanency, but 
excels it in non-irritating and aseptic qualities. Silver wire is equally 
permanent and equally aseptic; it is, however, more troublesome to 
tie, less pliable after burial, and the metal cut ends are perhaps more 
irritating than the ends of silkworm gut. Kangaroo tendon and cat- 
gut are absorbable and cannot, therefore, give a permanent guarantee 
against hernia; besides which no reliance can be placed upon the 
durability of the buried knot after it becomes moistened. 
Of what avail is kangaroo tendon, or eight-day, eighteen-day, or 
even twenty-eight-day catgut, if the buried knot slips or opens on the George M. Edebohls, A. M, M. D. 
4 
first, second or third day, as I have frequently known it to do. Besides 
which, it is a mistake to take it for granted that sutures become super- 
fluous after a week, or two, or even three, and that union by that time 
is so strong as to defy separation, especially in wounds of the abdominal 
walls, which are exposed to strains such as obtain no where else in the 
body. I have repeatedly known diastasis of the recti and separation 
of the fascia along the line of incision to occur in coeliotomy scars 
six months and longer after operation. Whether the intestines 
will then prolapse far enough through the rent to form a constantly 
visible question is merely a question of length of mesentery in the 
particular patient. 
Differences of opinion as to what constitutes a ventral hernia will 
possibly explain the discrepancies in results claimed by different 
operators. The man who insists on the presence of a constantly 
visible tumor before he admits a ventral hernia may have quite a long 
series of cases without this unfortunate result. The more self-critical 
and less easily satisfied surgeon will record as a ventral hernia every 
case in which, after cceliotomy, the recti and the fascia separate along 
the line of incision so as to leave the abdominal contents, at that point, 
separated from the external world only by a covering of peritoneum, 
fat and skin. Applying this criterion, ventral hernias following coeliot- 
omy are by no means as infrequent as we would desire them to be. 
Silkworm gut, then, is the material par excellence for buried 
sutures of wounds of the abdominal walls; its non-irritating proper- 
ties, its non-absorbability and the security of the knot render it 
about ideal. 
Of course the conditio sine qua 7ion in its successful use is perfect 
asepsis. Next in importance comes the matter of not drawing it so 
tightly as to strangulate the tissues embraced in the loop. Care in 
tying the knots and in cutting the ends very short are points not to be 
lost sight of. With all the above conditions fulfilled, nothing but satis- 
faction will result from the use of the buried silkworm suture. 
I sterilize my silkworm gut by boiling for an hour in water and then 
transfer it to five per cent, carbolic acid solution, where it is kept until 
wanted. 
I will now endeavor to answer a few objections that may be made 
against the use of buried silkworm sutures. 
First, they may cause suppuration and ulcerate out. To this I 
answer they will not do so, except as a matter of mere accident, if 
buried aseptically and not drawn so tight as to strangulate the tissues. Prevention of Hernia After Incision of the Abdominal Walls. 
5 
This answer is based upon experience. Of all the silkworm sutures I 
have ever buried but two have appeared again, and that in a patient in 
whom, three weeks after a ventro-fixation of the uterus, a slight separa- 
tion of the lips of the cutaneous wound occured as the result of a 
trauma. Two of the buried silkworm sutures became infected and 
were cut out. Then the wound again closed, permanently burying the 
four sutures remaining in situ. In all the other wounds in which I 
buried silkworm sutures I obtained primary union and permanent reten- 
tion of the sutures. 
Another objection that may be raised is that the buried sutures may 
travel in the tissues, or perhaps even wander inward into the peritoneal 
cavity. A moment’s thought, however, will show that if the sutures 
change position at all, it will be in the direction of the knot, i. e. toward 
the surface of the body. 
Cutting very short the ends, after the knot is tied, will protect 
against a third possibility:—the protrusion, later on, of the cut ends 
through the skin. Even should this happen the surgeon could then 
remove that particular suture, or the patient may be instructed to seize 
the projecting end, pull upon it until the knot appears, cut the loop on 
one side behind the knot and withdraw the suture. This necessity has 
never arisen in my practice. 
In performing ventro-fixation of the uterus I have fastened the 
uterus to the abdominal wall by two or three of the buried silkworm 
sutures used to close the peritoneum, muscle and fascia. I confess I 
had some misgivings in those cases where a subsequent pregnancy was 
possible, as to whether the uterus in that event would be able to tear 
itself away from the buried suture. None of my patients thus operated 
on has as yet become pregnant and personal experience on this point 
is wanting. Recorded experience, however, goes to show that pregnan- 
cies have occurred and gone to term without a hitch in uteri ventrofix- 
ated with buried silk. 
The special advantage of this method of suture :—buried silkworm for 
the deeper tissues, catgut for the skin and subcutaneous fat—over other 
methods, as applied to very fat patients, is self-evident. 
With this method of suture of the wound I have allowed my coeliot- 
omy cases to get up a week earlier than formerly. They now, as a 
rule, leave bed at the end of two, and hospital at the end of two-and-a- 
half to three weeks. Nor do I require my patients any longer to wear 
an abdominal supporter after operation. At first, I confess, I was 
afraid to do without them. As experience and my confidence in the 6 
George M. Edebohls, A. M, M. D. 
buried silkworm suture grew, I gradually abandoned the supporter, 
and now advise against its use after operation, nor have I thus far had 
occasion to regret this course in a single instance. My patients have 
thus gained in three directions:—a shorter convalescence, relief from 
the annoyance and expense of abdominal supporters, and greater 
security against hernia. 
The writer feels that, as far as he is concerned, the question of the 
prevention of abdominal hernia following operations is practically solved. 
It was my intention to pursue these observations a little further before 
reporting upon the matter, but when I was requested by your presiding 
officer to prepare a short paper for this evening I found I had nothing 
else to offer which would be likely to interest you. I close with the 
hope that this communication may induce my colleagues to give the 
method advocated a trial. If they derive from it the same satisfaction 
that I have, I will be sure of their thanks. 
To prevent misunderstanding and possible misinterpretation I will 
distinctly state that I do not advance any claim to priority in the use 
of the buried silkworm suture. I was led to it by necessity, June 29th, 
1891, and practiced it in a desultory fashion until May Ist, 1892, since 
when I have applied it to every incised wound of the abdominal wall 
I have had occasion to make. Until four or five months ago I was 
unaware that any one else was systematically using the buried silkworm 
suture; since that time, however, I have learned of quite a number of 
surgeons using it in practically the same way as myself. If anything 
has been published upon the subject it has escaped my attention. 
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