A NEW METHOD OE PEDICLE-LIGATION IN 
ABDOMINAL SURGERY. 
BY 
SCHUYLER C. GRAVES, M.D., 
OF GRAND RAPIDS, MICH.. 
VISITING SURGEON TO THE U. B. A. HOSPITAL, AND SURGEON TO THE 
CHILDREN'S HOME, GRAND RAPIDS, MICH. 
FROM 
THE MEDICAL NEWS, 
January 12, 1895. [Reprinted from The Medical News, January 12, 1895.] 
>1 NEW METHOD OF P E 01C L E-LIG AT 10 N IN 
ABDOMINAL SURGERY. 
By SCHUYLER C. GRAVES, M.D., 
OF GRAND RAPIDS, MICH., 
VISITING SURGEON TO THE U. B. A. HOSPITAL, AND SURGEON TO THE 
CHILDREN'S HOME, GRAND RAPIDS, MICH. 
The death of a patient from hemorrhage due to 
faulty pedicle-deligation during the course of an 
abdominal operation is a catastrophe sufficient to 
cause the cheeks of any surgeon to pale. When 
all else in the technique has been perfect; when 
asepsis has had full sway; when there has been 
no particular bleeding, no shock, no complication ; 
when the danger of subsequent peritonitis is prac- 
tically nil, and everything bespeaks a favorable out- 
come, the death of a patient from the slipping of a 
thread is an awful calamity, and any method by 
which the possibilities of such a denouement may be 
narrowed is a matter of vital interest to both patient 
and surgeon. 
It is my purpose to put on record, for the use of 
the profession, a new method of applying a pedicle- 
ligature in abdominal surgery, by which the same 
not only will not but simply cannot slip. 
The ligature has been employed in actual practice, 
with perfect satisfaction and ease of application, and 
has been exhibited to the members of the Grand 
Rapids Academy of Medicine at a recent meeting 
of that body. 2 
There are four sources of danger from interme- 
diary hemorrhage in the application of a pedicle- 
ligature : i. The employment of the wrong knot. 
2. The lack of sufficient force in tying the loop or 
loops. 3. The application of apparently sufficient 
force upon a pedicle while held in a state of tension. 
4. A defective method of application. 
1. No surgeon to-day needs to be told that the 
sailor-knot (also known as the reef, or square, or 
unslipable knot) is the one to be employed when- 
ever even an isolated artery is to be tied. Comment 
on this point is unnecessary. 
2. The lack of sufficient force in the tying of a 
ligature-loop is a real danger that should be care- 
fully guarded against. If thought best, when a 
consideration of this point is under discussion, the 
pedicle can be ligated in sections sufficiently small 
to insure the operator's ability to compress ade- 
quately the included tissues. 
3. Deaths have occurred from pedicle-hemorrhage 
after surgeons have used all the force they deemed 
necessary; but such force having been applied to 
the pedicle while rendered rigid by too great trac- 
tion, the result, after the withdrawal of this traction, 
has been the same as when too little force has been 
exerted upon a lax pedicle, viz., the liberation of 
vessels, with the escape of blood. 
4. The method heretofore employed in the appli- 
cation of pedicle-ligatures has been faulty in that 
it has always rendered possible a subsequent inter- 
mediary hemorrhage as the result of the slipping 
of a loop. 
Even the Staffordshire knot, which was said to be 3 
perfect, has slipped, and thus permitted hemorrhage 
to occur. 
In my opinion the Staffordshire method is vastly 
inferior to the one ordinarily used in this country, 
viz., central transfixion, linking, and tying both 
ways, as much more power can be employed in the 
latter than in the former. Of course, I am not 
discussing ligature-material in this contribution. 
Geometrically speaking, a line (in this instance a 
diameter) is determined by two points, and, there- 
fore, no looped ligature, single, double, or of the 
chain-variety, is safe, which is not fixed at two oppo- 
site points on the periphery of each loop, or, to be 
more explicit, at opposite extremities of their long 
diameters. 
It can be said that such a condition obtains in 
the Staffordshire ligature, for such is, indeed, the 
case; but the weak point of that ligature in this 
connection is the fact that, in securing the two 
fixed points on the periphery of the main loop, two 
subordinate loops are made, the lateral diameters of 
which are almost certain to be longer than the op- 
posite diameter of the main loop. Those familiar 
with the Staffordshire method will comprehend the 
force of this statement. The subordinate loops of 
this ligature are just as dangerous as the loops 
fashioned after the American plan, if not more so. 
It is not my belief that the so-called American 
ligature is particularly unsafe. It is not. Deaths 
therefrom are rare. But it is certainly dangerous 
enough to warrant improvement, if improvement be 
possible. That it is possible I leave the reader to 
judge. 4 
The old method is strong in this respect: that the 
ligature can never slip entirely away from the pedicle, 
for it has a fixed point at the center of the same; 
and this can also be said of the Staffordshire liga- 
ture, for I am now discussing the ordinary, double- 
looped ligature as described ; neither can it slip 
when the distance from the loop to the section is 
greater than, or even the same length as, the diameter 
Fig. i. 
Fig. 2. 
of the loop. These considerations, hove ver, could 
have no weight with a single-looped ligature, and 
they are not simple enough, not accurate enough, 
for universal use. The security of a pedicle-ligature 
should not depend upon the distance, long or short, 
from the planes of its loops to the point of section. 
The accompanying drawings are self-explanatory. 
The loops, it will be seen, are fixed by passage 
through the substance of the pedicle at points on 5 
opposite ends of their long diameters, viz., in the 
center and circumference of the pedicle. 
Fig. 3. 
Fig. 4. 
Any bleeding from the transfixions, and some 
does occur, may be disregarded, for all vessels of 
respectable size are included in the loops, or it can 
Fig. 5. 
be readily checked by throwing a loop from one of 
the remaining ligature-threads around the entire 
pedicle and tying the same, as per drawings. 6 
This long loop would, of course, have only one 
fixed point, and, therefore, might possibly slip; but 
such an accident is not at all likely to occur-not 
as likely as with the loops of the old ligature-be- 
cause the thread lies in natural grooves rendered 
possible by the traction of the primary loops at the 
points of peripheral penetration, and even if slipping 
should occur, the danger would be practically nothing, 
on account of the insignificant size of the involved 
vessels. 
Fig. 6. 
Fig. 7. 
Finally, if an operator, when he has occasion to 
deal with the pedicle of any variety of tumor, or 
with the bases of degenerated or suppurative tubo- 
ovarian masses, will, first, make use of the reef- 
knot in connection with his ligature ; second, em- 
ploy sufficient compressive force in his application 
of the same; third, be sure that the tissues to be 
ligated are lax when the knot is drawn, zxdf fourth, 7 
apply the method here described, he will, in my 
opinion, be doing all that it is possible for man to 
do in the prevention of one of the saddest accidents 
incident to the practice of surgery. 
The principle that underlies this new method, 
viz., that of peripheral fixation, is applicable in 
different ways. For instance, when a pedicle to be 
secured is slender or composed of soft tissues which 
are easily compressible and not too bulky, as is 
often the case, especially in the slighter forms of 
tubal and ovarian disease, there is no need of central 
transfixion. If the ligature-ends be simply drawn 
through the two peripheral points-opposite each 
other-and a single loop thus made, the ligature can- 
not slip. The ends of the ligature may then be 
passed around the entire pedicle as ligated and tied, 
to prevent the puncture-point bleeding, if thought 
advisable. 
That central fixation is not necessary in the tying 
of slender pedicles is shown in Figs. 6 and 7. The 
abandonment of central transfixion in proper cases 
will save time. 
I desire in this connection to acknowledge the 
artistic services of Dr. James Orton Edie, of this 
city, in the preparation of the drawings illustrative 
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