Wound Closure Technique of SUSHRUTA -2

Indications For Suturing: -
Brihattrayi were agreed on the fact that suturing should be resorted to the case of an open ulcer due to the action of the deranged fat after its vitiated contents has been fully scrapped out as well as in the case of an uncomplicated Sadyo Vrana.
Importance is given to Sadyo Vrana and clearly mentioned that the wound should be sutured Sadyo Dine i.e. at the same day

Dalhana in his commentary has elaborated this principle as wounds over head, forearm, face, ears, lips, nose, cheek, neck, upper extremities, abdomen, gluteal region, reproductive organs, penis, scrotum etc are to be sutured immediately. Acharya Vagbhata stated that immediate suturing should be done in excised or hanged out tissues. Charakacharya described that the flanks, bowels, abdomen etc which are subjected to deep surgery should be sutured.

Contra-Indications For Suturing: -
Wounds contaminated with dust, poisonous wounds, diabetic wounds, skin diseases, putrificated, gangrenous wounds, wounds from which air is leaking, burns due to alkali (Kshar) or heat (Agni), infected wounds are not to be sutured. In case if the wound is contaminated, one should clear the wound then suture it in all possible aseptic precautions.

The wounds containing any foreign body inside it like bony sequestration in osteomyelitis or the wounds where complete haemostasis is not achieved i.e. fresh bleeding in the wounds, penetrating injuries where there is presence of internal hemorrhage or hematoma, in such conditions wound should be left open and should not undergo suturing procedure.
Dalhanacharya comments that the wounds over the joints like knee, elbow etc where bones are fractured or dislocated and where much tissue is lost should not be sutured.

Materials to be used for suturing: -
Sushruta Samhita is one of the Indian surgical texts which includes detail description about different types of suture materials both vegetative and animal origin which are either absorbable or non-absorbable. Sushruta had worked with many natural materials like fine threads, flax of Ashmantak, Guduchi Pratan, Trinaushadhi like Shanaj (a type of grass), Cotton threads, Silk threads, horsehair and Snayu (tendons/ligaments).
He had used the Heads of Giant Ants to effectively staple a wound over intestine while performing surgery for perforations. The live creatures were affixed to the edges of the wound, which they clamped shut with their pincers. Then the physician cut the insects' bodies off, leaving the jaws in place.

Importance of blood in healing process: -
The ancients well knew the interference of blood in repair and regeneration of wounds. The rakta vitiated by vata causes dehiscence of wound, vitiated by pitta causes suppuration, vitiated by kapha causes itching of the wounds. Large amount of bleeding causes inflammation and ischemia hampers the wound healing. Blood is a uniting factor of wound edges, which is very important in wound healing. Keeping this very important factor in view, Sushruta had advised to confirm the circulation of the part before uniting. If there is poor perfusion and marked ischemia of the part then one should scrap the wound margin and let the blood flow to improve and thereafter proceed for suturing.

Importance of Haemostasis: -
Sushruta had given prime importance to achieve haemostasis while performing any surgical intervention. For the purpose, the act of tying bleeding vessels i.e. ligation was well known also various other methods like Sandhan (union) with suturing the wound will stop bleeding by applying pressure effect over small vessels and oozes, Skandan(coagulation) with kashayaushadhi and cold application so that the cut edge of bleeding vessel will shrunk and bleeding will stop, Dahan(cauterization) with agni and Pachan(chemical cautery) by means of bhasmas (alkalis).

Acharya Chakrapani emphasizes to clean the wound with chilled water, catch the bleeding vessel with instrument, and ligate its open end to arrest bleeding. In the same manner the procedure of ligating the vessels is described in Vagbhatartha Kaumudi. The bleeding vessel caught with forceps and tied tightly with snayu i.e. catgut and then the wound is bandaged with tight compression bandage.

Needles: -
Necessary for the placement of sutures in tissue, surgical needles must be designed to carry suture material through tissue with minimal trauma. They must be sharp enough to penetrate tissue with minimal resistance. They should be rigid enough to resist bending, yet flexible enough to bend before breaking. They must be sterile and corrosion- resistant to prevent introduction of microorganisms or foreign bodies into the wound.
Sushruta had given full account on needles. He had described three different types of needles that are still in use. These are Vritta (Curved), Aayata (Straight) and Tryastra (Triangular cutting).

A round body needle in the length of two fingers width should be used in sewing up an ulcer occurring about any joint or in a part of body where the flesh is thin and scanty. A needle of triangular body and measuring three fingers width in length is recommended in the case of an ulcer appearing at any fleshy part of the body. A semi- circular or bow shaped needle should be used in a case where the seat of ulcer would found to be on the scrotum, on the skin of abdomen or about any of the marmas. Needles of these three shapes should be so constructed as to be fit with sharp points capable of being handled with the greatest ease, having a girth equal that of the stem of a Malati flower.

Stitch Placement: -
Acharya Sushruta was well versed in observational methods. Therefore effect of suture material and suturing techniques on wound healing was not his out of site. He describes to keep equal distance between the two stitches. Acharya Vagbhat also agrees with this concept of Sushruta. Both the Acharyas had quoted that the stitches should not be very distant or too much close. The needle should enter at equal distance in the wound margin. If stitches given too wide it will increase pain the in wound and given too close then there will be constriction and tear in the wound margin. Dalhanacharya comments that the surgeon should insert needle in the tissues neither too far nor too close, distant from margin, close to margin considering the desired result. The stitches given too far from each other it will hamper wound healing and stitches given too close will contract the wound edges.

Reviewing all these principles, we can conclude that ancient day's surgery was very advanced and based on scientific principles and modern day surgery is evolved from these principles only.