In their work, surgeons use surgical sutures, there are different types of them, this is one of the most common methods used to connect biological tissues: the walls of internal organs, wound edges, and others. They also help stop bleeding, the flow of bile, all thanks to the right suture material. Recently, the main principle of creating any type of suture is considered to be careful attitude to each edge of the wound, regardless of its type. The suture should be applied so that the edges of the wound and each of the layers of the internal organ that requires suturing are exactly matched. Today, these principles are combined under the term "precision".
Depending on which tool is used to create the seam, as well as the execution technique, two types can be distinguished: manual and mechanical seams. For manual suturing, ordinary and traumatic needles, needle holders, tweezers and other devices are used. For stitching, absorbable threads of synthetic or biological origin, metal wire or other materials can be chosen. A mechanical seam is applied with a special apparatus, where metal staples are used. During the stitching of wounds and the formation of anastomoses, the doctor can suture, both in one row - single-row, and in layers - in two or even four rows. Along with the fact that the sutures connect the edges of the wound together, they are also excellent at stopping the bleeding. But what types of suture material exist today?

Classification of surgical sutures

As we have already said, seams can be both manual and mechanical, but there are several more classes of their separation:

It is also worth mentioning that surgical sutures, their types are divided depending on the material used: they can be absorbable if catgut is used - this is a biological species and vicryl, dexon - these are synthetic. They cut through the lumen of the organ - this type of suture is superimposed on hollow organs. Permanent - these are the types of sutures that are not removed, they remain in the body forever and are surrounded by a connective tissue capsule.

Types of raw materials for suturing

Suture material includes various materials that are used to ligate blood vessels by applying surgical sutures. The types of material for suturing tissues and skin have changed greatly every year, depending on how surgery has developed. What surgeons just did not use in order to connect the tissues of internal organs and skin:

But, thanks to modern developments, synthetic threads have now become popular. There are also cases when metal can also be used.
Certain requirements apply to any suture material:

But one of the important criteria that apply to the suture material is compatibility with the tissues of the human body. The currently known materials that are used for seams have antigenic and reactogenic properties. There are no absolute species beyond these characteristics, but their degree of expression should be minimal. It is also very important that the suture material be sterilized and stored for as long as possible, while its main characteristics should remain primary. The suture thread may consist of one or more fibers that are connected together by twisting, knitting or weaving, and to ensure their surface is smooth, they are coated with wax, silicone or Teflon. Currently, absorbable and non-absorbable types of suture material are used in surgery. The classification of surgical sutures, most of it involves the use of absorbable threads - catgut, which is made from the muscle membrane of the small intestine of a sheep, and the submucosal layer can also be used to create it. Today there are 13 sizes of catgut, which differ in diameter from each other. The strength of the seam material increases with size. So, for example, the strength of the three-zero type is about 1400 m, and the sixth size is 11500 r. This type of thread can dissolve from 7 to 30 days. With non-absorbable suture material, threads made of silk, cotton, linen and horsehair are used in surgery.

Types of seams

When suturing the skin, the doctor must take into account how deeply the wound is cut or torn, its length, and how far its edges have diverged. The location of the wound is also taken into account. The most popular in surgery are such surgical sutures, the photos in the article will show how they look:

This will help to understand which methods of surgical suture are most often used when suturing an external wound.

Continuous intradermal type

It has recently been used most often, providing the best cosmetic result. Its main advantage lies in the excellent adaptation of the wound edges, excellent cosmetic effect and minimal disruption of microcirculation when compared with other types of sutures. The thread for stitching is carried out in the layer of the actual plane of the skin parallel to it. However, for easier threading, it is better to take a monofilament material. After the primary surgical treatment of wounds is carried out, different types of sutures can be chosen, but often doctors prefer absorbable suture material: biosyn, monocryl, polysorb, dexon and others. And from threads that do not dissolve, monofilament polyamide or polypropylene are perfect.

knotted seam

This is another of the popular types of external seam. When creating it, the skin is best pierced with a cutting needle. If you use it, then the puncture looks like a triangle, the base of which is directed towards the wound. This shape of the puncture allows you to securely hold the suture material. The needle is inserted into the epithelial layer as close as possible to the edge of the wound, retreating only 4 mm, after which it is carried out on the braid in the subcutaneous tissue, while slightly moving away from the edge, as far as possible.
After reaching one level with the edges of the wound, the needle is turned towards the midline and injected into the deepest point of the wound. The needle in this case passes strictly symmetrically into the tissue on the other side of the wound, only in this case the same amount of tissue will fall into the suture.

Horizontal and vertical mattress seam

The types of surgical sutures and knots are selected by the surgeon depending on the severity of the wound, if there are slight difficulties in matching the edges of the wound, then it is recommended to use a U-shaped mattress suture that runs horizontally. If an interrupted primary surgical suture is applied

on a deep wound, then in this case a residual cavity can be left. It can accumulate what is separated by the wound and leads to suppuration. This can be avoided by applying a seam in several floors. This method of suturing is possible with both nodal and continuous types. In addition, the Donatti seam (vertical mattress seam) is often used. In its implementation, the first puncture is made 2 cm from the edge of the wound. The puncture is made on the opposite side and at the same distance. At the next injection and vicol, the distance from the edge of the wound is already 05 cm. The threads are tied only after all the sutures have been applied, thus, manipulations in the very depth of the wound can be facilitated. The use of the Donatti suture makes it possible to suture wounds with large diastasis. In order for the result to be cosmetic, during any operation, the primary surgical treatment of wounds must be carefully carried out, the types of sutures must be selected correctly. If the edges of the wound are inaccurately matched, then as a result this will lead to a rough scar. If you apply excessive force when tightening the first knot, then ugly transverse stripes will appear along the entire length of the scar. As for tying knots, all silk threads are tied with two knots, and synthetic and catgut threads with three.

Types of surgical sutures and methods of their application

When applying any type of suture, and there are many of them in surgery, it is extremely important to strictly observe the execution technique. How to apply a knotted suture?
Using a needle on a needle holder, first pierce the edges at a distance of 1 centimeter, holding with tweezers. All injections are carried out one opposite the other. The needle is allowed to pass through both edges at once, but it can be passed in turn, then through one, then through the other. After completion, the end of the thread is held with tweezers and the needle is removed, and the thread is tied, while the edges of the wound should be brought together as close as possible. So do other seams and until the wound is completely sewn up. Each seam should be 1-2 cm apart. In some cases, knots may be tied when all the sutures have already been applied.

How to tie a knot correctly

Most often, surgeons use a simple knot to tie the suture. And they do it this way: after the suture material occurs at the edges of the wound, the ends are brought together and a knot is tied, and another one above it. The surgical knot can be performed in another way: they also thread the thread into the wound, take it with one hand at one end, and with the other behind the other, and, bringing the edges of the wound together, make a double knot, and already over it a simple one. The ends of the thread are cut at a distance of 1 cm from the knot.

How to stitch a wound properly using metal staples

Types of surgical sutures and methods of their application may be different, which is determined by the location of the wound. One option would be to staple it with metal staples. Staples are metal plates, the width of which is several mm, and the length is about a centimeter, but may be more. Both ends are presented in the form of rings, and from the inside they have a point that penetrates the tissue and prevents the staples from slipping off. To put brackets on the wound, grab its edges with special tweezers, bring them together, attach well, holding it with one hand, and with the other you need to take the staple with another tweezers. After that, put it on the seam line, squeezing the ends, making an effort. As a result of such manipulation, the staple bends and wraps around the edges of the wound. Apply at a distance of 1 cm from each other.
Staples are removed, as well as sutures, 7-8 days after they are applied. For this, a hook and special tweezers are used. Once removed, the staples can be aligned, sterilized, and reused for suturing wounds.

Types of seams in cosmetology

Cosmetic surgical suture can be made on any of the existing suture materials: silk, catgut, linen thread, fine wire, Michel's staples or horsehair. Among all these materials, only catgut is resorbable, and all the rest are not. Seams are submersible or removable. According to the overlay technique in cosmetology, continuous and knotted sutures are used, the latter can also be divided into several types: marine, ordinary female or surgical. The knotted type has one major advantage over the continuous type: it securely holds the edges of the wound. But the continuous seam is in demand because it is applied faster and more economically as a material used. In cosmetology, the following types can be used:

In cases where the patient has a strong tissue tension, the doctor can use lamellar or lead-lamellar sutures, as well as a suture with rollers, thanks to which it becomes possible to close large defects and securely hold the tissues in one place. In plastic surgery, too, the doctor may sometimes use an apodactyl suture. Its essence lies in the fact that it is applied and tied only with the help of a special tool: a needle holder, tweezers and a torsion pean. Horse hair is the best suture material. It is good to create types of surgical sutures and knots that exist in cosmetology with its help. It is often used in ENT operations, because it practically does not become infected, does not irritate the skin and tissues, and there are no suppurations and scars in the places of its application. Horsehair is elastic, so unlike silk, it will not cut into the skin.

The use of sutures in dentistry

Dentists also use various types of sutures to stop bleeding or to seal the edges of a large wound. All types of sutures in surgical dentistry are very similar to those that we have already described, the only thing is that there are slight differences in the types of instrument. For suturing in the oral cavity, the most commonly used:

It can be difficult to perform operations in the oral cavity, and only a professional in his field will be able to do this work efficiently, because not only high-quality primary wound treatment is important here. It is also important to choose the right types of sutures in dentistry, but most often it is a simple interrupted suture. And it's laid out like this:

It is also worth remembering that it is necessary to properly suture from the middle of the wound and stitches should not be done too often so as not to disrupt blood circulation in the tissues. In order for healing to proceed stably, especially for wounds resulting from trauma, it is necessary to install drainage between the sutures for several days.

Varieties of surgical sutures and methods for applying internal sutures

Not only do the outer seams need to be applied correctly, the inside fabrics also need to be sewn securely. The internal surgical suture can also be of several types, and each of them is designed to stitch separate parts. Let's look at each of the types to better understand everything.

Seam of the Aponeurosis

Aponeurosis is a place where the fusion of tendon tissues occurs, which have high strength and elasticity. The classic site of aponeurosis is the midline of the abdomen, where the right and left peritoneum fuse. Tendon tissues have a fiber structure, which is why their adhesion along the fibers enhances their divergence among themselves, surgeons call this effect the saw effect. Due to the fact that these fabrics have increased strength, it is necessary to use a certain type of seams for stitching them. The most reliable is considered a continuous twisting seam, which is made using synthetic absorbable threads. These include "Polysorb", "Biosin", "Vikril". Through the use of absorbable threads, the formation of ligature fistulas can be prevented. Also, to create such a seam, you can use non-absorbable threads - "Lavsan". With their help, you can avoid the formation of hernias.

Seam on adipose tissue and peritoneum

Recently, these types of tissues are very rarely sewn together, because they themselves provide an excellent connection and rapid healing. In addition, the absence of seams does not disrupt blood circulation at the site of scar formation. In those cases, if you cannot do without a suture, the doctor can apply it using absorbable threads - "Monocryl".

Intestinal sutures

To stitch hollow organs, several sutures are used:

Seams of the liver

Due to the fact that this organ is rather "friable" and abundantly saturated with blood and bile, it can be very difficult to make a seam on its surface even for a professional surgeon. Most often in this case, the doctor applies a continuous suture without overlap or a continuous mattress suture. On the gallbladder, U-shaped or 8-shaped surgical sutures are used.

Seams on vessels

The types of surgical sutures used in traumatology have their own characteristics. If you need to sew the vessels, then in this case, a continuous seam without overlap, which ensures reliable tightness, will help as well as possible. Using it often leads to the formation of an "accordion", but this effect can be avoided if a single-row interrupted suture is used.
Surgical sutures, types used in traumatology and surgery are similar to each other. Each of the types has its own disadvantages and advantages, but if you correctly approach their imposition and choose the best version of the thread, then any seam will be able to fulfill its tasks and securely fix the wound or sew the organ. The timing of the removal of suture material in each individual case is determined individually, but basically they are removed already on the 8-10th day.

Surgical sutures

the most common way to connect biological tissues (edges, walls of organs, etc.), stop bleeding, bile leakage, etc. using suture material. In contrast to the stitching of tissues (bloody method), there are bloodless methods of their connection without the use of suture material (see. Seamless connection of tissues) .

Depending on the timing of Sh. x. distinguish: primary, which is applied to an accidental wound immediately after the primary surgical treatment or to an operating wound; delayed primary is applied until the development of granulations in terms of 24 h up to 7 days after surgery in the absence of signs of purulent inflammation in the wound; provisional suture - a delayed primary suture, when the threads are carried out during the operation, and they are tied after 2-3 days; an early secondary suture, which is applied to a granulating wound cleared of necrosis after 8-15 days; a late secondary suture is applied to the wound after 15-30 days or more with the development of scar tissue in it, which is previously excised.

The sutures may be removable when removed after fusion, and immersed, which remain in the tissues, absorbing, encapsulating in the tissues, or erupting into the lumen of a hollow organ. The sutures placed on the wall of a hollow organ can be through or parietal (not penetrating into the lumen of the organ).

Depending on the tools used and the execution technique, manual and mechanical seams are distinguished. For manual sutures, ordinary and atraumatic needles, needle holders, tweezers, etc. are used (see Surgical instruments) , as a suture material (Suture material) - absorbable and non-absorbable threads of biological or synthetic origin, metal wire, etc. A mechanical suture is performed using staplers, in which metal staples are the suture material.

Depending on the technique of stitching fabrics and fixing the knot, manual Sh. x. subdivided into nodal and continuous. Simple knotted sutures ( rice. 1 ) is usually applied to the skin at intervals of 1-2 cm, sometimes more often, and with the threat of suppuration - less often. The edges of the wound are carefully compared with tweezers ( rice. 2 ). The sutures are tied with surgical, marine or simple (female) knots. To avoid loosening the knot, keep the threads taut at all stages of the formation of seam loops. For tying a knot, especially ultrathin threads during plastic and microsurgical operations, an instrumental (apodactyl) method is also used ( rice. 3 ).

Silk threads are tied with two knots, catgut and synthetic - with three or more. By tightening the first one, the stitched tissues are compared without excessive force in order to avoid cutting through the seams. A properly applied suture firmly connects the tissues without leaving cavities in the wound and without disturbing blood circulation in the tissues, which provides optimal conditions for wound healing.

In addition to simple knotted sutures, other types of knotted sutures are also used. So, when suturing the wall of hollow organs, Pirogov-Mateshuk screw-in sutures are used when they are tied under the mucous membrane ( rice. 4 ). To prevent tissue eruption, looped interrupted sutures are used - U-shaped (U-shaped) eversion and screw ( rice. 5, a, b ), and 8-shaped ( rice. 5, in ). For a better comparison of the edges of the skin wound, a nodal adaptive U-shaped (loop-shaped) suture according to Donati is used ( rice. 6 ).

When applying continuous seams, the thread is kept taut so that the previous stitches do not weaken, and in the last one a double thread is held, which, after being punctured, is tied to its free end. Continuous Sh. x. have different options. Often a simple (linear) twist stitch is used ( rice. 7, a ), twisting seam according to Multanovsky ( rice. 7b ) and mattress seam ( rice. 7, in ). These sutures invert the edges of the wound if they are applied from the outside, for example, when suturing a vessel, and they are screwed in if they are applied from the inside of the organ, for example, when forming the posterior wall of the anastomosis on the organs of the gastrointestinal tract.

Along with linear, various types of circular seams are used. These include: a circular suture, which aims to fix bone fragments, for example, in case of a fracture of the patella with a divergence of fragments; the so-called - fastening with a wire or thread of bone fragments with an oblique or spiral fracture or bone grafts ( rice. 8, a ); block pulley suture for bringing the ribs together, used when suturing a chest wall wound ( rice. 8, b ), a simple purse-string suture ( rice. 8, in ) and its varieties - S-shaped according to Rusanov ( rice. 8, g ) and Salten Z-shaped ( rice. 8, d ) used for suturing the stump of the intestine, immersing the stump of the appendix, plastics of the umbilical ring, etc. A circular suture is applied in various ways when restoring the continuity of a completely crossed tubular organ - a vessel, intestine, ureter, etc. With a partial intersection of the organ, a semicirculatory or lateral suture is performed.

When suturing wounds and forming anastomoses, sutures can be applied in one row - a single-row (one-story, single-tier) suture or in layers - in two, three, four rows. Along with the connection of the edges of the wound, the sutures also provide a stop of bleeding. For this purpose, specially hemostatic sutures are proposed, for example, a continuous chain (chopping) suture according to Heidenhain-Hakker ( rice. 9 ) on the soft tissues of the head before their dissection during craniotomy. A variant of the interrupted chain suture is the Oppel suture for liver injuries.

Overlay technique Sh. x. depends on the operating methods used. For example, in hernia repair and in other cases when it is required to obtain a strong one, they resort to doubling (duplicating) the aponeurosis with U-shaped sutures or Girard-Zik sutures ( rice. 10, a ). When suturing eventration or for deep wounds, removable 8-shaped sutures are used according to Spasokukotsky ( rice. 10, b, c ). When suturing wounds of complex shape, situational (guide) sutures can be used, which bring the edges of the wound together in places of greatest tension, and after permanent sutures are applied, they can be removed. If the seams are tied on the skin with great tension or they are supposed to be left for a long time, the so-called lamellar (lamellar) U-shaped seams are used to prevent eruption, tied on plates, buttons, rubber tubes, gauze balls, etc. ( rice. eleven ). For the same purpose, secondary provisional sutures can be used, when more frequent interrupted sutures are applied to the skin, and they are tied through one, leaving the other threads untied: when the eruption of the tightened sutures begins, provisional sutures are tied, and the first ones are removed.

Skin sutures are removed most often on the 6-9th day after their application, however, the timing of removal may vary depending on the location and nature of the wound. Earlier (4-6 days) sutures are removed from skin wounds in areas with good blood supply (on the face, neck), later (9-12 days) on the lower leg and foot, with a significant tension of the wound edges, reduced regeneration. The sutures are removed by pulling the knot so that the part of the thread hidden in the thickness of the tissues appears with the skin, which is crossed with scissors ( rice. 12 ) and the entire thread is pulled by the knot. With a long wound or a significant tension of its edges, the sutures are removed first after one, and the rest in the following days.

When applying III. X. various types of complications may occur. Traumatic complications include an accidental vessel needle or a suture through the lumen of a hollow organ instead of a parietal suture. from a punctured vessel it usually stops when a suture is tied, otherwise it is necessary to apply a second suture in the same place, capturing the bleeding one into it; when a large vessel is punctured with a coarse cutting needle, it may be necessary to apply a vascular suture. If an accidental through hollow organ is found, this place is additionally peritonized with serous-muscular sutures. Technical errors in suturing are poor alignment () of the edges of the skin wound or the ends of the tendons, the lack of the effect of screwing in with an intestinal and eversion with a vascular suture, narrowing and deformation of the anastomosis, etc. Such defects can lead to suture failure or obstruction of the anastomosis, bleeding, peritonitis, intestinal, bronchial, urinary fistulas and other wounds, the formation of external and internal ligature fistulas and ligature abscesses occurs as a result of aseptic disorders during sterilization of the suture material or during surgery. Complications in the form of delayed-type allergic reactions (see Allergy) often occur with the use of catgut threads, much less often with silk and synthetic threads.

Rice. 8. Schematic representation of circular sutures: a - cerclage - fastening of bone fragments with an oblique fracture; b - block pulley seam for convergence of ribs; in - a simple purse-string suture; g - S-shaped purse-string suture according to Rusanov; e - Z-shaped purse-string suture according to Salten.

Rice. 4. Schematic representation of the screwing suture according to Pirogov - Mateshuk, superimposed on the intestinal wall: 1 - and the muscular layer of the intestinal wall; 2 - intestines; 3 - suture thread passed through the serous and muscular membranes; 4 - the knot is tied from the side of the mucous membrane.

Rice. Fig. 3. Schematic representation of the instrumental (apodactyl) method of tying a surgical knot: a - after the needle is punctured, the needle holder is wrapped with the long end of the thread, which captures the short end of the thread; b - after tightening the first loop, the long end of the thread is wrapped around the needle holder in the opposite direction.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

I Muscles (musculi; synonymous with muscles) Functionally distinguish between involuntary and voluntary muscles. Involuntary muscles are formed by smooth (non-striated) muscle tissue. It forms the muscular membranes of hollow organs, the walls of blood vessels ... Medical Encyclopedia

I The esophagus (esophagus) is the part of the digestive tract that connects the pharynx with the stomach. Takes part in swallowing food, peristaltic contractions of the P.'s muscles ensure the promotion of food into the stomach. The length of P. of an adult is 23 30 cm, ... ... Medical Encyclopedia

ABOMASOTOMY- (from Novolat. abomasum abomasum and Greek tome dissection), the operation of opening the abomasum. It is used in sheep to remove bezoars, U cr. horn. livestock in case of inversion and displacement of the abomasum or its blockage with dense fodder masses. A. in sheep is produced under ... ...

BURSITIS- Rice. 1. Precarpal bursitis in a cow. Rice. 1. Precarpal bursitis in a cow. bursitis, inflammation of the synovial sac (bursa). Cattle (Fig. 1) and horses are more often affected. Along the course of B. there are acute and chronic, by nature ... ... Veterinary Encyclopedic Dictionary

GASTROTOMY- (from the Greek. gastēr stomach and tomē incision), the operation of opening the lumen of the stomach. More often produced in dogs, cats and less often in piglets to extract foreign bodies from the stomach or from the initial part of the esophagus. Apply general anesthesia after ... ... Veterinary Encyclopedic Dictionary

aboiazotomy- (from Novolat. abomasum abomasum and Greek tomē; dissection), the operation of opening the abomasum. It is used in sheep to remove bezoars, in cattle when the abomasum is twisted and displaced or blocked by dense fodder masses. A. in sheep ... ... Veterinary Encyclopedic Dictionary

Devices for mechanical connection of organs and tissues during surgical operations. Their use reduces the time of suturing, simplifies the suturing process and increases the asepsis of the operation, reduces blood loss and tissue trauma, ... ... Medical Encyclopedia

COLONOTOMY- (from the Greek kólon large intestine and tomē incision, dissection), the operation of opening the colon in a horse when it is clogged with intestinal stones. K. is performed 45 days after the displacement of intestinal stones into the gastric extension ... Veterinary Encyclopedic Dictionary

SURGICAL OPERATION- (from lat. operatio action), a set of manual and instrumental techniques used to eliminate patol. process (therapeutic O. x.), clarification of the diagnosis (diagnostic O. x.), restoration of tissue continuity (plastic, restore. O. x.), ... ... Veterinary Encyclopedic Dictionary

In some cases, suturing the wound is the only way to prevent large-scale bleeding and the entry of pathogenic microflora into it. With the help of artificial collection of damaged tissues among themselves, natural regeneration processes proceed much faster. How to sew up wounds depends entirely on the situation. There are a number of tips and recommendations that can save a person's life in critical situations.

Stitching is a mechanical manipulation to connect the edges of damaged skin, which helps prevent microbes from getting inside and provides accelerated regeneration. Sutures are applied to restore the natural anatomical position of the epithelial tissues. In the absence of suturing, the wound becomes chaotic, often injured, and the surface grows together incorrectly, which is fraught not only with cosmetic defects, but also with limited mobility.

Methods for suturing wounds

Not all injuries need suturing, but in especially dangerous situations, this manipulation can save a person's life.

You need to know which wounds need to be sutured:

• 1. In case of damage not only to the epithelium, but also to the subcutaneous tissue, which is accompanied by a long healing process and a high probability of infection.
  2. In the presence of cuts in places of skin tension: knees, elbows, joints, limbs.
  3. In the presence of a lacerated wound that needs to match all edges.

Only a specialist can assess the importance of manipulation. If there is a wound, it is better to see a doctor who will decide on the need for stitching or suggest alternative methods of treatment.

Sewing is not subject to:

• scratches, abrasions;
• wounds with divergence of edges up to 1 cm;
• stab wounds without damage to vital organs;
• penetrating wounds.

Suturing is contraindicated in the state of shock of the victim and the presence of a pronounced purulent-inflammatory process in the wound.

Types of seams depending on the timing of the imposition

There are several types of seams, each of which is used in specific cases:

• 1. Primary blind suture - is applied after preliminary treatment and sterilization of the wound to prevent the penetration of pathogenic microflora into the bloodstream.
  2. Primary delayed suture - is applied after 3 days of injury, when swelling and inflammation in the wound has significantly decreased. Drainage is introduced, with the help of which the purulent contents will be brought out without stagnation inside the wound.
  3. Early secondary suture - used to identify the first signs of regeneration of the deep layers of the dermis. Drainage is installed between the sutures, and the newly formed pink cells are not excised.
  4. Secondary late suture - superimposed in the presence of a very deep wound, the regeneration of which is carried out from the inside. Manipulation is performed in the absence of pathological processes in the wound.

Currently, staged suturing is not used except in critical situations requiring immediate assistance without the possibility of visiting a qualified specialist. Suturing in the field is often necessary for injuries in hiking, crossings and extreme tourism, when an open deep wound appears.

What is needed for the procedure?

In the conditions of surgery, the procedure is carried out using sterile needles, suture material, sterile bandages, tweezers and a doctor's qualification. If it is necessary to apply primary sutures to save a person's life, the following materials should be prepared:

• sterile bandages or any clean cloth;
• needle and silk thread or any other thread, fishing line;
• scissors and tweezers;
• vodka, alcohol, hydrogen peroxide, brilliant green.

It is necessary to lay the victim on a flat surface covered with a clean cloth or blanket. Remove all unnecessary items, and cut the clothes at the wound site. If there is bleeding, it is stopped with hydrogen peroxide. If bleeding is severe, a tourniquet may be required. This procedure is temporary, and after the bleeding stops, the tourniquet is removed, since there is a high probability of the death of the clamped cells due to metabolic disorders.

The wound is washed with water, removing dust, dirt and debris from it. If there are fragments, they must be carefully removed with tweezers. All the necessary tools are calcined at the stake, or treated with alcohol-containing substances.

Hands are washed with soap and then treated with alcohol or vodka, which will minimize the chance of infection of the wound. If possible, it is better to move the patient to a closed room, protected from wind and precipitation.

In the presence of painkillers in the form of solutions, they can chop off the wound, which will reduce the pain during suturing (Lidocaine, Novocaine, Ultracaine).

Stages of suturing the wound

There are several stages of suturing the wound, following the sequence of which you can correctly suture:

• 1. Preparation of the needle and suture material - take any needle or fishing hook, thread a small piece of thread. Next, the thread is moistened with a needle in an alcohol solution or vodka. For convenience, the needle can be bent into an arc using forceps.
  2. The imposition of the first seam - the dissected tissues are compressed from two sides, after which they pass with a needle in the center, capturing two edges. Each suture is applied separately. First, the center is sewn together, after which the edges are processed.
  3. The imposition of subsequent sutures and fastening of the nodules - the sutures should be located on the intact edges of the epidermis, and the nodules should be fixed to the side of the wound. The distance between the stitches is 0.5-1 cm.
  4. Processing of the resulting seam - the seam is abundantly lubricated with any antiseptic. In the advantage of Zelenka and Chlorhexidine.
  5. Applying a sterile dressing - a bandage, gauze or any clean tissue is made of a bandage that protrudes 2-3 cm beyond the edges of the wound. It is tightly fixed to the seam and bandaged to prevent slipping.
  6. Immobilization of the damaged area - a tire is bandaged to the limbs, which reduces the likelihood of seam divergence due to additional tissue tension.

In the presence of a rapid deterioration in the condition or discharge of blood, ichor or pus from under the sutures, the immediate help of qualified specialists is required.

Seam care rules

To reduce the likelihood of infection of the seam, it is necessary to assess the condition of the wound several times a day. Bandaging of sutured wounds on the skin is carried out 2-3 times a day. The sterile dressing is carefully removed. If there is a difficult discharge, the bandage is pre-soaked with hydrogen peroxide.

The seam is treated with antiseptics, giving preference to brilliant green and Chlorhexidine. After 2-3 days, when a dry discharge of a sterile dressing is noted during dressing, the latter can not be applied. Open wound management involves suture treatment without additional dressing.

It is recommended to abandon hygiene procedures for the time of tissue fusion, as water can provoke suppuration and burden the postoperative period. After 5-7 days, water procedures are allowed under the shower, after which the seam is blotted with a terry towel and additionally treated with an antiseptic.

Healing time for sutured wounds

On average, the regeneration of the epithelium lasts 5-12 days, but the speed depends on the individual characteristics of the organism and the presence or absence of an inflammatory process. Deep wounds with dissection of the subcutaneous tissue, muscles and tendons grow together longer, and their treatment has its own characteristics.

In the presence of a purulent-inflammatory process, the suture can be removed prematurely, which is necessary to destroy the pathogenic microflora. How long a sutured wound heals in this case depends entirely on the degree of neglect of the inflammatory process and the complexity of the treatment.

In places of increased tension of the skin, the regeneration process takes a little longer, and the risks of seam divergence are higher. This requires additional fixation and immobilization of the damaged area of ​​the body.

The sutures are removed on the 10-14th day, when the damaged skin has grown together. With the help of scissors with thin long ends, the suture material is cut, resulting in two ends. Take tweezers, pinch one end and pull the thread. There are punctures that will heal soon.

The procedure is quite painful, so it is carried out under local anesthesia. After removing the sutures, the wound is treated twice a day with any disinfectant solutions. It is not recommended to take baths until complete healing.

Features of suturing wounds at home

At home, there is no way to achieve complete sterility, so suturing is always accompanied by the addition of an inflammatory process in the wound. But in the presence of a strong tissue divergence, this procedure is a necessary measure that can reduce the risk of developing sepsis.

To do this, prepare boiling water, alcohol, sterile bandages, gloves and a needle and thread. It makes no difference what kind of threads the wound is sutured with, since if it falls into the hands of specialists, the sutures will definitely be removed and redone using a suitable suture material.

Hands are washed with soap and then treated with alcohol. The thread is threaded into the needle and dipped for several minutes in alcohol or any disinfectant solution. With the help of the left hand, parts of the diverging tissues are brought closer to each other, and the first suture is applied in the middle of the wound with the right hand. Each suture should have a knot, and their number depends on the length of the wound.

All manipulations should be carried out carefully with minimal contact between the wound and objects. A sterile dressing or bandage is applied on top, after which the victim should be taken to surgery or an emergency room.

In the presence of heavy bleeding or a state of shock, sutures are not applied, and all forces are directed to maintaining the vital processes of the body until the ambulance arrives.

If you can visit a doctor, the wound is best sutured in an operating room. Incorrectly applied sutures and contact with the wound surface of non-sterile objects can provoke the development of an extensive inflammatory process. This, in turn, will aggravate the situation and slow down the wound healing process.

How to sew up a wound with a band-aid?

It is difficult to call it full-fledged seams, but in the presence of an adhesive plaster, the amount of tissue divergence can be reduced. For these purposes, several strips of the patch are taken, the healthy ends of the wound are squeezed with the left hand and the patch is attached. This allows you to speed up the regeneration processes, and also reduces the likelihood of penetration of pathogenic microflora inside.

This method is suitable for stitching shallow cuts and wounds. In the future, you will need to consult a surgeon who will indicate the need for suturing or make sure that this procedure is unnecessary.

Long, but shallow wounds require sutures to prevent germs from entering them. This is done by the surgeon, but in the absence of the possibility of obtaining medical assistance, the sutures are applied independently. If there is no confidence in the actions, it is best to cover the wound with a clean rag or bandages and provide the victim with the fastest qualified assistance.

7.1. DISCONNECTING THE TISSUE

The general principle of tissue separation is strict layering. There is dissection and delamination of tissues.

The section is made with a cutting tool - a scalpel, knife, scissors, saw. The main tool for tissue dissection is the scalpel.

The abdominal scalpel is used to make long incisions on a horizontal or convex surface of the body, the pointed one is used for deep incisions and punctures.

Holding the scalpel in the form of a bow provides the movement of the hand with more scope, but less force; the position of the table knife allows you to achieve both greater pressure force and a significant cut size; in the position of a writing pen, it is held when making small incisions or extracting anatomical formations in a sharp way. The amputation knife is held in the fist with the cutting edge towards the surgeon.

All incisions are made from left to right (for right-handers) and towards yourself.

Technique of dissection of the skin and subcutaneous adipose tissue. The direction of the skin incisions is chosen in accordance with the projection site of the organ to be operated on the skin. At the same time, they try to ensure that the incision line is (if possible) parallel to the visible folds of the skin, which, in turn, correspond to the lines of Langer's tension. With cuts perpendicular to the lines of Langer, the edges of the wound gape, which is convenient in the treatment of purulent diseases. However, with such incisions, the connection of the edges of the wound and their union occur worse. Such incisions in the area of ​​the joints can cause skin contracture. The incisions in the area of ​​the joints should be parallel to the plane of flexion.

Stretching and fixing the skin on both sides of the intended incision line with the thumb and forefinger of the left hand, the operator carefully injects the scalpel at an angle of 90? into the skin, after which, tilting it at an angle of 45?, it smoothly leads to the end of the incision line. At the end of the incision, the scalpel is again transferred to the position

perpendicular to the skin. This technique is necessary so that the depth of the incision is the same throughout the wound.

Technique of dissection of fascia and aponeurosis. After an incision in the skin with subcutaneous fatty tissue, the operator, together with an assistant, lifts the fascia with two surgical tweezers, cuts it and inserts a grooved probe into the incision of the fascia. Passing the scalpel with the blade up along the groove of the probe, the fascia is dissected along the entire length of the skin incision.

Technique of dissection and separation of muscles. The muscle is either stratified along the fibers or dissected. When exfoliating, the perimysium is first dissected with a scalpel, and then, using two folded tweezers or two Kocher probes, the muscles are moved apart, introducing Farabeuf lamellar hooks into the wound. In some cases, it is necessary to cross the muscle fibers in the transverse direction. Sometimes before crossing the muscle is clamped with two hemostatic forceps and dissected between them. The edges of the transected muscle are sheathed with a blanket catgut suture for the purpose of hemostasis. It must be borne in mind that, due to the contractility, the crossed muscles diverge over a fairly significant distance.

Technique of dissection of the parietal peritoneum. The parietal sheet of the peritoneum, incised between two tweezers, is cut along the entire length of the skin wound with Richter scissors, lifting it on the index and middle fingers of the surgeon's left hand inserted into the peritoneal cavity. The edges of the abdominal incision are fixed to gauze pads with Mikulich clamps.

7.2. FABRIC CONNECTION

The connection of tissues is performed as the final stage of the surgical intervention or during the surgical treatment of the wound. In doing so, you must remember:

The edges of the wound must not be sutured under tension, the sutures should only hold the approximate edges of the tissues;

Foreign bodies (ligatures) should not be left in the wound for a long time, as they prevent its normal healing;

Only special tools are used to connect tissues; other tools are unacceptable for this purpose.

7.2.1. Types of suture material and needles

When connecting tissues, special threads are used, loaded into surgical needles, which are fixed in needle holders. See section 3 for how to load the thread into the needle and how to hold the needles.

Types of surgical needles

Cutting (trihedral):

■ thick (gynecological);

■ thin (surgical);

Curved (curvature 120?):

■ eye;

■ for leather stitching.

Stab (round):

Direct:

Curved (curvature 180?):

■ thin (vascular);

■ medium thickness (intestinal);

■ thick (chopping).

Flat (liver):

Straight, semi-curved, curved.

Atraumatic:

Straight, curved.

Microsurgical.

Suture material used in surgery can be classified according to several criteria:

According to the degree of resorption - absorbable, conditionally absorbable and non-absorbable;

By thickness;

By building.

The oldest absorbable suture material - catgut - was made from the submucosa of the small intestine of small cattle. Depending on the processing technique, the terms of its complete resorption range from 1 week to 1-1.5 months. In the second half of the 20th century, synthetic absorbable sutures were obtained, the first of which were deson and vicryl.

Conditionally absorbable materials include silk and nylon.

The group of non-absorbable threads includes horse hair, wire (steel, nichrome, etc.), various synthetic materials.

Catgut comes in 9 numbers: 000, 00, 0, 1, 2, 3, 4, 5, 6.

Surgical silk is produced in 12 numbers: 000, 00, 0, 1, 2, 3, 4, 5, 6, 7, 9, 10; thickness? 1 - 0.1 mm, each subsequent number is 0.1 mm thicker than the previous one.

According to its structure, suture material can be divided into two groups: monofilaments (in the form of a single fiber); complex threads, which, in turn, are divided into three groups - braided, twisted and coated threads.

Among the new types of suture material, it should be noted antibacterial suture material (caprogen, caproag, capromed, etc.), as well as threads capable of stimulating wound healing processes - rimin, biofil. These groups of suture material are in their infancy and are not yet widely used in surgical practice.

All types of suture material are delivered to surgical departments in two forms: sterile (in ampoules); non-sterile (in coils).

Surgical needles and suture threads should be selected strictly differentiated. In this case, it is necessary to take into account what fabric the seam is applied to, what type of seam is used and what tasks the seam serves. The size and diameter of the needle must always match the thickness of the suture.

Atraumatic sutures - disposable complex needle + thread, manufactured in the factory. A distinctive feature of such a suture material is that a single thread is pulled behind the needle, approximately equal to the diameter of the needle, and not double, as in classical suturing. Under these conditions, the thread almost completely closes the defect in the tissues after the passage of the needle, which makes it possible to use atraumatic suture material in vascular operations, as well as in cosmetic surgery.

7.2.2. Types of seams and knots

Three types of nodes are used in surgery: simple (female), marine, surgical (Fig. 7.1).

When tying knots, it is necessary to keep the ends of the threads taut, since when they are relaxed, the knot may unravel and be

Rice. 7.1.Technique of knitting "marine" (a) and surgical (b) knots: 1-6 - consecutive moments of knitting knots

fragile. Manipulations are performed with the thumbs and forefingers of both hands. When tying a simple knot, 8 points are distinguished. To tie a sea knot, the first 5 moments are initially repeated, and the second knot is tied so that the course of its turn is directed in the opposite direction to the first turn. Tying a surgical knot requires a double overlap of the thread at the first moment and tying an oncoming second turn like a sea knot.

7.2.3. Suture technique

There are nodal, continuous twisting, continuous screwing, continuous mattress, U-shaped, purse-string, Z-shaped seams.

Nose suture produce by stitching the skin and subcutaneous tissue, aponeuroses of the broad muscles. The first injection of the needle is made from the surface side of the tissue, after which it is punched out.

and a second injection on the inside of the second stitched edge. In this case, the distance of the first injection and the second injection from the edge of the stitched tissues should be equal. After suturing, the threads are tied with one of the knots. When applying a nodal suture, a possible mistake is the mismatch of the sewn edges of the fabrics and their tucking. This happens due to the unequal distance between the injection of the needle and the puncture from the stitched edges and the creeping of the tissues on each other due to this when the knot is tightened.

Overlay of a continuous twisting seam produced by stitching fascia, aponeurosis, serous membranes (peritoneum, pleura) (Fig. 7.2). The technique is as follows. At the edge of the wound, an interrupted suture is applied so that one end of the thread is much longer than the other. Then, with a needle threaded with the long end of the thread, the fabric is continuously sewn stitch to stitch throughout. The distance between the stitches should be 0.5-0.7 cm. During the last stitching, the thread is not completely removed, but is used to tie the last knot with the working end of the ligature.

ab Rice. 7.2. Technique of imposing a continuous twisting suture on the peritoneum: a - the beginning of the suturing of the peritoneum; b - completion of the seam

The imposition of a continuous mattress seam. One type of continuous suture is the mattress suture. The technique of its imposition, in contrast to the twisting seam, is that before tightening each stitch, the working end of the thread is passed into the loop formed by each previous turn of the seam. All other manipulations with the thread are similar to those with a twisted seam.

Imposition of a continuous screw-in suture (Schmiden) used as one of the stages of imposing interintestinal anastomosis (Fig. 7.3). The Schmiden suture technique is similar to the continuous twist suture technique. The difference is that the needle is injected in all cases from the inner surface of the stitched edges.

U-shaped seam used for suturing muscles, tendons, aponeuroses (see Fig. 7.3). The technique is as follows: the needle is injected from the surface of one edge of the wound, then it is injected from the depth, and the needle is injected on the surface of the other connected side. Stepping back 0.4-0.6 cm, from the same side they make the same stitch in the opposite direction. When tying the ends of the thread, the seam has a U-shape.

ab Rice. 7.3. Schmiden suture technique (a) and U-shaped suture (b)

Rice. 7.4.Technique for applying purse-string (a) and Z-shaped (b) sutures

The imposition of a purse-string suture. A gray-serous or serous-muscular suture is applied around the wound opening or the organ to be removed along its entire circumference so that the last needle puncture corresponds to the very first puncture site. Both ends of the thread, when tightened, collect the wall of the organ to be sewn, as if into a pouch. A Z-shaped suture is placed on top of the tightened purse-string suture (Fig. 7.4).

7.2.4. Soft tissue stitching technique

Stitching of the wound of the stomach, small and large intestine produce intestinal suture in the direction transverse to the axis of the body. At the same time, two-row sutures are applied to the stomach and small intestine, and three-row sutures are applied to the large intestine. The first row of sutures (through, continuous screwing) is applied through the entire thickness of the organ wall with catgut of the appropriate size on a round needle. The second and third rows of sutures (serous-muscular, gray-serous, nodular or continuous) are applied with a silk thread on a round needle. For small wound defects, a purse-string suture and a Z-shaped suture above it can be applied.

Stitching of the parietal peritoneum carry out catgut (? 4) on a round needle with a continuous twisting seam.

Muscle stitchingcarry out catgut (? 4, 5) U-shaped seams.

Stitching of fasciae and aponeuroses produced with silk thread (? 1, 2) loaded into a round needle. Impose separate nodal, U-shaped or continuous seams. When stitching, it is necessary to ensure that the distance between the injection on one side and the injection on the other is equal. The distance between individual knotted seams or stitches of a U-shaped and continuous seam should be no more than 5 mm. The sutures are tightened with a marine or surgical knot.

Skin stitchingcarried out with a silk or nylon thread (? 4, 5, 6) charged into a cutting needle with a curvature of 120?. Stitching is performed with separate nodal sutures. The technique is as follows (Fig. 7.5). With the help of serrated or surgical tweezers, alternately stitched edges of the skin are held. The needle is injected from the outer side of one of the edges to be sewn, and the needle is punctured from its inner side. Then, the opposite edge of the skin is grasped with tweezers, an injection is made from the inner surface of the skin flap and an injection is made on its outer surface. At the same time, it is necessary

Rice. 7.5.The imposition of interrupted sutures on the skin: a - correct; b - wrong

make sure that the distance between the puncture on one side and the puncture on the opposite side with respect to the edges of the edges to be sewn is the same. A simple or marine knot is tightened so that it is on the side of the cut edges to be joined. When applying skin sutures, the following rules should be followed: minimize tissue trauma; be sure to produce separate stitching of the edges of the wound.

To apply a corner adaptive seam, it is necessary to strictly observe the technique for its implementation (Fig. 7.6). Corner suture is used in cases where two triangular skin areas need to be connected to the longitudinal edge of the wound (T-shaped wound), and also if a small wound has a triangular shape.

If it is necessary to achieve a high degree of cosmeticity, intradermal sutures are used (Fig. 7.7). In the presence of superficial wounds, a single-row suture is performed, and in the presence of deep wounds, a double-row suture is performed.

When applying a single-row continuous suture, the thread is carried out in the thickness of the dermis. The application is started by suturing the skin at a distance of 1 cm from one of the corners of the wound. Then it is sewn parallel to the skin surface at the same height, capturing the same layer of tissue on both sides. Having finished suturing, both ends of the ligature are stretched in opposite directions, carrying out a complete adaptation of the wound edges. The ends of the thread are fixed to the skin either with a patch or interrupted skin sutures.

When applying a double-row continuous suture, a deeper ligature passes in the subcutaneous adipose tissue, and the second, more superficial one, in the dermis. Complete adaptation of the wound edges

Rice. 7.6.Adaptive Fillet Welding Technique (from: Zoltan Ya., 1974)

Rice. 7.7.Closure of superficial (1) and deep (2) skin wounds with one- and two-row sutures (from: Zoltan Ya., 1974)

reach by stretching in opposite directions of both ligatures at the same time. The ends of the superficial and deep ligatures are tied at the corners of the sutured wound.

Removal of skin sutures carried out using tweezers and pointed scissors (Fig. 7.8). Having seized the knot or one of the free threads with tweezers, slightly pulling the subcutaneous part of the thread above the skin and, bringing the sharp jaw of the scissors under the thread, cross it at the skin surface (see Fig. 7.8), after which the thread is easily removed.

Rice. 7.8.Technique for removing the interrupted skin suture

A continuous seam is removed by pulling the knot of the connected superficial and deep ligatures, followed by their simultaneous intersection and pulling from the opposite side (Fig. 7.9).

Rice. 7.9.Technique for removing a double-row continuous seam (from: Zoltan Ya., 1974)

7.3. STOP BLEEDING

Bleeding is understood as the exit of blood outside the vascular bed. Bleeding can be external (blood bleeds into the external environment) and internal (blood bleeds into serous cavities, soft tissues, lumen of hollow organs). There are also arterial, venous, capillary and mixed bleeding. Bleeding resulting from the direct action of a traumatic agent is called primary, bleeding that develops as a result of slipping of the ligature, necrosis of the vascular wall, bedsores from foreign bodies - secondary. In order to temporarily stop the bleeding, finger pressure of the vessel, the imposition of a pressure bandage or tourniquet are used. Methods for the final stop of bleeding include the imposition of a hemostatic clamp, followed by ligation of the vessel in the wound, its electrocoagulation, and ligation of the vessel throughout.

A technique for ligating a blood vessel in a wound. In almost any operation, the surgeon is forced, when dissecting tissues, to dissect small-caliber blood vessels along the incision. Bleeding in this case (especially from small vessels) can stop on its own, which is associated with the development of vascular spasm and thrombosis of the cut ends of the vessel, however, reliable hemostasis can be achieved by tying the vessel with a ligature after capturing it with a hemostatic clamp. The position of the hemostatic clamp in the hand should be as follows: the nail phalanx of the thumb in one ring, the distal phalanx of the IV or III finger in the other, the index finger on the clamp. After tissue dissection, the surgeon or assistant applies hemostatic clamps to the vessels, always in a perpendicular direction to the tissues, and it is necessary to capture with the clamp as little volume of surrounding tissues as possible. Oblique capture of the bleeding site with a clamp is incorrect, since this takes a lot of surrounding tissue, and ligation of its large area can lead to necrosis, which prevents the primary healing of the wound. After capturing the bleeding vessel, the surgeon brings the ligature under the clamp, the assistant lifts the tip of the clamp up so that the ligature lies under it, otherwise it will tighten on the tip of the clamp. After the ligature is established, the surgeon ties the first knot, preferably surgical, making sure that the knot is not tightened on the instrument itself. While the surgeon tightens the knot, the assistant smoothly

removes the clamp, and the operator, making sure that the ligature does not slip, imposes a second knot. The assistant shortly (up to 5 mm) cuts the ends of the thread. For ligation of blood vessels, silk, nylon and lavsan threads are used. Because of the possibility of developing secondary bleeding, it is better not to use catgut threads. When using silk, a double knot is sufficient; when using kapron and lavsan, it is necessary to tie a triple knot.

When ligating blood vessels in the wound, the movements of the hands of the operator should be smooth. It is necessary to be able to apply and remove the clamp with one right or left hand equally.

Electrocoagulation of a blood vessel in a wound. In some cases, for example, when removing malignant tumors, brain surgery, microsurgery, and also to reduce the time of surgery, electrocoagulation of the vessel in the wound is used. To do this, you must have a device for diathermocoagulation. Any of its models has a power transformer, a high-frequency current generator, a control pedal, shielded wires ending in electrodes. It is possible to use both monoactive and biactive coagulation. In the first case, one of the electrodes (passive) in the form of a plate is fixed to the patient, and the second electrode is active - working. In the mode of biactive coagulation, special tweezer electrodes are used, the branches of which are the active and passive electrodes. The principle of operation of the device is to convert electrical energy into heat when the circuit of the device is closed at the point of contact of the active electrode with the tissues. The thermal effect primarily occurs in the blood (a thrombus is formed), and then it spreads in the vessel wall from the inside to the outside, causing protein coagulation.

In both modes of coagulation, you can directly touch the bleeding vessels with electrodes, but this technique is more convenient when using biactive coagulation. When using the monoactive coagulation mode, it is better to clamp the vessels with hemostatic clamps, and then touch the clamps with electrodes, making sure that the clamp does not come into contact with other tissues in order to avoid burning them.

Technique of ligation of the main blood vessel throughout. Indications for ligation of vessels throughout are the impossibility of applying hemostatic clamps with subsequent ligation within the wound; the need for preliminary

dressings before some operations (amputation, jaw resection, tongue resection).

The dressing is performed under anesthesia or local anesthesia. The incisions are usually made along the projection lines of the vessels. In addition to projection incisions, roundabout accesses are used to expose some vessels, making incisions at a certain distance from the projection lines through the sheaths of adjacent muscles.

Dissect the skin, subcutaneous tissue, superficial and own fascia area. Then it is necessary, having pulled the muscle with a lamellar hook, to open the wall of the sheath of the neurovascular bundle along the grooved probe. Isolation of the artery is performed in a blunt way. Holding a grooved probe in the right hand, and in the left tweezers, the operator grabs the perivascular fascia (but not the artery!) with tweezers from one side and, carefully stroking the end of the probe along the vessel, isolates it. In the same way, the artery is exposed on the other side for 1-2 cm. It is not necessary to isolate the vessel over a longer distance so as not to disrupt the blood supply to the vessel wall. A silk or nylon ligature is brought under the artery on a Deschamp or Cooper ligature needle. When ligating large arteries, the needle is brought in from the side on which the accompanying vein is located (between the artery and the vein), otherwise it may be damaged by the end of the needle. The ligature on large arteries is tightly tightened with a double surgical or marine knot. When ligating and crossing large arterial trunks, two ligatures are applied to the central end of the vessel, and the distal one is pierced, and one ligature is applied to the peripheral one.

7.4. VASCULAR SEAM

A vascular suture is both one of the ways to finally stop bleeding, and one of the surgical interventions on the vessels.

Circular vascular suture technique according to Carrel (Fig. 7.10). In case of damage to the arteries, vascular suture is currently the operation of choice.

The technique for performing this intervention according to the Carrel method is as follows. Vascular clamps are applied to both ends of segments of the vessel isolated over a short distance. For overlay

Rice. 7.10.Vascular suture according to Carrel:

a - suturing-taped; b - imposition of a twisting seam

seam use round stabbing atraumatic needles. Three fixation sutures are placed along the perimeter of the vessel at an equal distance from each other. The assistant stretches the vessel wall by two adjacent sutures-holders, giving it a linear shape. Then, with frequent (at a distance of 1 mm from each other) stitches of a continuous seam, the walls of the segments of the vessel are connected between the holders. The beginning of the suture thread is connected with the 1st holder, the end - with the 2nd. In the same way, successively stretching the vessel wall between the 2nd and 3rd holders, the 3rd and 1st holders, a suture is applied along the entire circumference of the vessel.

After the end of the suture, the vascular clamps are removed: on the arteries, first from the peripheral, then from the central segment, on the veins, vice versa.

When blood leaks along the suture line, the bleeding site is pressed with a swab moistened with hot saline, or additional interrupted sutures are applied to this place.

Microsurgical vascular suture. Performing a microvascular suture requires an operating microscope or a surgical loupe, microsurgical suture material of conditional number 8/0-10/0, and microsurgical instruments. The conditions for a successful microvascular suture are good visualization of the vessel ends, thorough hemostasis, capturing the vessel wall with instruments only by the adventitia, juxtaposition of the vessel ends without tension, excision of the adventitia at the vessel ends to prevent it from entering the vessel lumen.

For stitching a vessel with a diameter of 1 mm, 7-8 interrupted sutures are required. Preliminary impose two seam-holders. The sutures are first placed on the anterior wall of the anastomosis, and then the vessel is rotated using holders and the posterior wall is sutured. You can use the technique when, after tying a knot, one of the ends of the thread is cut off, and the second is used as a holder for rotating the vessel wall. When suturing small veins, more sutures are required, since the guarantee of the success of the venous suture is the exact matching of the sutured segments of the vessel. For tying knots, an apodactyl technique is used, in which one of the ends of the thread is circled around the needle holder lips with tweezers, and the other is captured by the needle holder lips. When the first thread slips, a knot is formed. If the sponge is circled twice with the first end of the thread, a surgical knot will be obtained. After applying the microsurgical vascular suture, the clamp is first removed from the distal end of the vessel at the suture of the artery and from the proximal end at the suture of the vein.

7.5. VENESECTION

Indications:the need for prolonged intravenous infusions or the inability to perform catheterization of the main veins, as well as when puncturing superficial veins.

Position of the patient on the operating table: lying on your back; if venesection is performed on the upper limb, the limb should be abducted at a right angle on a side table.

Venesection technique (Fig. 7.11) . Under local anesthesia with a 0.25% novocaine solution, an incision is made in the projection of the corresponding vein 1.5-2 cm long. The vein is exposed for the entire length of the incision. Using folded clamps or tweezers, the vein is isolated from the surrounding tissues and two ligatures are brought under it, which are bred into opposite corners of the wound. In the distal corner of the wound, the vein is bandaged. Then the vein is lifted by the distal ligature and incised by 1/2 of the diameter. The incision is made obliquely with respect to the axis of the vein. A polyethylene catheter is inserted into the incision. It is carried out to a depth of 1.5-2 cm. A proximal ligature is tied on the catheter. The ends of the ligatures are cut off. The skin is sutured. The catheter is fixed to the skin with a plaster, an aseptic dressing is applied on top.

After the catheter is inserted into the vein, it is washed with novocaine and a heparin plug is placed.

Rice. 7.11.Stages of venesection

7.6. SEAM NERVA

To restore the anatomical integrity of the nerve, the imposition of separate interrupted sutures on its outer shell (epineurium) and on the shells of each of the bundles (perineurium) is used. For this purpose, it is necessary to use atraumatic (when applying an epineural suture) or microsurgical (when applying a perineural suture) round needles.

When suturing the nerve, it is advisable to use optical magnification with a bifocal loupe or an operating microscope. The technique is as follows (Fig. 7.12). Mobilized

and the matched ends of the crossed nerve are sutured around the circumference behind the shells of each of the ends to be sutured with separate interrupted sutures. After all the sutures are applied, they are alternately tied with a marine or surgical knot in such a way that a diastasis of 1-2 mm remains between the sutured proximal and distal ends of the nerve. The number of sutures should be proportional to the thickness of the nerve trunk to be sutured.

Microsurgical suture of the nerve can significantly improve the results of this operation. For stitching, an operating microscope with a working 25-40-fold magnification and suture material with a conditional number 10/0-11/0 are used.

According to the location of the suture thread, a perineural suture is distinguished (when the needle and thread pass through the perineurium of individual bundles), an interfascicular suture (when the thread captures the connective tissue between adjacent nerve bundles and brings two adjacent bundles together), epineural suture (when the thread also captures part of the outer epineurium). Epineural sutures reinforce the nerve suture, but can be used alone to suture small nerves. The most reasonable is the interrupted suture of the nerve (the technique of the interrupted suture is described in the section on vascular microsurgery). Most often, no more than one suture is placed per bundle. Sometimes only the largest bundles are connected, due to which smaller ones are compared.