A simple interrupted suture should ensure the connection of the edges of the wound without the formation of "dead space". This is achieved by exact convergence of the corresponding tissue elements and the edges of the epithelial layer. When performing a suture, more subcutaneous and connective tissue should be captured than the epithelial layer and dermis, so that the deeper layers with their mass push the overlying layers upward.

With a simple knotted suture, the knots should be tied so that they are located on one side of the wound, and not above it.

If the edges of the wound are excessively raised, underprepared, of unequal thickness, it is better to use a vertical mattress suture (Donati suture). This suture provides closure of the wound without the formation of "dead space" to the full depth. A horizontal mattress suture is used to connect the edges of superficial wounds. It provides maximum edge adaptation.

Vertical mattress suture (Donati suture)

The execution of a vertical mattress suture begins with the introduction of a needle into the skin obliquely outwards at a distance of 2-3 cm from the edge of the wound. The needle is then passed towards the base of the wound. The tip of the needle should be brought out at the deepest point of the cut plane. The base of the wound is stitched, and the needle is brought out through its other edge, symmetrically to the injection site. The points of injection and removal of the needle on the surface of the skin should be at the same distance from the edges of the wound. The needle is again injected on the side where it was taken out, a few millimeters from the edge of the wound, and so that it comes out in the middle of the dermis layer. On the opposite side, the needle is brought to the surface of the skin also through the middle of the dermis.

The surface part of the stitch should be made in such a way that the distance of the points of injection and removal of the needle from the edge of the wound, that is, the place where the needle appears in the dermis on both sides, is the same (c=d and e=f). By tightening a correctly applied vertical mattress suture, the edges of the wound are exactly approached and fixed to the base, slightly raised, the dermis and the epithelial layer are accurately compared.

Intradermal continuous suture

Superficial skin wounds extending to the subcutaneous adipose tissue are closed with a single-row intradermal continuous suture.

The suture is started near the corner of the wound, retreating from its edge by 3–5 mm. Later, they sew parallel to the skin surface, at the same height, capturing the same amount of tissue with each stitch.

The main difficulty of this type of suture lies in the fact that the place where the needle was punctured on one edge of the wound should always be located opposite the place where it was punctured on the opposite edge of the wound. In this case, when tightening the thread, these two points coincide. If this rule is not observed, then the edges of the wound in some areas are not compared or a gap is formed between them.

A horizontal mattress suture is performed as follows: an atraumatic needle with a fine thread (3-0 - 5-0) is injected 2-3 mm from the edge of the wound so that the needle exits through the middle of the incision plane

On the other edge of the wound, the needle should be withdrawn in a similar way, symmetrically to the place of its injection. Then the needle is turned, injected 4-6 mm from the thread exit point and the stitch is repeated in the opposite direction. A knot is tied with a needle holder.

Deep skin wounds are closed with two-row continuous sutures.

The first row runs in the subcutaneous adipose tissue, approximately in the middle of the plane of the adipose tissue incision, the second row goes to the skin itself (dermis). The ends of the threads of both rows of sutures are brought to the surface of the skin at the end points of the wound and connected to each other.

The most important condition for the healing of any wound is rest. In order to exclude the possibility of movement, the operating area must be immobilized. The limbs at the end of all operations (except for minor superficial interventions) are immobilized with a plaster cast and fixed in a position that facilitates venous outflow of blood.

Literature: Traumatology and orthopedics: / ed. V.V. Lashkovsky. - 2014.

Benefits of knotted sutures
Precision matching of connected tissues, the possibility of modeling stitch parameters depending on the shape of the wound; the possibility of high-quality connection of the edges of wounds of complex shape (arc-shaped, angular, polygonal, etc.);
ensuring a strong fixation of the edges of the wound, if it is necessary to remove one or more sutures of a row according to the relevant indications; preservation of blood supply to the edges of the wound; hemostatic properties.
Disadvantages of interrupted sutures
The relative complexity of the imposition (the need for a separate thread and its tying for each seam). This disadvantage is determined by the very name of the seams - "nodal";
the need for an accurate additional comparison of the edges of the wound before applying each subsequent suture;

• duration of manipulation - a lot of time is spent on the formation of loops of each seam. It takes 5-6 knots to fix a single seam made of modern synthetic threads. The summation of this time when performing a complex abdominal operation (for example, gastric resection) can significantly increase the time of surgical intervention.

1. TYPES OF PIECE WELDS

Rice. 19. Vertical circular knotted seam.
Disadvantages of a vertical circular knotted seam
Significant tissue compression within the circular thread with a tendency to subsequent eruption, ischemia or necrosis; the possibility of deformation of the edges of the wound due to the deviation of the plane of the seam from the normal to the length of the wound. The plane of the interrupted circular seam must be strictly perpendicular to the lines of force of the wound;
the possibility of developing a postoperative scar in the form of a "railroad track" due to a mismatch between the stable rigid construction of the circular suture and the volumetric dynamic properties of the wound edges; with a significant swelling of the edges of the wound after the suture of a fixed ring-shaped structure, the thread can be cut through the tissues, and with a rapid subsidence of the edema, the edges of the wound may diverge and heal by secondary intention due to the impossibility of changing the parameters of the circular suture. These shortcomings limit the use of a circular suture on edematous loosened edges of wounds and can be corrected by using the so-called plate suture (Fig. 20).
A feature of this seam is the ability to adjust the length of the section of the thread intended for fastening the edges of the wound. For this, pellets are used, put on the ends of the thread. Fixation of changes in the length of the thread as tissue edema decreases is carried out by flattening the pellets. This allows you to maintain an accurate constant comparison of the edges of the wound. The plates applied to the edges of the wound reduce the specific pressure of the thread on the tissue, preventing the formation of a rough scar.
The vertical U-shaped suture adapts the edges of the wound, accurately matching them without much tissue stress and the formation of "dead space" (Fig. 21). A relative disadvantage of the vertical U-shaped suture is the discrepancy between tissue tension at the suture site and in adjacent areas.
Rice. 20. Lamellar suture applied to the wound of soft tissues of the lateral part of the face.

Rice. 21. Vertical U-stitch

Rice. 22. MacMillan-Donati suture, which increases the strength of the connection of the edges of the wound of the anterolateral abdominal wall.
One of the varieties of nodal vertical U-shaped seam is the Mac Millan-Donati seam. To completely exclude the formation of a closed cavity near the bottom of the wound and increase the strength properties, the seam is applied in such a way that, along with the edges of the wound, its bottom is captured. A feature of this suture is that the surface thread passes directly through the thickness of the dermis (Fig. 22).

Rice. 23. Suture Algover

Rice. 24. Horizontal U-stitch

In addition, to improve the aesthetic properties of the vertical U-shaped suture, the ends of the thread are passed through the dermis and subcutaneous adipose tissue without puncturing the skin surface on one side - the Algover suture (Fig. 23).
A horizontal nodal suture is usually applied in a U-shape (Fig. 24).
Advantages of a horizontal U-shaped knotted seam
Improved quality of the connection of the middle part of the deep wound; little labor intensity.
Disadvantages of a horizontal U-shaped knotted seam
The possibility of divergence of the edges of the skin with wound healing by secondary intention; insufficient hemostatic properties;
the danger of the formation of a closed cavity with the possibility of suppuration between the suture line and the bottom of the wound.

A doctor of any specialty should be able to perform primary surgical treatment of a wound in emergency situations. To do this, you need to master the main elements of operational technology, with which you can do:

- tissue separation;

- stop bleeding;

- tissue connection.

Tissue separation can be done in a variety of ways. used to separate soft tissues puncture(puncture needle, trocar - a pointed rod with a steel tube put on it), dissection(scalpel, scissors) blunt separation(with some tool or even fingers), separation by special physical methods(laser beam, ultrasound, etc.).

Stop bleeding. Stopping bleeding is temporary and permanent.

Temporary stop of bleeding. External venous and capillary bleeding is stopped with a pressure bandage. Temporary arrest of arterial bleeding on the extremities is achieved either by finger pressure on the site of the projection line, where the artery passes next to the bone, or by applying a rubber tourniquet above the injury site. It should be remembered that the tourniquet is applied to a limb segment with one bone (shoulder, thigh), since the arteries located between the bones, for example, on the forearm or lower leg, cannot be squeezed sufficiently reliably.

In the wound, including the operating room, it is possible to temporarily stop the bleeding by pressing the bleeding vessels with a sterile swab or finger. More often, bleeding is stopped by applying a hemostatic clamp to the vessel.

The final stop of bleeding. Usually it is produced by ligation of vessels at the site of damage or, less often, throughout. The damaged vessel together with surrounding tissues

mi (subcutaneous fatty tissue, muscle, etc.) is clamped with a hemostatic forceps and tied with a thread (ligature). Silk, catgut and synthetic materials (nylon, dacron, prolene, etc.) are used for ligation of vessels.

In dense (rigid) tissues (aponeurosis, dura mater), sometimes it is not possible to apply a hemostatic clamp; in these cases, bleeding is stopped by stitching the tissues of the bleeding area through its thickness.

The electroknife used in surgery (diathermocoagulation) reliably stops bleeding from small vessels and even vessels of medium diameter, which saves time spent on stopping bleeding.

In case of damage to large vessels, one should resort to the imposition of a vascular suture and, possibly, less often, to their ligation.

For tissue connections most often sutures (manual or mechanical) with various suture materials (silk, catgut, nylon, metal, etc.), technical devices (metal rods, staples, wire, etc.) are used. Less commonly used welding (ultrasonic, etc.), gluing with various adhesives, etc.

SURGICAL INSTRUMENTATION

Surgical instruments can be divided into general purpose instruments and special instruments. Examples of sets of special instruments are given in special manuals for operative surgery. General-purpose tools should be known to a doctor of any specialty and be able to use them.

GENERAL PURPOSE TOOLS

1. To separate tissues: scalpels, knives, scissors, saws, chisels, osteotomes, wire cutters, etc. Cutting tools also include resection knives used to cut dense tendon tissues near the joints, and amputation knives.

2. Auxiliary instruments (expanding, fixing, etc.): anatomical and surgical tweezers; blunt and sharp hooks; probes; large wound dilators (mirrors); forceps, Mikulich clamps, etc.

3. Hemostatic: clamps (such as Kocher, Billroth, Halsted, "Mosquito", etc.) and Deschamp's ligature needles.

4. Tools for connecting fabrics: needle holders of different systems with piercing and cutting needles.

The surgical instruments used in the manipulations must be sterile.

Surgical instruments are passed from hand to hand with blunt ends towards the receiver so that the cutting and piercing parts do not injure the hands. In this case, the transmitter must hold the instrument by the middle.

Most surgical instruments are made from chrome-plated stainless steel. The number of surgical instruments currently reaches several thousand.

INSTRUMENTS FOR DISCONNECTING SOFT TISSUES

Scalpels or surgical knives

Purpose: dissection of any soft tissues (skin, subcutaneous fatty tissue, fascia, aponeuroses, intestinal wall, etc.).

Device: handle, neck, blade (cutting edge) and butt. Removable blade for single use.

According to the shape of the blade, pointed and belly (with a strongly convex cutting edge) scalpels are distinguished (Fig. 2.1). A belly scalpel is used to make long linear incisions on the surface of the body, a pointed one is used for deep incisions and punctures.

Position in the hand:

In position table knife, when the index finger rests on the butt, for cutting the skin, other dense tissues, for making deep cuts, strictly metered according to the force of pressure (Fig. 2.2);

Rice. 2.2. Positions of the scalpel in the hand:

1 - table knife;

2 - writing pen; 3 - bow

In position writing pen when puncturing tissues, separating (preparing) tissues, when making short, precise cuts in the depth of the wound;

In position bow for making long superficial, shallow incisions. Should not be cut with a scalpel blade,

directed upward, except when the incision is made along the probe.

Surgical scissors

Purpose: dissection of formations of small thickness (aponeurosis, fascia, serous sheets, vessel wall, etc.) and suture material.

Scissors crush tissue between the blades, so they cannot be used to cut skin, bulky tissue, such as muscle.

Device: two blades turning into branches with rings at the ends, and a screw connecting them. The ends of the blades are sharp or blunt, the blades can be bent along the plane and at an angle to the axis.

The most commonly used are blunt-pointed scissors curved along the plane - Cooper's scissors. They have the advantage that they do not injure tissue as they move forward. They can also be used for blunt separation of tissues by spreading the blades. Cooper's scissors dissect the tissues pulled with the help of hooks or tweezers (Fig. 2.3).

Rice. 2.3. Surgical scissors:

1 - pointed straight lines; 2 - blunt curved

Rice. 2.4. The position of the scissors in the hand

Position in the hand: the nail phalanx of the IV finger of the working hand is located in the lower ring, the III finger lies on the ring at its junction with the branch, the II finger rests on the screw. In the ring of the upper branch is the nail phalanx of the first finger (Fig. 2.4).

AUXILIARY TOOLS

Auxiliary instruments are used to expand the surgical wound, fixate and retract tissues.

Tweezers

To capture tissues in the wound, tweezers are used, consisting of two elastically connected metal plates-branches.

Purpose: fixation of an organ or tissues when working with them; fixation of the needle at a certain moment of suturing.

Device: two springy steel plates diverging at an angle, anatomical ones with transverse notches at the ends, surgical ones with sharp teeth (Fig. 2.5). Anatomical tweezers capture tissues more gently, and surgical tweezers are more traumatic, but hold more securely.

Rice. 2.5. Tweezers:

a - anatomical; b - surgical

During operations on soft tissues, vessels, intestines, anatomical tweezers are used, for capturing denser tissues (aponeurosis, tendon, skin edges) - surgical.

Position in the hand: the tweezers are grasped, as a rule, with the left hand in the middle part of the plates, where there are corrugated areas in order to regulate the compression force of the spring and firmly fix the tissues.

Rice. 2.6. Fixing tweezers:

a - correct; b - wrong

The correct position of the tweezers in the hand is the position of the writing pen (Fig. 2.6).

Lamellar hooks (Farabefa)

Purpose: dilution of the edges of a deep wound near large vessels or removal of volumetric formations (for example, muscle bundles). The size of the selected hooks depends on the length of the surgical incision and the depth of the surgical wound.

Device: a plate with smoothed blunt edges and curved in the form of two Russian letters "G", connected by long parts (Fig. 2.7).

Position in the hand: usually the assistant grabs the hooks by the long crossbar of the letter "G" into fists, introduces the short crossbars

Rice. 2.7. Farabeuf hooks

into the wound, placing them symmetrically against each other at a right angle to the edge of the wound. The traction when diluting the edges of the wound should be uniform so as not to shift its direction.

Serrated hooks (blunt and sharp) Volkmann

Purpose: sharp hooks are used only for pulling and fixing the skin and subcutaneous tissue; blunt - for abduction of individual anatomical formations in the depth of the wound (vessels, tendons, etc.) (Fig. 2.8).

Device: a surgical tool in the form of a fork, the teeth of which (sharp or blunt) are smoothly curved at an angle of more than 90 °, and the handle is provided with a finger ring.

Position in the hand: the handle of the hook is captured in a fist, the second finger is inserted into the ring for a stronger fixation of the tool in the hand.

Rice. 2.8. Hooks notched Volkmann

Grooved probe

Purpose: used to protect deeper tissues from damage by a scalpel when dissecting lamellar anatomical formations (fascia, aponeurosis, etc.).

Device: a strip with a groove and blunted edges, turning into an expanded plate (Fig. 2.9).

Position in the hand: the probe is fixed by the plate between fingers I and II

auxiliary hand of the surgeon.

ruyut for the plate between I and II pas
Rice. 2.9. Grooved probe

Deschamps ligature needle

Purpose: holding ligatures under a blood vessel and other anatomical formations. According to the bend, the needle can be for the right and left hands.

Device: a curved blunt needle with a hole at the end and a long handle (Fig. 2.10).

Position in the hand: the handle of the tool is taken into a fist. The ligature is inserted into the hole, like a thread into a sewing needle. The disadvantages of the needle are the lack of a mechanical eye and the difficulty of threading, therefore, when working with a Deschamp needle, the ligature should be
inserted into the ear. Rice. 2.10. Deschamps needle

Kornzang (straight and curved)

Purpose: the tool is used to deliver sterile items in the operating room and dressing room with non-sterile hands (the forceps are placed in a disinfectant solution from the side of the sponges; the jaws and rings remain non-sterile). Korntsang can be used during a surgical operation if it is necessary to pass through the tissues bluntly (for example, when opening phlegmon and abscesses).

Device: long branches with rings, wide massive sponges in the form of olives and a cremaler lock (Fig. 2.11). Korntsang can be straight and curved.

Rice. 2.11. Korntsang straight:

1 - lock-cremalier; 2 - ring; 3 - branch; 4 - screw; 5 - sponges

Position in the hand: similar to the position of the scissors, only the curved ends of the tool are directed downwards (when feeding materials).

To open the cremaler lock, you should lightly press on the rings, move the branches along the plane, and only then spread them apart.

HEAT CLAMPS

Hemostatic clamps are among the most used and necessary tools.

Purpose: temporary stop of bleeding.

Device: a clamp of any kind consists of two branches connected by a screw, which divides the branches into a working part (sponges) and an annular part. (a stepped cremaler lock near the rings fixes the clamp in a certain working position, provides compression of the vessel without the constant participation of the surgeon's hands and allows you to adjust the force of this compression.

1. Billroth clamps - straight and curved, with notches on the jaws, but without teeth.

2. Kocher clamps - straight and curved, with notches and teeth at the ends of the jaws.

3. Clips "Mosquito" - straight and curved, with very narrow and short jaws (Fig. 2.12).

Rice. 2.12. Hemostatic clamps:

1 - Kocher clamp; 2 - Billroth clamp; 3 - clamp "Mosquito"

Position in the hand: the same as when using scissors and forceps.

CONNECTION TOOLS

SOFT FABRICS WITH MANUAL SEAMS

Surgical needles

Device: straight and curved steel rods, pointed at one end, with a specially designed eyelet on the other end for quick insertion of the thread. Currently widely used

and the so-called atraumatic disposable needles without an eyelet with a thread soldered into the end of the needle.

According to the shape of the section, needles are round - piercing and trihedral - cutting. Needles are also distinguished by length and degree of bend (Fig. 2.13).

Rice. 2.13. Surgical needles:

1 - cutting; 2, 3 - piercing curved and straight lines; 4 - atraumatic

The minimum dimensions of a curved surgical needle are 0.25 mm in diameter and 8 mm in length, the maximum are 2 mm in diameter and 90 mm in length. The needles are classified by numbers and types, and the suture material is selected accordingly.

Cutting triangular surgical needles with curvature of different curvature radii are used for stitching relatively dense tissues (skin, fascia, muscle, aponeurosis); piercing needles with a circular cross section - for connecting the walls of hollow organs and parenchymal organs. In the latter case, triangular needles cannot be used, since the sharp side edges of such a needle can lead to additional tissue damage. Atraumatic needles are used, as a rule, for applying a vascular or intestinal suture.

When working without a needle holder, use long, straight needles.

Needle Holders Gegara

Purpose: fixation of the needle for the convenience of suturing and eliminating the touch of fingers to the tissues.

Device: are similar in design to hemostatic clamps, but have more massive and shorter jaws, on the surface of which small cross cuts are applied to increase friction between the needle and jaws and firmly fix the needle (Fig. 2.14).

Rice. 2.14. Needle holder Gegara

Preparing the tool for work:

1. Grab the needle with the jaws of the needle holder at a distance of 2-3 mm from its tip - the narrowest part of the jaws (grabbing the needle with the wider part of the needle holder, closer to the screw, can lead to breakage of the needle). In this case, 2/3 of the length of the needle from the tip should be free and be to the left of the needle holder (for right-handed people), the tip of the needle is directed towards the loader.

2. To thread the suture thread into the needle, the long end of the thread is grasped into a fist together with the handles of the needle holder with the working hand, and with the other, its short end is pulled along the tool, wound behind the needle to the left of it and, using the needle as an emphasis, pull the thread to the right of the needle holder and bring it to the incision in the middle of the ear. With a tightly stretched thread, they press on the spring of the ear: the thread will separate the walls of the ear and pass into it automatically. The ends of the thread are straightened and connected together. One end of the ligature should be 3 times longer than the other

Position in the hand: The needle holder is grasped into a fist along with the long end of the ligature (if the surgeon works with an assistant, the assistant captures the long end of the ligature), the second finger is placed along the jaws of the instrument and fixed on the screw or jaw. The first finger is at the top. In the other hand chi-

Rice. 2.15. Threading the suture into the needle

rurg holds tweezers (surgical - for the skin, anatomical - for other tissues), fixing the tissue to be stitched or holding the needle.

SUTURE MATERIAL

Currently, more than 30 types of suture material are used.

According to the ability to biodegrade (resorbable), all suture materials are divided into absorbable And non-absorbable, by origin - natural and artificial according to the structure of the thread - on monofilament(homogeneous structure) and polyline(in cross section, consisting of many threads - twisted, braided, coated with polymeric material or without it).

Catgut- absorbable monofilament of natural origin. It is made from the muscular and submucosal layers of the small intestines of sheep or the serous membranes of cattle. Used catgut 9 numbers (? 000, 00, 0, 1-6). Thread thickness - from 0.2 to 0.75 mm. Catgut? 000-2 is used for ligation of small vessels, ? 3-4 - for submerged seams of soft tissues, ? 5-6 - for stitching large muscles, etc.

The timing of catgut resorption depends on the thickness of the threads, as well as on the condition of the tissues in the suture area. To slow down the resorption, the threads are treated with formalin, metallized (chrome-plated catgut).

Negative properties of catgut are low strength, allergenicity, high absorption capacity. Besides

it also causes a strong tissue reaction in the suture area. A special manufacturing technology makes it possible to reduce the negative qualities of catgut, so it is widely used in surgery.

Okcelon, caselon- absorbable artificial polythreads made on the basis of cellulose.

Vicryl, Dexon, Polysorb- absorbable artificial polythreads made on the basis of polyglycosides.

Absorbable threads made of artificial materials are non-toxic, biologically inert, stronger than catgut. In addition, during their manufacture, the terms of resorption and loss of strength, as well as elasticity, can be easily dosed.

Silk- non-absorbable natural suture material from which polyfilaments are made. Thread diameter - 0.3-0.7 mm. Silk is convenient for suturing and tying a knot (only two knots are enough). However, silk is very reactogenic, has a pronounced sorption capacity and wick properties. These shortcomings are currently eliminated with the help of a special coating.

Nylon, kapron, lavsan, prolene and other non-absorbable artificial sutures are available as braided, twisted, or monofilament sutures. They have high strength, elasticity, inert, indispensable for prosthetics, as well as for the seam of tissues that are under tension for a long time (aponeurosis, muscles, blood vessels, skin, etc.). However, many threads make it difficult for the surgeon to manipulate - at least three knots are required.

Metal used as a suture material is relatively rare. So, metal wire is used to connect bones, for example, for the seam of the sternum.

Tantalum paper clips loaded into a stapler for a mechanical suture (vessel, bronchus, intestine, etc.).

TECHNIQUE OF KNITTING LIGATURE KNOTS

All nodes used in surgical practice, double(Sometimes triple). The first knot is the main one and should be tightened as much as possible. The second knot secures the first, that is, prevents it from untying, weakening. The third knot is imposed

when using catgut and synthetic ligatures for greater strength, since these threads are very elastic and their surface is slippery.

In surgery, many types of knots are distinguished, but the basic ones are considered simple, marine and surgical (Fig. 2.16).

Rice. 2.16. Surgical knots:

I - simple; 2 - marine; 3 - surgical

Here is a classic way to tie a simple knot (Fig. 2.17).

The ends of the thread are grasped by hands (see Fig. 2.17; 1).

When forming the first (main) knot, the position of the ends of the threads in the hands is first changed - the left end of the ligature is taken in the right hand, and the right end in the left, and a cross of threads is formed (the thread in the left hand is placed on top of the thread fixed with the right hand) (see Fig. Fig. 2.17; 2). This crossover is fixed between

II and I fingers of the left hand (II finger on top, the cross of threads is pressed to the base of its nail phalanx on the palmar surface, see Fig.

rice. 2.17; 3).

I and II fingers of the right hand fix the end of the thread, pull it and bring it under the protruding end of the nail phalanx of the II finger of the left hand. The gap between the threads can be expanded with the third finger of the right hand (see Fig. 2.17; 4). Then, by turning the left hand with a nodding movement of the second finger, the end of the thread is passed into the slot (see Fig. 2.17; 5).

The knot is tightened (see Fig. 2.17; 6).

For the formation simple knot the second (fixing) knot is tied similarly to the first, but the second stage - shifting the ends of the ligatures - is not performed.

A simple knot is not strong enough, it slips, and can be stretched by pulling one end of the ligature from the loops of the other.

Rice. 2.17. Stages of tying a knot. Explanation - in the text

When forming maritime knot at the second stage, repeat all the steps from the beginning: capturing the ends of the thread, shifting the ends of the thread from hand to hand (cross), holding one of the ends of the thread into the slot, tightening.

Surgical the knot differs from a simple one in that when tying the first (main) knot, the right end of the ligature is wrapped twice around the left end. When tightened, such a first knot is more firmly fixed as a result of friction and does not relax.

before tying the second. This is the most reliable knot, but more cumbersome compared to a marine or simple one.

To successfully tie a knot, the ends of the threads must be constantly stretched.

The choice of the type of node depends on the stage of the operation, the suture material used.

In addition to the described classical method of knitting a knot, there are many other ways of knitting knots in surgical practice. However, as a result of any manipulations, one of the three types of nodes described above should be obtained.

INCECTION OF THE SKIN, SUBCUTANEOUS FAT FIBER AND SUPERFICIAL FASCIA

The size and direction of the skin incision depend on the choice of access to the organ, the purpose of the intervention, the topography of the organ and its projection on the skin.

Tools: scalpel belly or pointed. The scalpel is held in the right hand like a table knife. Before making an incision, it is necessary to determine the thickness of the subcutaneous tissue by taking the skin into a fold. The depth of the scalpel injection will depend on its thickness.

Due to the mobility of the skin with subcutaneous tissue before the incision, it must be fixed with fingers I and II of the left hand in the direction of the incision. The incision is made with one smooth movement of the scalpel, most often from left to right (Fig. 2.18). First, a scalpel is injected perpendicular to the skin surface to a depth corresponding to the thickness of the subcutaneous adipose tissue layer, then it is tilted at an angle of 45 ° and the incision is continued to the final

Rice. 2.18. The position of the scalpel in the hand and fixation of the skin during the incision

points. Punching is also performed perpendicularly. The incision of the skin, subcutaneous tissue and superficial fascia is performed in one step to ensure smooth incision edges. With repeated dissections of the skin, uneven edges are formed, small flaps that can become necrotic. If the subcutaneous tissue is poorly developed, it is safer to hold the scalpel at an angle of 45 ° from the very beginning, and then additionally cut the tissue at the beginning and end of the incision.

If the incision is made correctly, the depth of the wound is the same throughout, the underlying layers (proper fascia, aponeurosis) are not damaged.

TEMPORARY STOPPING OF BLEEDING FROM VESSELS OF SUBCUTANEOUS FATTY FIBER

Tools: notched Volkmann sharp hooks, surgical tweezers, gauze pads and tampons, Billroth and Kocher hemostatic clamps.

After dissection of the skin and subcutaneous tissue, the edges of the wound are expanded with Volkmann's serrated hooks, leading them alternately at both edges of the wound. After dilution of the edges of the wound, bleeding areas become visible. The blood is removed with tampons - gauze pads clamped into the hemostatic clamp. The wound is not wiped, but wetted. At the same time, especially strongly bleeding vessels become clearly visible. They must be clamped with a hemostatic clamp in the first place, that is, to carry out temporary stop of bleeding. The clamp is set perpendicular to the wall of the surgical wound, capturing the bleeding vessel and a small amount of fiber (Fig. 2.19).

Rice. 2.19. Stop bleeding. Clamping on a bleeding vessel

As a rule, the surgeon and assistant apply clamps to the bleeding vessels opposite the edges of the surgical wound, if necessary, turning it with tweezers. In this way, all bleeding vessels are sequentially clamped. Clamps may lie on the sides of the wound.

After that, in the already dry wound, the final stop of bleeding is carried out.

FINAL STOPPING OF BLEEDING FROM THE VESSELS OF THE SUBCUTANEOUS FIBRE

Suture material(catgut? 000-1, silk or synthetic absorbable threads 20-25 cm long), Cooper's scissors.

To ligate a vessel fixed with a clamp, the assistant lifts and turns the clamp in such a way that the end of its jaws (“nose”) becomes visible. The surgeon draws the ligature around the clamp so as to tie a knot on the vessel, under the "spout". To do this, first make the first knot at a distance from the vessel, and then lower the resulting loop with two index fingers to the jaws of the clamp, bringing it under the “nose” (Fig. 2.20). If the ligature is not correctly brought under the clamp, the jaws of the clamp may get into the knot, and the vessel will not be tied.

Then the main technique is performed, which requires well-coordinated, synchronous work of the surgeon and assistant. The surgeon begins to tighten the knot under the “spout”, and the assistant smoothly opens the clamp lock and spreads its branches. At this point, the surgeon finally tightens the knot, which should coincide in time with the removal of the clamp from the vessel. If the clamp is removed before the first knot is tightened, then the ligature will slip off the vessel.

Without loosening the tension of the ends of the threads, they tie a second, fixing knot (see Fig. 2.21).

Rice. 2.20. Stop bleeding. Applying a ligature under the "nose" of the clamp

Rice. 2.21. Tightening the ligature after removing the clamp

When using synthetic threads, a third knot is also tied. The ends of the ligatures are immediately cut with scissors very shortly, leaving 0.2-0.3 cm (the width of the tip of the scissors blade).

As a result of a correctly performed manipulation, the ligature is firmly fixed on the vessel and its surrounding tissues, and the bleeding is stopped.

DISSECTION OF OWN FASCIA AND APONEUROSIS

Tools: scalpel, Cooper scissors, anatomical tweezers, grooved probe.

The fascia and aponeurosis are dissected with a scalpel using a grooved probe to prevent damage to the underlying muscles and blood vessels. First, a small puncture or incision is made with a scalpel, a grooved probe or tweezers is inserted through the hole formed and the fascia is lifted on it. With the correct insertion of the probe, the fascia stretched on it is clearly visible, and the probe often shines through under it.

The fascia is cut along the grooved probe with a scalpel, setting its blade with the cutting edge up and away from you (Fig. 2.22).

The fascia can be dissected with Cooper's scissors. Closed blades of scissors are inserted into the formed hole and they are stupidly

Rice. 2.22. Opening of the aponeurosis

separating deeper structures. Then, one blade of scissors is inserted under the fascia, the fascia is lifted with it and dissected.

DISCONNECTION OF MUSCLES IN THE STRUCTURE OF MUSCLE BUNKS. MUSCLE CUTTING

Tools: scalpel, anatomical tweezers, Cooper scissors, Faraboeuf hooks.

Muscle bundles, as a rule, try not to dissect. After careful dissection of the perimysium with closed Cooper's scissors, the muscle bundles are bluntly separated. This can be done by spreading the jaws of the scissors. If the muscles are located in several layers, then they should be separated sequentially, since the direction of the muscle bundles may not coincide. Between the parted fibers of the muscle, blunt serrated hooks or lamellar Farabeuf are inserted.

If it is impossible to bluntly separate the muscle bundles, the muscles are dissected with a scalpel.

STOP BLEEDING FROM THE MUSCLE (TEMPORARY AND FINAL)

Tools: Billroth hemostatic forceps, Hegar's needle holder, piercing curved needles, absorbable suture material, Cooper's scissors.

Since muscle tissue is more elastic and denser than adipose tissue, it is easy to stop bleeding from a vessel.

bandaging, as when stopping bleeding from the subcutaneous tissue, fails: the ligature will slip off the muscle tissue. Use a special method of fixing the ligature - stitching(Fig. 2.23).

A Billroth clamp is applied to the bleeding area of ​​muscle tissue across the fibers. Holding the clamp, the surgeon, with the help of a needle holder, passes the needle through the thickness of the muscle tissue behind the clamp as close as possible to it (Fig. 2.23; 1), fixing the long end of the ligature, and releases it from the needle. The assistant grabs the clamp by the rings and unfolds it so that the “nose” is clearly visible to the surgeon. The surgeon brings one end of the ligature under the "nose" and ties one knot (Fig. 2.23; 2), then draws one end of the ligature around the clamp from the side of the rings and ties another knot (Fig. 2.23; 3). At the moment of its tightening, the assistant

Rice. 2.23. Stopping bleeding from the muscle with stitching. Explanation - in the text

smoothly removes the clamp, releasing the captured muscle tissue, and the surgeon pulls the knot (Fig. 2.23; 4).

Without loosening the tension of the threads, the surgeon ties a fixing knot, and, if necessary, another one.

With proper manipulation, the ligature does not slip off the tissues, the bleeding is stopped.

CONNECTION OF SOFT TISSUES OF THE SURGICAL WOUND USING MANUAL SUTURES

Suturing is the most common way to connect tissues. Seams are of various types: nodal, continuous, mattress, etc. (Fig. 2.24).

A B C

Rice. 2.24. Types of seams:

A - nodal; B - continuous; B - mattress

The knotted suture consists of separate stitches, each of them is superimposed with a separate ligature 20-25 cm long. Each stitch includes 4 moments: injection, injection, pulling the ligature and tying it.

Interrupted sutures are usually applied to the skin, aponeurosis and muscles.

The tissue is fixed with tweezers, and the tip of the needle is directed perpendicular to the pierced surface next to the tweezers.

A continuous seam is applied with one thread, the length of which depends on the length of the seam (30 cm or more). After the first stitch is applied, the thread is pulled through the fabric, leaving a small end, which is tied to the main thread. With this main thread, the entire seam is applied to the end. When applying the last stitch, the thread is not pulled to the end, and the unstretched part is folded in half and tied to the remaining free end.

The interrupted suture is less traumatic and does not cause severe tissue ischemia.

A continuous suture provides a tighter matching of the wound edges and hermeticism, but causes ischemia, and when at least one of the stitches is cut, the wound edges diverge.

Currently, numerous modifications of both interrupted and continuous sutures are used in surgery. The choice depends on the specific surgical situation (the structure and function of the organ, the type of tissue, the nature of the incision, etc.). Connection of muscles with interrupted catgut sutures is more often used after blunt separation of muscle bundles. Interrupted catgut sutures are carried out with a stabbing or cutting needle through the entire thickness of the severed muscles. Muscle bundles are brought together until the edges touch. Strongly tighten the threads should not be, as the knots can cut through, injure the muscle bundles.

U-shaped interrupted sutures on the muscle are used both for blunt separation of muscle bundles and for their transverse dissection. First, the “upper” edge of the muscle is stitched, and then the “lower” one, passing the needle “towards itself”. Using tweezers, change the position of the needle in the needle holder so that the needle point is directed to the right side. Stepping back 1-1.5 cm to the left, first the “lower” and then the “upper” edge of the muscle are stitched, passing the needle “away from you”. On the "lower" edge of the muscle remains the crossbar "P". On the "upper" edge, two ends of the ligature remain, which are tied (Fig. 2.25). The knot should be located at a distance of 1-2 cm from the edge of the wound on the surface of the muscle.

Fascia and aponeuroses are connected with a stabbing needle with non-absorbable suture material using interrupted sutures. When stitching

Rice. 2.25. U-shaped seam on the muscle

In the case of connective tissue formations, one should try not to stitch the formations lying deeper, for which the edges of the stitched tissues are lifted with tweezers. The distance between the seams is 0.5-1.5 cm.

With proper stitching of the fascia and aponeuroses, their edges are in close contact, the suture line is mobile in relation to the formations located deeper.

CONNECTION OF SKIN EDGES AND SUBCUTANEOUS ADIPOSE FIBER

This manipulation is performed with interrupted sutures using non-absorbable suture material and a slightly curved cutting needle. The suture should ensure the connection of the edges of the wound without the formation of a "dead" space (residual cavity in the tissues), where tissue fluid can accumulate. This is achieved by precise matching of the layers of the wound (subcutaneous fatty tissue and skin) and stitching to its entire depth (Fig. 2.26).

Rice. 2.26. Correct (a) and incorrect (b) suturing of the skin

A more accurate comparison of the layers of the wound is achieved by two-stage stitching, in which the needle is inserted from one edge of the wound and punctured from the other in two steps.

First, the edge of the skin wound is captured with tweezers, an injection is made perpendicular to the skin at a distance of 1-1.5 cm from the edge, placing the tissue on the needle with tweezers, and at the same time, with a supinating movement of the brush, the needle is passed through the skin and subcutaneous tissue, immersing as much as possible (to the place of fixation in the needle holder) through the entire thickness of the skin. With proper manipulation, the needle passes through the tissue without much effort. Then they pick up the needle with tweezers (not with fingers!) At the place of its exit from the subcutaneous tissue, the needle holder is moved towards the tip of the needle and the needle is fixed with sponges on the other side of the tissue to be sewn (as far as possible from the tip), while the hand with the needle holder is turned so that I finger was located below. The needle and thread are pulled out of the sewn tissue. In this case, the needle moves inside the fabric along a curve, without cutting it with the sharp edges of the lock. Holding the needle with tweezers, it is fixed with the sponges of the needle holder in the same way as in the starting position. The needle is brought with a tip to the puncture point of the opposite edge of the subcutaneous tissue and skin and the supinating movement of the brush is repeated. Then, having fixed the edge of the skin with tweezers, they grab the needle from the skin in the same way as in the first stage (I finger is pointing down), and with a short sharp movement the needle is removed from the tissues, leaving a ligature in them. The assistant holds the long end of the ligature, and the surgeon pulls the needle holder with the needle towards him until the short end of the thread comes out of the needle.

With a significant thickness of the subcutaneous tissue, first sutures are placed on a deep layer of fiber (catgut or thin nylon), and then silk sutures are placed on the skin. Interrupted sutures are placed at a distance of 1.5 cm from each other and tightened until the skin edges touch, without squeezing the tissues. When tying the knot, the assistant matches (adapts) the edges of the wound with the help of two surgical tweezers so that the edges are slightly inverted above the skin surface (Fig. 2.27). The suture knot should be placed to the side of the wound line.

Stitching both edges of the wound in one step recommended when the wound is superficial.

The right (or opposite) edge of the skin wound is fixed with surgical tweezers, lifting the skin towards the needle. The point of the needle is placed perpendicular to the surface to be pierced.

Rice. 2.27. Comparison of the edges of the skin wound when tying knots

at a distance of 0.5-1 cm from the edge of the wound (depending on the thickness and turgor of the skin) and advance it in an oblique direction with a rotational movement of the brush through the skin, subcutaneous tissue and superficial fascia, gradually moving the brush from the position of pronation to the position of supination.

At the same depth, the needle is passed strictly symmetrically through the same layers of the opposite wall of the wound, fixing the skin and the needle alternately with tweezers. Surgical tweezers injure the skin, so do not strongly squeeze their branches. The needle holder is moved to the needle tip from the other edge of the wound, the needle is captured at the point of its exit from the skin and removed from the tissues. Holding the long end of the thread, pull the needle holder with the needle towards you and release the thread from the needle.

The distance between the nodes is 0.5-1 cm, depending on the thickness of the skin and subcutaneous tissue (the thicker they are, the greater the distance).

The nodes are placed on the side of the wound so as not to disrupt the adaptation of its edges and to avoid the pressure of the node on the scar tissue.

If the surgeon works alone, then after applying and tying all the sutures, he, using two surgical tweezers, eliminates defects in matching the edges of the wound (“plowing” the edges on top of each other, tucking the edges in the form of a roller).

Threads are usually cut after all sutures have been applied. The length of the remaining ends of the threads after cutting them off should be 0.8-1.0 cm for the convenience of subsequent removal of sutures.

With the correct execution of interrupted sutures, the edges of the wound touch “layer to layer”, are not tied together with knots, are not tucked inward, are not “wrapped” on top of each other, like the floors of clothes.

However, it is not always possible to clearly compare the layers of the wound edges, which leaves a rather rough, noticeable postoperative scar. A thin, almost imperceptible scar is formed when the edges of the skin are sutured with a Donati interrupted adaptive suture. The seam technique is shown in fig. 2.28.

A b

Rice. 2.28. Nodal adaptive seam according to Donati:

A- the scheme of the needle and thread through the tissue;

b- view of connected edges of the wound after tying the knot

REMOVAL OF NODAL SKIN SEAMS

Tools: surgical tweezers, scissors. To remove the interrupted suture, fix the ends of the suture threads and the knot with surgical tweezers, lift and tighten them in the direction of the skin scar so that a wet white part of the thread 0.1-0.2 cm long appears from the ligature canal. This part is cut with scissors, and remove the thread from the channel with tweezers (Fig. 2.29). At the same time, only that part of the thread that was there passes through the tissues, and polluted Rice. 2.29. Removal of nodal leather (outer) sections of thread sutures pass.

PRIMARY SURGICAL TREATMENT OF WOUNDS

There are three classical types of wound healing: healing by primary intention; secondary healing and healing under the scab.

Healing by first intention characterized by fusion of the edges of the wound by the connective tissue organization of granulation tissue, which firmly connects the walls of the wound. The scar after wound healing by primary intention is even, smooth, almost imperceptible.

Healing by primary intention is possible with close contact of the wound edges, maintaining their viability and, most importantly, wound asepticity. Postoperative wounds or small incised wounds heal by primary intention, when the edges are no more than 1 cm apart from each other.

Wound healing by secondary intention occurs with extensive wounds, the presence of non-viable tissues in the wound, the development of infection. In some areas of the bottom of the wound, islands of granulations appear, which gradually fill the entire wound and begin to reorganize into a scar. In parallel, there is a process of epithelialization from the edges of the wound.

Wound healing by secondary intention always ends with the formation of a more or less pronounced scar. The more severe the infection, the more severe the scar will be.

Healing under the scab usually occurs with minor abrasions, abrasions, small burns of I-II degrees. The scab is formed as a result of coagulation of the outflowing blood and lymph, under it there is a rapid regeneration of the epidermis, after which the scab is rejected. If the infection has not joined, then after the wound has healed, there is no trace left under the scab.

Thus, wound healing is determined by the presence or absence of infection in the wound. The degree of wound infection, in turn, depends on the presence of necrotically altered tissues in the wound.

Under primary surgical treatment gunshot and traumatic wounds understand surgical intervention, which consists in excising its edges, walls and bottom with the removal of all damaged, contaminated and blood-soaked tissues, as well as foreign bodies.

The purpose of the operation is to prevent wound infection and acute suppuration of the wound and, consequently, rapid and complete wound healing.

Primary surgical treatment of the wound is performed in the first hours after the injury. Even with indirect signs of necrosis (crushing, contamination, isolation of damaged tissues), damaged tissues are excised.

Surgical treatment of the wound in the first days after injury with direct signs of necrosis (decay, disintegration of necrotic tissues) and suppuration of the wound is called secondary.

For good access, the skin edges of the wound are excised with two semi-oval incisions within healthy tissues, taking into account the topography of large anatomical formations in this region and the direction of the skin folds (Fig. 2.30).

When excising the skin, its crushed, crushed, thinned and sharply bluish areas should be removed. Cyanosis or severe hyperemia of the skin usually indicates its subsequent necrosis. The criterion for the viability of the skin edges of the wound should be considered profuse capillary bleeding, easily determined when making an incision.

The viable muscle is shiny, pink in color, bleeds profusely, contracts when cut. The dead muscle is often

disintegrated, cyanotic, does not bleed when cut, often has a characteristic “boiled” appearance.

These signs, with some experience, almost always make it possible to correctly determine the boundary between the living and the dead and quite completely excise non-viable tissues. With combined injuries, when large vessels, nerves, bones are damaged, the primary surgical treatment of the wound is carried out in a certain sequence.

After excision of non-viable tissues, bleeding is stopped: small vessels are ligated, large vessels are temporarily captured with clamps.

Rice. 2.30. Excision of the edges of the wound during primary surgical treatment

In case of damage to large vessels, the veins are tied up, and a vascular suture is applied to the arteries.

The primary suture of the nerve in the wound is applied if it is possible to create a bed for the nerve from intact tissues.

A bone wound with open fractures of any etiology should be treated as radically as a soft tissue wound. The entire area of ​​crushed, devoid of periosteum bone must be resect within healthy tissues (usually 2-3 cm away from the fracture line in both directions).

After the primary surgical treatment, the wound is sutured in layers, the limb is immobilized for the period necessary for bone consolidation, nerve regeneration, or strong tendon fusion. In doubtful cases, the wound is not tightly sutured, and only the edges of the wound are pulled together with ligatures. After 4-5 days, with a favorable course of the wound process, the sutures can be tightened; in case of complications, the wound will heal by secondary intention. Drainages are left in the corners of the wound, if necessary, using active drainage - the introduction of antiseptic solutions through the drainage tube and suction of the liquid along with purulent exudate.

Vascular suture

The circular wrapping suture according to Carrel is the prototype of all numerous modifications of the vascular suture. If the artery is damaged, if it is possible to bring its ends together, vascular clamps are applied above and below the place of the future suture. After excision of the damaged areas and removal of the adventitia (2-3 mm on each side), the ends of the artery are brought together and 3 U-shaped sutures-holders are applied to them using atraumatic needles. In this case, the edges of the vessel turn inside out, and here the intima is tightly adjacent to the intima. The section of the vessel between the two nearest holders is sewn with a twisted seam, passing the needle from the outside to the inside. Usually they sew from top to bottom, that is, “on themselves”. Having finished sewing one side, the ligature is tied to one of the ends of the holder, making sure that the continuous seam is not pulled or corrugated. Then the other two faces are sewn in the same way. Before tying the last stitch, the distally applied vascular clamp is slightly opened to allow blood to displace air. Having tied the last knot, completely open the distal vascular

clamp, the bleeding areas of the vascular suture are pressed with a finger for several minutes, after which the bleeding usually stops. If the bleeding does not stop, additional interrupted sutures are applied (Fig. 2.31).

Currently, surgeons often use the Carrel vascular suture in Morozova's modification. According to this modification, two sutures-holders are applied, using a ligature with a needle as the third, with which they begin to sew the vessel.

Rice. 2.31. Stages of performing a vascular suture according to Carrel:

1 - 3 seam-holders superimposed on the sewn ends of the vessel; 2 - overlay

a twisted seam between two holders; 3 - final view of the vascular

anastomosis

If it is not possible to bring together the edges of the damaged artery, they resort to prosthetics using either an autovein or a synthetic prosthesis. The technique for connecting the artery to the graft remains the same.

When a part of the circumference of the artery is injured, a lateral vascular suture is applied, continuous or nodal.

The mechanical suture with the Gudov vasostapling apparatus, quite popular in the 60s of the twentieth century, is not currently used due to the difficulties of preparing arterial edges for suturing.

In conclusion, it should be noted that the vascular suture is the basis of all reconstructive cardiovascular surgery.

Operations on the veins of the extremities

The most common intervention on the veins is venipuncture, with the help of which medicinal substances are administered, blood is taken for examination, venography is performed, probing of the heart cavities.

Most often used for puncture v. intermedia cubity. If this vein is poorly expressed, then you can use v. cephalica, v. basilica at the level of the cubital fossa.

After applying a tourniquet in the middle third of the shoulder, the puncture site is treated with alcohol or an alcohol solution of iodine. The puncture of the contoured vein is performed either only with a needle, or with a needle put on a syringe. The needle is injected with the right hand, and the skin at the puncture site is pulled with the thumb of the left hand. If the needle without a syringe is inserted correctly, then drops of blood appear in the cannula of the needle, then you need to quickly attach a syringe or drip system to the needle. If a needle is injected with a syringe attached, blood appears in the syringe.

The tourniquet is removed, the needle is slightly advanced along the vein and the solution is slowly injected. When taking blood for analysis, the tourniquet is not removed until the end of the procedure.

Exposing and cutting a vein is called venesection. Indications for venesection are continuous intravenous infusions, as well as single-stage infusions in cases where it is impossible to puncture the vein. An incision is made in the skin and subcutaneous tissue 3-4 cm long along the projection of the vein. Allocate a vein from the surrounding tissue. Two ligatures are brought under the selected vein, the distal vein is tied up. The vein is raised, an incision is made on its front wall with scissors, through which a needle or catheter is inserted into the lumen of the vein, on which a proximal ligature is tied with one knot. A system for transfusion of blood or solutions is attached to the needle (catheter).

Tendon suture

The indication for suturing the tendons is most often trauma. The primary suture is applied in the first 6 hours after injury, under the protection of antibiotics, this period can be extended up to 24 hours. With heavily contaminated wounds and significant tendon defects, the primary suture cannot be applied. The secondary suture can be early (up to 2 months after injury) or late (more than 2 months).

The technique of suture of the tendon located outside the synovial sheath is simpler. The ends of the crossed tendon are pulled up and brought in behind each other, after which they are sewn through or with side seams (overlap). The injured limb is immobilized.

If the tendon located inside the synovial sheath is damaged, the task of the surgeon becomes more complicated, since there should be no knots on the surface of the tendon. In this regard, quite a few methods have been proposed in which the knots remain between the connected ends of the tendon - intra-stem adaptive sutures (Fig. 2.32).

Nerve suture

Indications for surgical interventions on the nerves of the extremities are usually their complete or partial interruption, tumors and neuromas. If the integrity of the nerve fibers is violated, their fusion by primary intention is excluded.

The purpose of the operation of suturing the ends of the damaged nerve is to bring the central and peripheral ends closer so that the axons growing from the central end of the nerve penetrate into the sheaths of the peripheral end, in which the axons and their myelin sheaths gradually undergo Wallerian degeneration (Fig. 2.33). During the initial surgical treatment of the wound, the ends of the dissected nerve are sutured. Pe-

Rice. 2.33. Nerve suture (schematically)

Before suturing, the damaged ends of the nerve are cut off with a sharp scalpel or a safety razor blade in one motion. With an atraumatic needle with the thinnest synthetic thread, the epineurium is sutured first at one and then at the other end, the same is done on the opposite side of the diameter. Carefully pulling the threads, bring the ends of the nerve together so that there is a minimum gap between them. Knots are tied. Depending on the diameter of the nerve, several more sutures are placed on the epineurium between the first two nodes. After suturing the nerve, the limb is fixed with a plaster cast for 3-4 weeks.

knotted seams apply at a distance of 1-2 cm from each other. The knot is tightened until the edges of the wound touch. A closer location and tight tying of sutures lead to malnutrition and necrosis of the wound edges.

Knots you need to tie so that they are on one side of the wound, and not above it. When tying knots with two surgical tweezers, it is necessary to match the edges of the wound and hold them in this state until the first knot is tightened. Comparison of the edges of the wound should be done without tension. With the violent approach of the edges of the wound, the sutures are cut, the edges of the wound diverge. It is possible to avoid tension of the edges of the wound by layer-by-layer suturing of the wound using lamellar U-shaped sutures tied with balls, buttons, tubes, etc. If the edges of the wound are excessively raised, of unequal thickness, and are difficult to compare, then nodal adaptive sutures are used.

McMillan-Donati suture- vertical U-shaped seam. The needle is injected at a distance of 2-3 cm from the edge of the wound and carried outward. Having reached the base of the wound, the needle is turned to the midline of the wound and removed at its deepest point. Symmetrically pierce the other edge of the wound. The points of injection and puncture of the needle should be at the same distance from the edges of the wound. Then, on the side of the needle pricking, a few millimeters from the edge of the wound, the needle is pricked again so that it comes out in the middle of the dermis layer. On the opposite side of the wound edge, the needle is passed in the opposite direction. The knot is tied closer to the place of the first injection of the needle, while the edges of the wound are slightly raised, which improves their comparison.

Seam Struchkov- a multi-stitch adaptive suture, differs from the McMillan-Donati suture in that, with a large depth of the wound, its edge is stitched with several stitches.

Gillis suture- nodal adaptive seam. The needle is injected at the edge of the epidermis, widely capturing the dermis and subcutaneous tissue. Poke out the needle in the opposite direction.

Intradermal horizontal U-shaped suture. Performed with small superficial wounds with an atraumatic needle with a thin (3/0 -5/0) thread. The needle is injected at a distance of 2-3 cm from the edge of the wound, and you are injected through the middle of the dermis. On the other edge of the wound, the needle is carried out in the opposite direction, sticking from the middle of the dermis, and sticking out at a distance of 2-3 mm from the edge of the wound, then the needle is turned, stuck at a distance of 4-6 mm from the place where the thread was taken out and the next stitch is applied in the opposite direction.

Halsted's seam- continuous internal adaptive seam. Performed using an atraumatic needle with a thin but strong monolithic thread. The needle is injected from the side of the epidermis at a distance of 1 cm from the corner of the wound. A needle is injected in the middle of the dermis layer. The free end of the thread is tied on a gauze ball. The needle is injected and punctured along one edge of the wound, passing it only through the dermis in a horizontal direction. The next stitch is made on the other edge of the wound, and the place where the needle is inserted on this edge should correspond to the place where it is punctured on the other edge of the wound. When tightening the thread, these two points should match. To do this, after each stitch, the thread is pulled, thereby bringing the edges of the wound closer together. The needle is injected at the other edge of the wound exactly opposite the exit point of the thread. On both sides, the same amount of dermis is captured in the suture.

After suturing the wound the needle is punctured on the skin 1 cm away from the corner of the wound. The thread is tied on a gauze ball.

When stitching the edges of long wounds the thread is interrupted every 6-8 cm. At the same time, one of the loops is brought to the surface and a rubber tube or gauze ball is placed in it.

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