The imposition of skin sutures. Surgical sutures. Use of stitches in dentistry

Federal Agency for Health

and social development

GOU VPO "Izhevsk State Medical Academy"

Department of Operative Surgery and Topographic Anatomy

Department of Hospital Surgery

Z.M. Sigal, F.G. Babushkin ,

A.N. Nikiforova, B.B. Kapustin

SURGICAL SUTURES

Tutorial

Izhevsk 2009

UDC 617.5 - 089 (075.8)

BBK 54.54Ya73

C35
Authors - Compilers : Honored Scientist of the Russian Federation and UR, Head. Department of Operative Surgery and Topographic Anatomy, Doctor of Medical Sciences, Professor Sigal 3. M .; Candidate of Medical Sciences, Associate Professor of the Department of Operative Surgery and Topographic Anatomy Nikiforova A.N .; Ph.D., senior lecturer of the Department of Operative Surgery and Topographic Anatomy Babushkin FG; Head of the Department of Hospital Surgery, Associate Professor Kapustin B.B.

С 35 Surgical sutures. Tutorial

(Author-comp. Z.M.Sigal, F.G. Babushkin, A.N. Nikiforova, B.B. Kapustin. - Izhevsk, 2009. - 136 p.)
The tutorial presents skin sutures, muscle sutures; seams of fascia and aponeuroses, tendons; bone connection methods; intestinal sutures, sutures of the liver and bile ducts; vascular sutures and nerve sutures.

To control the assimilation of the material, tasks were developed in a test form.

The textbook is intended for senior students of the medical faculty who study questions of operative surgery.

INTRODUCTION ……………………………………………………	2
CHAPTER 1 SKIN SEAM ………………………… .. …… ...	3

CHAPTER 2 MUSCLE SEAM …………………… ... …… ...	13

CHAPTER 3 SEAM OF FASCIOS AND APONEUROSIS ... ... ... ... ...	21
CHAPTER 4 SEAM OF TENDENCY ……… .. ……………… ..…	26
CHAPTER 5 BONE SEAMS …………………… .. ……… ...	37
CHAPTER 6 MECHANICAL SEAM ……………… .. …… ..	43
CHAPTER 7 INTESTINAL SEAMS, CLASSIFICATION ... ...	45




CHAPTER 8 SEAM OF FAT CELL AND PADDERS	95
CHAPTER 9 SEAM OF HEPATIC COOLER ……………… ..	96
CHAPTER 10 LIVER SEAM ……………………… .. ……… ...	97
CHAPTER 11 VASCULAR SEAMS, CLASSIFICATION ...	105



CHAPTER 12 NERVE SEAM, CLASSIFICATION …… ... ……	120
CHAPTER 13 TASKS IN TEST FORM .................... ... ... ...	124
	136

INTRODUCTION

Tissue joining can be done manually by suturing, creating a mechanical suture using various staplers, or gluing (polymerization of liquid monomers after contact with tissue fluids, accompanied by rapid hardening). The most general principle of making any suture is to respect the edges of the wound being sutured. In addition, the suture should be applied, trying to accurately match the edges of the wound and the layers of the organs being sutured. The choice of this or that method depends on the type of tissue, the complexity of the operation and the equipment of the clinic. Mainly interrupted and continuous sutures are used.

Depending on the threading, the interrupted sutures are divided into 2 groups:

vertical;
horizontal.

Vertical interrupted seams are circular (circular) and U-shaped. A horizontal interrupted suture is usually applied in a U-shape.

the needles are made at a distance of 1 cm from the edge of the incision. The needle is then sequentially passed through the thickness of the dermis, capturing sections of the same length on each side so that the injection site of the needle on one side coincides with the injection site on the other. At the same time, the ends of the thread are pulled in different directions, bringing the edges of the wound closer together. The beginning and end of the thread is tied on a gauze ball, roller or button for convenience.

When suturing a deep wound, the subcutaneous tissue is first stitched with a continuous suture, capturing in each stitch such an amount of tissue that would correspond to the size of the needle and the degree of its curvature. The seam should run parallel to the skin surface, and the start of the stitch in and out on each side should be symmetrical. The ends of the thread are brought out onto the skin, pulled until the edges of the wound come together and held in this position. After that, an intradermal suture is applied according to the rules described above. The ends of the threads are tied on one side on a ball, plate, roller or button; then, pulling on the ends of the threads at the other end of the wound, they achieve complete alignment of the edges of the skin and also fix the knot.

In some cases (with a postoperative wound of considerable length), a continuous overlap suture is used (according to Multanovsky).

Seam Multanovsky.

The continuous twisted suture of Multanovsky is often used to suture wounds of the scalp with a kegtut. This eliminates the need to remove stitches, a satisfactory cosmetic effect and quick recovery are achieved.new microcirculation at the edges of the wound (Fig. 3).

Rice. 3. Seam of Multanovsky.
One-sided mattress seam.

An injection and an injection are made from one side of the wound through the entire thickness of the skin, on the other hand, the needle only captures soft tissues at the same depth, but it is not brought out to the surface of the skin. Used to fix individual especially sensitiveplaces and when it is difficult to match the edges of the skin wound (Fig. 4).

Rice. 4. One-sided mattress seam.
If it is difficult to match the edges of the skin wound, mattress sutures can be used.
Horizontal mattress or U-shaped seam.

It is applied if you need to raise the edges of the wound. It is differentfrom the vertical mattress seam in that the thread on the skin surface lies parallel to the incision line (Fig. 5).

Fig. 5. The imposition of a U-shaped seam on the skin.
When a conventional interrupted suture is applied to a deep wound, a residual cavity may be left (Fig. 6).

Fig. 6. "Residual cavity" when applying a skin suture

to a deep wound.
In this cavity, wound discharge can accumulate and lead to wound suppuration. This can be avoided by suturing the wound in several floors (Fig. 7).

Rice. 7. For deep wounds, you can apply it

floor-by-floor suturing.

TO Besides the floor-by-floor wound suturing, in such situations, a vertical mattress suture is used (according to Donatti) (Fig. 8). An intermittent suture, when applied, the needle is removed from the tissue to the same side of the edge of the wound where it is inserted. In this case, the thread lies perpendicular to the edges of the wound. The next stitch is made on the other edge of the wound. The alignment of the wound edges is very good. Usually used vertical mattress seams McMillan or Donatti. The McMillan suture differs only in that, in addition to the subcutaneous tissue, it additionally captures part of the deep-lying tissues.

Rice. 8. Vertical mattress seam according to Donatti.
In this case, the first injection is made at a distance of 2 cm from the edge of the wound, the needle is drawn as deep as possible to capture the bottom of the wound. An injection on the opposite side of the wound is made at a distance of 2 cm symmetrically injected. When holding the needle in
10

in the opposite direction, the puncture and the puncture are at a distance of 0.5 cm from the edges of the wound so that the thread passes through the layer of the skin itself. When suturing a deep wound, the threads should be tied after all the sutures have been applied - this facilitates manipulation in the depths of the wound. The use of Donatti's suture allows you to match the edges of the wound with a large diastasis.
1.1 INSIDE SEAMS.

Indications: hidden (intradermal) sutures are preferable for plastic surgery (tension on the edges of the wound decreases, there are no suture marks on the skin).

Requirements: when applying intradermal continuous sutures (there can be both truly intradermal and subcutaneous), the stitches are applied without bringing the thread to the surface of the skin, parallel to it and at the same depth. It should, however, be well remembered that inaccurate alignment of the wound edges leads to the formation of a rough scar.

Surgical instruments: general surgical scalpels, fine forceps, scissors, hemostatic clamps, button hooks, microsurgical and long thin needle holders, atraumatic needles.

Suture material: absorbable materials are used (polysorb, biosin, monosof, vicryl) andnon-absorbable materials (polypropylene, polyamide).
Superficial single row intradermal technique

continuous seam.
The suture begins at one end of the wound, injecting a needle into skin to the middle of the dermis, 1 cm from the edge of the wound. The suture is continued parallel to the skin surface at the same height, capturing the same amount of dermis on both sides. The point where the needle is pierced is always located opposite the point where it is pierced so that when the thread is tightened, these two points coincide.

If the suture is not applied at the same height, then the edges of the epithelial layer do not exactly come together. Used for superficial skin wounds that extend to the subcutaneous tissue; for a more complete convergence of the wound edges, sterile "Steril-strip" is glued, they also provide suture fixation. A continuous intradermal suture has recently been used as an alternative to an interrupted suture for suturing wounds. Its features are very good adaptation of the wound edges, good cosmetic effect and less disturbance of microcirculation in the wound edges. The suture thread is passed in the layer of the skin itself in a plane parallel to its surface (Fig. 9).

Fig. 9. Intradermal suture on use

monofilament thread.
To avoid breaking the thread, it should be tightened after each needle puncture. With this type of seam, it is better to use synthetic monofilament to facilitate thread pulling. If you use a multifilament thread, then after every 6-8 cm of the seam you need to poke out onto the skin (Fig. 10). The thread is subsequently removed in parts between these punctures.

Fig. 10. When using a multifilament thread, it is necessary to poke out on the skin every 6-8 cm.

The skin suture must be applied very carefully, especially in women, since the cosmetic result of any operation depends on it. This largely determines the authority of the surgeon in patients. Inaccurate matching of the wound edges leads to the formation of a rough scar. Excessive efforts when tightening the first knot located along the entire length of the surgical scar. It can deliver to the sick not only myphysical, but also physical suffering.

The cosmetic suture after the operation allows you to mask the trace of the surgical intervention as much as possible. But why sometimes a rough scar in the form of a fish skeleton or just an inaccurate uneven line remains on the operated area? The fact is that a cosmetic suture can not always be applied due to the peculiarities of the operation performed (incision site, severity of the wound). Therefore, sometimes it is necessary to mask surgical sutures with the help of additional cosmetic procedures.

Suture materials for cosmetic seam

The requirements for surgical sutures were formed during the entire process of the development of the operating business. Initially, they had to be just strong in order to exclude the risk of dehiscence of the wound and getting inside the infection. Then they began to attach importance to the appearance, especially in the visible areas of the body (face, neck). Gradually, not only various types of surgical sutures began to appear, but also suture materials, as well as needles, on which the visibility of the future scar also depends.

By the way! A cosmetic suture differs from a conventional surgical suture precisely in its appearance. It is almost invisible and represents the thinnest line running along the natural outlines (sometimes it resembles a wrinkle or fold, for example, on the neck or in the lower abdomen).

Self-absorbable sutures that do not require removal have become especially popular today. They are organic in nature, therefore, over time, after suturing, they simply disappear under the influence of biological fluids (blood, lymph) and enzymes, in particular proteins. Such threads are often used in dentistry so that the doctor, removing the sutures, does not once again disturb the delicate tissues of the gums.

Cosmetic self-absorbable sutures are often applied using a suture material called MedPHA. The last three letters mean that the threads are made on the basis of polyhydroxyacetylic acid.

Initially, this thread is very strong and allows you to tightly sew the edges of the leather. On the 20th day, about 50% of its strength remains, but this is enough to hold an already healed wound. MedPHA completely resolves in 60-90 days.

There are also three other types of self-absorbable surgical sutures used for cosmetic sutures.

Catgut. Resorption time is from 1 to 4 months, depending on the diameter of the thread and the operated area.
Lavsan. It dissolves faster than catgut: from 12 to 50 days.
Vicryl. Analogue of catgut. The vicryl suture dissolves in an average of 70-80 days.

Types of stitches in surgery

Of all the surgical sutures, only a few are cosmetic. And the doctor is not always able to impose them. After all, the elasticity of the skin and its surface tension depends on the operated area and the depth of the wound.

When evaluating a wound, the surgeon first tries to determine if a cosmetic suture will work. Moreover, it does not matter on which part of the body the operation is performed, and what gender the patient is. And the saying "scars adorn men" is inappropriate here, because the doctor always tries to minimize the visibility of the scar.

Therefore, conventional surgical sutures are used only in extreme cases, when it is inappropriate to risk aesthetics due to a complex or deep wound. Also, depending on the situation, the surgeon chooses which suture materials to use, i.e. whether these will be self-absorbable sutures, or they will have to be removed after a while.

If after a cesarean a scar did not remain on the abdomen, then, probably, more women would prefer this method of delivery. After all, many are frightened not by the fact of abdominal surgery (and in fact it is), but by the presence of an ugly scar on the abdomen. In addition, very young girls often become mothers who do not want to lose their attractiveness due to a huge scar.

The cosmetic suture after a cesarean section will not be particularly noticeable if a planned operation was performed with a transverse incision in the pubic area. Due to the anatomical nature, the sutures will be applied continuously and they will heal quickly. The remaining thin scar will run along the lower abdominal fold, i.e. along the underwear line.

By the way! If your incision after a cesarean section hurts, you should see your doctor. You must first find out the exact cause of the pain (infection, spasm, provoked by a hernia operation), and not take painkillers without a prescription, as mothers often do.

In an emergency caesarean section, doctors are sometimes forced to make a vertical incision from the navel to the pubis. The scar will be visible for two reasons. Firstly, because of the location, and secondly, because of the peculiarities of the stitching technology. The resulting nodules will subsequently thicken, and the scar will be not only wide, but also convex. Suture plastic after cesarean section will help to eliminate such a defect.

Is it possible to remove the stitches yourself

Doctors usually forbid any action on the seam, but patients still sometimes pull out the protruding threads. If they remain after the doctor has removed the suture, then, as a rule, nothing terrible happens. But if these are self-absorbing threads, then it is better not to do anything, but wait until they dissolve naturally.

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Conditions for suturing the skin

1. Lack of pronounced tension when comparing the edges of the wound.
2. Good blood supply to the edges of the skin.
3. Absence of signs of local infection or tissue necrosis.

The sutures on the skin can be either interrupted or continuous. Interrupted vertical sutures are most often used to close postoperative wounds.

Technique for making a circular knotted suture on the skin

The knotted suture can be performed simultaneously or in stages.

In the first case, the movement algorithm is as follows.
1. Surgical tweezers fix the sutured edge of the wound on one side.
2. The needle is inserted from the same side.
3. Sew the edge of the skin and subcutaneous fat.
4. Use tweezers to fix the edge of the skin on the other side and pierce it with a needle.
5. The needle is punctured in such a way as to pass the point and part of the body through the skin.
6. Fix the needle with tweezers by the body at the skin surface.
7. Open the ends of the needle holder.
8. The needle is pushed forward with tweezers.
9. The needle is fixed by the body at the surface of the skin with a needle holder and finally brought to the surface.
10. Tie a knot.

With a phased suture of a skin wound, the algorithm of actions is the same, but it is performed in full only on one side. The other edge of the skin wound is stitched using a similar technique. Such stitching of tissues "with a puncture" is advisable to use with significant diastasis of the edges of the wound.

To facilitate the stitching of strong, thick areas of the skin, it is recommended to “push” the skin onto the end of the surgical needle by means of a counter movement with tweezers (Fig. 32).

Rice. 32. Opposite movements of the needle and tweezers when sewing the edge of the skin.

It should be borne in mind that when performing an interrupted suture, the edges of the skin may wrap inward, preventing its healing. Therefore, before tying the knot, the skin is fixed with two surgical tweezers above and below the seam so that its edges are turned outward.

The needle is injected and removed at a distance of 0.5-1 cm from the edge of the wound. Tissue resistance is maximal near the surgical incision; therefore, it is very difficult to pass the needle through the skin here. When the suture is performed at a distance of more than 1.5 cm from the edge of the incision, too much tissue is captured in the suture, which will lead to corrugation of the skin, disruption of its blood supply and the development of a rough postoperative scar;

The injection and withdrawal of the needle should be performed perpendicular to the layer to be sewn.
Passing the needle parallel to the skin will lead to a sharp increase in the load on the needle and its deformation.
The places where the needle is punctured and punctured must be strictly symmetrical, otherwise a non-linear scar will form.

The needle should be fixed only by the body, as the needle holder easily deforms its tip and eyelet.

To close clean superficial wounds in open areas of the body, for example, on the face, a continuous single-row intradermal Halstead suture should be used (Fig. 33).

Rice. 33. Continuous intradermal Halstead suture.

With pronounced subcutaneous adipose tissue, it is recommended to use the previously described two-row Halstead-Zoltan suture.

The technique of performing a continuous intradermal (cosmetic) suture according to Halstead

For the correct imposition of the intradermal suture, the needle is inserted at a distance of 1 cm from the edge of the incision. The needle is then sequentially passed through the thickness of the dermis, capturing sections of the same length on each side so that the needle puncture site on one side coincides with the injection site on the other.

For atraumatic application of a continuous planar suture, it is recommended to pull off the edge of the skin not with tweezers, but with a small one-toothed hook.

Simultaneously pulling the ends of the thread in different directions, the edges of the wound are brought closer together. The beginning and end of the thread is tied on a gauze ball, roller or button for easy removal of the seam.

In some cases (with a postoperative wound of considerable length), a continuous overlap suture is used (according to Multanovsky).

G.M. Semenov, V.L. Petrishin, M.V. Kovshova

7.1. DISCONNECTING THE FABRICS

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

Cutting is performed with a cutting tool - a scalpel, knife, scissors, saw. The main tool for performing tissue dissection is a scalpel.

The abdomen is used for the production of long cuts on the horizontal or convex surface of the body, the short-cut for deep cuts and punctures.

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

All cuts are made from left to right (for right-handers) and towards oneself.

Technique of dissection of the skin and subcutaneous fatty tissue. The direction of skin incisions is selected in accordance with the place of projection 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 Langer's lines of tension. With cuts perpendicular to Langer's lines, 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 fusion are worse. Such incisions in the joint area can cause skin contracture. The joint incisions should be parallel to the plane of flexion.

Stretching and fixing the skin on both sides of the line of the intended incision 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 °, smoothly leads to the end of the incision line. At the end of the incision, the scalpel returns to the position

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

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

Muscle dissection and severing technique. The muscle is either dissected along the fibers or dissected. When peeling, the perimisium is first dissected with a scalpel, and then, using two folded forceps or two Kocher probes, the muscles are pushed to the sides, inserting Farabef's lamellar hooks into the wound. In some cases, it is necessary to cross the muscle fibers in the transverse direction. Sometimes, before transection, the muscle is clamped with two hemostatic clamps and dissected between them. The edges of the transected muscle are sheathed with a twisted catgut suture for the purpose of hemostasis. It must be borne in mind that, due to the contractile ability, the crossed muscles diverge over a fairly significant distance.

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

7.2. CONNECTING FABRICS

The connection of tissues is performed as the final stage of an operation or during surgical treatment of a wound. In this case, you must remember:

The edges of the wound must not be stitched under tension; the seams should only hold the edges of the tissues close together;

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

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

7.2.1. Types of sutures and needles

When connecting tissues, special threads are used, charged 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 (triangular):

■ thick (gynecological);

■ thin (surgical);

Curved (curvature 120?):

■ eye;

■ for stitching leather.

Stitching (round):

Direct:

Curved (curvature 180?):

■ thin (vascular);

■ medium thickness (intestinal);

■ thick (chipping).

Flat (hepatic):

Straight, semi-curved, curved.

Atraumatic:

Straight, curved.

Microsurgical.

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

By the degree of resorption - absorbable, conditionally absorbable and non-absorbable;

By thickness;

By structure.

The oldest absorbable suture material, catgut, was made from the submucosa of the small intestine of small ruminants. Depending on the processing technique, the time for its complete resorption is from 1 week to 1-1.5 months. In the second half of the twentieth 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 horsehair, wire (steel, nichrome, etc.), various synthetic materials.

Catgut is issued in 9 issues: 000, 00, 0, 1, 2, 3, 4, 5, 6.

Surgical silk is issued 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.

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

Among the new types of suture material should be noted antibacterial suture material (caprogen, caproag, capromed, etc.), as well as threads that can stimulate wound healing processes - rimin, biophil. These groups of suture material are undergoing a stage of development 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 skeins).

Surgical needles and sutures should be selected in a strictly differentiated manner. In this case, one should take into account what kind of 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 thread.

Atraumatic suture materials - a disposable needle + thread complex, manufactured at the factory. A distinctive feature of such a suture material is that a single suture 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 covers the defect in the tissues after passing 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

In surgery, three types of nodes are used: 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 can open and will

Rice. 7.1.Technique of knitting "sea" (a) and surgical (b) knots: 1-6 - successive moments of knot knitting

fragile. Manipulations are performed with the thumbs and forefingers of both hands. When tying a simple knot, there are 8 points. 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 direction opposite 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

Distinguish between nodal, continuous wraparound, continuous screwing, continuous mattress, U-shaped, purse-string, Z-shaped seams.

Interrupted suture produced by stitching the skin and subcutaneous tissue, aponeuroses of broad muscles. The first injection of the needle is made from the surface side of the fabric, after which the injection is made

and a second prick from the inside of the second seam edge. In this case, the distance of the first injection and the second injection from the edge of the sewn fabrics should be equal. After the suture is applied, the threads are tied with one of the knots. When applying an interrupted suture, a possible mistake is the mismatch of the stitched edges of the tissues and their tucking. This is due to the unequal distance between the needle stick and the stick cut from the stitched edges and the resulting tissue creeping onto each other when the knot is tightened.

Continuous wrap-around stitching produced by stitching fascia, aponeuroses, 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 fabrics are continuously sewn stitch to stitch throughout. The distance between the stitches should be 0.5-0.7 cm. During the last sewing, the thread is not pulled out to the end, but is used to tie the last knot with the working end of the ligature.

ab Rice. 7.2. The technique of imposing a continuous twisted suture on the peritoneum: a - the beginning of the suturing of the peritoneum; b - the end of the seam

The imposition of a continuous mattress seam. One type of continuous seam is the mattress seam. The technique of its imposition, in contrast to the twisting stitch, 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 the twisted seam.

Continuous screw-in suture (Schmiden) is used as one of the stages of the interintestinal anastomosis (Fig. 7.3). The Schmieden suture technique is similar to the continuous twist suture technique. The difference is that the needles are injected in all cases from the inner surface of the seamed edges.

Applying a U-shaped seam used for stitching 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 it is punctured on the surface of the other side to be connected. Having stepped 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. Technique of applying a Schmiden suture (a) and a U-shaped suture (b)

Rice. 7.4.The technique of applying purse string (a) and Z-shaped (b) sutures

Purse-string suture. Around the wound hole or the removed organ along its entire circumference, a serous-serous or serous-muscular suture is applied so that the last puncture of the needle corresponds to the place of the very first injection. Both ends of the thread, when tightened, collect the wall of the organ to be stitched, as it were, into a pouch. On top of the tightened purse-string suture, a Z-shaped suture is applied (Figure 7.4).

7.2.4. Soft tissue stitching technique

Suturing the wound of the stomach, small and large intestine produced by an intestinal suture in a direction transverse to the axis of the organ. In this case, two-row sutures are applied on the stomach and small intestine, and three-row sutures are applied on 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, serous-serous, nodular or continuous) are applied with a silk thread on a round needle. For small wound defects, a purse string and over it a Z-shaped suture can be applied.

Suturing the parietal peritoneum carry out catgut (? 4) on a round needle with a continuous twisted seam.

Stitching musclecarry out with catgut (? 4, 5) U-shaped seams.

Suturing fascia and aponeuroses produce silk thread (? 1, 2), charged into a round needle. Separate nodal, U-shaped or continuous sutures are applied. When sewing, 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 interrupted seams or stitches of the U-shaped and continuous seam should be no more than 5 mm. The sutures are tightened with a marine or surgical knot.

Stitching the skincarry out a silk or nylon thread (? 4, 5, 6), charged into a cutting needle with a curvature of 120?. Sewing is performed with separate interrupted sutures. The technique is as follows (Figure 7.5). With the help of toothed-gripping or surgical tweezers, the edges of the skin that are stitched alternately are held. The needle is injected from the outside of one of the stitched edges, 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. In this case, 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 to the edges of the sewn edges is the same. Tighten a simple or marine knot so that it is on the side of the cut edges to be joined. When applying skin sutures, you should adhere to the following rules: to minimize tissue trauma; it is imperative to perform separate stitching of the wound edges.

To apply an adaptive fillet weld, it is necessary to strictly observe the technique of its implementation (Fig. 7.6). The fillet suture is used in cases where two triangular skin areas need to be connected to the longitudinal edge of the wound (T-shaped wound), as well as 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 applied, and in the presence of deep wounds, a double-row suture.

When applying a single-row continuous suture, the thread is carried out in the thickness of the dermis. The application begins by suturing the skin at a distance of 1 cm from one of the corners of the wound. Then they sew parallel to the skin surface at the same height, grabbing 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 plaster or with interrupted skin sutures.

When a two-row continuous suture is applied, a deeper ligature passes in the subcutaneous fatty tissue, and the second, more superficial, in the dermis. Complete adaptation of the wound edges

Rice. 7.6.Adaptive fillet weld technique (from: Zoltan J., 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 with tweezers and sharp-pointed scissors (Fig. 7.8). Having grabbed a knot or one of the free threads with tweezers, slightly pulling out the subcutaneous part of the thread above the skin and, bringing the sharp branch of the scissors under the thread, it is crossed at the skin surface (see Fig. 7.8), after which the thread is easily removed.

Rice. 7.8.Technique for removing an interrupted skin suture

The continuous suture 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 J., 1974)

7.3. STOP BLEEDING

Bleeding is understood as the release of blood outside the vascular bed. Bleeding can be external (blood flows into the external environment) and internal (blood flows into serous cavities, soft tissues, the 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 resulting from slipping of the ligature, necrosis of the vascular wall, pressure ulcers from foreign bodies - secondary. In order to temporarily stop bleeding, finger pressure of the vessel, the imposition of a pressure bandage or tourniquet are used. The methods of the final stop of bleeding include the imposition of a hemostatic clamp followed by ligation of the vessel in the wound, its electrocoagulation, ligation of the vessel throughout.

The technique of ligating a blood vessel in a wound. In almost any operation, the surgeon is forced to dissect small-caliber blood vessels along the incision when dissecting tissues. 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 ligating 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 dissecting the tissues, the surgeon or assistant applies hemostatic clamps to the vessels in the perpendicular direction to the tissues, and it is necessary to grasp with the clamp as little volume of the surrounding tissues as possible. Oblique grasping of the bleeding site with a clamp is incorrect, since it takes a lot of surrounding tissue, and bandaging a large area of it can lead to necrosis, which prevents the primary wound healing. After grasping the bleeding vessel, the surgeon puts the ligature under the clamp, the assistant raises the tip of the clamp up so that the ligature lies under it, otherwise it will tighten on the tip of the clamp. After inserting the ligature, the surgeon ties the first knot, preferably a surgical one, 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, applies a second knot. The assistant cuts the ends of the thread shortly (up to 5 mm). Silk, nylon and lavsan threads are used to ligate blood vessels. Because of the possibility of secondary bleeding, it is better not to use catgut threads. When using silk, a double knot is sufficient; when using nylon and lavsan, it is necessary to tie a triple knot.

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

Electrocoagulation of a blood vessel in a wound. In a number of cases, for example, when removing malignant tumors, operations on the brain, in microsurgery, as well as in order to reduce the operation time, electrocoagulation of the vessel in the wound is used. For this, it is necessary to 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 bioactive 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 bioactive coagulation, special electrodes-tweezers are used, the branches of which are the active and passive electrodes. The principle of operation of the device consists in converting electrical energy into thermal energy when the device circuit is closed at the point of contact of the active electrode with tissues. The thermal effect first of all 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 bioactive coagulation. When using the monoactive coagulation mode, it is better to squeeze 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 their burns.

The technique of ligation of the main blood vessel throughout. Indications for ligation of blood vessels throughout are the impossibility of imposing hemostatic clamps with subsequent ligation within the wound; need for prior

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

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

The skin, subcutaneous tissue, superficial and own fascia of the region are dissected. Then it is necessary, by pulling the muscle with a lamellar hook, to open the wall of the vagina 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 tweezers in the left, the operator grasps the perivascular fascia (but not the artery!) From one side with tweezers and, gently stroking the end of the probe along the vessel, isolates it. The same technique is used to expose the artery from the other side for 1-2 cm. It is not necessary to isolate the vessel over a greater length, so as not to disrupt the blood supply to the vessel wall. A silk or nylon ligature is brought under the artery using a Deschamp or Cooper ligature needle. When ligating large arteries, the needle is brought in from the side of the accompanying vein (between the artery and the vein), otherwise it may be damaged by the end of the needle. The ligature on the 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, the distal one being pierced, and one ligature to the peripheral one.

7.4. VASCULAR SEAM

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

Carrel circular vascular suture technique (fig. 7.10). In case of damage to 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 the vessel segments isolated over a short distance. To overlay

Rice. 7.10.Carrel vascular suture:

a - the imposition of stitch-holders; b - the imposition of a twisted seam

the suture uses round atraumatic piercing needles. Three fixation sutures are placed along the perimeter of the vessel at equal distances from each other. The assistant stretches the vessel wall for two adjacent holding sutures, giving it a linear shape. Then, with frequent (at a distance of 1 mm from each other) stitches of a continuous seam are connected the walls of the vessel segments between the holders. The beginning of the suture thread is tied with the 1st holder, the end with the 2nd. In the same way, sequentially 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, vascular clamps are removed: on the arteries, first from the peripheral, then from the central segment, on the veins, vice versa.

When blood seeps out along the suture line, the bleeding site is pressed with a swab soaked in 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 magnifying glass, microsurgical suture material, conditional number 8 / 0-10 / 0, and microsurgical instrumentation. The conditions for the successful placement of the microvascular suture are good visualization of the ends of the vessel, careful hemostasis, the capture of the vascular wall by instruments only by the adventitia, matching the ends of the vessel without tension, excision of the adventitia at the ends of the vessel to prevent it from entering the lumen of the vessel.

For suturing a vessel with a diameter of 1 mm, 7-8 interrupted sutures are required. Two retaining sutures are preliminarily applied. Sutures are first placed on the front wall of the anastomosis, and then the vessel is rotated with the help of holders and the back wall is sutured. You can use the technique when, after tying the knot, one of the ends of the thread is cut off, and the other 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 alignment of the sutured sections of the vessel. For tying knots, the apodactyl technique is used, in which one of the ends of the thread is drawn around the jaws of the needle holder with tweezers, and the other is captured by the jaws of the needle holder. When the first thread slides off, a knot is formed. If you circle the first end of the sponge thread twice, you get a surgical knot. After applying a 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 long-term intravenous infusions or the inability to perform catheterization of the main veins, as well as puncture of superficial veins.

The 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 the side table.

Venesection technique (fig. 7.11) ... Under local anesthesia with 0.25% novocaine solution, an incision is made in the projection of the corresponding vein 1.5-2 cm long. The vein is exposed along the entire length of the incision. Using folded clamps or tweezers, the vein is isolated from the surrounding tissue and two ligatures are brought under it, which are spread into opposite corners of the wound. In the distal corner of the wound, the vein is ligated. Then the vein is lifted by the distal ligature and incised 1/2 of the diameter. The incision is made obliquely in relation to the vein axis. 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. Sutures are applied to the skin. The catheter is fixed to the skin with a plaster, and an aseptic bandage 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 OF NERVE

To restore the anatomical integrity of the nerve, apply the imposition on its outer sheath (epineurium) and on the sheaths of each of the bundles (perineurium) of individual interrupted sutures. 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 a nerve, it is advisable to use optical magnification with a bifocal loupe or an operating microscope. The technique is as follows (Figure 7.12). Mobilized

and the matched ends of the transected nerve are stitched circumferentially behind the sheaths of each of the sutured ends with separate interrupted sutures. After all sutures are applied, they are tied in turn with a marine or surgical knot so that a diastasis of 1-2 mm remains between the proximal and distal ends of the nerve being sutured. The number of sutures should be proportional to the thickness of the nerve trunk to be sutured.

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

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

Surgical sutures are used to connect the edges of wounds using absorbable (catgut) or non-absorbable (silk, nylon, nylon, and other synthetic threads). Distinguish (see), imposed immediately after surgery or injury, and a secondary suture (see), applied to the granulating wound. Surgical sutures applied to the wound, but not tightened, are called provisional. They are tied on the 3-4th day after application in the absence of an inflammatory process in the wound. The delayed primary suture is applied 2-4 days after the initial surgical treatment. Removable sutures are applied to the skin, which are removed after the wound has healed. Surgical sutures made of non-absorbable material placed in deep tissues are usually left permanently in the tissues.

Rice. 1. Types of surgical sutures: 1 - nodal;
2 - continuous; 3 - purse string; 4 - Z-shaped; 5 - straight knot; 6 - double knot.

Rice. 2. Threading the needle.

In appearance, surgical sutures can be interrupted (Fig. 1.1), continuous (Fig. 1.2), purse string (Fig. 1.3), Z-shaped (Fig. 1.4) and twisted. After suturing, they are pulled together so that the edges of the wound are in contact, and tied with a non-opening straight (sea) knot (Fig. 1.5). Some suture materials (nylon, nylon) are tied with a double (Fig. 1.6) or triple knot due to the fact that otherwise they are easily untied.

For suturing, needle holders and curved or straight needles of various curvatures and sections are used. Thread the thread into the eye of the needle from above (Fig. 2). More and more widespread use is received by a mechanical seam with the help of (see), and metal staples (mainly tantalum) serve as the suture material.

Fig 3 Removing the seam.

A self-employed paramedic can apply stitches in case of accidental cut, uncontaminated wounds of the skin, face, lips, fingers. Suture, accompanied by surgical treatment of the wound, is performed only by a doctor. Removal of stitches is often entrusted to a paramedic or dressing room. It is performed on the 7-10th day after application (at an earlier time - on the face, neck, in the absence of tissue tension and good wound healing, later - in elderly and senile patients). After lubricating the suture line with an alcoholic solution of iodine, take one of the ends of the suture with anatomical tweezers and pull it so that a part of the thread not stained with iodine tincture appears below the knot (Fig. 3). It is crossed with scissors and the entire seam is removed by pulling. After the secondary lubrication of the seam line with an alcoholic solution of iodine, a cleol dressing is applied. Preparation of material for seams - see.

On some tissues and organs, special types of surgical sutures are used - an intestinal suture (see), a nerve suture (see), (see), (see). Surgical sutures connecting the bones - see Osteosynthesis.

Surgical sutures are bloody and bloodless ways of joining the edges of accidental and surgical wounds. Bloody surgical sutures are placed by passing suture material through the tissue. If the suture material is removed after the wound has healed, then such surgical sutures are called removable, if it remains, they are submerged. Usually, removable surgical sutures are applied to the integument, and submerged sutures are applied to internal organs and tissues.

Surgical sutures, which are supposed to fasten tissues only during any one stage of the operation, are called temporary, or hold sutures. According to the timing of the imposition of surgical sutures on wounds, primary surgical sutures on a fresh wound, primary delayed, early and late secondary sutures are distinguished. A delayed primary suture is called, which is applied to the wound not at the conclusion of its surgical treatment, but during the first 5-7 days (before the appearance of granulations). A type of delayed surgical suture is provisional, in which the threads are passed through the edges of the wound at the end of the operation, but do not tighten until it becomes clear that there is no infection. A secondary suture is a surgical suture applied to a granulating wound without excision of granulations (early secondary suture) or after excision of the granulating defect and surrounding scars (late secondary suture).

Depending on the methods of application and the materials used, the following surgical sutures are distinguished: bloodless, metal lamellar skin (according to Lister), metal wire bone, soft ligature threads (the most common), mechanical metal staple.

Non-bloody Surgical sutures - tightening the wound edges with adhesive tape or passing threads through the fabric (flannel) glued along the wound edges are recommended mainly to accelerate the healing of granulating wounds (Fig. 1). For wounds of the chest and abdomen, it is recommended to impose plastic "bridges" across the operating incisions, which should facilitate faster healing. The possibility of using methods of joining the edges of wounds of soft tissues and bones using synthetic cyanoacrylate glue (Eastman-910, USA; Cyacrin, USSR; Aron-Alpha, Japan) is being investigated.

Rice. 1. Adhesive bandage with drawstring seams.
Rice. 2. Wire plate seams.
Rice. 3. Interrupted skin seams on the rollers.
Rice. 4, a and b. Wire bone sutures: a - two staples and wire bonding; b - tightening the wire seam.

Metal wire surgical sutures were used already in the first half of the 19th century (lead-silk surgical sutures of N.I. Pirogov; aluminum Naderfer). Wire lamellar surgical sutures make it possible to bring the edges closer even with relatively large tissue defects, and therefore are shown with a high tension of the wound edges (Fig. 2). To reduce the tension and avoid cutting the skin sutures, you can make them knotted using soft ligature threads that are not knotted, but tied on each side on rollers (Fig. 3).

Metal wire bone Surgical sutures are passed through holes made by a drill in bone fragments (Fig. 4, a), or the bone is pulled together with a wire, or through grooved notches (Fig. 4, 6). The ends of the wire are twisted.

Rice. 5. The position of the hand when using the needle holder: a - the hand is in the pronation position (injected); b - hand in supination position (stick out); c - atraumatic needle.

Rice. 6. Types of ligature knots: a - double surgical; b - oblique; c - sea, or straight.

For surgical sutures with soft ligature threads, as well as flexible metal wire, surgical straight or curved needles are used; the latter are manipulated with a needle holder. The most simple and convenient is a Hegara-type needle holder with a ratchet. The needle is inserted into the needle holder so that it is clamped at the border of the middle and rear third (Fig. 5).

The needle is inserted into the fabric perpendicular to the surface to be stitched and advanced following its curvature.

For denser fabrics (leather), a triangular (cutting) curved needle should be used, for less dense fabrics (intestines) - a round (stabbing) curved or straight needle, which is sewn without a needle holder. Conventional open-eye surgical needles traumatize the tissue as double-fold sutures are pulled through the suture channel. In this regard, in vascular, eye, cosmetic surgery, in urology, atraumatic needles are used, characterized in that the tip of the thread is pressed into the lumen of the posterior end of the needle (Fig. 5). In order to eliminate unwanted rotation of round curved needles in the needle holders, the inner surfaces of the working jaws of the needle holders began to be coated with diamond chips (diamond needle holders). At the suggestion of E.N. Taube, the part of the needle that is pinched by the needle holder should be made not round, but oval.

Surgical sutures are applied sequentially from left to right or towards oneself, but not away from oneself. The simplest type of surgical suture with a soft thread is an interrupted (old term "knotted") surgical suture, in which each stitch is applied with a separate thread and tied with a double surgical (Fig. 6, a) or marine (Fig. 6, c), but not oblique ( "Woman", Fig. 6, b) a knot. Various techniques are used to tie a knot (Fig. 7, a-f). For long or complex wounds of the skin and subcutaneous tissue, guiding (situational) sutures are first applied: one suture in the middle of the wound, then one or two more in the places of greatest divergence of the edges and tie them with a double surgical knot. Usually, skin sutures are applied at intervals of 1-2 cm and removed on average after 7 days. Having lifted the knot with tweezers, they pull the thread out of the canal a little so that when the thread is removed, that part of it that was outside the canal is not pulled through it, then the thread is cut below the knot (Fig. 8) and removed.

Rice. 7. Techniques for tying knots:
a and b - tying the first loop of a double surgical knot; the thread is held with the little finger of the right, hands from left to right;
c - the first loop of the double knot is tied;
d - tying the second loop of the sea knot; the thread is carried out with the III and IV fingers of the left hand from right to left;
e and f - Frost's technique: a loop at the end of the thread is thrown onto the tip of the pricked needle and tightens automatically when the latter is pulled out.

Rice. 8. Reception of removal of the cutaneous nodular suture.

Aponeurotic and pleuromuscular sutures should be applied frequently - at a distance of 0.5-1 cm from each other. The ends of the silk thread are cut off, leaving the antennae no more than 2 mm from the knot. The ends of the catgut thread are usually cut off at a distance of at least 1 cm from the knot, taking into account the possibility of the thread sliding and unraveling of the knot (even a triple one!). When stitching muscles crossed transversely to the axis of their bundles, mattress, interrupted or U-shaped sutures are used to avoid eruption (Fig. 9). As hemostatic, or chipping, you can make Z-shaped interrupted sutures (Fig. 10) according to Zultan or purse string (Fig. 11).

Rice. 9. U-shaped seam on the muscle, dissected across the course of the beams.
Rice. 10. Z-shaped interrupted suture on the intestine according to Zultan.
Rice. 11. A purse string suture for immersion of the stump of the appendix.

Rice. 12. VNIIKHAI instruments and a needle (1) for applying purse-string sutures: a - on the duodenum; b - into the small intestine; c - on the cecum; d - a diagram of a straight needle (1).

Rice. 13. Michel's staples for skin sutures (a) and tweezers store (b) for stapling.

The advantage of interrupted skin sutures (Fig. 14, a) is that, by removing one suture, you can give an outlet to the wound discharge.

A continuous suture is applied faster than a nodal suture, but in the event of a thread break in one place or the need to partially open the wound, it diverges along its entire length. Continuous surgical sutures are of different types: simple (Fig. 14, b), twisted according to P. Ya. Multanovsky (Fig. 14, c), mattress (Fig. 14, d), furrier according to Schmiden (Fig. 14, e) , intradermal cosmetic according to Halstead (Fig. 14, e). If it is difficult to bring the edges of the wound together (for example, ribs), they are pulled together with a block pulley suture (Fig. 15, a). To strengthen the fascial-aponeurotic layer, it is doubled (Fig. 15, b) or the so-called greatcoat fold is made (Fig. 15, c). To strengthen the anterior abdominal wall, they prefer to make two or even three levels of sutures, not counting the suture applied to the parietal peritoneum, instead of the more complex Moser suture (Fig. 16). In order to close the line of sutures imposed on the wall of a hollow organ with a serous membrane (peritoneum, pleura), a second suture is applied over this first row of sutures - a serous-serous suture, called invaginating, or immersion (to be distinguished from submerged, see above).

Rice. 14. Various types of soft ligature sutures: a - a line of correctly applied interrupted skin sutures; b - a simple continuous suture and a method of tying it; в - continuous twisted seam according to Multanovsky; d - continuous mattress seam; d - furrier's seam according to Schmiden; e - intradermal cosmetic suture according to Halstead.

Rice. 15. Seams for strengthening the fascial-aponeurotic layers: a - block pulley; b - doubled; c - seam in the form of a "greatcoat fold".

Rice. 16. Suture for strengthening the anterior abdominal wall according to Moser: upper suture - on the skin, subcutaneous fatty tissue and muscles; lower - on the peritoneum.

Thus, a two-story seam is obtained. In some cases, a three-level seam may also be needed.

Mechanical immersion seams are applied with metal staples, which have become widespread after the introduction into practice of stapling devices developed at VNIIKHAI. Michel (P. Michel) suggested braces for removable skin sutures (Fig. 13).

For the formation of anastomoses of hollow organs (intestines, blood vessels), in addition to manual and mechanical seams, they use various devices designed to facilitate the operation technique, ensure greater strength of the seams and asepticity. For operations on the intestines, a press and a needle by I. G. Skvortsov are offered; for operations on blood vessels - the instruments of G.M.Shpug and N.K. Talankin, V.I.Bulynina, V.I. Pronin and N. V. Dobrova, D. A. Donetsky's rings.

See also Intestinal suture, Nerve suture, Osteosynthesis, Vascular suture, Tendon suture, Surgical instruments, Suture material.

The imposition of skin sutures. Surgical sutures. Use of stitches in dentistry

Suture materials for cosmetic seam

Types of stitches in surgery

Is it possible to remove the stitches yourself

The last

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