RU2180531C2 - Method for putting in intestinal sutures - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves suturing seromuscular layer with the first stitch. The serous and muscular layers are cut. The serous and muscular layers are shifted as an envelope. Seromusculosubmucous layer is sutured with the second stitch. The second stitch is done on the same side with the first one. Puncture penetration direction is changed within the limits of submucous layer. Blood vessels passing through the submucous layer are caught. The third and the fourth stitches are done in inverse order. The third one is done by making puncture into the submucous layer of the opposite intestine segment capturing blood vessels by changing needle movement direction and making exit puncture to the serous membrane. After making preventing knots on the anterior lip, the mucous and submucous layers are cut. EFFECT: enhanced effectiveness of treatment; stable intestinal suture hemostasis.

Description

 The invention relates to the field of medicine, namely to surgery of the gastrointestinal tract for the application of gastric, gastrointestinal, small intestine, small colon and large intestine anastomoses.

 There is a method of applying a nodal intestinal suture of Arslanov, according to which an injection is made from the side of the edge of the mucous membrane with a puncture on the serous membrane and an additional serous-muscular stitch, then a serous-muscular stitch of the opposite segment of the intestine and an additional injection from the serosa with a puncture through the edge of the mucous membrane and by tightening the ligature from the mucosa (Arslan PM "Intestinal suture in conditions of peritonitis." Auth. cand. diss., Alma-Ata, 1983, p. 21, inventory 01/75914 SCMB).

 The disadvantages of this method is that the seam involves tying a knot in the lumen of the organ with the location of the knot in the intermucosal space, therefore, it determines the secondary nature of healing with a rough anastomotic scar, and due to the biological leakage of the through element of the seam, it is possible to develop infectious inflammation with the development of infiltrates and microabscesses in the interstitch zone, and finally, in the case of abscessed interstitch space, a breakthrough into the free abdominal cavity is possible, the development of toyatelnosti seams and peritonitis.

 There is also known a method of applying intestinal sutures Zhuchenko-Kostyuk (Zhuchenko S. P., Kostyuk G. "The formation of a double-row intestinal suture." Surgery, 1984, 12, S. 105-106), taken as a prototype, namely, that the serous-muscular layer is stitched with the first stitch, then the serous and muscle membranes are stitched with the same thread with the capture of the submucosal layer of the opposite edge of the intestine. After that, the thread is passed through the submucosal, muscle and serous membranes of the opposite segment of the intestine, then the serous-muscular layer of the opposite edge is sutured with the same thread. Seams are taken on the clamps, the anastomosis is tightened by turns, the knot is tied on the serous membrane.

 The disadvantages of this method is that due to the cross nature of the elongated suture threads and the inability to control the degree of protraction of the inner stitch when tying the knot, there is a strong contact of the serous membrane due to earlier contact of the serous membranes and insufficient contact of the anastomosed layers, especially the mucous and submucosal, is stitched stitch. This leads to infection of the suture material, suture line, infectious inflammation of the anastomosis, its failure and peritonitis. Also, the cross nature of the threads causes excessive compression of the serous and muscle layers by the inner stitch (flagging, noose), leads to ischemia of these layers and their necrosis with weakening of the physical strength of the suture. In addition, the suture does not involve flashing the vessels of the submucosal layer, which causes a high risk of bleeding from the anastomosis line into the lumen of the hollow organ.

 The essence of the claimed invention lies in the fact that according to the method of applying the intestinal suture, which consists in dissecting the intestinal wall, the serous-muscular layer is stitched with the first stitch, the sero-muscular-submucosal layer is stitched with the second, and the third and fourth stitches are performed in the reverse order tie a knot on the serous membrane, dissect the serous and muscle layers of the intestinal wall to the submucosal layer and shearly displace them, the second stitch is produced on the side of the first, changing the direction of the injection within the lucous layer, capture the vessels passing in it, and the third stitch is injected into the submucosal layer of the opposite segment of the intestine with the capture of blood vessels, by changing the direction of the needle with a puncture on the serous membrane, after alternately tying the nodes of the posterior lip and the preventive application of nodes of the anterior lip taken on the clamps, make a dissection of the submucous and mucous layers.

 The application of the proposed method allows, by changing the direction of the puncture during the passage of the submucosal layer with the capture of intramural vessels, to ensure stable hemostasis of the suture. When tightening the thread, it allows you to control and evenly tighten both stitches of a single-row seam. The shear displacement of the serous-muscular layers allows the submucosal, most durable layer to be included in the suture band. The passage of the thread with a puncture not through the edge of the submucosal layer, but departing 0.1 cm from its edge within the case of its shear displacement, provides a moderate inversion (turn) of the edges of the submucosal layer and a more accurate comparison of the submucosal and mucous layers, which provides more reliable isolation of the suture filaments from the intestinal lumen and protecting it from infection. The inversion of the submucosal and mucous layers of the first stitch is complemented by the second stitch and is accompanied by the creation of a cuff with two muscle layers, which gives the seam special strength. The seam provides a tight comparison of the mucous membranes, their early soldering (sticking together) and the primary nature of healing with a tender scar, which ensures biological and physical integrity. Biological and physical tightness, the absence of infected inflammation along the suture thread ensure the full functioning of the suture and anastomosis and unidirectional evacuation.

 The method is as follows. Along the line of the alleged anastomosis, the serous-muscular layers of the anterior and posterior lips are dissected of the anastomosed hollow organs of the gastrointestinal tract and their displacement is 4-5 mm case; retreating 0.8-0.9 cm from the edge of the intestine, suture the serous-muscle layer with a length of 0.2-0.3 cm with a puncture on the serous membrane at a distance of 0.5-0.6 cm from the edge of the intestine. Then the same thread, departing from the edge of the intestine by 0.3-0.4 cm, sutures the serous, muscle and submucosal layers, and within the submucosal layer, the needle changes direction, passing under the intramural vessels for 0.2-0, 3 cm. The puncture is carried out by departing 0.1 cm from the edge of the submucosal layer within the previously performed case-like displacement of the serous-muscular layer. After that, the thread is carried out in the reverse order through the opposite intestinal wall: 0.1 cm away from the edge of the submucosal layer at the level of its shear displacement, an injection is made into the submucosal layer with a change of direction and capture of blood vessels, followed by a puncture through the muscle and serous layers at a distance of 0 , 3-0.4 cm from the edge of the serous layer, with a further thread, retreating 0.2 cm from the injection through the serous-muscular layer for 0.2-0.3 cm.

 Example 1. Patient A, diagnosis: villous polyp of the antrum. Operation: tubular resection of the stomach according to Billroth-1 with gastroduodenoanastomosis end to end with the proposed suture. The postoperative period is smooth. Discharged on the 11th day. Fibrogastroscopy (3 months): the stump of the stomach is empty, the anastomosis is closed, it is easy to pass. Duplications of the mucosa of the anastomosis are visible; inflammation of the stump of the stomach, anastomosed intestine and anastomotic zone is not visualized. Radioscopy of the stomach stump (3 months): the stump of the stomach is retort-shaped, empty on an empty stomach, the initial evacuation is timely, then rhythmic portioned. Duodenogastric reflux is not observed. After 2 hours in the cult of the stomach traces of barium suspension. Gastroscintigraphy (3 months): no duodenogastric reflux was detected, the half-life of the radiopharmaceutical was 64.1 minutes. There are no complaints, I am not following a diet, senior citizen. Recovery.

 Example 2. Patient B, diagnosis: giant circular duodenal ulcer with penetration into the hepatoduodenal ligament, liver, gall bladder, pancreas. Chronic ulcer of the antrum. Uncompensated stenosis of the output section of the stomach. Cachexia. Operation: tubular resection of the stomach according to Billroth-2 with the formation of antireflux anastomosis single-row gray-serous-muscular-submucosal suture. The postoperative period is smooth. Discharged on the 14th day. Fibrogastroscopy on the 10th day: the stump of the stomach is empty; the anastomosis is closed, freely passable, its mucosa does not differ from the rest of the mucous membrane of the gastric stump and anastomosed intestine. X-ray examination of the stump of the stomach (1 month): the stump of the stomach is funnel-shaped, empty on an empty stomach, the initial evacuation of barium suspension is timely, periodically portioned evacuation is noted. Evacuation to the discharge loop; reflux during the course of the study is not observed. After 2 hours there is no barium in the stomach cult. Gastroscintigraphy (6 months): half-life of the radiopharmaceutical 40.9 min. Duodeno and enterogastric reflux were not detected. There are no complaints, she does not comply with the diet, she recovered by 7 kg, her working capacity was restored. Recovery.

Claims (1)

 The method of applying the intestinal suture, namely, that the intestinal wall is dissected, the sero-muscular layer is stitched with the first stitch, the sero-muscular-submucosal layer is stitched with the second, and the third and fourth stitches are performed in the reverse order, a knot on the serous membrane is knotted, characterized in that dissect the serous and muscle layers of the intestinal wall to the submucosal layer and displace them casingly, the second stitch is produced on the side of the first, changing the direction of injection within the submucosal layer, capture vessels passing e in it, and the third stitch is injected into the submucosal layer of the opposite segment of the intestine with the capture of blood vessels by changing the direction of the needle with a puncture on the serous membrane, after tying the nodes of the posterior lip and preventively applying the nodes of the anterior lip taken on the clamps, they dissect the submucosa and mucous layers.