RU2223048C1 - Method for suturing laparotomic wound in - Google Patents

Abstract

FIELD: medicine, abdominal surgery. SUBSTANCE: one should apply 8-shaped onto laparotomic wound at forming ligature's overlapping above aponeurosis due to making a double ligature through muscular-aponeurotic layers of abdominal wall by capturing up peritoneum. Ligature in the site of needle's puncture in or puncture out should be separated to perform punctures in with needles with separated single ligatures from both sides against the site of ligature's separation. Then one should apply ligatures intracutaneously at punctures out at opposite edge of the wound. After that withdrawn double ligature and separated single ligatures should be tightened to make a knot. The method enables to achieve good adaptation of wound edges. EFFECT: higher efficiency of suturing in. 1 cl, 3 dwg

Description

 The invention relates to medicine, in particular to surgery, to methods for suturing postoperative wounds of the anterior abdominal wall.

 Currently, the main methods of treatment of postoperative wounds of the anterior abdominal wall are methods of closing wounds after rehabilitation by applying various sutures.

 Known methods of suturing a postoperative wound: nodular, mattress, U- and U-shaped, single and double row, depreciation (Kochnev O. S, Izmaylov SG, Monograph "Methods of suturing wounds." Publishing house of Kazan State University, 1992 g.) - [1]. When suturing the edges of the wound, they puncture the needle with the thread and tighten them, thus performing several seams with various modifications: passing the thread through gauze napkins, buttons, rubber tubes and others (Buyanov V. M, Egiev V.N., Udatov O.A. "Surgical suture." Publishing house "Dimitrade Graph Group", 2000. Slepts IV, Chernikova RA "Nodes in surgery". Sat: Salit-Medkniga, 2000) - [2].

 However, in the case of suturing laparotomic wounds with severe inflammation of the tissues, many known methods have a number of disadvantages: they do not prevent the eruption of sutures, disrupt blood circulation - wound healing conditions, lead to an extensive scarring process.

 There is a Donati suture along which a thread is passed through all layers of the abdominal wall at a distance of 20-30 mm from the edge of the wound. Then the needle is again injected on the side where it was withdrawn, but a few millimeters from the edge of the wound. The needle is carried out in the thickness of the dermis, which is a prerequisite, and displayed on the surface of the skin symmetrically to the opposite side. After that, both ends of the thread are pulled together and tied into a knot. This achieves a good adaptation of the edges of the wound, as well as a fairly reliable fixation. The positive properties of the Donati suture are manifested especially in those cases when the edges of the wound tend to wrap inward or invert. Donati suture is also used to prevent free space in the subcutaneous tissue of the laparotomy wound when the abdominal wall is sutured after relaparotomy and eventuation using rubber pads (Operational Surgery under the editorship of Prof. I. Littmann. Budapest, 1982, p.333-334) - [3].

 A disadvantage of the known seam is that the tightly knitted threads begin to erupt after a few days, the skin is injured, and additional seams must also be put between Donati's seams.

 To conduct a comparative analysis with the claimed invention, the well-known Moser suture is used, which is used to strengthen the anterior abdominal wall (O.S. Kochnev, S.G. Izmailov. Methods for suturing wounds. Kazan University Press, 1992, pp. 80-81) - [4].

 The seam is performed as follows. The peritoneum is sutured with separate interrupted sutures. A needle with a single ligature is injected 15 mm from the edge of the surgical wound and punctured in subcutaneous tissue from the same side as the injection. Next, the injection is carried out into the aponeurosis of the opposite side of the wound through the muscles to the peritoneum and is punctured, after which a needle with a ligature is pricked above the latter in the direction of the first injection. In the next step of suturing, a ligature needle is injected into the subcutaneous tissue of the opposite side of the surgical wound and punctured above the skin 15 mm from the wound edge, the ligatures are connected and tied into a knot, forming an eight-shaped seam.

Known seam has significant disadvantages:
- simultaneous tightening of the eight-shaped suture into a single block of skin, subcutaneous fat and aponeurosis dramatically increases the strength of the thread tension, since the comparison of the edges of the aponeurosis compared to the skin requires more effort, while there is a pronounced sawing effect of the thread with damage to the walls of the suture canal;
- blood supply to the tissue area is disrupted, which worsens the course of regenerative processes, promotes thread eruption and the formation of pressure sores.

The unfavorable listed factors are the cause of the development of purulent complications and eventings, and a significant increase in the tension force when the edges of the surgical wound come closer makes it necessary to use suture material of a larger diameter, for example, silk 6-8 than is required to keep the tissues in an already closed state;
- this method does not achieve the exact layer-by-layer anatomical restoration of homogeneous tissues, which is also one of the reasons for the violation of the healing process of the wound and a decrease in its strength properties;
- a cavity is formed between the peritoneum and aponeurosis, where the accumulation of fluids, which can lead to the development of postoperative complications, is also possible;
- suturing separately the peritoneum and aponeurosis does not ensure the integrity of the seam, which is a direct way for infection to enter the wound from the abdominal cavity - [1], in addition, it is traumatic and practically impossible, therefore the peritoneum is not separately sutured - [2] or sutured together with aponeurosis (Burnovy M. P., "Technologies of surgical operations", Rostov-on-Don. Publishing house "Phoenix", 1999) - [5].

 The invention solves the problem of preventing wound complications (ligature disease, eventation, suppuration of the wound), increasing the strength of the scar while improving its cosmetic effect.

 This object is achieved in that according to the method of suturing the laparotomy wound with a removable eight-shaped suture, including ligature through the skin, subcutaneous tissue, muscle-aponeurotic layers of the abdominal wall, with the formation of a loop by overlapping the ligature over the aponeurosis, tightening the ligatures and tying a knot, loop through the muscle-aponeurotic layers of the abdominal wall with the capture of the peritoneum, using a double ligature, which is bred at the site of the injection or injection, perform injections and with divorced single ligatures on both sides of the breeding site of the double ligature and spend them intradermally with punctures on the opposite edge of the wound, the extracted double and divorced single ligatures are pulled together and tied into a knot, forming an eight-shaped seam, with the first injection and needle with a double ligature carried out at a distance of 20-25 mm from the edges of the surgical wound, and the injection and puncture with needles with diluted single ligatures are performed at a distance of 10-15 mm from the edges of the wound at an angle to them.

The invention is illustrated in figures 1 to 3, where
1, 2 - ligature (thread);
3 - place injection into the skin of the needle with a double ligature on the first side of the wound;
4 - the first side of the surgical wound (first edge);
5 - subcutaneous tissue of the first side of the wound;
6 - aponeurosis;
7 - the second side of the surgical wound (second edge);
8 - muscles;
9 - peritoneum;
10 - a place of a needle with a double ligature above the aponeurosis in the first side of the wound;
11 - subcutaneous tissue of the second side of the wound;
12 - the place of the puncture over the skin of the needle with a double ligature on the second side of the wound;
13 - place overlap ligatures over the aponeurosis;
14 - places of single filaments in the dermis;
15 - knotted knot with double and single threads;
16 - places of injection of needles with divorced single threads;
17 - place puncture in the subcutaneous tissue of the needle with a double ligature on the first side of the wound;
18 - places of puncture of needles with the divorced single threads.

 The proposed method is carried out by through removable eight-shaped suturing of the wound, first using a double ligature, and after diluting it into two single ligatures, using single ligatures, while the tensile strength of the through suture applied to the skin is reduced by half after tightening and tying the ends of the ligatures.

 A needle with a double thread, for example 3, 1-2 is injected in place 3 at a distance of 20-25 mm from the edge of the first side of the surgical wound 4 with their removal through subcutaneous tissue 5 on the side of the first injection and holding on the opposite side 7 of the surgical wound followed by through aponeurosis 6 and peritoneum 9. Next, ligatures 1-2 are carried out through peritoneum 9 and muscle-aponeurotic layer 8, 10 of the first edge of the surgical wound with their removal through subcutaneous tissue 5 of the second edge of the surgical wound above the skin in place 12 with preliminary ostomy in place 13 above the aponeurosis 6, 10 (Fig. 1). Then, from one of the edges of the surgical wound, for example 4, a double ligature 1-2 is tilted and inclined towards the edge of the wound, for example at an angle of 35-45 degrees, and at a distance of 1015 mm from the edge in 16 places on both sides of the injection site 3 perform injections with needles with diluted single ligatures 1 and 2 and spend them intradermally on the opposite second edge 7 of the wound with excretion (also: intradermally, angle, distance) in places 18 (Fig. 2). Derived double yarns 1-2 and divorced 1.2 after the formation of an eight-shaped seam are pulled together and tied into a node 15 (figure 3).

The proposed method for suturing a laparotomy wound showed the following significant advantages over the known prototype:
- achieved a good adaptation of the edges of the wound and their reliable enough fixation, which ensures favorable healing of the wound;
- the continuity of the suture, applied simultaneously to all layers of the abdominal wall, ensures uniform tension of the tissues without disturbing the local blood flow;
- complete removal of ligatures creates favorable conditions for the formation of a durable postoperative scar with the complete exception of the formation of ligature fistulas;
- the difference between the injection and puncture distances of the duplicated thread and their disconnected ends simplifies the seam due to the greater tissue capture, and the intradermal holding of a thinner thread, in contrast to the underlying tissues, improves the cosmetic effect;
- an eight-shaped loop reduces tissue tension, immobilizes them, which eliminates the sawing effect during intradermal holding of a small diameter thread;
- simultaneous capture in the seam of the parietal sheet of the peritoneum with fascia makes it possible not only to achieve reliable adaptation of the peritoneum, which is almost impossible to achieve with its inflammation, but also to obtain a more airtight seam.

 Thus, the claimed invention differs significantly from the prototype, it is simple in technical performance, safe, slightly traumatic, provides a comparison of stitched tissues and the earlier formation of a gentle postoperative scar, which gives the right to accept it into wide surgical practice along with traditional methods of treating surgical wounds.

Claims (2)

1. The method of suturing a laparotomic wound with a removable eight-shaped suture by ligating through the skin, subcutaneous fat, muscle and aponeurotic layers of the abdominal wall with a loop by overlapping the ligature over the aponeurosis, characterized in that the loop is formed by ligating through the muscle and aponeurotic layers of the abdomen with the capture of the peritoneum, at the same time use a double ligature, which is bred at the site of the injection or needle injection and carry out injections with needles with diluted single ligatures on both sides no breeding places ligatures and spend their intradermally with the pitch dark on the opposite edge of the wound, the deduced double and divorced single ligature pull together and tied in a knot to form vosmiobrazny seam. 2. The method of suturing a laparotomy wound according to claim 1, characterized in that the first injection and puncture with a double ligature needle is carried out at a distance of 20-25 mm from the edges of the surgical wound, and the injection and puncture with needles with diluted single ligatures is performed at an angle to the edges wounds at a distance of 10-15 mm from them.

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