RU2288651C2 - Method for applying epineural suture - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: nerve's ends should be brought together, fix a tube to surrounding tissues and apply a fixing knot from external side, suture the epineurium of proximal and then distal ends of the nerve. Ligature should be tightened up till nerve's approaching the middle of tube's lumen and then one should bind a ligature's end to fixing knot. The innovation enables to improve the process of regeneration and reconstruct conductivity in sutured nerve more completely.

EFFECT: higher efficiency of suturing.

1 dwg, 1 ex

Description

The invention relates to medicine, namely to neurosurgery, and is intended for reinnervation of tissues with damage to peripheral nerves.

Currently, there are many methods and various modifications of the surgical recovery of peripheral nerve continuity.

Among the methods for connecting the ends of the nerves, one can distinguish the technique of applying a manual epineural suture, an epineural suture in combination with a perineural suture, a mechanical epineural suture (I.D. Kirpatovsky, E.D. Smirnova. Fundamentals of microsurgical technique. 1978, p. 104-110), nerve plastic surgery using tubing from an arterial allograft (G.N. Akuev, G.S. Kokin, I.Chumasov, L.I. Kolosova and others. Questions of Neurosurgery, 1988, No. 6, p. 32-36).

However, each of these methods has its own drawbacks: often when the epineural suture is applied, the longitudinal orientation of the nerve bundles and insufficient contact between their ends are observed, the nerve bundles can bend for a while during bleeding and the formation of a hematoma at the junction of the nerve, rotation of the ends along the longitudinal axis is possible , which leads to the ingrowth of sensitive axons in the motor paths and vice versa - this ultimately leads to a loss of function. The combination of the epineural suture with the perineural suture is accompanied by an increase in the operation time, an increase in the tissue reaction in the suture area, which leads to the formation of a more severe scar, impaired blood supply to isolated bundles due to the intersection of blood vessels during their isolation. A mechanical epineural suture is technically more complicated and requires technical equipment (I.D. Kirpatovsky, E.D. Smirnova. Fundamentals of microsurgical technique. 1978, p. 104-110). Wrapping the suture line or tuba with an arterial allograft causes an inflammatory reaction of the surrounding tissues and creates additional sources of scarring in the circumference of the nerve, which greatly complicates the regeneration process (G.N. Akuev, G.S. Kokin, I. Chumasov, L.I. Kolosova, etc. G. Issues of Neurosurgery, 1988, No. 6, p. 32-36).

As a prototype, we chose a method of connecting the nerves with a manual epineural suture (I.D. Kirpatovsky, E.D. Smirnova. Fundamentals of microsurgical technique. 1978, pp. 104-108). The technique for applying a manual epineural suture is as follows: suturing of the nerve begins with the application of two guides or fixing sutures that provide fixation of the nerve in a certain position. These two sutures are applied to the epineurium at two opposite points, separated from each other at a distance of 180 ° around the circumference of the nerve or closer to its front surface at a distance of 120 ° and tied. The ends of the nerve do not tightly pull together. Then, continuous (or nodal) sutures are applied to the anterior and then to the posterior surface of the nerve.

The disadvantages of the prototype are: 1) it is possible to rotate the stitched ends along the longitudinal axis with the ingrowth of sensitive nerve axons in the motor paths and vice versa, which ultimately leads to loss of function; 2) insufficient contact of the nerve bundles leads to their curvature throughout and growing into the perineural tissue between the bundles of the opposite stitched end; 3) one cannot be sure of the correct orientation of the nerve bundles, as they can deviate from the direct direction and bend after the operation and be involved in the scar tissue at the junction of the nerve.

The aim of the invention is to optimize the surgical technique for applying the epineural suture in combination with tubulation of the site of the anastomosis to improve the regeneration and restoration of conduction in the stitched nerve.

SUMMARY OF THE INVENTION

The drawing shows a diagram of the stages of applying the epineural suture in combination with tubulation of the ends of the nerve, where: 1 - the fixing unit on the outer wall of the tube with a "antennae"; 2 - the stage of introducing an atraumatic needle with a thread into the lumen of the tube through its proximal section with the removal and stitching of the epineuria of the distal end of the nerve with pulling it to the middle third of the tube in the opposite direction; 3 - withdrawal of an atraumatic needle from the opposite end of the cut of the tube and capture of the epineuria of the opposite proximal end of the nerve with the stitched nerve being drawn behind the needle into the lumen of the tube until the nerve ends are precisely matched; 4 - an atraumatic needle with a thread is brought out through the distal end of the tube, tightened and tied with a "tendril" of the fixing unit on the outer surface of the tube wall.

The essence of the invention is as follows. Using the microsurgical technique, damaged ends of a nerve are separated from surrounding tissues before suturing a nerve under an operating microscope or a magnifying glass. We carefully prepare its ends, which consists in crossing each end, 1 mm from the place of damage. In the presence of neurinoma, neurolysis is performed according to the accepted method. To tubulate the stitched ends of the nerve, a polyvinyl chloride tube is used, the lumen diameter of which depends on the thickness of the nerve. We select suture atraumatic material taking into account the size of the nerve.

At the beginning of the drawing (1), on the outside in the middle of the tube, its wall is stitched and fixed to the surrounding tissues, while the “antennae” of the atraumatic thread unit is not cut off.

An atraumatic needle (2) with a thread is inserted through the proximal section into the lumen of the tube and brought out from its opposite end, the epineuria of the proximal end of the nerve is captured with the subsequent holding of the atraumatic needle with the stitched nerve in the opposite direction. In this case, the distal end of the nerve is brought only to the middle of the length of the lumen of the tube, and the needle with the thread is brought out through the opposite proximal section of the tube. Next (3), we capture the epineuria of the proximal end of the nerve, and again insert the needle into the lumen of the proximal section of the tube and pull it through its opposite section. We pull the thread until the ends of the nerve come closer and tie (4) outside with the “antennae” of the first fixation unit.

EXAMPLE: White mongrel rat, weighing 200 g.

A left-sided pararectal incision made a laparotomy. Through the transabdominal access in the lumbar region, the femoral and sciatic nerves are distinguished. After surface irrigation with a solution of lidocaine, both nerves were transected.

Further, under the increase of a binocular magnifier using microsurgical technique and atraumatic suture material No. 10/0 according to the proposed method, the ends of both nerves are alternately stitched. To fix the tubes, they were hemmed with single interrupted sutures to the lumbar muscles. The wound was sutured in layers tightly.

This method performed 50 operations on outbred white rats. 3 months after the operation, the integrity of the cross-linked nerves is observed morphologically without the formation of cicatricial neuromas with a gradual restoration of the motor and sensory function of the lower limb on the side of the operation. After 8 months, as shown by visual observations and studies of the reflex during electrodiagnostics, conduction in the sciatic and femoral nerves with a slight increase in the threshold of irritation was restored, normal electroexcitation and activation of the motor function of the muscles of the flexors and extensors of the lower limb indicate good reinnervation of the limb.

SUMMARY OF THE INVENTION DIFFERENT FROM THE PROTOTYPE

1. According to the proposed method, the ends of the nerve precisely approach and stabilize in the lumen of the tube. In the prototype, the ends of the nerve come together and are stabilized by two epineural guide sutures.

2. According to the proposed as an invention method, the anastomosed ends of the nerve are sutured with one suture, in the prototype, in addition to the guides of two sutures, several nodular or continuous sutures are additionally inserted between them.

3. At the first stage of the method of applying the epineural suture, a fixing unit is applied on the outside of the middle third of the tube with preservation of the "antennae", and at the last stage of the operation, after the distal and proximal ends of the nerve are brought together, the end of the thread is tied to the "antennae" of the fixing node , that is, the node is absent on the line connecting the ends of the nerve. In the prototype, nodulation is performed directly on the anastomosis line of the ends of the nerves.

Using the proposed method for applying an epineural suture in combination with tubulation of the nerve ends compared with existing methods has the following advantages: reduction of the operation time, precise comparison of the proximal and distal ends of the crossed nerve, minimal trauma, the absence of nodes on the anastomosis line and associated compression ischemia. The presence of a tube (tubulation of the anastomosis) isolates the stitched ends of the nerve from the surrounding tissues, ensuring their intactness with the exception of the formation of a scar-adhesion process with them, gives the correct direction to the growth of nerve fibers, prevents the displacement, bending and rotation of the stitched ends of the nerve during and after surgery.

A positive effect of the proposed method is the restoration of the integrity and conductivity of peripheral nerves with the restoration of lower limb function in 75% of cases.

The proposed method for applying an epineural suture can be implemented in neurosurgical and trauma departments, with microsurgical reconstructive interventions on damaged peripheral nerves.

The relevance of the proposed method is related to the importance of the issue of early post-traumatic reconstruction of the damaged peripheral nerve with the subsequent full restoration of the function and sensitivity of the tissues innervated by it.

Claims (1)

A method of applying an epineural suture, including the approach of the ends of the nerve and the suture, characterized in that the tube is fixed to the surrounding tissues and the fixation node is applied from the outside, then an atraumatic needle and thread are inserted into the tube’s lumen, the proximal, then distal nerve ends of the nerve are sutured, the thread pull up to the convergence of the ends of the nerve in the middle of the lumen of the tube, after which the end of the thread is tied to a fixing node.