RU2307603C2 - Lamellar sutures - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should apply uninterrupted mattress suture, for this purpose at the end of sutured wound the needle should be turned back to fulfill the next puncture in the site of previously fulfilled puncture in. Moreover, cutaneous longitudinal sectors of sutures at total length of stitches except peripheral one should be doubled, at the last stitch of the suture the ends of ligature should be tightened together to form a knot. Then on should apply lamellar sutures represented by wire figuredly curved closed loops which should be applied so that central arch-shaped curvature of wire loops to be above the line of mutually adapted edges of the wound, for this purpose under the loop of mattress suture from both sides of the wound one should successively apply peripheral parts of a wire loop which should be slightly lifted up by forming symmetrical peripheral curvatures. The innovation enables to increase reliability of the suture and decrease the loading per the unit of skin area.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to surgical surgery.

As a rule, each surgical operation is accompanied by a layer-by-layer connection of tissues. The basic principles of suturing wounds are careful attitude to the connected tissues and the need for consistency of surgical sutures. Errors in suturing can be the cause of serious complications, such as eventing of the intestine or other internal organs, the formation of postoperative hernias, loss of tightness of the chest or abdominal cavity, joint capsule, etc. This is especially true when suturing loose tissue or the development of the inflammatory process. After suturing the wound, the sutures often cut into the skin, plunging below the level of its surface and ceasing to hold the edges of the wound in contact. This occurs both due to the forced intraoperative tension of the suture by the surgeon when he pulls together the diverging edges of the wound (in the presence of a skin defect, for example), and due to the associated inflammation. When suturing a wound under conditions of inflammatory changes in its edges, lamellar sutures are usually used. However, during the operation it is not always possible to accurately predict the course of the wound process and establish clear indications for the use of plate sutures. They are applied in the process of suturing the wounds and removed with the removal of sutures. The use of plate sutures is associated with an increase in the duration of surgical intervention and other inconveniences and complications, for example, the accumulation of wound discharge under them, causing diaper rash, maceration, etc. Therefore, it is natural that the surgeon, as a rule, refrains from using them without sufficiently serious reasons, and when they occur, inflammatory phenomena around the existing skin sutures limit the possibility of their replacement with plate sutures.

Lamellar sutures described in the monograph "Wounds and wound infection" edited by Acad. Were selected as a prototype of the proposed device. M.I.Kuzina and prof. B.M. Kostyuchenok (M .: Medicine, 1981, 688 p.), Used as follows. After surgical treatment of the wound, ordinary knotted or mattress stitches are placed on it, before tying them between the skin and the stitch loop, plate seams are used as shock absorbers, represented by rubber tubes, gauze balls, buttons, etc. Moreover, the size and area of the plate seams are inversely correlated with the size the pressure of the seam on the skin, preventing the possibility of its eruption. However, along with the prevention of teething and divergence of joints, the prototype device has significant disadvantages:

1) application to the wound only in the process of suturing - in the presence of obvious tension of the sutures or for prophylactic purposes with a high probability of subsequent inflammation and swelling of the edges of the wound;

2) the lack of the possibility of imposing, removing or replacing plate sutures without replacing sutures on the wound;

3) the impossibility of subsequent (postoperative) regulation of the degree of tension of the joints and mutual adaptation of the edges of the wound;

4) frequent accumulation under the seams of the wound discharge, causing diaper rash and maceration.

Lamellar seams and a method for applying them are offered. They are represented by closed loops made of pieces of wire (for example, stainless steel paper clips or wire for osteosynthesis), with a diameter of 0.5-1 mm and a length of 8-12 cm, the ends of which are connected by "twisting" in 2-3 turns (Fig. 1a). In order that the “twist” assembly subsequently does not interfere (does not cling to the suture material or does not shed skin near the wound) during clinical use of sutures, as well as for a more tight connection of the ends of the wire segment, it is flattened by hammer blows on the anvil in the plane of both knee wire loop. The ends of the wire outside the flattened knot are cut. In the middle of the loop with pliers (needle holder, Kocher clamp, etc.), an arcuate bend is formed that is symmetrical on both its knees (Fig. 1, b). The purpose of this bend is twofold: firstly, for the availability of a reserve for the length of the plate seam, lengthening when aligning the bend of the loop, and secondly, so that when using the plate seam the wire does not come into contact with the line of the surgical wound. Then the edges of the elongated wire loop are slightly raised, forming its symmetrical peripheral bends (Fig. 1, c), convenient for preventing the falling of the plate seam from the cutaneous loops of the continuous mattress seam, the purpose and essence of which are as follows.

For the use of wire plate seams, the wound is sutured with a special continuous mattress suture (Fig.2, a, b). Starting from one of the two edges of the tissues to be connected, a needle is inserted with a suture thread and it is punctured on the other side of the wound. Then, on the same (second) side of the wound, backing 2-3 cm, a needle is injected with its puncture on the opposite (first) side of the wound. This action is repeated throughout the sutured wound, at the end of which the needle is deployed in the opposite direction (Fig.2, a) and its subsequent injection is performed at the point of the previously performed injection. In this case, the cutaneous (longitudinal) segments of the sutures along the entire length of the stitches on both edges of the wound are continuously located (with the presence of two injections with a needle at one point), and the subcutaneous (transverse) segments (except for both peripheral ones) are doubled (Fig. 2, b). When suturing the wound with this continuous mattress suture, it must be ensured that the thread is in tension sufficient to adapt the edges of the wound. At the last stitch of the seam, the ends of the suture are connected with each other by a double-triple surgical node. The advantages of this continuous mattress seam are:

1) increase the reliability of the seam due to the doubling of suture loops between the stitches;

2) reducing the load per unit area of the skin with minimizing the likelihood of eruption of sutures or the formation of subsequently cosmetically vicious "suture marks" on the skin;

3) the possibility of using the proposed removable wire seams.

Immediately after applying a continuous mattress seam or in the future, as applicable, use plate-type wire seams. They are laid in such a way that the central bend of the wire loops is above the line of mutually adapted wound edges. To do this, under the raised tweezers, the loop of the mattress suture on both sides of the wound sequentially winds up the peripheral parts of the plate suture (Fig. 3, a). In order to keep the plate seam in the loops of the mattress seam, the latter is lifted with a needle holder or pliers (Fig. 3, b). With increasing curvature of the peripheral bends of the plate seam (and, accordingly, shortening its length), the thread tension of the mattress seam increases (Fig. 3, c). Thus, this seam allows you to adjust the thread tension and the degree of mutual adaptation of the edges of the wound. In addition, due to the lattice structure of wire plate sutures, they do not prevent the outflow of the wound discharge and are not accompanied by diaper rash and maceration.

As an example of the application of the proposed device, the following observation.

Patient D., 45 years old, medical history No. 2-1227, in critical condition, was taken by ambulance on 10/11/04 1.5 hours after the car trip with a diagnosis of Concomitant injury: Concussion. Dumb abdominal injury. An open comminuted fracture of the bones of the left tibia in the middle third with parietal damage to the anterior tibial artery. Traumatic shock of the II degree. Alcohol intoxication.

In the course of intensive therapy (catheterization of the subclavian vein and bladder, infusion therapy, plasma transfusion, blood transfusion, etc.) and normalization of blood pressure, an operative manual was performed: Primary extrafocal osteosynthesis of the left lower leg with Ilizarov’s apparatus, PHO of the wound of the lower leg with restoration of the damaged anterior tibial artery. Due to the suspicion of damage to the abdominal organs, laparocentesis was performed and a blood-stained fluid was obtained, which was an indication for emergency laparotomy.

A mid-midline incision was performed laparotomy with revision of the abdominal organs. In the abdominal cavity there was about 400 ml of blood and two ruptures of the mesentery of the small intestine - 4.0 by 1.0 cm and 5.0 by 2.0 cm with uneven edges and moderate bleeding. The tears are sutured. In layers - stitches on the wound; abdominal drainage.

10/13/04 - The abdomen is swollen, the dressing is profusely wet with serous-hemorrhagic discharge. Two skin sutures were dissolved and loops of the small intestine were found at the bottom of the wound. A subcutaneous intestinal event was diagnosed, which was an indication for emergency surgery, during which skin sutures were removed. The edges of the wound along the entire length appeared to have diverged due to the eruption of sutures drawn close to its loose edges. The intestinal loops are sharply inflated, with the exception of a small area in the final section of the intestine. Intubation of the small intestine with a probe was performed. The intestines are free of gas. About 120.0 ml of novocaine 0.25% was introduced into the root of the mesentery. The abdominal cavity is washed with a solution of furacilin. Drainage from the left lateral canal is removed, and left in the small pelvis.

Since eventing occurred due to eruption of sutures through atonic flaccid and somewhat inflamed abdominal wall tissues against the background of bloating, indications were given for the use of the proposed plate sutures. Sutures were applied through all layers of the wound as follows. Starting from one of the edges of the tissues to be connected, a needle was made with a nylon thread and it was punctured on the other side of the wound. Then, on the same side of the wound, backing 3 cm, a needle was injected with a needle on the opposite side of the wound, repeating this manipulation throughout the sutured wound. At the end of the last, the needle was turned in the opposite direction and the subsequent injection was performed at the point of the previously performed injection. In this case, the longitudinal cutaneous segments of the sutures along the entire length of the stitches at both edges of the wound were continuously located (with two injections with a needle at one point), and the transverse subcutaneous segments (except for both peripheral ones) were doubled. When suturing the wound, it was ensured that the thread was in tension sufficient to adapt the edges of the wound. At the last stitch of the seam, the ends of the thread were tied together by a triple surgical knot. Then applied the proposed wire plate seams, which were laid so that the central bend of the wire loops was above the line of mutually adapted wound edges. For this, under the raised forceps, the loop of the mattress suture on both sides of the wound sequentially wound the peripheral parts of the plate suture. So that the plate seam does not fall out of the loops of the mattress seam, they were lifted with a needle holder. This seam made it possible to regulate the tension of the thread and the degree of mutual adaptation of the edges of the wound, and due to the lattice structure of the wire plate sutures, they were not accompanied by diaper rash and maceration. The sutures were removed on 10/25/04. The wound healed by first intention.

Thus, the advantages of the proposed device are the following:

1) non-invasiveness of the application of lamellar seams;

2) the possibility of applying to the wound not only in the process of suturing (mainly with a preventive purpose), but also in the future - as necessary (for example, with an increase in edema and incision of sutures into the skin);

3) the possibility of not only applying, but also removing or replacing plate sutures (with more suitable in size and shape) without the need to replace sutures on the wound;

4) the ability to control the degree of tension of the joints and mutual adaptation of the edges of the wound;

5) due to the lattice structure of lamellar sutures - the absence of conditions for the accumulation of wound discharge under them, and therefore - the prevention of diaper rash and maceration.

Thus, the proposed lamellar sutures are optimal in comparison with existing analogues and can improve the effectiveness of the treatment of surgical patients.

Bibliography

1. A short course of surgical surgery with topographic anatomy // Guide edited by V.N. Shevkunenko and A.N. Maximenkov. - L .: Medgiz. - 1951. - 796 p. - S. - 42-45.

2. Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy. - Kursk; Moscow: CJSC Litera, 1996 - 720 p. - S.- 35-38.

3. Brown M.P. General principles of surgical technology // Guide for surgeons. - Rostov N / A: Publishing House "Phoenix", 1999. - 544 p. - S.- 427-432.

4. Wounds and wound infection. Edited by Acad. M.I.Kuzina, prof. B.M. Kostyuchenok. M .: Medicine, 1981, 688 p. (p. 365-378) - prototype device.

Claims (1)

A method of applying a lamellar suture to an operative wound, characterized in that a continuous mattress suture is applied, for which the needle is turned in the opposite direction at the end of the sutured wound and a subsequent injection is performed at the point of the previously performed injection, while cutaneous longitudinal segments of the seams along the entire length of the stitches on both the edges of the wound are positioned continuously, and the subcutaneous segments, in addition to the peripheral ones, are doubled, at the last stitch of the seam, the ends of the thread are knotted together, then lamellar sutures, represented by wires figuratively curved closed loops that are laid so that the central arcuate bend of the wire loops is above the line of mutually adapted wound edges, for which, under the loop of the mattress suture on both sides of the wound, the peripheral parts of the wire loop are sequentially raised, which are slightly lifted, forming symmetrical peripheral bends .

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