RU2319462C1 - Method for suturing wound on uterine surface after surgical uterus treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying continuous and interrupted suture combination including step-by-step suturing techniques. The first and the last steps are used for fixing purposes and they are carried out beyond the wound boundaries. The second step covers wound length and depth. Serous membrane edge is caught with one thread end, making 1.0-1.5 cm long step from knot towards the wound and pulling the thread from outside to inside, then, it passes from inside to outside with space of 2/3-3/4 of wound depth making exit pierce 1.0-2.0 cm far wound edge. Next, the second thread end is led from the other side in the like manner. The knot is tightened and tied, and the second stage repeated several times until the wound is completely closed.

EFFECT: simplified suture-placing method; reliable juxtaposition of wound walls and bed; soft cicatrix formation; reliable hemostasis.

Description

The invention relates to medicine, in particular to gynecology, and can be used when suturing a wound on the uterus after conservative myomectomy, as well as in reconstructive plastic surgery for an abnormality of the uterus without opening its cavity.

There is a method of suturing a wound of the uterus - Salekhov S.A., Radzinsky V.E., Korabelnikov A.I. and others. The method of suturing a wound of the uterus - RU No. 2194466 C2.

The method is as follows.

Perpendicular to the edge of the wound, the visceral peritoneum and underlying muscle layer are sutured. The thread is transferred to the other side. Stitch the uterine wall through all layers. The thread is transferred to the second side and stitched from the edge of the wound perpendicular to him muscle layer and visceral peritoneum. The outer tier is located in the middle of the inner tier perpendicular to it. Before tying the suture, the ends of the thread are bred perpendicular to the edges of the wound of the uterus to the side of it. Invert and map the muscle layer. When tying the threads, the muscle layer and the visceral peritoneum are compared.

The advantages of this method are a thorough comparison of the edges of the wound and high hemostaticity, however, according to the authors of the proposed method

- repeated stitching and constriction of tissues can cause severe ischemia, which prevents the formation of a full scar;

- the use of a large amount of suture material creates the conditions for an inflammatory reaction in the area of the forming scar;

- this method of suturing a wound is technically complicated and significantly lengthens the operation time.

There is a method of suturing a wound on the uterus by stitching two cochlearly wrapped serous-muscular flaps (Blind AS, Atypical gynecological operations. M: Medicine, 1981, 56 S., S. 43-45).

Typically, this method is used for conservative myomectomy after husking a large enough node whose diameter exceeds 10 cm. The technique for suturing a wound on the uterus after enucleation of the node is as follows. Over the greatest convexity of the node, an oval cut is made mainly in the longitudinal direction. The node is captured with Muso forceps and enucleated in the usual way. Since the uterus is pulled up from the abdominal cavity, bleeding from the bed of the node is small. Then, a large half of the capsule is wrapped in a spiral shape inward, like the body of a snail, while hemming it to the bed with knotted catgut sutures, thus providing hemostasis. The procedure for suturing is from the edge of the capsule to the bottom of the bed. After that, the capsule of the other side is wrapped and hemmed. In the described manner, the wound of the uterus is easily sutured without leaving free spaces and cavities. The systemic tissue connection "into the castle" reliably strengthens the uterine wall.

When using this method of suturing a wound on the uterus, the authors of the proposed method noted the following disadvantages:

- repeated, over several floors, flashing of the muscle layer of the uterus leads to its pronounced trauma, which leads to difficulty in the subsequent healing of the wound;

- when tightening the muscular-muscle joints, a forced tension of the tissues occurs, which subsequently leads to a local circulatory failure with the possible development of necrosis;

- there is a great risk of eruption of muscle-muscle joints during their tightening;

- a large amount of catgut administered is not indifferent to the body;

- a continuous looped serous-muscular suture requires additional peritonization, otherwise it contributes to the formation of adhesions in the pelvic area;

- despite multistory flashing, the incomplete connection of the wound walls and the development of hematomas in the resulting dead spaces, prone to suppuration, which, in turn, can lead to the development of peritonitis and subsequently to the extirpation of the uterus, are inevitable;

- the disadvantages of this method of suturing a wound on the uterus are high blood loss, since suturing is done by sequentially stitching 12-18 sutures over several floors, while the wound walls located above the stitching site are exposed and bleed continuously;

- as a result of cutting off excess tissue, a decrease in the volume of the muscular membrane of the uterus occurs, which can subsequently lead to anomalies of labor, impaired contractile function of the uterus, hypotonic bleeding in the postpartum period;

- the most significant drawbacks are the insufficient strength of the scar, which is formed when the wound on the uterus is sutured by this method, and, therefore, there is a high risk of uterine rupture in the scar area during pregnancy and childbirth. In this regard, spontaneous delivery through the natural birth canal becomes very problematic, and, as a rule, preference is given to surgical delivery by cesarean section.

There is also a method of suturing a wound on the uterus using a suture according to Logotetapolos (Kustarov V.N., Linde V.A., Aganezova N.V. Uterine fibroids. - SPb .: SPbMAPO. - 2001. - 32 p. - p. 28 Kustarov VN, Linde VA, Aganezova NV Conservative myomectomy during cesarean section // Obstetrics and Gynecology, 2001. - 2. P.54-55.)

The essence of this technique for suturing a wound on the uterus is as follows.

When suturing, a round needle is passed through the entire thickness of the capsule of the husked myomatous node on one side with a needle stick at the base of the capsule and a puncture at the edge, then on the other, but in the reverse order. The distance from the injection to the needle should approximately correspond to the depth of the bed. After tying the nodes so laid, the capsule of the husked node is screwed into its bed, creating reliable hemostasis and eliminating the need for peritonization. The distance of the seams from each other is 1.0-1.5 cm, which ensures a complete reposition and prevents ischemia of stitched tissue sites.

However, this technique, according to the authors of the proposed method, has several disadvantages:

- the thread is carried out subserosally with minimal capture of the muscle layer. With itramural or intraligamentary arrangement of nodes, when there are no or very few capsule tissues, this leads to the deepening of the bed of a large surface of the uterine tissue (area). This creates excessive tension and conditions for ischemic tissue and increase the activity of adhesions in the postoperative period;

- Excessive tissue tension can create conditions for the formation of inferior scars;

- tamponade of the bed of the myomatous node mainly due to the tissue of the capsule creates the conditions for the formation of hematomas in the space between the bottom of the bed and the tissues of the capsule, which significantly slows the formation of the scar and complicates the course of the postoperative period;

- hematomas can form deep in the wound at the sites of least tension between the nodes;

- the contraction of a large number of tissues in the process of suturing the bed of one remote site can lead to a pronounced complication of suturing the bed of a nearby site. And an attempt to take this circumstance into account will inevitably lead to an increase in the risk of hematoma formation in the area of the sutured bed of the node;

- there is a risk of eruption of the seams during their tightening.

As a prototype for the closest technical nature, we have chosen a method for suturing a wound on the uterus by applying an omega-shaped suture (Lukin V.A. Method for suturing a wound on the uterus after surgical treatment of the uterus. - RU 2139001 C1).

The technique for suturing a wound on the uterus with an omega-shaped suture after surgical treatment of the uterus is as follows. Pass the thread from the side of the serous membrane of the uterus through the thickness of the wound wall, departing from the edge of the wound to the bottom of the wound. At the same time, a loop is left in the wound cavity. A thread is drawn from the side of the wound wall closer to its edge and further from the side of the serous membrane from the opposite side of the wound in the region of its edge to the bottom of the wound cavity. Leave a loop in it. The thread is brought out through the thickness of the opposite wound wall. Retreat from its edge. Both sides of the wound are sutured with omega-shaped seams 2-4 times.

When using the prototype method, the authors of the proposed method revealed the following disadvantages:

- the thread is passed through the entire thickness of the uterine tissues, with the exception of the endometrium, with a puncture in the bottom. In the presence of a large intramural or intramural-submucous myomatous node, it is technically difficult to pass the thread through all layers. If, according to this technique of suturing, the puncture is not performed in the area of the bed of the bed of the myomatous node, adequate bed plugging does not occur, which creates conditions for the appearance of hematomas in the area of the bed. The latter, as a rule, leads to prolonged hyperthermia and, rarely, pain in the pelvis in the postoperative period. And, in addition, prevents the formation of a full scar;

- when using the prototype method, the nodes are not tightened until all the seams are applied, this leads to an increase in blood loss - both due to the duration of the unhealed wound surface and due to additional trauma associated with the application of unstretched sutures on the area of the bed of the myomatous node. At the same time, according to the authors of the proposed method, the volume of blood loss is greater, the greater the diameter of the removed node.

The number of blood loss when using the prototype method according to its own data is an average of 300 ml.

The objective of the invention is to develop a method of suturing a wound on the uterus, which allows to reduce blood loss during surgery, to reduce the number of postoperative complications and to reduce their severity, as well as to shorten the postoperative period and simplify the technique of suturing.

The technical result of the method is to provide reliable direct comparison of the walls and bed of the wound while preserving the architectonics of the muscle wall with the formation of a tender scar, ensuring reliable hemostasis, and also eliminating the appearance of dead spaces, cavities and pockets, and accordingly, hematomas, with or without suppuration.

The problem is solved in that they impose a continuously-nodular screw-in suture, including stepwise suture, and the first and last suture steps, which are fixing, are performed outside the wound. The second step is performed along the length and depth of the wound. This step is carried out, retreating towards the wound from the site by 1.0-1.5 cm, at one end of the thread they pick up the edge of the serous membrane, spend the thread from the outside to the inside. Then the thread is passed through 2 / 3-3 / 4 of the depth of the wound from the inside out with a puncture 1.0-2.0 cm from the edge of the wound, after which the second end of the thread is carried out on the other side in a similar way, the knot is tightened and tied. After this, at the point of separation of the edges of the wound, the second step is repeatedly repeated until the wound is completely sutured.

Consider the implementation of the proposed method for suturing a wound on the uterus using the example of a conservative myomectomy operation. After appropriate treatment of the skin of the anterior abdominal wall, an incision is made according to Pfannenstiel. The uterus is removed to the wound. Myomatous nodes enucleate sequentially, starting with the largest. After husking the myoma node, a Geghar needle holder is taken and a curved needle with a trihedral cutting diameter is fixed in it. Then they take catgut from No. 4 to No. 6 and put it into the needle. The thread is cut so that its length is 50-60 cm. Mentally divide the length of the wound by the number of steps so that the distance between the nodes is not less than 1.0 and not more than 1.5 cm. The first step is carried out by applying a serous-muscular suture beyond the borders wounds, departing from the edge of the wound by 0.3-0.5 cm so that both ends of the thread are the same size, from 20 to 50 cm depending on the length and depth of the wound, then the first knot is tied. The second step is carried out, retreating 1.0-1.5 cm from the first node to the side of the wound, picking up the edge of the serous membrane so that the thread passes from the outside to the inside, after which the thread is drawn from the inside out through 2/3 -3/4 of the depth of the bed with puncture 1.0-2.0 cm from the edge of the wound, then the second step is repeated with the other end of the thread, the knot is tightened and tied, after which the second step is repeated with both ends of the thread, departing from the beginning of the divergence of the edges of the wound by 1.0-1 , 5 cm from the previous knot, the knot is tightened and tied, and the second step is repeatedly repeated until complete closure s, the last step is carried out superposition sero-muscular suture outside the wound with the opposite edges of the wound at an angle of 45 ° from the wound with pitch-axis 0.5 cm from the wound angle of the thread pull, tied knot and cut the yarn residues.

After the continuous-nodular screwing seam is applied, proceed to the toilet of the abdominal cavity. Next, the peritoneum is sutured with a continuous catgut suture. Muscles are sutured with the same continuous catgut suture. Then the aponeurosis is sutured with a continuous catgut suture. The skin is stitched with 3-4 silk stitches according to Donati. Blood loss during surgery is 250-300 ml.

In the postoperative period, infusion and antibacterial therapy is performed. Sutures from the skin of the anterior abdominal wall are removed on the fifth day. Extract is carried out on 7-8 days.

Distinctive essential features of the proposed method are the imposition of a continuously-nodular screwing seam, including:

- step-by-step tightening of nodes;

- the implementation of the first and last steps, which are fixing, beyond the borders of the wound;

- the implementation of the second step along the length and depth of the wound;

the second step is carried out as follows: retreating 1.0-1.5 cm from the knot away from the knot, at one end of the thread they pick up the edge of the serous membrane, draw the thread from the outside inward, then the thread is drawn through 2 / 3-3 / 4 of the depth of the wound from the inside out with a puncture 1.0-2.0 cm from the edge of the wound, the knot is tightened and tied; after which the second end of the thread is carried out on the other hand in a similar way, the knot is tightened and tied;

- repeated repetition of the second step at the point of separation of the edges of the wound until it is completely sutured.

A causal relationship between the hallmarks and the result.

Step-by-step tightening of the nodes of the continuous seam provides reliable direct comparison of the walls and the bed of the wound. In this case, vessels and nerves from the muscle layer of one wall freely grow into the muscle layer of the opposite wall of the wound without violating the architectonics of the muscle wall. In addition, the step-by-step tightening of the nodes when applying a continuous suture provides reliable hemostasis of sutured wound sites and minimizes blood loss.

The first and last steps of the suture are fixing and are performed beyond the borders of the wound, as this provides tissue tightening along the length of the wound.

The second step by pulling the tissues along the length and depth of the wound ensures reliable matching of the walls and bed of the wound, which helps preserve the architectonics of the tissues and the formation of a delicate scar, and also prevents the formation of hematomas with or without suppuration due to the elimination of dead spaces, cavities and pockets in areas of the bed of the myomatous node, thereby reducing the severity and frequency of postoperative complications and shortening the postoperative period.

The retreat in the second step towards the wound from the node not less than 1.0 cm and not more than 1.5 cm is sufficient for full tissue tightening along the length of the wound.

Passing the thread through 2 / 3-3 / 4 of the depth of the wound is sufficient to ensure reliable tamponade of the wound, since the selected depth of suturing the wound provides stitching of the wall and screwing tissue.

A puncture of 1.0-2.0 cm from the edge of the wound after passing the thread through 2 / 3-3 / 4 of the depth of the wound provides the necessary amount of screw-in tissue for tamponade of the wound.

The second end of the thread is carried out on the other side of the wound in a similar manner to match the edges of the wound.

Repeated repetition of the second step at the place where the edges of the wound diverge until it is completely sutured provides tissue matching along the entire length of the wound and reliable hemostasis.

The application of a continuous-nodal screwing suture to the uterine wound provides reliable hemostasis due to tight tamponade of the bed, both by screwing the wound tissues into its depth (screw-in suture) and by tightening the tissues along the length of the wound (continuous-nodular).

Distinctive essential features are new and can reduce blood loss during surgery, reduce severity and reduce the number of postoperative complications, and as a result, reduce the postoperative period, as well as simplify the technique of suturing the wound.

We give examples from clinical practice illustrating the inventive method.

Example 1. And / b No. 1253

Patient P., 35 years old. Diagnosis: Symptomatic uterine fibroids.

10/14/04. Gluttony. Myomectomy

Under aseptic conditions, the abdominal cavity was opened in layers according to Pfannenstiel. Found: uterus increased to 15 weeks. pregnancy due to six intramural-subserous nodes. The nodes are located in the uterine fundus (two, with a diameter of 6 and 4 cm), on the posterior surface (two, with a diameter of 3 and 5 cm), on the front surface of the uterus (one, with a diameter of 4 cm) and along the left uterine rib more anteriorly in the isthmus uterus (one, 6 cm in diameter). The intramural node was located on the border of the bottom and posterior surface of the uterus on the right (3 cm in diameter). Appendages on both sides without features.

Produced: a myomectomy of all detected myomatous nodes with suturing of the bed of nodes with a continuous-nodular screwing suture was sequentially performed. Blood loss - 280 ml.

In the postoperative period, hyperthermia (37.1-37.9 °) for 2 days. Ultrasound of the pelvic organs on the 4th day of the postoperative period revealed no pathology. The patient was discharged on the 5th day of the postoperative period.

Example 2 (by the prototype method). I / b No. 3452

Patient K., 34 years old. Diagnosis: Symptomatic uterine fibroids.

02/19/04. Gluttony. Myomectomy

Under aseptic conditions, the abdominal cavity was opened in layers according to Pfannenstiel. Found: uterus increased to 14 weeks. pregnancy due to four intramural-subserous and one intramural node. Intramural-subserous nodes are located in the uterine fundus (one, with a diameter of 6 cm), along the posterior surface (two, with a diameter of 4 and 5 cm) and the anterior surface of the uterus (one, with a diameter of 6 cm). The intramural node was located on the border of the bottom and posterior surface of the uterus on the right (3 cm in diameter). Appendages on both sides without features.

Produced: a myomectomy of all detected myomatous nodes with suturing of the bed of nodes with omego-shaped sutures was sequentially performed. Blood loss - 350 ml.

In the postoperative period, hyperthermia (37.1-38.2 °) for 5 days. With pelvic ultrasound on the 4th day of the postoperative period, a suture of 4.7 by 1.8 cm in size along the posterior surface of the uterus. The patient was discharged on the 7th day of the postoperative period.

According to the claimed method, 32 women were operated on, according to the prototype method - 25. Diagnoses: uterine fibroids with intramural, intramural-subserous or subserous nodes, incomplete doubling of the uterus, bicornuate uterus.

In 3 women operated on by the present method, postoperative complications were observed in the form of hyperthermia (up to 37.9 °) for 2-3 days, which is 9.4%, and according to the prototype method, in 6 patients, body temperature was 38.2- 38.3 ° held for 4-5 days, that is, in 24.0% of patients. The hematoma of the bed of the myomatous node in the postoperative period was observed in 2 operated patients by the present method, which is 6.3%, and when using the prototype method in 4 patients, which is 16.0%, respectively.

Thus, when using the proposed method by 14.6% compared with the prototype method, postoperative complications, manifested in the form of hyperthermia, are reduced, and the severity of such complications is also reduced. Postoperative complications, manifested in the presence of hematomas, are reduced in comparison with the prototype method by 9.7%.

Blood loss in the present method is 250-300 ml, when using the prototype method - 300-350 ml, therefore, the inventive method allows to reduce blood loss compared to the prototype method to 100 ml.

The postoperative period according to the claimed method is 5-6 days, and according to the prototype method - 7-8 days, thus, the postoperative period when using the proposed method is reduced by 2 days.

The method simplifies the technique of suturing the uterus in comparison with the prototype method, since the thread is carried out only at 2 / 3-3 / 4 of the depth of the wound, and not through the entire thickness of the uterine tissue, with the exception of the endometrium, as in the prototype method.

The inventive method of suturing a wound on the uterus provides:

- reliable direct comparison of the walls and bed of the wound without violating the architectonics of the muscle wall with the formation of a tender scar;

- reliable hemostasis, which reduces blood loss in the surgical period;

- prevention of hematomas, which reduces the severity and reduces the number of postoperative complications, which, in turn, reduces the length of hospital stay of patients;

- simplification of the technique of suturing.

Claims (1)

A method of suturing a wound on the uterus after surgical treatment of the uterus by suturing, characterized in that a continuous-nodular screwing suture is applied, including stepwise suturing, the first and last steps, which are fixing, are performed outside the wound, and the second in length and on the depth of the wound, the second step is carried out, retreating 1.0-1.5 cm from the node to the side of the wound, pick up the edge of the serous membrane with one end of the thread, draw the thread from the outside inwards, then through 2 / 3-3 / 4 of the depth of the wound from the inside out with a cut of 1.0-2.0 cm from the edge wounds, after which the second end of the thread is carried out on the other hand in a similar way, the knot is tightened and tied, then at the point of separation of the edges of the wound, the second step is repeatedly repeated until the wound is completely sutured.