RU2345721C2 - Method of application of combined "пх"-shaped blanket continuous liver suture - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: needle with thread is passed through parenchyma of liver edge which is sutured and pricked out at wound bottom. Stick into section of opposite sutured wound edge is performed 0.5 cm lower than serous surface with prick out on the surface 1-1.5 cm from wound edge. Needle is stuck into 2.5-3 cm from wound edge on parallel level, with point of last prick-out being perpendicular to wound axis, making "П"- shaped loop. Needle is pricked out on wound bottom and thread is pulled. Needle is stuck 0.5 cm lower than serous coveting into section of opposite wound edge with prick out on liver surface 1-1.5 cm from cut edge, making X-shaped thread decussation in the centre of wound canal. Thread is pulled and blanket criss-cross through "П"-shaped loop on the opposite side of wound is made. Ligatures are tightened to full approximation of wound surfaces and first fixing knot is put in continuous suture. Further suture formation is carried out by similar methods.

EFFECT: reduction of risk of cutting, increase of suture strength.

1 ex, 1 dwg

Description

The invention relates to medicine, namely to abdominal surgery, and is intended for suturing wounds of the liver.

Surgical treatment of traumatic injuries of the liver has a long history and, despite significant achievements, suggestions and improvements, it still represents one of the most difficult problems of modern abdominal surgery, especially since they are considered the most dangerous in their severity and frequency of complications, especially in patients with combined and multiple trauma. The issue of hemo- and cholestasis in wounds and surgical interventions on the liver, despite significant achievements, suggestions and improvements, remains a complex problem of modern hepatosurgery.

Damage to the liver is always more or less accompanied by blood and bile leakage as a result of rupture of small or large blood vessels and bile ducts. These injuries always require emergency surgical care.

Among the large number of proposed methods for suturing liver wounds, U-shaped and eight-shaped sutures are most widely used as the simplest and with the effect of hemo- and cholestasis - Kuznetsov-Pensky's suture, Giordano, V.A. Oppelya, N.A. Rubanova (A.A. .Shalimov, A.P. Radzikhovsky, V.N. Polupan "Atlas of operations on the liver, bile ducts, pancreas and intestines", 1979, p.30-33; V.N. Voilenko, A.I. Medelyan, V. .M. Omelchenko "Atlas of operations on the abdominal wall and organs of the abdominal cavity", 1965, p. 464-470; O.P.Bolshakov, G.M.Semenov "Practical x irurgy and topographic anatomy ”, 2001, p.665-666), an eight-shaped seam (V.N. Egiev, V.M. Buyanov, OA Udotov“ Surgical suture ”, 2001, p.66).

However, each of these methods has its drawbacks: most of them are difficult to perform and do not provide reliable hemostasis and hermetic intrahepatic biliary tract due to the eruption of the liver parenchyma with subsequent leakage of blood and bile into the abdominal cavity with the occurrence of biliary fistulas and peritonitis, and also the possibility of leaving residual cavities deep in the wound where purulent cysts can form.

After stitching M.M.Kuznetsov-Yu.R. Pensky, Giordano it is necessary to cut the stitch loops and tie the ends of the threads together, which complicates the technique and prolongs the operation time. The complexity of the techniques used by V.A. Oppel and N.A. Rubanova when applying mattress stitches makes them more traumatic.

As a prototype, the seam of M.M. Kuznetsov-Yu.R. Pensky (V.N. Voilenko, A.I. Medelyan, V.M. Omelchenko, “Atlas of operations on the abdominal wall and abdominal organs”, 1965, p. 464-470). The technique of M.M.Kuznetsov-Yu.R. Pensky's suture is as follows: the liver tissue is stitched through the entire thickness with a thick blunt liver needle with a double catgut thread, which is alternately brought to the upper and lower surfaces of the liver, and in the case of a cut wound, on both its sides. In the future, the loops are cut, and the ends of the threads are tied in turn. Thus, the edge of the liver or a stab wound is stitched with oncoming U-shaped sutures, compressing the ends of the blood vessels together with the parenchyma.

The disadvantages of the prototype are the need to dissect the stitch loops, followed by tightening and tying the ends of the threads together on the upper and lower surface of the liver with the formation of nodal U-shaped sutures, which complicates the operation technique and increases the time of its operation, the possibility of cutting through the liver parenchyma with subsequent leakage of blood and bile into the abdominal cavity.

The aim of the invention is to improve the technique of forming a hepatic suture in case of liver damage.

The essence of the invention

The drawing shows a diagram of the stages of applying a combined PH-shaped-twisting continuous suture of the liver, where: pos. A - the first injection, 2.5-3 cm away from the edge of the wound, the needle with the thread is drawn through the entire thickness of the parenchyma of the stitched liver edge and punctured at the very bottom of the wound; then this needle with a thread is pulled and injected into the slice of the opposite stitched wound edge 0.5 cm below the serous surface and, passing the parenchyma, they are punctured 1-1.5 cm from the edge of the wound cut; Pos. B - they are injected with the same needle 2.5-3 cm from the edge of the wound at the same level with the point of the last puncture perpendicular to the axis of the wound, forming a U-shaped loop. The thread is passed through the entire thickness of the stitched edge and punctured at the bottom of the wound, and then injected 0.5 cm below the serous cover into a slice of the opposite edge of the wound with a needle on the surface of the organ 1-1.5 cm from the edge of the wound. At the same time, an X-shaped cross of threads is formed in the center of the wound channel; Pos. B - stretching the ligature, it is produced with a twisted overlap on the opposite stitched edge of the wound, where the needle with the thread is passed through the U-shaped loop; Pos. G - tightening the ligatures to a full comparison of wound surfaces, impose the first fixing node in a continuous suture; Pos.D - a finished view of the superimposed combined PH-shaped-twisted continuous suture of the liver.

The essence of the invention consists in the following: the first injection is made, 2.5-3 cm away from the edge of the wound, a needle with a thread is drawn through the entire thickness of the parenchyma of the stitched edge of the liver and punctured at the very bottom of the wound, then this needle and thread are pulled and produced into the slice of the opposite stitched wound edge 0.5 cm below the serous surface and, passing the parenchyma, puncture 1-1.5 cm from the edge of the wound cut (see drawing, item A). Then the ligature is pulled out until at the point of the first injection there is only that segment of 6 cm that is sufficient for nodule formation. Next, the same needle is injected 2.5-3 cm from the edge of the wound at the same level with the point of the last puncture, perpendicular to the axis of the wound, forming a U-shaped loop. The thread is passed through the entire thickness of the stitched edge and punctured at the bottom of the wound, and then injected 0.5 cm below the serous cover into a slice of the opposite edge of the wound with a needle on the surface of the organ 1-1.5 cm from the edge of the wound. At the same time, an X-shaped cross of threads is formed in the center of the wound channel (see drawing, item B).

After that, the ligature is pulled and it is entangled with an overlap to the opposite stitched edge of the wound, where the needle with the thread is passed through a U-shaped loop (see drawing, pos. B).

After tightening the ligatures until the wound surfaces are completely matched, the first fixing unit is placed in a continuous suture (see drawing, pos. D).

The further formation of the suture is carried out in exactly the same manner as at the beginning, only without knots in the process, only at the end of the length of the wound after the last twisting overlap and passing the thread through the U-shaped loop, the threads are finally tightened with the fixing assembly applied (see drawing, pos. .D).

EXAMPLE (experiment). Mongrel dog weighing 30 kg. They performed a mid-median laparotomy. Using a scalpel on the anterior surface of the lobe of the liver, a model of a stab-cut wound 5 cm long and 2 cm deep was created.

The first injection was made, retreating from the edge of the wound by 2.5 cm, a needle with a thread was drawn through the entire thickness of the stitched liver wall and punctured at the bottom of the wound. Having stretched the thread, an injection was made into a slice of the opposite edge of the wound 0.5 cm below the serous cover of the organ and punctured 1 cm from the edge of the wound cut. Then the main length of the thread was pulled out, leaving at the end (at the point of the first injection) only a tip 6 cm long for applying the first fixing unit of a continuous seam. Then, 2.5 cm back from the edge of the wound, an injection was made with the same needle and thread at the same level as the last puncture point. In this case, a U-shaped loop was formed perpendicular to the axis of the wound. The needle was drawn through the entire thickness of the stitched edge and was punctured at the bottom of the wound, pulling the thread, injected 0.5 cm below the serous cover into a slice of the opposite edge of the organ and punctured 1 cm from the edge of the wound.

Having stretched the thread, they made a twisted overlap to the opposite edge, where the needle and thread were passed through the U-shaped loop and, tightening the ligatures until the wound edges were completely matched, they were fixed with the first node of the continuous suture.

Then the suture was applied in the same manner as at the beginning, only without nodule formation in the process, only at the end of the length of the wound after the last overlap and passing the thread through the U-shaped loop, the ligatures were finally tightened and a fixing knot was applied.

This method performed 35 operations on outbred dogs. After 3 months after surgery, regeneration is observed morphologically with the complete formation of a connective tissue scar at the suture site. Animals in the postoperative period felt good, there were no complications in the form of biliary peritonitis and bleeding, and there were no fatal outcomes.

Signs of the invention, distinctive from the prototype:

1. According to the proposed method, the comparison and fixation of wound surfaces is provided by combined PX-shaped-twisted sutures. In the prototype, the edges of the wounds of the liver come together and stitch together due to the U-shaped seams.

2. In the proposed combined PH-shaped-twisting continuous suture in the center of the wound channel, an X-shaped cross is formed between the ligatures connecting the bottom and the surface of the wound cut. In the prototype, ligatures extend across the entire thickness of the parenchyma.

3. In this method, for a precise comparison of the surface edges of the wound, a ligature is entwined by a loop over the loop on the opposite side of the wound. In the prototype, after suturing the entire wound, it is necessary to sequentially cut one of the two loops of each stitch on both sides and only then tighten and tie the ends of the threads separately.

4. In this method, we apply a combined PX-shaped-twisted continuous seam, in the prototype, a U-shaped continuous seam is initially applied, but then, separating the loops of each stitch, they turn it into a U-shaped nodal seam.

Using the proposed method of applying a liver suture in comparison with existing methods has the following advantages: reduction of operation time, strength of the suture, precise and tight comparison of wound surfaces, eliminating the risk of leaving residual cavities in the depth of the wound, where central hematomas under the suture can form, complicated by suppuration and formation cysts, minimal trauma, the possibility of bleeding, bile duct and teething is minimized, as well as simplicity and access Nost wide range of surgeons. This suture has 4 fixation points on the surface of the liver, a twisted overlap and an X-shaped cross in the center of the wound canal, and therefore the traction force at each point is reduced, which helps to prevent the thread from cutting through the liver tissue while fully matching the edges of the wound.

A positive effect of the proposed method is the restoration of the integrity of the body and the prevention of hemorrhage and bile leakage in 100% of cases.

The proposed method of applying a hepatic suture can be implemented in the departments of abdominal surgery, during surgical interventions on the liver.

Claims (1)

The method of applying a combined PH-shaped-twisting continuous suture of the liver, characterized in that, retreating from the edge of the wound by 2.5-3 cm, the needle with the thread is passed through the parenchyma of the stitched edge of the liver and punctured from the bottom of the wound, then it is injected into a section of the opposite stitched wound edge is 0.5 cm below the serous surface with a puncture on the surface 1-1.5 cm from the wound edge, then, pulling up the ligature, they are injected 2.5-3 cm from the wound edge at a parallel level with the point of the latter a puncture perpendicular to the axis of the wound, forming a U-shaped loop, then poked out a needle is inserted at the bottom of the wound and the thread is pulled, again injected 0.5 cm below the serous cover into a slice of the opposite edge of the wound with a puncture on the surface of the liver 1-1.5 cm from the edge of the cut, forming an X-shaped filament cross in the center of the wound channel and then they pull the thread and twist it through the U-shaped loop on the opposite side of the wound, then tighten the ligatures until the wound surfaces are completely matched and put the first fixing knot in a continuous suture, further formation of the suture is carried out in the same ways as at the beginning, at the end of the length of the wound after the last winding overlap of the thread through the U-shaped loop, the ligature is finally tightened with the last fixing knot imposed.