RU2373871C1 - Method of hypotension aponeurotic suture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for sewing of aponeurosis. Sutures are applied in form of chain, oriented by course of collagen fibres. In similar way sutures are applied on opposite flap of aponeurosis. Ends of ligatures are tied from opposite sides. Interrupted sutures are applied on aponeurosis edges.

EFFECT: method allows to reduce risk of suture failure.

1 ex, 1 dwg

Description

The invention relates to medicine, namely to surgery, and can be used for stitching aponeurosis.

The use of traditional individual nodal joints for suturing the aponeurosis in some cases is ineffective - the sutures erupt. The main reason for this is excessive tissue tension, which is especially pronounced in the presence of a defect in stitched structures (ventral hernias, traumatic injuries), in a number of obese patients, with abdominal compartment syndrome and other conditions. In addition, inflammatory tissue infiltration, for example during eventization, significantly reduces the level of hypertension sufficient for the development of suture failure (Gostishchev V.K., 1996).

In this regard, a number of aponeurotic suture methods have been proposed to reduce the likelihood of a discrepancy in the stitched structures.

The imposition of additional nodal joints reduces stress on each of them individually. However, each seam surrounds an area with broken trophy. Therefore, in this case, the main cause of suture failure is ischemia of the edges of the stitched aponeurosis, which is exacerbated by the presence of additional foreign material in the scar formation zone (Belokonev V.I. et al., 2005).

The application of “unloading” sutures with wide grip of tissue far from the edges of the stitched aponeurosis, for example, on the cases of the rectus abdominis muscles after median laparotomy, also causes significant tissue nutritional disorders. In addition, such sutures are not able to significantly reduce the load on the main row of sutures, because, firstly, their number is limited due to the risk of developing ischemia and leaving a large amount of foreign material in the wound, and, secondly, the tension in the tissues is necessary for comparison, the edges of the aponeurosis are evenly distributed between each of the nodal joints (the main row and the additional). That is, this additional seam is able to withstand a teething load no more than each of the seams of the main row. And the capture of muscle or adipose tissue in the suture can only accelerate the eruption and movement of the load on other sutures (Littman I., 1985).

The formation of an aponeurosis duplicate with the aim of strengthening it according to Sapezhko or Krymov enhances hypertension by superimposing stitched structures on top of each other, which largely eliminates the fact that the load is evenly distributed on joints located in different planes. In addition, broad mobilization of the aponeurosis (at least one of its surfaces) is necessary, which can cause trophic disorders (Egiev V.N., 2002).

The known method recommended for the treatment of median ventral hernias (RF patent No. 2277384 from 11.29.04.), In which a duplicate aponeurosis is formed and two layers of the implant are used to prevent suture eruption. Nevertheless, this technique cannot significantly reduce the likelihood of eruption, since it usually occurs along the fibers and is not associated with their transverse destruction, and the essence of the method is precisely to prevent the penetration of U-shaped seams across the course of collagen fibers with a synthetic gasket. In addition, the formation of a duplicate of the white line of the abdomen leads to an increase in intra-abdominal pressure, which may cause abdominal compartment syndrome. The disadvantage of this method is the leaving in the wound of foreign material (endoprosthesis).

Known hardware methods for suturing the aponeurosis (Patents of the Russian Federation No. 2045234 from 10.10.95, No. 2164090 from 01/06/99, No. 99100523 from 10.10.2000), which consist in the fact that ligatures, widely capturing the aponeurotic tissue, are removed through the skin to the surface of the body and fixed with metal staples. As ligatures erupt, these staples allow you to maintain the necessary tension in the seam. The disadvantages of these methods are that they increase the length of hospitalization, can be the cause of purulent-septic complications, and are not always effective. In individuals with severe subcutaneous fat, it is problematic to regulate the degree of tension of the aponeurotic layer.

A known method of suturing an aponeurosis using a continuous suture (RF patent No. 2261665 from 10.07.2005). The disadvantage of this method is that it does not reduce hypertension. In addition, with the eruption of one of the stitches, the likelihood of further development of the failure of the entire seam increases sharply.

Eight-shaped seams are proposed (RF patent No. 2223048 dated 02.10.2004), the application of which is carried out as follows. An injection into one of the aponeurosis flaps is performed at a distance of 2-3 cm from the edge, and an injection is not more than 5 mm from the edge of another flap. Further similarly from the opposite side. These sutures differ slightly from ordinary nodules and slightly reduce the probability of eruption, while worsening trophic tissue due to a more massive capture of heterogeneous tissues.

The aim of the invention is to reduce the likelihood of insolvency of the aponeurotic suture due to the distribution of force aimed at the eruption of the joints between the individual joints. Pressure reduction is achieved by linking the seams in the form of a chain, as well as minimizing the impact on tissue trophism with a slight increase in the amount of foreign material in the wound.

This goal is achieved by the fact that the tension in the tissue of the aponeurosis is distributed to additional auxiliary sutures connected in the form of a chain and located along the collagen fibers.

The first suture (1) is applied at a distance of 2-3 cm from the edge of the dissected aponeurosis (2) in a direction parallel to the course of collagen fibers characteristic of this region. A surgical site is tied. Next, another 2-3 seams are applied in the same direction in the form of a chain. In this case, the injection of the subsequent seam is located as close as possible to the puncture of the previous one (3). Similar stitches in the form of a chain must be applied to the opposite flap of the aponeurosis. After that, the ends of the ligatures from the opposite sides are tied (4). Depending on the magnitude of the force necessary to reduce the edges of the wound, such additional sutures are applied every 3-7 cm. When suturing the middle laparotomy wound, hypotensive sutures can be performed on both the front and back walls of the vagina of the rectus abdominis muscle. After this, the usual nodal sutures are applied to the edges of the aponeurosis.

Thus, the force directed to the eruption of the seams is distributed to all links of the seam chain. The orientation of these chains along the collagen fibers provides minimal trophic changes in aponeurosis, which develop far from the edges of the wound. This is due to the fact that the nutrition of a dense, formed fibrous connective tissue is carried out by vessels located in the loose connective tissue surrounding the fibrils of the first and subsequent orders, and oriented along their course, as well as diffusion from the surrounding tissues. In addition, in General, the amount of foreign material in the wound increases slightly compared with the described prototypes. The method avoids the failure of the suture of the aponeurosis in a number of patients predisposed to this.

Example.

Patient V., 73 years old, was admitted on June 24, 2007 on an emergency basis with complaints of cramping abdominal pain, nausea, repeated vomiting, delayed stool and gas discharge. Sick for 26 hours. With an objective examination, there is a clinic of acute adhesive intestinal obstruction. Of the concomitant pathology - hypertension, obesity of the 3rd degree. After 2 hours from admission after preoperative preparation, the patient was operated on. Revealed acute commissural small bowel obstruction. Performed adhesiolysis, nasointestinal intubation, drainage of the abdominal cavity. Given the nature of the pathology, age and obesity of the patient for the prevention of eventation and herniation, the median wound is sutured according to the proposed methodology. The early postoperative period was difficult, with symptoms of prolonged intestinal paresis. On the third day after the intervention, the patient independently removed the intestinal probe. However, there was no failure of wound sutures in the early postoperative period. The patient was discharged in satisfactory condition. Examined after 6 months. No complaints. There is no postoperative hernia.

Claims (1)

A method of suturing an aponeurosis, characterized in that the sutures are laid in the form of a chain oriented along the collagen fibers, similarly sutures are made on the opposite flap of the aponeurosis, the ends of the ligatures are tied from the opposite sides, after which the nodal sutures are placed on the edges of the aponeurosis.

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