RU2739860C1 - Method for making a final sliding knot in an intracorporeal continuous surgical suture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for the final sliding intracorporeal knot. Method is implemented by means of endosurgical instruments: two laparoscopic needle-holders or one needle holder and one grasper-type clamp. Last stitch is stitched and stretched with leaving a loop with height of 5-6 cm. Then two asymmetric left and right loops are formed on the "passive" end of the thread, tightened and a sliding knot is formed. While holding the "passive" thread end with the right tool of the left instrument with the branches of the left instrument, the sliding knot is lowered to the tissue. Stretching of the loops and fixation of the sliding knot is corrected. At the end, two or four differently directed loops are arranged to block the sliding knot.

EFFECT: method enables improving the reliability of an intracorporeal continuous surgical suture by forming a trailing sliding knot, as well as reduce the risk of errors when performing the sliding knot as the final one due to improved control of the degree of tightness of the loops in the sliding knot and, thus, to increase safety when performing it.

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Description

The invention relates to the field of medicine, namely to surgery, and can be applied to perform the final sliding intracorporeal assembly.

In the surgical practice of surgeons, gynecologists, oncologists, urologists, orthopedic traumatologists, a significant and increasing role is played by intracorporeal and pre-surgical operations.

(laparoscopic, thoracoscopic and others). The reliability of intracorporeal sutures plays a key role in the success of endosurgical operations. Among them, the sliding knot occupies an important place: it has advantages in cases of tension of the stitched tissues and limited space for safe manipulation of instruments. In addition, the sliding knot saves suture material and surgical time. However, the implementation of a sliding knot is an advanced skill for a surgeon, requiring the appropriate qualifications from the doctor.

One of the types of surgical sutures used in endosurgery is the intracorporeal continuous suture. The intracorporeal continuous suture is performed in three stages: 1) sewing and forming the first knot, 2) making a continuous suture in the form of several stitches, and 3) forming a knot at the end of the seam.

The success of the seam and the operation itself depends on the reliability and strength of the formed knots.

In the practice of endosurgical (laparoscopic) operations, the following requirements are imposed on the nodes used in intracorporeal continuous sutures:

• ensuring reliable alignment of the wound edges;

• knot strength - the ability to withstand rupture and weakening of the knot;

• safety for sewn and surrounding tissues;

• simplicity in execution and training.

A number of knots have been described in the literature, which can be applied both in separate interrupted (interrupted) intracorporeal sutures and at the beginning of a continuous suture. However, the literature describes single methods of forming knots used for completion. Known "traditional" intracorporeal surgical and Aberdinian nodes.

1. Intracorporeal surgical site

Relatively easy to form, according to the "2 + 1 + 1" pattern, where the function of the "passive" end of the thread, around which the loops forming a knot are tightened, is performed by a loop from the last loose stitch (Fig. 1). The "2 + 1 + 1" scheme means that the first loop is performed by a double semi-knot, the second and third are single multidirectional.

The disadvantage of the surgical knot is its lower strength, since there is a high risk of its weakening when the knot "reverse" slides along the two ends of the last loose stitch. Especially this risk is high when the fabric is pulled and yarn with increased slip properties is used.

2. Laparoscopic Aberdinia three-loop knot

The Aberdeen three-finger knot is considered more reliable than the surgical knot. It is performed by forming three successive loops from the distal end of the suture. However, when using threads with increased slip properties, such as monofilament threads or coated braided threads, there is a high risk of loosening each previous loop during the formation of the next, especially under conditions of tension in the fabric. And, although the formation of the Aberdian knot requires minimal tool rotation, it is technically difficult to execute and rarely used.

It is known that the requirement for strength and reliability of knots is largely met by intracorporeal sliding knots blocked by additional fixing loops. Such knots are used in interrupted (interrupted) surgical sutures and as the first knot at the beginning of a continuous suture. Sliding knots have advantages in a number of situations faced by the surgeon in the operating room:

1. in conditions of tension on the edges of the wound, the sliding knot allows you to "pull" the knot to the required degree and ensure alignment of the edges of the wound.

2.In conditions of limited space, where the amplitude of the necessary movements of the instruments when performing an intracorporeal node is associated with a high risk of tissue damage, the sliding assembly can be performed with a minimum amplitude of instrument movements.

However, there is insufficient information in the literature on the use of a sliding knot at the end of an intracorporeal continuous surgical suture.

The authors propose a method of forming a blocked sliding assembly for use in the end of an intracorporeal continuous surgical suture.

The purpose of the proposed method: to improve the reliability of the intracorporeal continuous surgical suture by forming a final sliding node

Method description

The following is a step-by-step description of the method where the dominant hand of the surgeon is the right one; pre-stitching of the fabric with a needle and thread with a continuous seam. The method demonstration starts by sewing the penultimate stitch.

Step 1. Sewing the last stitch.

Sew the last stitch - sewing on the fabric. Tighten the penultimate stitch partially, leaving a loop in the form of a loop 5-6 cm high

- loop "P" (see explanation below). This loop will further act as a “passive end of the thread. Thus it is necessary to highlight the sections of the thread "A", "B", "C" and "loop of the last stitch" (Fig. 1).

Buttonhole of the penultimate stitch "P" - the section of the thread formed by the shoulders A and B. It is the last loose stitch and also, in this case,

- "passive" end of the thread (PCN).

Thread section "A" - the thread section that is the beginning of the last stitch and the beginning of the stitch loop.

Thread section "B" - the thread section that is the end of the stitch loop.

Section of the thread "C" - the section of the thread, which is the "active" end of the thread (ACN); participates in the formation of a sliding knot.

Step 2. Forming the left (right) loop.

With the right tool, grab the top of the loop "P" (like the "passive end of the thread) and pull it up, holding it vertically." Both parts of the loop - "A" and "B" - will take the form of two taut strings. Take the long end of the thread "C" of the "active" end with a thread length of 8-12 cm with the left instrument and bring it to the base of the loop "P" (the place of the last puncture with the needle). Then form a left (right) asymmetric loop (Fig. 2), where loop "P" plays the role of the passive end of the thread.

Step 3. Forming the right (left) loop

Form a right (left) asymmetrical loop in the same way.

Note: it is possible to perform 2 and 3 steps in reverse order. It is important that in steps 2 and 3 the first loop is opposite the second (Fig. 3).

The thread will take the form of a stretched loop, around which two asymmetric loops of the "active" end of the thread are wrapped (Fig. 3) - it resembles a "pretzel" with "strings" A and B stretched through it. This type of loops in a sliding knot allows for improved visual control over its size when tightened further.

Step 4. Tightening two loops - forming a slip knot.

With the right tool, grab the top of the loop "P" (as the "passive" end of the thread) and pull it up, holding it vertically. Pull the "active" end of the thread to the left, tightening asymmetrical loops at a distance of 2-3 cm from the fabric. A sliding knot will be formed, the density of which should be monitored visually by the absence of gaps inside it, until the “strings” fit tightly (improved visual control) (Fig. 4). At this stage, when tightening the sliding knot, avoid sliding it down, keeping the distance between the knot and the fabric at least 10 mm. You should also avoid damaging the fabric while pulling the "strings" A and B.

If it is not possible to tighten the sliding knot to a tight, visually controlled state by pulling the "active" end of the thread to the left, do the following: grab and hold the section of the thread "C" below the knot with the right tool, and pull on the "active" end of the thread. Maintain visual control over the density of the sliding knot. Avoid pulling the area "C" downwards to avoid tissue damage by the instrument (Fig. 5)

Step 5. Sliding the sliding knot along the "strings" (A, B and C)

While holding the top of the loop “P” with the right tool, press the sliding knot with the jaws of the left tool to slide it down to the fabric being sewn. In this case, the sliding knot slides along the "strings" A and B. (Fig. 6), with some resistance. At this time, vibrations from the friction of the knot with threads A and B are transmitted through the thread and the instrument to the surgeon's right hand. The resistance force and vibrations from the thread allow the doctor to carry out tactile control on the degree of tightening of the sliding knot.

When the sliding knot slides in the direction of the fabric, threads C and B, and then thread A, can sequentially loosen their tension. In this case, you should sequentially pull the threads B and A up to eliminate the weakening of the tension of the "strings".

If the hinges of the sliding knot are loose, repeat Step 4 (Figs. 4 and 5).

Step 6. Checking the fixation of the sliding assembly

Holding the "passive" end of the thread in tension vertically, lower the sliding knot until the required alignment of the wound edges, avoiding excessive pressure of the threads on the tissue in order to avoid damage (Fig. 7).

At this stage, the compliance of the sliding knot with the requirements is checked: the possibility of sliding along the "passive" end of the thread and at the same time fixing the knot at a given point, preventing back sliding.

Step 8. Pulling up loose threads A and B

Having relaxed the tension of the "passive" end of the thread, make sure that the sliding knot is held on it - the requirement to fix the knot at a given point is fulfilled.

If the slip knot is not held on strings A and B, reverse slip occurs, it is necessary to tighten the loops more tightly, repeating the steps of Step 4 (Figs. 4 and 5).

After lowering the sliding knot to the required level, threads A and B can gradually release their tension. In this case, you should again sequentially pull the threads B and A up to eliminate the weakening of their tension.

Step 9. Forming the blocking loops

To securely fix the sliding knot, form the blocking loops. The right and left blocking loops should alternate, a total of 2-4, depending on the properties of the thread and the tension of the tissues (Fig. 8).

Step 10. Cutting the threads.

After making sure of the safe alignment of the wound edges and reliable fixation of the knot, cut off the "active" end of the ACN thread and the "P" loop thread, leaving the ends 6-10 mm long (Fig. 9).

The novelty of the method is as follows:

1. a sliding knot was used as the final one for an intracorporeal continuous surgical suture;

2. the improved visual and tactile types of control over the degree of stitch tightness of the suture and loops in the sliding knot in the intracorporeal continuous surgical suture were applied;

3. the description of the step-by-step execution of the sliding knot as the final one when performing the intracorporeal continuous surgical suture has been compiled.

Application of this method allows:

1. to increase the reliability of the intracorporeal continuous surgical suture by forming the final sliding knot;

2. to reduce the risk of errors when performing the sliding knot as a final one due to improved control over the degree of tightening of the loops in the sliding knot and, thus, to increase the safety during its execution;

3. to reduce the likelihood of stressful situations during the operation associated with errors in the execution of the sliding assembly, which ultimately leads to a decrease in the total number of errors during surgery and increases the safety of the intervention itself as a whole.

Sliding knot literature for intracorporeal continuous surgical suture

1. Sleptsov I.V., Chernikov R.A. Knots in surgery. - 2nd ed., Rev. and add. - SPb .: Salit-Medkniga, 2004 .-- 112 p.

2. Liceaga A., Fernandes L.F. Romeo A. Romeo's gladiator rule: knots, stitches and knot tying techniques. - Endo: Press® Tuttlingen, Germany, 2013

3. Koh C.H. Laparoscopic suturing in the vertical zone ™. - Endo: Press® Gmbh, 2015.

4. Jaffe U. Forming an intracorporeal slip-knot in laparoscopic suturing. Can J Surg. 2009 Apr; 52 (2): E23-E24.

5. Romeo A.et others. Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots. Journal of Minimally Invasive Gynecology (2019) 00, 1-10. © 2019 AAGL

6. Croce E., Olmi S. Intracorporeal Knot-Tying and Suturing Techniques in Laparoscopic Surgery: Technical Details. - JSLS (2000) 4: 17-22

7. Shepherd G et others. Slip-Knot-Loop Suture for Continuous Suturing in Laparoscopy. - Journal of Laparoendoscopic & Advanced Surgical Techniques Vol. 26, No. 3

8. Philip M Stott, l Lionel G Ripley, 2 and Michael A Lavelle3. The Ultimate Aberdeen Knot. - Ann R CollSurg Engl. 2007 Oct; 89 (7): 713-717.

Miyazaki D., Hirano S., Ebihara Y. A New Technique for Making the Aberdeen Knot in Laparoscopic Surgery. - Journal of Laparoendoscopic & Advanced Surgical Techniques 25 (6) ⋅ May 2015.

Claims (1)

A method of forming a blocked sliding knot at the end of an intracorporeal continuous surgical suture using endosurgical instruments: two laparoscopic needle holders or one needle holder and one grasp-type clamp, which consists in sequentially performing the following actions: the last stitch is sewn and pulled, leaving a loop of 5-6 height cm; form two asymmetric left and right loops at the "passive" end of the thread; tighten two loops and form a sliding knot; while holding the "passive" end of the thread with the right tool, the jaws of the left tool lower the sliding knot to the tissue; carry out correction of the tension of the loops, control the tightness of the stitches of the seam and loops on the sliding knot; control the fixation of the sliding knot by loosening the tension of the "passive" end of the thread; tighten the weakened threads of the "passive" end of the thread; form two to four multidirectional loops that block the sliding knot.

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