RU2793529C1 - Method for forming a sliding self-locking knot for an intranasal suture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to otorhinolaryngology, and can be used to form an extracorporeal self-fixing surgical knot during plastic closure of perforation of the nasal septum, septoplasty. In the method of forming a sliding self-locking knot for intranasal suture, the driven thread is held by the 1st and the 3rd fingers of the left hand, and the leading thread is held by the 1st and the 2nd fingers of the right hand. The leading thread is thrown onto the palmar surface of the 2nd finger of the left hand, the driven thread is also placed on the palmar surface of the 2nd finger of the left hand, creating a cross with the leading thread. The needle holder is carried out under the driven and leading threads. Then the leading thread, fixed with the 1st and the 2nd fingers of the left hand, is grasped with a needle holder and passed under the taut driven and leading threads. The leading thread is moved with a needle holder into a loop formed around the 2nd finger of the left hand, and intercepted by the 1st and the 2nd fingers of the left hand. The driven thread is captured by the needle holder, it is pulled and the formed sliding knot is lowered until the joined edges of the tissue incision are brought closer together.

EFFECT: providing reliable fixation of the moved flaps, stability of the nasal septum and reducing the risk of re-perforation of the nasal septum in the postoperative period.

1 cl, 1 ex, 12 dwg

Description

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology, and can be used to form an extracorporeal self-fixing surgical knot during plastic closure of perforation of the nasal septum, septoplasty.

The dissatisfaction of surgeons with the results of surgical treatment for perforations of the nasal septum and curvature of the nasal septum leads to the constant improvement of the surgical technique and the emergence of new techniques. One of the promising areas of surgery in otorhinolaryngology is endoscopic rhinosurgery. The main disadvantage is the need to work with one hand; for this purpose, it is extremely difficult to use the generally accepted methods of stitching and tying knots in narrow and deep cavities. Also, the anatomical features of the nasal cavity, which complicate the maneuverability of instruments with simultaneous visual control, present great difficulties in applying intranasal sutures. In this connection, the development of techniques for sliding self-locking knots, which are suitable for tying with one hand, while providing a reliable approximation of the edges of the displaced flaps, is relevant.

A known method of forming an extracorporeal protracted surgical node during laparoscopic surgical interventions, the essence of which is the alternation of the directions of the two formed coils. Ligation and connection of tissues is achieved by pulling the fixed end of the thread, as a prevention of the weakening of the formed ligature contours, an additional intracorporeal knot is applied (RF Patent 2701770, A.V. Abolmasov).

A known method of forming an extracorporeal tightening sliding knot. The authors used this method to ensure reliable clamping of vessels, ducts, other organs and tissues during endoscopic operations. The method consists in forming a driven thread held by 4 and 5 fingers of the left hand, 4.5 turns around the 2nd and 3rd fingers of the left hand in the proximal direction clockwise, then, holding the resulting spiral with 1 finger, the driven and leading threads are drawn along the back surface of the fingers into a spiral hole. The driven and leading threads are held by 4 and 5 fingers of the left hand in a clamping grip, while they are wrapped around 4 fingers of the left hand on one side of the spiral, and 3,4 and 5 fingers of the right hand are wrapped around 3 fingers on the other side of the spiral. Next, the driven thread is pulled out with the first fingers of two hands to the right of the spiral to the left in the plane of the 2nd and 3rd fingers of the left hand. The knot is tightened by removing the spiral from the fingers. (Patent RF 2732698, R.A. Bashirov).

A known method of forming a sliding knot, including the extracorporeal formation of a flat nodal loop, a spiral of 3 turns and a knot. After the formation of the nodal loop, one end of the thread is wrapped around the first loop and both ends of the thread are placed on one side. Next, the same end of the thread is inserted into the coil and pulled simultaneously with the other end of the thread. Next, 2 knots are tied around each branch of the loop, alternating the ends of the thread, in the form of an anti-tying lock, with the help of which the ability of the sliding knot to untie is reduced. (Patent RF 2270621, A.L. Lomonosov).

An extracorporeal sliding surgical Matveev-Petrov knot and a method for tying it are known, in which the first thread is circled around the 5th finger of the right hand, placed on the palmar surface of the 3rd and 4th fingers of the right hand, and its end is fixed with 1st and 2nd fingers of the right hand. The end of the second thread, held by the 1st and 2nd fingers of the left hand, is placed parallel to the first thread also on the palmar surface of the 3rd and 4th fingers of the right hand. The distal phalanx of the 3 fingers of the right hand grabs the second thread and passes it under the first thread, thereby forming a loop of two threads on the 3rd finger of the right hand. The end of the second thread, fixed with 1 and 2 fingers of the left hand, is intercepted by 1 and 2 fingers of the right hand together with the end of the first thread. 2 and 3 fingers of the left hand lead into the loop formed on the 3rd finger of the right hand, under the second thread and grab the ends of the threads and pull them into the loop. Next, the ends of the threads are held by fingers 1 and 2 of the left hand, and the fingers of the right hand, using a pusher, lower the sliding knot to the surface of the incision to be stitched in the cavity. (Patent No. 2619751, E.V. Matveev)

A known method of forming a sliding self-locking node. The end of the first thread is thrown over the second thread and passed under two threads, then the end of the first thread is circled around the second thread, with the formation of a spiral. The end of the first thread from below goes around the second thread. Next, the knot is moved by pulling on the end of the second thread and fixed by pulling on the end of the first thread. The authors report good results from arthroscopic shoulder surgery (Kim SH, Na KI. The SMC knot--a new slip knot with locking mechanism. Arthroscopy. 2000 Jul-Aug; 16(5):563-5).

A known method of forming a sliding self-locking node. The end of the first thread is carried out under the second thread with the formation of a loop, crossing the first thread. The end of the first thread is re-wound around it, crossing the second thread, the end of the first thread, bending around the second thread, is brought out under the first loop. The knot is tightened by pulling on the end of the second thread. The authors note the advantage of this knot is the ability to loosen the first knot, in case of unintentional premature tightening of the knot, and pull it into the wound cavity. (Kuptniratsaikul S, Promsang T, Kongrukgreatiyos K. The chula knot: a new sliding locking knot with a special property. Arthrosc Tech. 2014 Jul 21; 3(4):e465-7).

A known method of forming a sliding lockable node. The stages of tying a knot are: the formation of a single weave of threads, then the main thread is held with the left hand, and the working thread with the right hand, with 1 finger of the left hand hold the first loop, and with 2 and 3 fingers of the left hand the main thread is transferred from right to left, so that the working thread remains on top . Thus, two loops are formed: upper and lower. The end of the working thread is first passed into the upper loop, and then into the lower one, while bending around the main thread. 1 finger of the left hand is removed from the loop and the knot is tightened by pulling on the end of the main thread. The authors report possible iatrogenic damage to fragile tissues during the slip of the knot, as well as its possible premature tightening (Parada SA, Shaw KA, Eichinger JK, Boykin NT, Gloystein DM, Ledford CL, Arrington ED, Wiese PT. The Wiese Knot: A Sliding-Locking Arthroscopic Knot Arthrosc Tech 2017 Jan 2;6(1):e21-e24).

A known method of forming a sliding self-locking node. The authors report that this technique has been successfully used during a transsphenoidal endonasal approach to seal the sella turcica diaphragm with a fascial flap to eliminate liquorrhea. The technique consists in the formation of a single weave of threads, the formed loop is turned to the left so that the end of the first thread is on top, and the end of the second thread is on the bottom. The needle holder is passed into the loop from the bottom up, then they go around the first one and grab the end of the first thread under the stretched first and second threads. The end of the first thread is pulled out with a needle holder. The knot is lowered and tightened by pulling on the second end of the thread. (Sakamoto N, Akutsu H, Takano S, Yamamoto T, Matsumura A. Useful 'sliding-lock-knot' technique for suturing dural patch to prevent cerebrospinal fluid leakage after extended transsphenoidal surgery. Surg Neurol Int. 2013;4:19. doi : 10.4103/2152-7806.107546 Epub 2013 Feb 20. PMID: 23493948; PMCID: PMC3589849).

A known method of forming an arthroscopic sliding self-locking node. The ends of the first and second threads are clamped with 1 and 3 fingers of the left hand. The end of the second thread is thrown over 1 finger of the left hand and passed under both threads. The end of the second thread forms three turns around both threads. The end of the second thread is looped around the second thread and brought up through the first loop held by 1 finger of the left hand. The knot is lowered by pulling on the first thread and tightened by pulling on the second thread. (Wolfe JA, Pickett AM, Van Blarcum G, Owens BD, Giuliani J, Posner M, Dickens JF. The West Point Knot: A Sliding-Locking Arthroscopic Knot. Arthrosc Tech. 2018 Jun 4; 7(7):e685-e689 ). The disadvantage of this method is the relative bulkiness of the node, which increases the risk of tissue eruption and further formation of hemorrhagic crusts on the node, which can lead to local inflammation and reduced regeneration. The method chosen by us as a prototype.

The objective of the invention is to develop a method for forming a sliding self-locking knot for an intranasal suture.

The technical result of the task is reliable fixation of the moved flaps in the correct position, which ensures the stability of the nasal septum and reduces the risk of re-perforation of the nasal septum in the postoperative period.

This goal is achieved in that the driven thread A is held by 1 and 3 fingers of the left hand, and the leading thread B is held by 1 and 2 fingers of the right hand, the leading thread B is thrown onto the palmar surface by 2 fingers of the left hand, the driven thread A is also placed on the palmar surface of the 2 fingers of the left hand, creating a cross with the leading thread B, the needle holder is held under the driven and leading threads A and B, then the leading thread B, fixed with 1 and 2 fingers of the left hand, is captured by the needle holder and held under the taut driven and leading threads A and B, the leading thread B is moved with a needle holder into a loop formed around the 2nd finger of the left hand and intercepted with 1 and 2 fingers of the left hand, and the driven thread A is captured by the needle holder, tensioned and the formed sliding knot is lowered until the joined edges of the tissue incision are brought together.

The method for forming a sliding self-locking knot for an intranasal suture is illustrated in FIG. 1-8.

Position #1. The driven thread A is held by 1 and 3 fingers of the left hand, and the leading thread B is held by 1 and 2 fingers of the right hand (Fig. 1).

Position number 2. The leading thread B is thrown onto the palmar surface of 2 fingers of the left hand, the driven thread A is also placed on the palmar surface of 2 fingers of the left hand, creating a cross with the leading thread B (Fig. 2).

Position number 3. The needle holder is carried out under the driven and leading threads A and B (Fig. 3).

Position number 4. The leading thread B, fixed with 1 and 2 fingers of the left hand, is grasped with a needle holder and passed under the tensioned driven and leading threads A and B (Fig. 4).

Position number 5. The leading thread B is moved by a needle holder into a loop formed around the 2nd finger of the left hand and intercepted by 1 and 2 fingers of the left hand (Fig. 5). Position number 6. Leading thread B is moved by a needle holder into a loop formed around the 2nd finger of the left hand (Fig. 6).

Position number 7. The leading thread B is intercepted by 1 and 2 fingers of the left hand (Fig. 7). Position number 8. The driven thread A is captured by the needle holder, it is pulled and the formed sliding knot is lowered until the joined edges of the tissue incision are brought together (Fig. 8).

Clinical example of the implementation of the method.

Patient A., 17 years old, was admitted to the Department of Otorhinolaryngology with a surgical group of head and neck diseases in June 2021 at the National Research Center for Children's Health of the Ministry of Health of Russia with complaints of recurrent nosebleeds, crusting in the nose, and wheezing when breathing. From the anamnesis it is known that complaints have been disturbing for two years, she denies operations on the nasal septum. The patient was examined by a rheumatologist and pediatrician: Wegener's granulomatosis, sarcoidosis, syphilis and tuberculosis were excluded. On examination: the shape of the external nose is not changed, the mucous membrane of the nasal cavity is pink, moist, the septum is slightly curved to the left, the perforation in the cartilaginous section of the nasal septum is 0.8 by 2.1 cm. shown in Fig. 9. An endoscopic photograph of the perforation of the nasal septum before surgery, the right half of the nose, is shown in Fig. 10. The inferior turbinates are not enlarged, there is no pathological discharge in the nasal passages. On CT, the pneumatization of the paranasal sinuses is not disturbed, deformity of the nasal septum to the left, perforation of the nasal septum in the cartilaginous region is determined. Diagnosis: Perforation of the nasal septum. The child underwent plastic closure of the perforation of the nasal septum with a flap on the posterior ethmoid arteries with redistribution of the edges and a circular flap on the other side. Under endotracheal anesthesia and after local infiltration anesthesia of the nasal mucosa with Ultracaini forte solution under the control of the endoscope, a fringing incision was made, 0.5 cm from the edge of the perforation on the left. The mucosa is separated, turned away from the periphery to the center of the perforation, the edges are brought together by sliding self-fixing knots. The flap was mobilized and cut out on the left side of the pedicle due to the branches of the ethmoid artery along the bottom of the nasal cavity, under the inferior turbinate with the transition to the nasal septum. Fixation of the flap with sliding sutures. An endoscopic photograph of the nasal cavity after plastic closure of the perforation of the septum, the left half of the nose, is shown in Fig. 11. Endoscopic photograph of the nasal cavity after plastic closure of the perforation of the septum, the right half of the nose, is shown in Fig. 12. Installed silicone tires. Transverse sutures. Hemostatic sponges in the lower nasal passage on the left. The child tolerated the operation satisfactorily, without complications. The postoperative period was uneventful. On the 1st day after the operation, the girl complained of moderate difficulty in nasal breathing, mucosanal discharge from the nose; on examination, moderate reactive phenomena of the mucous membrane of the nasal cavity, a septum along the midline, splints are well-to-do, the mucosa under the splints is pink, the seams are well-founded, in the general nasal passage there is scanty mucosanguineous discharge, nasal breathing is difficult. The toilet and anemization of the nasal mucosa were performed. On the 3rd day after the operation: the general condition is satisfactory, the body temperature is 36.7 C, the skin is clean, of physiological color. The child noted improvement in nasal breathing. ENT status: subsiding reactive phenomena of the mucous membrane of the nasal cavity, splints are well-founded, in the general nasal passage there is mucous discharge. Made toilet, anemization of the nasal mucosa. On the 3rd day after the operation, the child was discharged from the hospital. Recommendations are given. On the 14th day after the operation, as part of the control examination, the removal of splints was performed - the mucous membrane was pink, the nasal septum was in the midline, nasal breathing was free. At control examinations after 1,3,6 and 12 months, the patient did not complain about the nose, when examining the nose, the shape of the external nose was not changed, the mucous membrane of the nasal cavity was pink, the nasal septum was without diastases, the flaps were completely vascularized, well-founded, the inferior turbinates are not enlarged, there is no pathological discharge, nasal breathing is not disturbed.

Thus, the proposed surgical knot is sliding and self-fixing, well reaches into the depth of the wound and does not dissolve, has high strength properties, which is proved by a low percentage of recurrences of nasal septal perforation when this suture is applied during the closing process, which allows it to be recommended for suturing movable vascularized flaps with plastic closure of perforation of the nasal septum and mucous membrane sheets during septoplasty.

Claims (1)

A method for forming a sliding self-locking knot for an intranasal suture, characterized in that the driven thread is held by 1 and 3 fingers of the left hand, and the leading thread is held by 1 and 2 fingers of the right hand, the leading thread is thrown onto the palmar surface by 2 fingers of the left hand, the driven thread is also placed on the palmar surface of 2 fingers of the left hand, creating a cross with the leading thread, the needle holder is carried out under the driven and leading threads, then the leading thread, fixed with 1 and 2 fingers of the left hand, is captured by the needle holder and held under the driven and leading threads stretched, the leading thread is moved to the the loop formed around the 2nd finger of the left hand is intercepted with 1 and 2 fingers of the left hand, and the driven thread is grasped by the needle holder, tensioned and the formed sliding knot is lowered until the joined edges of the tissue incision are brought together.

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