Surgical knot: types, use, knitting technique. Surgical knot - the basis of surgical technology Medical knot on a fishing line

Every practicing doctor knows how to tie a surgical knot of one kind or another. Also, people of other professions or hobbies, for example, fishermen, also know some techniques. They also often use a variety of surgical knots to weave nets. What types of nodules exist in medicine, and what properties should they have?

Requirements for surgical nodes

Surgeons don't like to use the word "strength" because it's not really the basic requirement for surgical nodules. After all, you can pull the threads very, very tightly, but this will injure the tissue and cause bleeding and suppuration. The correct node must be reliable, i.e. incapable of spontaneous divergence due to sliding of the threads. And only a professional and experienced doctor can correctly achieve such a balance.

If we list all the requirements applied to nodes in surgery, we will get a whole list:

1. easy to perform;
2. quick in education;
3. eliminates self-tightening in the process of changing the nature of the seam;
4. the properties of the nodule are preserved for the entire period of wound healing (it does not diverge, does not tear, does not move);
5. has a minimum volume (this especially applies to cosmetic seams);
6. the first loop is the strongest, each subsequent one is weaker;
7. The tightening technique corresponds to the chosen suture material.

The most difficult thing to work with is monofilament threads. They are slippery and smooth, they have a high “shape memory”. Therefore, knots made from such threads tend to return to their original state and straighten out. Braided suture material is the easiest to tighten because the knot is held in place by the interlocking of the threads.

A similar example can be given from everyday life: it is easy to tie a regular sewing thread, but a knot tied with the same force on a smooth elastic fishing line will quickly come undone.

Types and methods of tying surgical knots

The entire classification of methods for tightening and securing suture material is more correctly called knots in surgery. A surgical (or naval) knot is one specific type that consists of two loops. The first (main) is double: one end, for example, the left one, wraps around the second, right, twice. This allows you to fix the knot more firmly. The second loop is single, but it is knitted in the other direction: the right thread around the left.

Curious! It turns out that doctors call such a knot a marine one. And sailors consider it a medical invention, which is why it is often called surgical.

In surgery, knots are knitted differently from laces: without crossing the ends of the threads and twisting them behind each other. There are special tying techniques that require dexterous finger manipulation. This is specially taught in medical schools. In practice, during operations, knots are often knitted with instruments. It is more convenient, faster and more reliable.

In addition to surgical knots in medicine, there are several other types of knots (not to be confused with the classification of sutures), differing in knitting technique and ultimate strength. They are used depending on the selected suture material and the organ being operated on.

• Female (ladies', women's, woman's). Elementary, from two simple loops.
• Academic. Complex, parallel and uniform. Consists of three loops. There is also double academic: this means that there is a double weave in each loop.
• Triple sea. The same as the surgical one, but with three loops, modifications of which can be combined (for example, one double and two simple, or outer double and the central simple, etc.).
• Parisian's knot. Sliding, blocked, consists of four loops that are formed in a specific way.

Experienced practicing surgeons do not keep in mind the names of the types of surgical nodes. During suturing, they automatically tie knots, focusing on the surgical field. Sensitivity also plays a role: if the doctor understands that the skin in this place is very stretched and the stitches may come apart, he adds another knot. If your hands feel that a double knot is enough, then the surgeon will not create a third loop.

A correctly tied surgical or other knot is a guarantee of maintaining the quality of the suture and the normal condition of the tissues. It’s these little things that make up the professional work of surgeons, who have been developing practice for years and decades in order to masterfully knit knots literally with their eyes closed.

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To fix the specified linear and volumetric characteristics of the seam, the ends of the thread are fastened with knots. Tying knots is an important element of any surgical procedure.

A surgical knot is the result of the sequential execution of two actions:
the formation of a loop due to the mutual entwining of the ends of the thread;
tightening the loop tightly until the edges of the wound are completely connected (the actual formation of a knot).

Correct execution of all the details of these actions ensures the achievement of high quality surgical units, which are subject to numerous requirements.

Requirements for units used in surgery

Methods for forming loops

The main method of forming loops and knots is manual.

Apodactylic methods are used in the following cases:
for tightening a knot deep in a wound of complex shape;
in microsurgery;
in video endosurgery (VES).

In such cases, loops can form both extracorporeally and intracorporeally.

The instrumental method of forming and tightening knots can significantly reduce the consumption of suture material.

Loops used in surgery are divided into single-wrap (simple) and multi-wrap (complex) (Fig. 77).

Rice. 77. A simple loop formed by wrapping a thread once (the left side of the thread is dark, the right side is light).

Rice. 78. A complex loop formed by repeatedly wrapping a thread (the left side of the thread is dark, the right side is light).

When tightening the loop with repeated wrapping of the thread, a double-turn loop of the surgical knot is formed (Fig. 79).

Rice. 79. Double-turn loop of surgical knot.

Depending on the number of loops used to fasten the ends of the thread, knots are divided into three groups:
- single-loop;
- two-loop;
- multi-loop.

1. Single-loop nodes are usually used to change the orientation of the wound of the small intestine, colon, stomach, and bladder (Fig. 80). After completing the appropriate stage of the operation, they are removed.

Rice. 80. Use of single-loop stay sutures to orient the wound of a hollow organ in the transverse direction.

2. Usually, successive formation and tightening is sufficient to connect tissues. two-loop node. In most cases, a double loop satisfies the requirements for knots to the maximum extent.

In surgical practice, loops of simple (female), marine and complex two-loop knots are used.

Loops of a simple (female) knot

Rice. 81. A simple (female) knot formed by two identical unidirectional single-wrap loops.

The surgeon should only know about the existence of a simple (female) node, but it should be used as rarely as possible, only when absolutely necessary.

Sea knot loops

Rice. 82. Sea knot.

Rice. 83. The principle of formation of a sea knot:
1 - the left (dark) part of the thread crosses the right (light) part of the thread, first from the back and then from the front; a single wrap around the left side of the thread is performed right hand;
2 - tighten the first loop;
3 - when forming the second loop, the left side of the thread first crosses the right side from behind, and then from the front (the thread is wrapped with the left hand).
4 - tighten the second loop.

Disadvantages of a sea knot
— Difficulty of implementation;
Labor intensity can be reduced by using rational methods of forming loops and achieving a good technical level of knot tying over long periods of practice.
- tendency to self-unravel when using synthetic monofilament suture materials.
The sea knot is ideal for silk threads.

Combination loops

I. A combination of two successively formed multi-wrap and single-wrap loops (Fig. 84). In this case, it is possible to form a variant of both female and sea knots with their inherent positive qualities and shortcomings.

Rice. 84. A combination of two successively formed multi-twist and single-twist loops (the right part of the thread is light, the left is dark): 1 - with the formation of a female knot, 2 - with the formation of a sea knot.

It is advisable to use such a combined knot for applying a piercing ligature to the end of a large-caliber artery or vein deep in a wound of complex shape. You need to be guided by the rule: “a large vessel - a thick thread.” For this type of knot, it is preferable to use threads with a high coefficient of surface friction.

Disadvantages of a combined unit
Possibility of thread rubbing when tightening the first loop;
- large volume of the node, slowing down its resorption;
— the complexity of loop formation;
- tendency to unraveling when using synthetic threads with a pronounced sliding surface;
- insufficient fastening properties of the second loop;
Adding a third (“locking”) loop eliminates this drawback.
- a discrepancy in the strength characteristics of the first (multi-wrap) and second (single-wrap) loops, leading to deformation of both the knot and adjacent tissues.

II. A combination of two multi-wrap loops makes it possible to form a so-called “academic” knot (Fig. 85). This knot can be in women's and marine versions.

Rice. 85. Scheme of the “academic” knot: 1 - variant of the female knot, 2 - variant of the marine one

Disadvantages of the “academic” node
Relative labor intensity of loop formation;
large unit volume;
impossibility of use to stop bleeding from small vessels due to the large lumen of the internal loop.

Increasing the strength and reliability of the knot can be achieved by doubling the thread, however, excessively increasing the volume of the knot limits the use of this option. A compromise solution is the Barkov knot.

III. A combination of two successively formed single-strand mutually reinforcing loops, the inner of which consists of a double thread, and the outer of which consists of a single thread (Barkov knot) (Fig. 86).

Rice. 86. Barkov knot.

Disadvantages of the Barkov knot
Significant labor intensity;
using a fragment of thread of considerable length to form a knot;
discrepancy between the elastic-elastic properties of the internal and external loops.

It is preferable to use this type of node:
with a suture on the bone;
when ligating large vessels deep in a narrow wound;
to prevent weakening of the first loop during the formation of the second;
for comparison of low-elastic tissues of significant thickness (for example, when applying sutures to soft tissues in the fronto-parietal-occipital region).

Loops of a multi-loop knot

Rice. 87. Scheme of a multi-loop knot with single-wrap unidirectional loops.

Disadvantages of a multi-loop knot
— Poor fastening properties;
- maintaining a tendency to loosen the loops, just like a regular simple (female) knot.

This type of knot is a multiplied version of a simple (female) knot without any improvement in properties and maintaining the previously mentioned disadvantages.

Multi-tiered sea knot

Rice. 88. Scheme of a multi-loop knot with single-wrap mutually reinforcing loops.

Disadvantages of a multi-tiered node
Relative labor intensity;
the possibility of loosening loops when using mono-filament synthetic threads;
significant node volume.

Various options for combined multi-loop knots are presented in Fig. 89, 90 and 91.

Rice. 89. Three-loop knots, which are a combination of female and sea knots: 1 - female knot, 2 - sea knot.

Rice. 90. Three-loop knot, which is a combination of academic and naval knots: 1 - female, 2 - naval.

Rice. 91. Three-loop knot, which is a combination of marine (1) and feminine (2) knots.

Disadvantages of these node options
— Labor intensity;
— significant volume of the unit;
- a disproportionate increase in the volume of the unit with a weakly expressed improvement in strength characteristics.

Multi-tiered surgical unit

Rice. 92. Double “academic” knot.

Disadvantages of a surgical multi-tiered unit
Labor intensity;
large volume of thread complex in the knot;
significant consumption of suture material;
high probability of formation of ligature fistulas due to the possibility of developing a pronounced tissue reaction.

Based on the level of loop formation relative to the wound surface, two options can be distinguished.
1. Directly approaching the level of loop formation to the seam line (Fig. 93).

Rice. 93. Forming loops near the seam line.

Rice. 94. Formation of the Aberdeen croquet loop.

Rice. 95. Sliding loops formed on the basis of standard knots: 1 - female, 2 - marine, 3 - surgical.

Rice. 96. Multi-turn sliding loop: 1 - loop formed at a distance from the edge of the wound, 2 - tightening the loop at the edge of the wound.

However, in a number of cases the use of sliding loops is advisable and necessary:
to bring the knot down to the bottom of a deep wound;
when using microsurgical equipment;
in performing operations using video endosurgical methods.

Methods for bringing down sliding loops

Rice. 97. Reduction of the sliding loop by the distal phalanx of the finger.

In Fig. 98 presented various options bringing down sliding loops:

Rice. 98. Methods of bringing down sliding loops (explanations in the text).

Rice. 98 (continued).

Using a Vinogradov stick when using “open” access (1);
using Clark's fork: an extracorporeal method of forming a loop with
subsequent reduction, used in video endosurgery (2);
using a standard pusher: bringing down the extracorporeal loops of Roeder (3) and Melz (4) - in video endosurgery;
using remote manipulators: delivery of extracorporeally formed Dandy loop (5) and “anchor” loop (6) into the abdominal or chest cavity in video endosurgery.

Methods for tightening loops to form a knot

Rice. 99. Securing the ends of the thread with knots immediately after applying each seam.

2. Sequential tying of knots of all previously applied sutures when strengthening the hernial orifice of the anterolateral abdominal wall or applying pleuromuscular sutures (Fig. 100).

Rice. 100. Sequential tying of previously applied sutures to connect the edges of the chest wall wound.

Rice. 101. Use of support sutures to better adapt the edges of a wound of complex shape, followed by suturing the spaces between them.

One of the conditions that ensures the strength of the seam is tying knots that secure the threads. Tying knots is an important element of any surgical procedure. A surgical knot is the result of the sequential execution of two actions:

Formation of a loop due to the mutual entwining of the ends of the thread;

Tightly tightening the loop to bring together and firmly hold the connected edges of the wound (the actual formation of a knot).

Correct execution of all the details of these actions ensures the achievement of high quality surgical units, which are subject to numerous requirements.

Requirements for units used in surgery

1. Ease of implementation.

2. Maximum strength with a minimum number of loops.

3. Minimum unit volume.

When forming loops and tightening the knot, it is necessary to use techniques to avoid:

1) thread chafing and tissue damage when tightening the knot;

2) weakening of the previous node when performing each subsequent one.

In practice, you have to use different methods of forming loops and tightening knots.

Methods for forming loops

Methods for forming loops (knots) used in surgery are divided into two groups:

Instrumental (apodactyl).

The main method of forming loops and knots is manual. Apodactylic methods are used in the following cases:

To tighten a knot deep in a wound of complex shape;

In microsurgery;

In endovideosurgery.

In the latter case, loops can be formed both extracorporeally and intracorporeally.

The instrumental method of forming and tightening knots, compared to the manual method, can significantly reduce the consumption of suture material.

Loops used in surgery are divided into single-wrap (simple) and multi-wrap (complex) (Fig. 65).

Rice. 65. A simple loop formed by wrapping a thread once (the left part of the thread is dark, the right part is light) (according to: Semenov G. M., Petrishin V. L., Kovshova M. V., 2001).

Increasing the mechanical strength of the knot by increasing the contact surface of the thread is achieved by increasing the number of entanglements, the number of which varies from 2 to 4 (Fig. 66).

Rice. 66. A complex loop formed by repeated winding of a thread (the left part of the thread is dark, the right part is light) (according to: Semenov G. M., Petrishin V. L., Kovshova M. V., 2001).

A knot when tightening a loop with a double twist of thread is called a surgical knot (Fig. 67).

Rice. 67. Double-turn loop of a surgical knot (according to: Semenov G. M., Petrishin V. L., Kovshova M. V., 2001).

A significant increase in strength due to an increase in the contact surface of the thread can contribute to the manifestation of the “sawing” effect and its fraying.

Depending on the number of loops used to fasten the ends of the thread, knots are divided into three groups:

Single loop;

Two-loop;

Multi-loop.

Single-loop knots usually used for temporary fixation of the thread (for example, when applying so-called stay sutures) (Fig. 68). After completing the appropriate stage of the operation, the thread secured with a single-loop knot can be easily removed.

Rice. 68. The use of single-loop stay sutures for intestinal surgery (according to: Semenov G. M., Petrishin V. L., Kovshova M. V., 2001).

Double loop knot most often used. The second loop, as a rule, securely fastens the thread, preventing the knot from untying or slipping.

In surgical practice, double loops are used to form simple (female), marine and complex nodes.

The purpose of a surgical knot is to tie together two fishing lines of different thicknesses (diameters). However, experienced and avid fishermen do not recommend tying a surgical knot on thick fishing lines and undergrowth if the load on the fishing line exceeds 27 kilograms.

The surgical knot is one of the simplest and most durable fishing knots.

This unit is suitable for the main types of fishing lines:

• braids;
• fluorcarbon fishing line;
• monofilament.

Surgical knot for leash or feeder

Place the line and leash together. The fishing line is a white lace. Leash - blue lace.
Form a loop from the leash and fishing line.
Pass the running ends of the leash with fishing line into the resulting loop.
Overlap and re-pass the running ends into the loop
Repeat the action and pass the running ends of the leash with fishing line into the loop
Pull the running ends of the leash with fishing line and the main end of the fishing line. The knot is tightened. Trim the excess end of the fishing line.

In fishing, many types of tying knots on fishing gear can be used. The main ones are:

• "Surgical loop" knot
• fishing knot, for fishing line and attachment to the reel
• knots intended for baits and hooks
• specific units (for example: used in the form of fly fishing)
• surgical knot

Marine Surgical Unit

We take the main leader and a leash or two different fishing lines. We fold them crosswise.
Re-wrap the running ends of the line around the main ends.
Bring the running ends over the resulting half-knot.
Cross the running ends of the fishing line again.
Pull the ends, tying a second half-knot.
Pull the running and root ends of the rope, tightening the resulting surgical knot.

Now the line and leash are firmly connected to each other. Please note that with this type of knot it is almost impossible to tie the break points on the fishing line. The most durable and similar version of the knot will be.

The surgical knot is only suitable for tying fishing line and leashes, since during tying the leash must be passed through the entire loop a couple of times.

How to knit a surgical loop

Take the fishing line and fold it in half.
Then we form a loop from the double fishing line.
We take the end of the loop, bring it into the loop itself, and pass it in the same way 2-3 times.
Now you need to moisten the knot with any liquid and tighten it thoroughly.
The remaining remnants of the fishing line must be trimmed.

The noose tied with a surgical knot is so strong that it is simply impossible to untie it. Moreover, the surgical unit itself practically does not lose its strength, which is a very important property.

Having learned to knit surgical loops and knots, you are guaranteed a great mood and a successful catch!

Origin of the node

Knots used by experienced fishermen for tying different types and parts of equipment, mainly adopted from other areas of activity.

Most fishing loops or knots originated in the fishing hobby from mountaineering, and many ideas were taken from sailors themselves.

Interestingly, this type of knot, widely used in the navy, is referred to by sailors as surgical knots, but surgeons, when tying medical threads, on the contrary, call them “sea knots”!

Mono fishing lines used in fishing are almost identical (same sliding) to surgical suture materials. That is why fishermen began to use surgical loops and knots in their hobby.

During fishing, snags and breakdowns of gear often occur, as a result of which you need to bandage or tie a leash, hook or pendant. It is at this moment that it becomes necessary to tie two fishing lines of different thicknesses, and tie them in such a way that it is not only strong, but also reliable!

However, not many knots used for tying fishing line are suitable for connecting fishing line of different diameters, but a surgical knot, on the contrary, guarantees a very strong grip.

Video of knitting a medical surgical knot using a clamp:

The natural development of a straight knot with the aim of strengthening it is to increase the number of runs around the running ends. This results in a stronger surgical knot than a straight one. In this case, you need to monitor the direction of the drifts.

In Fig. 1, the runs are made against the direction of movement of the clock hand, when viewed from the root part of the left rope, and in Fig. 2, the runs are made clockwise, when viewed in the same direction. If we do not change the direction of the pulls in Figures 1 and 2, then we will get an improved woman’s knot, which is not as strong as a surgical one.

A surgical knot is easier to tie than a straight one if the rope is under tension, since after completing those indicated in Fig. 1, the running ends do not slip, and the actions indicated in Fig. 1 can be completed. 2.

Technique of tying threads. Knitting knots. Technique of knitting surgical knots. How to tie a surgical knot?

All nodes, used in surgical practice, double (sometimes triple). The first knot is the main one and should be tightened as much as possible. The second knot secures the first one, that is, it prevents it from untying or loosening. The third knot is applied when using catgut and synthetic ligatures for greater strength, since these threads are very elastic and their surface is slippery.

Surgical node. How to tie surgical knots?

Stage I - fixation of the threads in the original position. The free ends of both threads are crossed and held with the thumb and forefinger of both hands.

Stage II - crossover of threads. The third finger of the right hand is placed over the thread fixed by this hand. The thread, fixed with the left hand, is placed on the nail phalanx of the third finger.

Stage III - taking the thread and passing it through the loop. The nail phalanx of the third finger is brought behind a thread fixed with the same hand. When the finger is extended, the thread located on its back surface is passed through the loop.

Stage IV - fixation of the thread drawn through the loop. After passing through the loop, the free end of the thread is pressed with the thumb to the palmar surface of the third finger. In this case, the index finger is placed above the thread.

Stage V - tightening the knot. The threads are retracted in the opposite direction. Using the index fingers of both hands, the knot is moved towards the tissues.

Stage VI - tying the second knot. The technique of tying the second knot is similar to that of the first, but the second

the knot is tied with the opposite hand. 5th method of knitting knots.

Stage I - fixation of the threads in the original position. The free ends of the crossed threads are held with the third and fourth fingers of both hands, and the thread held by the right hand should be located higher.

Stage II - crossover of threads. The thumb of the right hand is placed under the thread held by the same hand. The thread, fixed with the left hand, is placed under the index finger of the right hand and shifted upward, crossing with the opposite thread at the base of the nail phalanx of the thumb of the right hand.

Stage III - taking the thread and passing it through the loop. The nail phalanx of the index finger is brought behind a thread held by the right hand below the intersection of the threads. When the finger is extended, the thread is passed through the loop.

Stage IV - fixation of the thread drawn through the loop. The thread passed through the loop is first fixed with the thumb and forefinger of the right hand, then with the thumb and third fingers of the same hand. By the end of this stage, the index finger should be positioned above the thread.

Stage V: tightening the knot. The threads are pulled in opposite directions and the knot is moved with the index fingers of both hands.

Stage VI: tying the second knot. The technique for tying the second knot is similar to that of the first, but the second knot is tied with the opposite hand.

Instrumental knot tying technique. After passing the thread through the fabric, its long end is fixed with the left hand. The needle holder, held with the right hand, is placed over the long end of the thread. By turning the needle holder clockwise, wrap the long end of the thread around it, after which, spreading the jaws, the needle holder grabs the free end of the thread. The free end of the thread, fixed with a needle holder, is passed through the loop and the knot is tightened, moving it towards the tissue with the index finger of the left hand. To tie the second knot, the long end of the thread is also wound around the needle holder, rotating it counterclockwise. If two tools are used to tie a knot, this method is called apodactyl.

5. Surgical sutures.

The most general principle for making any suture is to be careful with the edges of the wound being stitched. In addition, the suture should be applied, trying to accurately match the edges of the wound and the layers of the organs being sutured. Recently, these principles have been commonly combined under the term “precision.”

Skin suture
When applying a skin suture, it is necessary to take into account the depth and extent of the wound, as well as the degree of divergence of its edges. The most common types of sutures are: Continuous intradermal cosmetic suture is currently used most widely, as it provides the best cosmetic result. Its features are good adaptation of the wound edges, good cosmetic effect and less disruption of microcirculation compared to other types of sutures. The suture thread is passed through the layer of skin itself in a plane parallel to its surface. With this type of seam, to facilitate thread pulling, it is better to use monofilament threads. Absorbable threads are often used, such as biosin, monocryl, polysorb, dexon, vicryl. Non-absorbable threads are monofilament polyamide and polypropylene. If you use polyfilament threads, then after every 6-8 cm of the seam it is necessary to puncture the skin. The thread is subsequently removed in parts between these punctures.

The second most common skin suture is metal staples. Metal braces are widely used by Western surgeons, as they provide cosmetic results comparable to cosmetic sutures. Why does using braces give such cosmetic results? The staple is designed in such a way that when it is applied, the back of the staple is above the wound. During healing, the volume of tissue connected by the staple increases, but the back does not put pressure on the tissue and does not create a transverse strip (unlike a thread).

A simple interrupted suture is no less common. The skin is most easily pierced with a cutting needle, and it is believed that it is better to use a “reverse cutting” needle. When using such a needle, the puncture is a triangle, the base of which faces the wound. This form of puncture holds the thread better. Injections and gouges should be located on the same line, strictly perpendicular to the wound, at a distance of 0.5-1 cm from its edge. The optimal distance between stitches is 1.5-2 cm. More frequent stitches lead to disruption of the blood supply in the suture area; sparser stitches make it difficult to accurately match the edges of the wound. To prevent the wound edges from turning in, which prevents healing, the deeper layers should be grasped more “massively” than the skin. The knot should be tightened only until the edges match; excessive force leads to disruption of skin trophism and the formation of rough transverse stripes. In addition, it is recommended to remove these sutures as early as possible (3-5 days after surgery) for the same purpose - to prevent the formation of rough transverse stripes. The tied knot should be located at the puncture or puncture points, but not above the wound itself.

If it is difficult to compare the edges of the skin wound, a horizontal mattress U-shaped suture can be used. When applying a conventional interrupted suture to a deep wound, a residual cavity may be left. Wound discharge can accumulate in this cavity and lead to suppuration of the wound. This can be avoided by suturing the wound in several layers. Stage-by-stage suturing of the wound is possible with both interrupted and continuous sutures. In addition to floor-by-floor suturing of the wound, in such situations a vertical mattress suture is used (according to Donatti). In this case, the first injection is made at a distance of 2 cm or more from the edge of the wound, the needle is inserted as deep as possible to capture the bottom of the wound. A puncture on the opposite side of the wound is made at the same distance. When passing the needle in the opposite direction, the injection and puncture are made at a distance of 0.5 cm from the edges of the wound so that the thread passes through the layer of skin itself. When suturing a deep wound, the threads should be tied after all the sutures have been applied - this facilitates manipulation in the depths of the wound. The use of the Donatti suture allows the edges of the wound to be compared even with their large diastasis.

The skin suture must be applied very carefully, since the cosmetic result of any operation depends on it. This largely determines the authority of the surgeon among patients. Inaccurate alignment of the wound edges leads to the formation of a rough scar. Excessive efforts when tightening the first knot cause ugly transverse stripes located along the entire length of the surgical scar. This can cause patients not only moral, but also physical suffering.

Aponeurosis suture
IN last years There have been major changes in the technique of suturing the aponeurosis. The most widely used continuous suture is synthetic absorbable sutures, such as polysorb, biosin, vicryl. In this case, threads with a nominal diameter of 1, 2 are used, and double threads (loop) are often used. After the initial stitching, the needle is threaded through a loop of thread and tightened. Then a blanket suture is applied. At the end, one of the threads is cut and stitched in the opposite direction, after which both threads are sewn together. If any problems in wound healing are suspected, non-absorbable sutures such as polypropylene can be used for such a suture.

No less often, an interrupted suture of the aponeurosis is used using non-absorbable materials such as lavsan. General requirement For all methods of suturing the aponeurosis, care must be taken in matching the edges to exclude interposition of fat. This ensures the formation of a durable scar, that is, the formation of postoperative hernias is prevented. The use of absorbable materials has led to the fact that in recent years we have practically not observed the formation of ligature fistulas.

Seam of fatty tissue and peritoneum.
Currently, among surgeons the issue of the need for a suture of fatty tissue and a suture of the peritoneum is being discussed. The peritoneum heals well even without its precise adaptation. Moreover, the use of catgut to suture the peritoneum causes an inflammatory reaction. Therefore, now wounds after median laparotomy are sutured without a peritoneal suture. There is also disagreement about the need to suture the fatty tissue. As you know, the suture disrupts the blood supply and increases the likelihood of suppuration. Therefore, if there is fascia of fatty tissue (as is the case with inguinal hernia repair), it is advisable to stitch only it. If the fiber is not expressed, it is not recommended to stitch it. Aspiration drainage of the residual cavity is possible.

If you consider it necessary to sew the fatty tissue, then it is better to use a continuous suture with absorbable suture materials (monocryl material is specifically designed for suture of fatty tissue and peritoneum).

Intestinal suture
While there is a wide variety of intestinal sutures, only a few types of suture are most widely used. We strongly recommend using a single-row continuous seam as the method of choice.

The technique for applying this suture is quite simple and the same. The suture is used for anastomosis and suturing of gastrointestinal incisions. The distance between stitches is 0.5 - 0.8 cm, depending on the thickness of the walls of the organs being stitched, the distance from the edge of the organ being stitched to the needle insertion is 0.8 cm for the intestine, 1.0 cm for the stomach (Fig. 3) . For operations on the stomach and small intestine, we use threads with a nominal diameter of 3/0-4/0, and for operations on the large intestine, threads with a diameter of 4/0-5/0. Of other types of sutures, single-row interrupted serous-muscular-submucosal sutures are used with the node located on the serosa (suture Pirogov).

The seam Mateshuka differs in that the node is located on the side of the intestinal lumen. The idea of ​​the Mateshuk suture is to facilitate the migration of the thread into the intestinal lumen. This type of suture was widely recommended when non-absorbable materials were used, which also caused a reaction in the body tissues. When using synthetic absorbable threads, the problem of knot location ceases to be fundamental.

Another single-row seam - seam Gumby used in colon surgery. This suture resembles the Donatti skin suture. In this case, the intestine is initially punctured at a distance of at least 1 cm from the edge of the wound with a puncture of the mucous membrane. After puncturing the second intestine, both intestinal lumens are punctured in the opposite direction at a distance of 2-3 mm from the edge. When the suture is tightened, the serous layers of the intestinal wall are accurately compared over a fairly large area.

In this manual we do not describe the technique of applying two - three-row sutures, since, firstly, they are described in numerous manuals. Secondly, we believe that all techniques except single-row seam techniques have no future. Stapling devices are often used for gastric and intestinal sutures. In this case, two methods of applying anastomosis are used - the first involves the application of an inverted anastomosis, the second - the application of an everted anastomosis. How it's done? When applied inverted During the anastomosis, the branches of the GIA apparatus are inserted into the lumen of the organs being sutured, which, when used, stitches the tissue with two rows of staple sutures and dissects it in the middle. In this case, a ready-made anastomosis is obtained. Depending on the length of the working part of the device, anastomosis with a length of 5, 6, 7 and 8 cm can be applied.

In the second technique, the walls of the organs are everted in such a way that the mucous membranes of the stitched organs are compared. After this, the anastomosed organs are sutured using linear suture devices, such as UO-40, TA-55. Hepaticocholedochus suture. Sutures of the bile ducts are used after choledochotomy, in case of accidental damage to the ducts. If possible, a precision continuous overlap suture should be used, which involves precise alignment of the layers of the duct wall without entrapping the mucosa. Particular care should be taken to apply a suture to the thin-walled common bile duct. For this purpose, monofilament absorbable threads (biosin) with a nominal diameter of 5/0 - 7/0 are used. This technique differs from the traditional one by increased suture tightness and a minimal number of complications in the early and late periods. We use this seam as the method of choice.

When applying biliodigestive anastomoses, only a single-row continuous suture is also used, which is the easiest to use and produces fewer complications. For anastomosis, absorbable monofilament or polyfilament sutures with two needles are used. Initially, the posterior lip of the anastomosis is sutured; both threads with needles are located on both sides of the future anastomosis. After this, the right and left parts of the anastomosis are applied alternately from the right and left until the threads meet on the anterior lip of the anastomosis. The threads are tied together and after this the anastomosis is performed.

Liver suture
To date, liver suturing remains a very difficult problem. The most modern methods of preventing postoperative bleeding and bile leakage from the liver are ultrasonic cavitation, treatment of the liver parenchyma with hot air, and application of fibrin glue to the liver tissue. With this technique, a liver suture is not expected. However, due to the insufficient availability of the necessary equipment, liver suture is currently used very widely.

Basically, various techniques of U- and 8-shaped seams are used. When suturing the gallbladder bed, it is more convenient to use a continuous overlapping suture. When suturing the liver, it is advisable to use absorbable suture materials (Polysorb, Vicryl, Dexon) of large diameters with large atraumatic blunt needles.

Vascular suture
The main requirement for a vascular suture is its tightness. The simplest technique is to apply a continuous suture without overlap. The continuous mattress seam is more reliable, but at the same time more complex. A common disadvantage of both sutures is the possibility of corrugation of the vessel wall when tying the thread. Therefore, for microsurgical restoration of a small-diameter vessel, a single-row interrupted suture technique is used. To sew the prosthesis to the vessel (if it is a polytetrafluoroethylene prosthesis), the same thread is used, which allows you to obtain a “dry” anastomosis due to the fact that the thread completely fills the suture channel.

Tendon suture
When suturing a tendon, you should avoid using rough clamps or surgical tweezers. Directly suturing the tendon requires strong threads on atraumatic needles of round cross-section. Of the many techniques for suturing a tendon, the most widely used are the Cuneo and Lange methods. Special attention when restoring a tendon, attention should be paid to the conditions for its regeneration sliding surface. To do this, the edges of the tendon are adapted with separate sutures using absorbable threads with a nominal diameter of 6/0-8/0. It is especially important to follow this rule when restoring hand tendons. To prevent suture dehiscence, external immobilization of the limb in the position of maximum tendon unloading is usually required.

6. Suture material

In recent years, the attention of surgeons has increasingly been drawn to the role of suture material in the outcome of operations. And this is understandable. Suture material for most operations (with the exception of organ prosthetics) is essentially the only foreign body that remains in the tissues after the end of the operation. And it is natural that the outcome of operations not least depends on the quality, chemical composition and structure of the suture material and the reaction of surrounding tissues to it. The use of adequate, non-reactogenic suture material is one of the components successful operation. In modern surgery, the choice of suture material is determined primarily by the requirements placed on it.

Requirements for suture materials first began to be formulated in the 19th century. So, N.I. Pirogov in “The Beginnings of Military Field Surgery” wrote: “...the best material for a suture is one that: a) causes the least irritation in the puncture channel, b) has a smooth surface, c) does not absorb liquid from the wound, does not swell, does not go into fermentation, does not become a source of infection, d) with sufficient density and ductility, it is thin, not bulky and does not stick to the walls of the puncture. This is the ideal seam.” It should be admitted that Nikolai Ivanovich, in comparison with modern surgeons, was surprisingly modest in his demands. More modern requirements were formulated by A. Szczypinski in 1965.

1. Easy to sterilize

2. Inertia

3. The strength of the thread must exceed the strength of the wound at all stages of its healing

4. Node reliability

5. Resistance to infection

6. Absorbability

7. Comfort in the hand (more precisely, good handling qualities)

8. Applicability for any operations

9. Lack of electronic activity

10. Lack of carcinogenic activity

11. No allergenic properties

12. Tensile strength in the knot is not lower than the strength of the thread itself

13. Low price

Let's take a closer look at some of these requirements.

Biocompatibility(inertia). In the broadest sense of the word, this is the absence of any tissue reaction to the suture material. In particular, the severity of the allergenic, toxic, teratogenic effects of the thread on the body tissues is assessed. They look at the nature and severity of the inflammatory reaction.

Biodegradation(absorbability). This is the ability of a material to be absorbed and excreted from the body. The purpose of the thread is either to stop bleeding from a vessel or to connect tissues until a scar forms. In any case, after completing its main mission, the thread becomes simply a foreign body. And of course, it is ideal if, after performing its function, the thread dissolves and is removed from the body. In this case, the rate of loss of thread strength (the main parameter for all absorbable threads) should not exceed the rate of scar formation. For example, if a strong scar is formed during the suture of the aponeurosis no earlier than on the 21st day, and the thread loses its strength on the 14th day - as you understand, there is a possibility of eventration. Only the threads that connect the prosthesis with the tissues of the body should not dissolve, since a scar never forms between the prosthesis and the tissues.

Atraumatic(one of the concepts of inertia). The concept of atraumaticity is a composite one and, in turn, includes several concepts - surface properties of the thread. All twisted or uneven threads have an uneven surface. When a thread is pulled through body tissue, a “saw effect” occurs, which leads to tissue injury and increases the inflammatory response. In this regard, most braided threads are produced with a special polymer coating, which gives the thread a monofilament property on the surface (see below). Monofilament threads generally do not have a saw-tooth effect and are pulled through the fabric without damaging it. The strength of the knot is also related to the surface properties of the thread. As a rule, the smoother the surface of the thread, the less strong the knot. This forces many more knots to be tied when using monofilament threads to prevent the thread from coming undone. By the way, one of the points of modern requirements for suture materials is the minimum number of knots required for its reliability. The fact is that any extra knot is a foreign suture material. The fewer nodes, the less the inflammation reaction. -method of connecting thread and needle Currently, there are still non-atraumatic needles, where the thread is threaded into the eye of the needle. This creates a duplication of the thread and sharply increases tissue trauma when it is pulled through. The basis of modern suture materials is atraumatic threads, when the thread is a continuation of the needle.

The following methods are used to connect thread and needle:

· The needle in the eye area is cut lengthwise, unrolled, the thread is inserted inside and the needle is folded and crimped around the thread. This creates a weak point in the needle where it can bend or break.

· The needle is drilled with a laser beam, a thread is inserted into the hole and crimped. This method is more reliable, since the strength of the needle is preserved as much as possible.

· When using threads of particularly small diameters, silt is obtained by spraying metal onto the thread, followed by chemical sharpening.

Manipulative properties of the thread (comfort in the hand). The handling properties of threads include elasticity and flexibility. Elasticity is one of the main physical parameters of the thread. Rigid sutures are more difficult for the surgeon to manipulate, resulting in more tissue damage. In addition, when a scar forms, the tissue initially becomes inflamed and the volume of tissue connected by the thread increases. An elastic thread stretches as the fabric increases, while an inelastic thread cuts through the fabric. At the same time, excessive elasticity of the thread is also undesirable, as it can lead to divergence of the edges of the wound. It is considered optimal to increase the length of the thread by 10-20% compared to the original. WITH flexibility The threads are connected not only with ease of manipulation for the surgeon, but also with less tissue trauma. It is still believed that silk has the best manipulation properties (it is also called the “gold standard” in surgery).

Strength threads The stronger the thread, the smaller its diameter can be used to sew fabric. And the smaller the diameter of the thread, the less foreign suture material we leave in the tissues, and, accordingly, the less pronounced the tissue reaction. Studies have shown that the use of a thread with a nominal diameter of 4/0 instead of 2/0 leads to a twofold decrease in tissue reaction. So thread strength is one of important parameters. Moreover, it is not so much the strength of the thread itself that should be taken into account, but its strength in the knot, since for most threads the loss of strength in the knot ranges from 10 to 50% of the original. For absorbable suture materials, one more parameter must be taken into account - the rate of strength loss. As we have already said, the rate of loss of thread strength should not be higher than the rate of scar formation. In surgery of the gastrointestinal tract, a scar is formed in 1-2 weeks, with aponeurosis suture - in 3-4 weeks. Accordingly, it is desirable that the suture material retains sufficient strength until 2-4 weeks after surgery (in this case, depending on the type of absorbable material, it will be necessary to use threads of different diameters).

How important the atraumatic properties of the thread are can be understood from the data of V.V. Yurlov, who, when applying colonic anastomoses, switched from a non-atraumatic needle and twisted nylon to atraumatic needles and monofilament suture material, reduced the incidence of anastomotic leakage from 16.6% to 1.1 %, and mortality from 26% to 3%.

Let's consider the classification of modern suture materials.

Classification of suture materials.

There are several criteria by which suture materials are divided. According to their ability to biodegrade: all suture materials are divided into absorbable And non-absorbable.

Absorbable materials include:

Catgut, collagen

Materials based on polyamides (nylon) Materials based on cellulose (occelon, cacelon)

Materials based on polyglycolides (polysorb, biosin, monosof, vicryl, dexon, maxon)

Materials based on polydioxanones (polydioxanone)

Materials based on polyurethanes (polyurethane)

Non-dissolvable materials include:

· Materials based on polyesters (lavsan, mersilene, etibond)

· Materials based on polyolefins (surzhipro, prolene, polypropylene, surzhilene)

Materials based on polyvinylidene (Koralen)

Materials based on fluoropolymers (gore-tex, vitaphone)

Metal-based materials (metal wire, staples)

The structure of the threads differs:

1. Monofilament ( monofilament). In cross section, such a thread is a homogeneous structure with a smooth surface. Such threads are distinguished by the absence of a “saw effect” and, as a rule, a less pronounced reaction of the body. However, even monofilament yarns are often additionally coated to improve the “draw” properties and reduce the “saw effect”.

2. Polythread ( multifilament) in cross-section consists of many threads. In turn, they distinguish

· - twisted threads This thread is obtained by twisting several filaments along the axis.

· - wicker threads This thread is obtained by weaving many filaments like a rope.

· - complex threads These are usually woven threads impregnated or coated with a polymer material. Due to the polymer coating, the “saw effect” is reduced. This type of thread is currently the most common.

Let us dwell on the properties of suture materials. Initially, it is necessary to say a few words about such widely used materials as silk and catgut. Catgut thread is the most reactogenic of all threads currently used. This is the only thread to which an anaphylactic shock reaction was obtained. The use of catgut thread can be considered a foreign tissue transplantation operation. Experimental research It has been shown that when suturing a clean wound with catgut, it is enough to introduce 100 microbial bodies of staphylococcus into it to cause suppuration. Catgut thread, even in the absence of microbes, can cause aseptic tissue necrosis.

Another disadvantage is the unpredictable timing of loss of strength and resorption of catgut thread. On average, catgut thread resolves within 3 weeks, but these periods can vary from 2 days to 6 months. Moreover, during the first five days, the catgut thread loses up to 90% of its strength. In addition, when comparing threads of the same diameter, the strength of catgut threads is less than that of synthetic absorbable threads.

All of the above leads to the fact that there are currently no indications for the use of catgut in surgery. At the same time, some surgeons continue to use it and consider catgut to be a satisfactory suture material. This is primarily due to the surgeons’ habits and lack of experience in using synthetic absorbable materials. However, all experimental and clinical studies conducted show the advantages of using synthetic threads. Therefore, we allow ourselves to repeat again - in modern surgery there are no areas for the use of catgut threads.

Now a few words about silk. Due to its physical properties, silk is considered the “gold standard” in surgery. It is soft, flexible, durable, and allows you to knit two knots. However, since silk is a material of natural origin, its chemical properties are comparable only to catgut. And the inflammatory reaction to silk is only slightly less pronounced than the reaction to catgut. Silk also causes aseptic inflammation up to the formation of aseptic necrosis. When using silk thread in the experiment, 10 microbial bodies of staphylococcus were enough to cause suppuration of the wound. Silk has a pronounced sorption capacity and wicking properties, so it can serve as a reservoir and conductor of microbes.

In addition, silk is an absorbable suture material with a resorption period of 6 months to a year, which makes it impossible to use in prosthetics. In recent years, attempts have been made to improve the properties of silk. Thus, the Ethicon company produces silk impregnated with wax, which sharply reduces its wick properties. However, impregnation negatively affects the reliability of the assembly. Impregnation of silk thread with silver salts results in silk acquiring antiseptic properties and reducing the risk of suppuration. However, we would like to emphasize that in modern surgery there are no areas of application for silk, just like for catgut. This is especially true for silk produced by domestic industry. We want to encourage surgeons stop using silk and catgut in favor of synthetic suture materials.

7. Stop bleeding in the wound.

1) Ligation of a vessel in the wound.

It is the most reliable method of stopping external bleeding. It is certainly preferable to ligate the vessel in the wound, directly at the site of damage, since this disrupts the blood supply to a minimal amount of tissue. More often, vessel ligation is done during surgical treatment of a wound or during surgery. To do this, a hemostatic clamp is applied to the bleeding vessel, after which the vessel is bandaged.

In cases where during surgery the vessel is visible before damage, it can be crossed between two previously applied ligatures.

2) Ligation of the vessel throughout.

The essence of the method is to ligate a fairly large, often main trunk proximal to the site of injury. Indications for ligation of the vessel along its length (Gunter method) are:

Bleeding from a large muscle mass, when the ends of the vessel in the wound cannot be detected (in case of massive bleeding from the muscles of the tongue, the lingual artery on the neck in Pirogov’s triangle is ligated, in case of bleeding from the muscles of the buttock - the internal iliac artery);

Secondary arrosive bleeding from a purulent wound (ligation in the wound is unreliable, since arrosion of the vessel stump and recurrent bleeding are possible, in addition, manipulations in a purulent wound can contribute to the progression of the inflammatory process).

In order to stop bleeding, an incision is made proximal to the damaged area based on topographic and anatomical data, the corresponding artery is exposed and ligated.

In this case, the ligature very reliably blocks the blood flow through the main vessel, but bleeding, although less serious, can continue due to collaterals and reverse blood flow. The main disadvantage of the method is that much more tissue is deprived of blood supply than when bandaging a wound. This method is fundamentally worse and is used as a forced measure.

3) Stitching the vessel.

When a bleeding vessel cannot be isolated and grasped with a hemostatic clamp in the wound and, therefore, bandaged, they resort to placing a purse-string or Z-shaped suture around the vessel through the surrounding tissue, followed by tightening the thread - the so-called suturing of the vessel.

4) Wound tamponade, pressure bandage.

These are methods of temporarily stopping bleeding, which can become permanent when bleeding from small-caliber vessels. After removing the pressure bandage (usually on days 2-3) or removing tampons (usually on days 4-5), bleeding may stop due to thrombosis of damaged vessels. Gauze swabs can be dry or moistened with various solutions. Biological tissues can be used as tampons: greater omentum, muscles, etc.

For epistaxis, tamponade is the treatment of choice. There is anterior (carried out through the external nasal passages) and posterior tamponade

Technique for posterior nasal cavity tamponade:

a) passing the catheter through the nose and mouth to the outside;

b) attaching a silk thread to the catheter;

c) reverse removal of the catheter with tampons.

5) Vascular suture and reconstruction of blood vessels.

The application of a vascular suture is fundamentally best method stopping bleeding, since only with this method is the blood supply to the tissues fully preserved. Vascular suture or vessel replacement is performed in cases where the damaged vessel cannot be excluded from the blood supply to the tissue (large main artery or vein). These manipulations require skill and experience, and therefore must be performed by specialist angiosurgeons with the availability of certain instruments.

The vascular suture must be highly airtight and meet the following requirements:

· do not disrupt the blood flow;

· there should be as little suture material as possible in the lumen.

There are mechanical and manual vascular sutures. A mechanical suture is applied using machines using tantalum staples. It is quite perfect and does not narrow the lumen of the vessel. However, hand stitching is much more often used. Method of applying a vascular suture according to Carrel:

When applying it, atraumatic non-absorbable suture material is used (threads No. 4\0-7\0 depending on the caliber of the vessel). After mobilizing the vessel and turning off its sections using elastic vascular clamps, the edges of the vessel are sparingly excised. The ends of the vessel are then stitched through all layers with three stay stitches, which are tied and stretched. After this, the walls of the vessel are sewn together between the guide seams with a continuous encircling seam.

The ideal is to connect the vessels “end to end”.

In the presence of a traumatic defect with a sufficiently large distance between the distal and proximal ends of the vessel, prosthetics is used - replacement of the vessel using autovein or synthetic material

In case of marginal damage to the vessels, a lateral suture or patch is applied from fascia, aponeurosis, autovein, or synthetic material.

Stopping bleeding in case of marginal vascular damage:

a) applying a transverse suture;

b) applying a longitudinal suture;

c) plastic side patch;

With significant traumatic injuries of large main vessels, there is a need for bypass surgery - creating a bypass path for blood flow. For this purpose, an autovein (great saphenous vein of the thigh or superficial vein of the forearm) and vascular prostheses made of synthetic materials (nylon, dacron, perlon, etc.) are also used.

6) Physical methods:

· Exposure to low temperature.

Under the influence of cold, vasospasm occurs, the speed of blood flow in them slows down, which contributes to the rapid process of thrombus formation.

Local hypothermia is used to prevent bleeding and hematoma formation in early postoperative period(an ice pack is placed on the wound after surgery for 1-2 hours), for soft tissue bruises (an ice pack on the first day after injury), for nosebleeds (an ice pack on the bridge of the nose), for gastric bleeding (an ice pack on the epigastric area, swallowing pieces of ice, irrigating a bleeding vessel with cold solutions during FGS).

Cryosurgery - the local application of very low temperature - is used in operations on richly vascularized organs (brain, liver, kidneys), especially when removing tumors. The method is based on local tissue freezing, which promotes hemostasis.

· Exposure to high temperature.

The hemostatic effect of high temperature is based on its ability to coagulate proteins of the vascular wall and accelerate the process of thrombus formation.

Hot solutions are used to stop bleeding during operations in case of damage to parenchymal organs (liver, spleen), diffuse bleeding from bone tissue. To do this, a napkin with hot saline solution (solution temperature 50-700C) is inserted into the wound for 5-7 minutes.

Diathermocoagulation is the main method of thermal stoppage of bleeding.

The method is based on the use of ultra-high frequency currents that cause coagulation of blood proteins and the vessel wall at the point of contact with the tip of the device. Along with ligation of a vessel in a wound, diathermocoagulation is the main method of stopping bleeding during surgery. With its help, you can quickly and without leaving ligatures stop bleeding from damaged vessels of subcutaneous fatty tissue, muscles, small vessels of the brain, parenchymal organs, etc. Diathermocoagulation is effective in stopping internal bleeding (coagulation of a bleeding vessel in the mucous membrane of the stomach or duodenum through a fibrogastroscope).