Technique for tying a simple surgical knot. How to tie surgical knots for fishing? Multi-tiered surgical unit

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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 important element any surgical operation.

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 done with the 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 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 fabrics of significant thickness (for example, when suturing on soft fabrics 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.

Knowing how to tie a surgical knot is one of the important requirements for mastering the medical profession. The doctor must be able to quickly and efficiently perform the necessary steps to apply a suture. Tying surgical knots is an important component of many operations. The time spent on training, developing technique and speed will give results in the form of high-quality treatment measures and will ensure the gratitude of patients.

Ways of education

Sutures can be applied manually and instrumentally (apodal) method. The predominant knitting method is the hand method. The instrumental approach is used in specific cases, such as deep wounds of complex shape, microsurgery, and endovideosurgery. With the apodal method, the consumption of suture material is reduced. Depending on the number of loops made, the knots can be:

• single-loop;
• two-loop;
• multi-loop.

A knot formed by one loop is used for short-term tissue fixation. In the future, the thread is easily removed after completing the task. Two-loop knots are the most widely used. In medical practice they are used for simple, marine and complex units.

Types of knots

Depending on the surgical procedure and suture material required nodes may vary. When using any method, the first knot is tightened as much as possible. And the second one fixes the first one. When using synthetic threads and catgut, a third knot is required to increase strength. In medical practice there are many options for tying threads, but the result of all actions will be one of three options:

These clarifications do not affect the performance of the node itself. To participate in the operation, each member of the operating team must be able to quickly and efficiently tie surgical threads.

Classic tying method

The ends of the ligature are fixed with the fingers. The threads are in constant, light and uniform tension - this is necessary for accurately connecting the edge of a wound opening or fixing a vessel. When forming the first knot, you need to cross the threads: Grab the one on the left with your right hand, and the one on the right with your left. Focusing on the position of the ligature on top, fixed in the left hand.

The cross is pressed between the thumb and index fingers of the left hand, so that it is fixed by the base of the nail phalanx of the index finger on the thumb. The end of the ligature, located in the right hand between the thumb and index finger, is pulled up and circled under the nail phalanx of the index finger of the left hand.

The gap between the suture material can be increased using the middle finger right hand. Next, turning the left hand and making a nodding movement with the index finger, the ligature is passed into the gap and fixed.

In order for the seams to have a finished look, you need to correctly form the ends of the connecting threads. The length can vary from 3 mm for multifilament threads to a minimum of 5 mm for monofilament threads. It is extremely undesirable to leave too long tendrils, which increase the amount of foreign material in the seam. When stitching, you need to pay attention to the following points:

All of the above methods of tying threads are still used by doctors in their work. Every year new technologies are introduced that significantly simplify this procedure. Patients after surgery have virtually no scars.

7.1. TISSUE SEPARATION

The general principle of tissue separation is strict layering. There is dissection and tissue delamination.

Dissection is carried out with a cutting instrument - a scalpel, knife, scissors, saw. The main tool when performing tissue dissection is a scalpel.

The abdominal rock pellet is used to make long cuts on a horizontal or convex surface of the body, and the pointed one is used for deep cuts and punctures.

Holding the scalpel in the form of a bow provides the movement of the hand with greater range, but less force; the position of the table knife allows you to achieve both greater pressure and a significant cut size; It is held in the writing pen position when making small incisions or sharply extracting anatomical structures. The amputation knife is held in the fist with the cutting edge facing the surgeon.

All cuts are made from left to right (for right-handers) and towards you.

Technique for dissecting skin and subcutaneous fat. The direction of the skin incisions is chosen in accordance with the location of the projection of the organ to be operated on the skin. At the same time, they try to ensure that the incision line is (if possible) parallel to the visible folds of the skin, which, in turn, correspond to the Langer tension lines. With incisions perpendicular to Langer's lines, the edges of the wound gape, which is convenient in the treatment of purulent diseases. However, with such incisions, the connection of the wound edges and their fusion occur worse. Such incisions in the joint area can cause skin contracture. The cuts in the joint area should be parallel to the flexion plane.

Stretching and fixing the skin on both sides of the intended incision line with the thumb and forefinger of the left hand, the operator carefully inserts the scalpel at an angle of 90? into the skin, after which, tilting it at an angle of 45?, it smoothly leads to the end of the incision line. When the cut is completed, the scalpel is again moved to the position

perpendicular to the skin. This technique is necessary to ensure that the depth of the incision is the same throughout the wound.

Technique for cutting fascia and aponeurosis. After making an incision in the skin with subcutaneous fatty tissue, the operator, together with an assistant, lifts the fascia with two surgical tweezers, incises it and inserts a grooved probe into the incision of the fascia. By moving the scalpel with the blade upward along the groove of the probe, the fascia is dissected along the entire length of the skin incision.

Technique for cutting and separating muscles. The muscle is either stripped along the fibers or dissected. When dissecting, the perimysium is first cut with a scalpel, and then, using two folded tweezers or two Kocher probes, the muscles are moved apart, introducing Farabeuf lamellar hooks into the wound. In some cases you have to cross muscle fibers and in the transverse direction. Sometimes, before crossing, the muscle is clamped with two hemostatic clamps and cut between them. The edges of the transected muscle are sutured with an enveloping catgut suture for the purpose of hemostasis. It must be borne in mind that due to contractility the crossed muscles diverge over a fairly significant distance.

Technique of dissection of the parietal peritoneum. The parietal sheet of peritoneum, incised between two tweezers, is cut along the entire length of the skin wound with Richter scissors, lifting it on the index and middle fingers of the surgeon’s left hand inserted into the peritoneal cavity. The edges of the peritoneal incision are fixed to gauze napkins using Mikulicz clamps.

7.2. CONNECTION OF TISSUE

Tissue joining is performed as the final stage of surgery or during surgical treatment of a wound. It is necessary to remember:

The edges of the wound must not be sutured under tension; the sutures should only hold the adjacent edges of the tissue;

Foreign bodies (ligatures) should not be left in the wound for a long time, as they interfere with its normal healing;

To connect tissues, only special tools are used; it is unacceptable to use other tools for this purpose.

7.2.1. Types of suture material and needles

When joining tissues, they use special threads loaded into surgical needles, which are fixed in needle holders. For the method of loading thread into a needle and the rules for holding needles, see section 3.

Types of surgical needles

Cutting (triangular):

■ thick (gynecological);

■ thin (surgical);

Curved (curvature 120?):

■ ophthalmic;

■ for stitching leather.

Piercing (round):

Direct:

Curved (curvature 180?):

■ thin (vascular);

■ medium thickness (intestinal);

■ thick (prickly).

Flat (liver):

Straight, semi-curved, curved.

Atraumatic:

Straight, curved.

Microsurgical.

Suture material used in surgery can be classified according to several criteria:

According to the degree of resorption - absorbable, conditionally absorbable and non-absorbable;

By thickness;

By structure.

The oldest absorbable suture material, catgut, was made from the submucosa of the small intestine of small cattle. Depending on the treatment method, the time for complete resorption ranges from 1 week to 1-1.5 months. In the second half of the twentieth century, synthetic absorbable sutures were developed, the first of which were deson and vicryl.

Conditionally absorbable materials include silk and nylon.

The group of non-absorbable threads includes horsehair, wire (steel, nichrome, etc.), and various synthetic materials.

Catgut is produced in 9 numbers: 000, 00, 0, 1, 2, 3, 4, 5, 6.

Surgical silk is produced in 12 numbers: 000, 00, 0, 1, 2, 3, 4, 5, 6, 7, 9, 10; thickness? 1 - 0.1 mm, each subsequent number is 0.1 mm thicker than the previous one.

According to its structure, suture material can be divided into two groups: monofilament (in the form of a single fiber); complex threads, which, in turn, are divided into three groups - braided, twisted and coated threads.

Among the new types of suture material, it is worth noting antibacterial suture material (caprogen, caproag, capromed, etc.), as well as threads that can stimulate wound healing processes - rimin, biofil. These groups of suture material are in their infancy and are not yet widely used in surgical practice.

All types of suture material are supplied to surgical departments in two forms: sterile (in ampoules); non-sterile (in skeins).

Surgical needles and suture threads must be selected in a strictly differentiated manner. In this case, you should take into account what kind of fabric the seam is applied to, what type of seam is used and what purposes the seam serves. The size and diameter of the needle should always match the thickness of the suture thread.

Atraumatic suture materials - disposable needle + thread complex, manufactured in a factory. A distinctive feature of this suture material is that a single thread is pulled behind the needle, approximately equal to the diameter of the needle, and not a double thread, as with classic sutures. Under these conditions, the thread almost completely covers the tissue defect after the needle passes, which makes it possible to use atraumatic suture material in vascular operations, as well as in cosmetic surgery.

7.2.2. Types of seams and knots

Three types of nodes are used in surgery: simple (female), marine, surgical (Fig. 7.1).

When tying knots, it is necessary to keep the ends of the threads taut, since when they relax, the knot can unravel and will

Rice. 7.1.Technique of knitting “marine” (a) and surgical (b) knots: 1-6 - successive moments of knitting knots

fragile. Manipulations are performed with the thumbs and index fingers of both hands. When tying a simple knot, there are 8 moments. To tie a sea knot, the first 5 moments are initially repeated, and the second knot is tied so that the stroke of its turn is directed in the direction opposite to the first turn. Tying a surgical knot requires double overlapping of the thread at the first moment and tying a counter second turn like a sea knot.

7.2.3. Suture technique

There are interrupted, continuous twisting, continuous screwing, continuous mattress, U-shaped, purse-string, Z-shaped sutures.

Interrupted suture produced by suturing the skin and subcutaneous tissue, aponeuroses of the broad muscles. The first injection of the needle is made from the surface side of the fabric, after which the needle is punctured

and the second injection with inside second edge to be stitched. In this case, the distance of the first injection and the second injection from the edge of the fabrics to be sewn should be equal. After applying the suture, the threads are tied with one of the knots. When applying an interrupted suture, a possible mistake is the mismatch of the stitched edges of the fabrics and their tucking. This happens due to the unequal distance between the needle insertion and the puncture from the edges being stitched and the resulting tissue creeping onto each other when the knot is tightened.

Continuous suture application produced by suturing fascia, aponeuroses, serous membranes (peritoneum, pleura) (Fig. 7.2). The technique is as follows. An interrupted suture is placed at the edge of the wound so that one end of the thread is much longer than the other. Then, using a needle threaded with the long end of the thread, the fabric is continuously sewn stitch to stitch throughout. The distance between the stitches should be 0.5-0.7 cm. During the last stitching, the thread is not completely removed, but is used to tie the last knot with the working end of the ligature.

ab Rice. 7.2. Technique for applying a continuous entwining suture to the peritoneum: a - beginning of suturing of the peritoneum; b - completion of the seam

Application of a continuous mattress suture. One type of continuous seam is the mattress seam. The technique of applying it, in contrast to the wrapping seam, is that before tightening each stitch, the working end of the thread is passed into the loop formed by each previous turn of the seam. All other manipulations with the thread are similar to those with a wrapped seam.

Application of a continuous screw-in suture (Schmieden) used as one of the stages of interintestinal anastomosis (Fig. 7.3). The technique of applying a Schmieden suture is similar to the technique of a continuous wrapping suture. The difference is that the needle is inserted in all cases from the inner surface of the stitched edges.

Applying a U-shaped seam used for suturing muscles, tendons, aponeuroses (see Fig. 7.3). The technique is as follows: a needle is inserted from the surface of one edge of the wound, then injected from the depths, and punctured on the surface of the other side being connected. Having retreated 0.4-0.6 cm, from the same side make the same stitch in the opposite direction. When tying the ends of the thread, the seam is U-shaped.

ab Rice. 7.3. Technique of applying Schmieden suture (a) and U-shaped suture (b)

Rice. 7.4.Technique for applying purse-string (a) and Z-shaped (b) sutures

Purse-string suture. A gray-serous or serous-muscular suture is placed around the wound opening or the organ to be removed along its entire circumference so that the last needle injection corresponds to the site of the very first injection. When tightened, both ends of the thread collect the wall of the organ being sewn together, as if in a pouch. A Z-shaped suture is placed on top of the tightened purse-string suture (Fig. 7.4).

7.2.4. Soft tissue suturing technique

Suturing a wound of the stomach, small and large intestine produced by an intestinal suture in a direction transverse to the axis of the organ. In this case, double-row sutures are placed on the stomach and small intestine, and three-row sutures on the large intestine. The first row of sutures (through, continuous screwing) is applied through the entire thickness of the organ wall with catgut of the appropriate size on a round needle. The second and third rows of sutures (serous-muscular, gray-serous, interrupted or continuous) are applied with a silk thread on a round needle. For small wound defects, a purse-string suture and a Z-shaped suture above it can be used.

Stitching of the parietal peritoneum carried out with catgut (? 4) on a round needle with a continuous twisted suture.

Stitching the musclecarried out with catgut (? 4, 5) with U-shaped sutures.

Stitching of fascia and aponeuroses produced with a silk thread (? 1, 2) charged into a round needle. Separate interrupted, U-shaped or continuous sutures are applied. When stitching, it is necessary to ensure that the distance between the puncture on one side and the puncture on the other is equal. The distance between individual interrupted seams or stitches of a U-shaped and continuous seam should be no more than 5 mm. The sutures are tightened with a marine or surgical knot.

Skin stitchingcarried out with a silk or nylon thread (? 4, 5, 6), charged into a cutting needle with a curvature of 120?. Stitching is done using separate interrupted sutures. The technique is as follows (Fig. 7.5). Using serrated or surgical tweezers, the alternately stitched edges of the skin are held. The needle is inserted with outside one of the stitched edges, puncture from its inside. Then the opposite edge of the skin is grabbed with tweezers, a puncture is made from the inner surface of the skin flap and a puncture is made on its outer surface. In this case it is necessary

Rice. 7.5.Application of interrupted sutures to the skin: a - correct; b - incorrect

Make sure that the distance between the puncture on one side and the puncture on the opposite side with respect to the edges of the edges being sewn is the same. Tighten a simple or maritime knot so that it is located on the side of the cut edges being connected. When applying skin sutures, the following rules should be followed: minimize tissue trauma; It is necessary to suture the edges of the wound separately.

To apply a corner adaptive suture, it is necessary to strictly follow the technique of its implementation (Fig. 7.6). The corner suture is used in cases where two triangular sections of skin need to be connected to the longitudinal edge of the wound (T-shaped wound), as well as when a small wound has a triangular shape.

If it is necessary to achieve a high degree of cosmeticity, intradermal sutures are used (Fig. 7.7). In the presence of superficial wounds, a single-row suture is applied, and in the presence of deep wounds, a double-row suture is performed.

When applying a single-row continuous suture, the thread is passed into the thickness of the dermis. Application begins by stitching the skin at a distance of 1 cm from one of the corners of the wound. Next, they sew parallel to the skin surface at the same height, capturing the same layer of fabric on both sides. Having finished applying the suture, both ends of the ligature are stretched in opposite directions, ensuring complete adaptation of the edges of the wound. The ends of the thread are fixed to the skin either with a plaster or with interrupted skin sutures.

When applying a double-row continuous suture, the deeper ligature passes through the subcutaneous fatty tissue, and the second, more superficial one, through the dermis. Complete adaptation of wound edges

Rice. 7.6.Technique for applying an adaptive fillet suture (from: Zoltan Y., 1974)

Rice. 7.7.Closure of superficial (1) and deep (2) skin wounds with single- and double-row sutures (from: Zoltan Y., 1974)

achieved by stretching both ligatures in opposite directions simultaneously. The ends of the superficial and deep ligatures are tied at the corners of the sutured wound.

Removing skin sutures carried out using tweezers and pointed scissors (Fig. 7.8). Having grabbed a knot or one of the free threads with tweezers, lightly pull the subcutaneous part of the thread above the skin and, bringing the sharp jaw of the scissors under the thread, cross it at the surface of the skin (see Fig. 7.8), after which the thread is easily removed.

Rice. 7.8.Technique for removing interrupted skin suture

A continuous suture is removed by pulling the knot of connected superficial and deep ligatures, followed by their simultaneous intersection and pulling from the opposite side (Fig. 7.9).

Rice. 7.9.Technique for removing a double-row continuous seam (from: Zoltan Y., 1974)

7.3. STOP BLEEDING

Bleeding refers to the release of blood outside the vascular bed. Bleeding can be external (blood flows into the external environment) and internal (blood flows into serous cavities, soft tissues, the lumen of hollow organs). There are also arterial, venous, capillary and mixed bleeding. Bleeding that occurs as a result of the direct action of a traumatic agent is called primary, bleeding that develops as a result of slipping of the ligature, necrosis of the vascular wall, or bedsores from foreign bodies is secondary. To temporarily stop bleeding, digital pressure on the vessel and application of a pressure bandage or tourniquet are used. Methods for definitively stopping bleeding include the application of a hemostatic clamp followed by ligation of the vessel in the wound, its electrocoagulation, and ligation of the vessel along its length.

Technique for ligating a blood vessel in a wound. In almost any operation, when dissecting tissue, the surgeon is forced to dissect small-caliber blood vessels along the cut. Bleeding in this case (especially from small vessels) can stop on its own, which is associated with the development of vascular spasm and thrombosis of the cut ends of the vessel, however, reliable hemostasis can be achieved by ligating the vessel with a ligature after grasping it with a hemostatic clamp. The position of the hemostatic clamp in the hand should be as follows: nail phalanx thumb in one ring, the distal phalanx of the IV or III finger in the other, the index finger on a clamp. After dissecting the tissue, the surgeon or assistant applies hemostatic clamps to the vessels, always in a perpendicular direction to the tissues, and it is necessary to grasp the smallest possible volume of surrounding tissue with the clamp. Obliquely grasping a bleeding area with a clamp is incorrect, since this takes a lot of surrounding tissue, and ligating a large area of ​​it can lead to necrosis, which prevents primary healing of the wound. After capturing the bleeding vessel, the surgeon places a ligature under the clamp, the assistant lifts the tip of the clamp upward so that the ligature lies under it, otherwise it will tighten at the tip of the clamp. After inserting the ligature, the surgeon ties the first knot, preferably a surgical one, making sure that the knot is not tightened on the instrument itself. While the surgeon tightens the knot, the assistant gently

removes the clamp, and the operator, making sure that the ligature does not slip, applies a second knot. The assistant cuts the ends of the thread short (up to 5 mm). For ligation of blood vessels, silk, nylon and lavsan threads are used. It is better not to use catgut threads due to the possibility of developing secondary bleeding. When using silk, a double knot is sufficient; when using nylon and lavsan, it is necessary to tie a triple knot.

When ligating blood vessels in a wound, the operator’s hand movements should be smooth. It is necessary to be able to apply and remove the clamp with one right or left hand equally.

Electrocoagulation of a blood vessel in a wound. In a number of cases, for example, during the removal of malignant tumors, brain surgery, microsurgery, and also in order to reduce the operation time, electrocoagulation of a vessel in the wound is used. To do this, you need to have a diathermocoagulation apparatus. Any of its models has power transformer, high frequency current generator, control pedal, shielded wires ending in electrodes. It is possible to use both monoactive and biactive coagulation. In the first case, one of the electrodes (passive) in the form of a plate is fixed to the patient, and the second electrode is active - working. In the biactive coagulation mode, special tweezer electrodes are used, the jaws of which are the active and passive electrodes. The operating principle of the device is to convert electrical energy into thermal energy by closing the device circuit at the point of contact of the active electrode with tissue. The thermal effect first of all occurs in the blood (a blood clot forms), and then spreads in the vessel wall from the inside out, causing protein coagulation.

In both coagulation modes, it is possible to directly touch the bleeding vessels with electrodes, but this technique is more convenient when using biactive coagulation. When using the monoactive coagulation mode, it is better to clamp the vessels with hemostatic clamps, and then touch the clamps with electrodes, making sure that the clamp does not come into contact with other tissues to avoid burning them.

Technique of ligation of the main blood vessel throughout. Indications for ligation of vessels throughout are the impossibility of applying hemostatic clamps with subsequent ligation within the wound; the need for preliminary

dressings before certain operations (amputation, jaw resection, tongue resection).

Dressing is carried out under general anesthesia or local anesthesia. Incisions are usually made along the projection lines of the vessels. In addition to incisions along the projection, indirect approaches are used to expose some vessels, making incisions at some distance from the projection lines through the sheaths of adjacent muscles.

The skin, subcutaneous tissue, superficial and intrinsic fascia of the area are dissected. Then it is necessary, by retracting the muscle with a lamellar hook, to open the wall of the vagina of the neurovascular bundle using a grooved probe. Isolation of the artery is carried out bluntly. Holding a grooved probe in his right hand and tweezers in his left, the operator grabs the perivascular fascia (but not the artery!) on one side with tweezers and, carefully stroking the tip of the probe along the vessel, isolates it. The same technique is used to expose the artery on the other side for 1-2 cm. The vessel should not be isolated over a larger length so as not to disrupt the blood supply to the vessel wall. A silk or nylon ligature is placed under the artery using a Deschamps or Cooper ligature needle. When ligating large arteries, the needle is inserted from the side on which the accompanying vein is located (between the artery and vein), otherwise it may be damaged by the end of the needle. The ligature on large arteries is tightly tightened with a double surgical or naval knot. When ligating and crossing large arterial trunks, two ligatures are applied to the central end of the vessel, the distal one being stitched, and one ligature being applied to the peripheral end.

7.4. VASCULAR SURE

Vascular suture is both one of the ways to finally stop bleeding and one of the surgical interventions on blood vessels.

Carrel's circular vascular suture technique (Fig. 7.10). For arterial injuries, vascular suture is currently the operation of choice.

The technique for performing this intervention according to Carrel’s method is as follows. Vascular clamps are applied to both ends of the vessel segments isolated over a short distance. For overlay

Rice. 7.10.Vascular suture according to Carrel:

a - application of stay sutures; b - application of a blanket suture

round piercing atraumatic needles are used to stitch the seam. Three fixation sutures are placed along the perimeter of the vessel at equal distances from each other. The assistant stretches the wall of the vessel using two adjacent stay sutures, giving it a linear shape. Then, with frequent (at a distance of 1 mm from each other) continuous stitches, the walls of the vessel segments are connected between the holders. The beginning of the suture thread is connected to the 1st holder, the end - to the 2nd. In the same way, sequentially stretching the wall of the vessel between the 2nd and 3rd holders, 3rd and 1st holders, a suture is applied along the entire circumference of the vessel.

After finishing the suture, the vascular clamps are removed: on arteries, first from the peripheral, then from the central segment, on veins, vice versa.

If blood leaks along the suture line, the bleeding site is pressed with a tampon moistened with hot saline solution, or additional interrupted sutures are placed at this site.

Microsurgical vascular suture. Performing a microvascular suture requires an operating microscope or a surgical loupe, microsurgical suture material code number 8/0-10/0, and microsurgical instruments. The conditions for successful application of a microvascular suture are good visualization of the ends of the vessel, careful hemostasis, grasping the vascular wall with instruments only by the adventitia, matching the ends of the vessel without tension, excision of the adventitia at the ends of the vessel to prevent it from entering the lumen of the vessel.

To stitch a vessel with a diameter of 1 mm, 7-8 interrupted sutures are required. Two stay sutures are first applied. Sutures are first placed on the anterior wall of the anastomosis, and then the vessel is rotated using holders and the posterior wall is sutured. You can use a technique when, after tying a knot, one of the ends of the thread is cut off, and the second is used as a holder for rotation of the vessel wall. When suturing small veins, more sutures are required, since the guarantee of success of a venous suture is the exact comparison of the sutured sections of the vessel. To tie knots, they use the apodactyl technique, in which one end of the thread is wrapped around the jaws of the needle holder using tweezers, and the other is grabbed by the jaws of the needle holder. When the first thread slips, a knot is formed. If you circle the first end of the sponge thread twice, you get a surgical knot. After applying a microsurgical vascular suture, the first to remove the clamp is from the distal end of the vessel when suturing an artery and from the proximal end when suturing a vein.

7.5. VENESECTION

Indications:the need for long-term intravenous infusions or the inability to perform catheterization of the main veins, as well as during puncture of the superficial veins.

Position of the patient on the operating table: lying on your back; If venesection is performed on an upper limb, the limb should be abducted at a right angle on an extension table.

Venesection technique (Fig. 7.11) . Under local anesthesia with a 0.25% novocaine solution, an incision is made in the projection of the corresponding vein 1.5-2 cm long. The vein is exposed along the entire length of the incision. Using folded clamps or tweezers, the vein is isolated from the surrounding tissue and two ligatures are placed under it, which are placed in opposite corners of the wound. In the distal corner of the wound, the vein is ligated. Then the vein is lifted using the distal ligature and incised to 1/2 the diameter. The incision is made obliquely relative to the axis of the vein. A polyethylene catheter is inserted into the incision. It is carried out to a depth of 1.5-2 cm. A proximal ligature is tied on the catheter. The ends of the ligatures are cut off. Sutures are placed on the skin. The catheter is fixed to the skin with a plaster, and an aseptic bandage is applied on top.

After inserting the catheter into the vein, it is washed with novocaine and a heparin plug is placed.

Rice. 7.11.Stages of venesection

7.6. NERVE SUTURE

To restore the anatomical integrity of the nerve, separate interrupted sutures are applied to its outer shell (epineurium) and to the shells of each of the bundles (perineurium). For this purpose, it is necessary to use atraumatic (when applying an epineural suture) or microsurgical (when applying a perineural suture) round needles.

When suturing a nerve, it is advisable to use optical magnification using a bifocal loupe or surgical microscope. The technique is as follows (Fig. 7.12). Mobilized

and the matched ends of the crossed nerve are stitched around the circumference of the shells of each of the stitched ends with separate interrupted sutures. After all sutures have been placed, they are tied alternately with a naval or surgical knot so that a diastasis of 1-2 mm remains between the proximal and distal ends of the nerve being sutured. The number of sutures should be proportional to the thickness of the nerve trunk being sutured.

Microsurgical suture of the nerve can significantly improve the results of this operation. For suturing, an operating microscope with a working magnification of 25-40x and suture material with the conventional number 10/0-11/0 are used.

Based on the location of the suture thread, there are perineural suture (when the needle and thread pass through the perineurium of individual bundles), interfascicular suture (when the thread captures the connective tissue between adjacent nerve bundles and brings two adjacent bundles together), epineural suture (when the thread also captures part of the external epineurium). Epineural sutures strengthen the nerve suture but can be used alone to suture small nerves. The most reasonable is the interrupted suture of the nerve (the interrupted suture technique is described in the section on vascular microsurgery). Most often, no more than one suture is placed per bundle. Sometimes only the largest bundles are connected, due to which smaller ones are compared.