Suturing skin wounds. Cosmetic (intradermal) suture for animals Technique for applying a skin suture

In cases of any surgical intervention and traumatic injuries to the skin, sutures are applied. The aesthetic result of any surgical procedure depends on how carefully and carefully they were applied. After all, inaccurate connection of the edges of the wound causes the appearance of rough scars. Such unpleasant consequences of surgical intervention can cause both physical and deep moral suffering to patients in the future.

Types of seams and suture material

To connect the edges of the wound, different types of sutures and different types of suture material are used. Specialists most often use a continuous seam with fixing knots at the ends, as well as a seam in the form of individual stitches, which are separately fixed with knots. It is the “separate seams” method that can provide the most reliable connection, because if the knot comes undone or the thread breaks on one stitch, the seam as a whole will not come apart.

To stitch the edges of wounds, special absorbable and non-absorbable threads are used, the former are made from animal intestines (catgut), the latter from synthetic polymeric materials (Dexon, Polysorb, Biosin, Vicryl). Threads made of linen, silk, polymers (nylon) are also used; in rare cases, staples, metal wire and even adhesive tape are used. When choosing a skin suture, the surgeon or cosmetologist must take into account the length and depth of the wound, the degree of divergence of its edges.

Features of cosmetic seams

A type of external sutures are cosmetic sutures; they are applied to the skin very thin threads. To apply subcutaneous sutures, absorbable materials are used, which are not removed after healing. Among surgeons and cosmetologists, an intradermal cosmetic suture is popular - in it, the edges of the wound adapt better, tissue microcirculation is less disrupted, which gives an excellent cosmetic result.

When connecting the edges of the wound, the thread is passed inside the skin parallel to its surface. Monofilament threads provide freer drawing. In cosmetology practice, not only absorbable threads are used: biosin, monocryl, vicryl, polysorb, dexon, but also non-absorbable ones, among them: monofilament polyamide and polypropylene. When applying polyfilament threads, it is recommended to bring the thread onto the skin through a 6-8 cm suture. After healing, the thread is easily removed between punctures in individual fragments.

The difference between a cosmetic seam and a regular seam

The type of seams depends depending on the severity of the wound. If the wound is not infected, a permanent suture is applied; in case of suppuration, internal injuries, etc., the suture is applied temporarily. A cosmetic stitch differs from a regular stitch in its aesthetic appearance; it is almost invisible on the surface of the skin, and a regular stitch leaves scars. The surgical suture can be external or internal; it is applied manually or using special devices. The cosmetic seam is only external.

When applying a cosmetic suture, the thread passes inside the skin, so the scar is a thin, invisible line. At the same time, ordinary sutures leave behind rough scars in the form of a “fish skeleton”, causing the patient a feeling of inferiority and inferiority. A cosmetic suture is applied using both conventional suture material (lavsan, silk, etc.) and synthetic threads (prolene, vicryl, etc.).

It is not recommended to apply absorbable material such as catgut, as this is fraught with a large number of complications. The suture is applied using a so-called atraumatic needle; the thread in this case is, as it were, a natural continuation of it. The type of suture applied does not in any way affect the speed of wound healing, but what the suture will be depends on the operating doctor. The seam got its name because of its cosmetic effect. Although, as you know, everything depends on the professionalism and hands of the surgeon, because an invisible cosmetic scar can be obtained by applying ordinary interrupted sutures.

When are sutures removed after surgery?

Remove the threads from the external seams no earlier than 7-10 days after surgery. If they are removed earlier, the seam may come apart under load, which can lead to an inflammatory process. During secondary healing, the postoperative suture may take on an ugly appearance. After surgery, some sutures placed on tissues and internal organs remain in the body for the rest of your life. For example, nylon monofilament, being in the tissues of the body, does not dissolve, but does not cause any negative reaction from the tissues of the body.

To apply a skin suture, it is desirable to use monofilament suture material. This ligature does not have wicking properties and is easily removed due to the lack of adhesion to tissues. When closing a wound, it is necessary to ensure that the instruments and suture material cause minimal trauma to the tissue. The edges of the wound should not be sutured under tension. Sutures should only hold the adjacent edges of the wound.

There are interrupted, continuous, intradermal sutures, as well as subcutaneous sutures or sutures on subcutaneous fat.

Simple interrupted stitch applied 4-5 mm from the edge of the wound, passing the needle obliquely to the level of the deepest part

Figure 10.Simple interrupted stitch

wounds where an injection is made into the other edge of the wound. The needle on both sides should pass symmetrically so that the same amount of fabric gets into the seam. When tying, we place the knot not over the wound, but on one of the sides (at the site of the injection or puncture).

Vertical seam Donati– applied to excessively raised and unequal thickness skin edges to ensure better adaptation of the edges. The needle is inserted obliquely - outward at a distance of 2-3 cm from the edge of the wound. The needle is then passed towards the base of the wound. The tip of the needle should be brought out at the deepest point of the cutting plane. The base of the wound is sutured and the needle is withdrawn through its other edge symmetrically to the injection site. The points of injection and removal of the needle on the surface of the skin should be at the same distance from the edges of the wound. The needle is re-injected on the side where it was removed, a few millimeters from the edge of the wound, and so that it comes out in the middle of the dermis layer. On the opposite side the needle is withdrawn

Figure 11. Vertical seam Donati

extends to the surface of the skin also through the middle of the dermis, the superficial part of the stitch should be performed so that the distance of the points of insertion and withdrawal of the needle from the edge of the wound, i.e. the place where the needle appeared in the dermis on both sides was the same.

By tightening the applied vertical mattress suture, the edges of the wound are precisely brought together and fixed to the base, slightly raised, the dermis and epithelial layer are precisely in contact.

"Cosmetic" seam provides the most ideal comparison of the edges of the skin wound. The success of its implementation is ensured by the preliminary application of submersible sutures to the deep layers of the dermis. Having turned the skin with tweezers, the first stitch is injected into the mesh layer of the skin, directed from the depths of the wound, and the needle is poked out at the surface layers, not reaching 1.5-2.0 mm to the surface of the skin. The second, final stitch, on the contrary, starts from the surface layers and is punctured deep into the wound through the mesh layer of the skin. It is more convenient to start the suture from the edge of the wound closest to the operator. When applying each seam, you must ensure that both ends of the thread are located on the same side of the loop of each seam. Otherwise, the knot will be on top of the loop and will not be able to sink. In this way

Fig 12 "Cosmetic" seam

sutures are placed at a distance of 1-1.5 cm. This ensures good adaptation of the wound edges and prevents divergence of the skin edges of the wound when connected to tension. The ends of the threads are slightly pulled up and cut off at the very knot that appears from the wound. The node turns out to be facing deep into the wound.

Intradermal suture They begin to apply the needle through the skin along the axis of the wound and puncture it directly in the plane of the cut of the skin itself. Then, holding the needle parallel to the skin surface, continue to sew so that the puncture points Figure 13. Intradermal suture

the needles were always positioned exactly opposite each other and the stitches captured the same number of symmetrical areas of the dermis located in the same plane. Having reached the edge of the wound opposite in length, the thread is brought to the surface of the skin. By simultaneously tensioning the two ends of the thread, the wound is tightened. Correct suture placement is indicated by accurate adaptation of the edges of the skin wound. The ends of a continuous suture are tied to the skin by passing through a button, on a rubber tube, fixed with an adhesive plaster or by the ends of a regular interrupted suture placed at the edges of the wound.

In their work, surgeons use surgical sutures, there are different types; this is one of the most common methods used to connect biological tissues: the walls of internal organs, wound edges, and others. They also help stop bleeding and the flow of bile, all thanks to properly selected suture material.

Recently, the main principle for creating any type of suture is considered to be careful treatment of each edge of the wound, regardless of its type. The suture should be placed so that the edges of the wound and each of the layers of the internal organ that requires suture are accurately matched. Today these principles are combined under the term "precision".

Depending on what tool is used to create the seam, as well as the execution technique, two types can be distinguished: manual and mechanical seams. To apply this method, ordinary and traumatic needles, needle holders, tweezers and other devices are used. Absorbable threads of synthetic or biological origin, metal wire or other materials can be selected for stitching.

The mechanical seam is applied using a special apparatus that uses metal staples.

When stitching wounds and forming anastomoses, the doctor can apply sutures either in one row - single-row, or layer-by-layer - in two or even four rows. Along with the fact that the sutures connect the edges of the wound together, they also perfectly stop the bleeding. But what types of suture material exist today?

Classification of surgical sutures

As we have already said, seams can be either manual or mechanical, but there are several more classes of their division:

according to the technique of their application, they can be nodal or continuous;
if you divide them by shape - simple, nodal, in the shape of the letter P or Z, purse string, 8-shaped;
according to their functionality, they can be divided into hemostatic and screw-in;
by the number of rows - from one to four;
according to the length of time they remain inside the fabric - removable and submerged; in the first case, the seams are removed after a certain time, and in the second case they remain in the human body forever.

It is also worth mentioning that surgical sutures, their types, are divided depending on the material used: they can be absorbable if they use catgut - this is a biological type and vicryl, dexon - these are synthetic. Erupting into the lumen of an organ - this type of suture is applied to hollow organs. Permanent sutures are those types of sutures that are not removed; they remain in the body forever and are surrounded by a connective tissue capsule.

Types of raw materials for suture

Suture material includes various materials used for ligating blood vessels using surgical sutures. The types of material for suturing tissue and skin changed greatly every year depending on how surgery developed. What surgeons did not use to connect the tissues of internal organs and skin:

mammalian tendons;
fish skin;
threads obtained from rat tails;
nerve endings of animals;
hair taken from the mane of horses;
the umbilical cord of a newly born person;
strips of vessels;
hemp or coconut fibers;
rubber tree.

But, thanks to modern developments, synthetic threads have now become popular. There are also cases when metal ones can also be used.

Certain requirements apply to any suture material:

high strength;
Smooth surface;
elasticity;
moderate stretchability;
high level of slip on fabrics.

But one of the important criteria for suture material is compatibility with the tissues of the human body. The currently known materials used for sutures have antigenic and reactogenic properties. There are no absolute types for these characteristics, but their degree of expression should be minimal.

It is also very important that the suture material can be sterilized and retain it for as long as possible, while its main characteristics must remain original. Suture thread can consist of one or more fibers that are connected together by twisting, knitting or braiding, and to ensure a smooth surface, they are coated with wax, silicone or Teflon.

Currently, absorbable and non-absorbable types of suture material are used in surgery. Classification of surgical sutures, most of it involves the use of absorbable threads - catgut, which is made from the muscular lining of the small intestine of a sheep, and the submucosal layer can also be used to create it. Today there are 13 sizes of catgut, which differ in diameter.

The strength of the seam material increases with size. So, for example, the strength of the three-zero type is about 1400 g, but the sixth size is 11500 g. This type of thread can dissolve from 7 to 30 days.

Non-absorbable suture material in surgery uses threads made of silk, cotton, flax and horsehair.

Types of seams

When applying a suture, it is imperative to take into account how deeply the wound is cut or torn, its length and how much its edges have diverged. The location of the injury is also taken into account. These surgical sutures are considered the most popular in surgery; the photos in the article will show what they look like:

This will help to understand which methods of applying surgical sutures are most often used when suturing an external wound.

Continuous intradermal type

It has recently been used most often, providing the best cosmetic results. Its main advantage is excellent adaptation of the wound edges, excellent cosmetic effect and minimal disruption of microcirculation when compared with other types of sutures. The thread for stitching is carried out in the layer of the skin plane itself parallel to it. However, for easier threading, it is better to use monofilament material.

After the sutures are made, different types of sutures can be chosen, but often doctors give preference to absorbable suture material: biosin, monocryl, polysorb, dexon and others. And for threads that do not dissolve, monofilament polyamide or polypropylene are ideal.

Interrupted seam

This is another popular type of outer seam. When creating it, the skin is best pierced with a cutting needle. If you use it, the puncture looks like a triangle, the base of which is directed towards the wound. This form of puncture allows you to securely hold the suture material. The needle is inserted into the epithelial layer as close as possible to the edge of the wound, retreating only 4 mm, after which it is carried out obliquely in the subcutaneous tissue, while moving slightly away from the edge, as far as possible.

After reaching the same level as the edge of the wound, the needle is turned towards the midline and injected into the deepest point of the wound. In this case, the needle passes strictly symmetrically into the tissue on the other side of the wound, only in this case the same amount of tissue will enter the seam.

Horizontal and vertical mattress seam

The types of surgical sutures and knots are selected by the surgeon depending on the severity of the wound; if there are slight difficulties in matching the edges of the wound, it is recommended to use a U-shaped mattress suture running horizontally. If an interrupted primary surgical suture is applied to a deep wound, then in this case a residual cavity can be left. It can accumulate what is separated by the wound and leads to suppuration. This can be avoided by applying a seam in several layers. This method of suturing is possible for both nodal and continuous types.

In addition, the Donatti suture (vertical mattress suture) is often used. When performing it, the first puncture is made 2 cm from the edge of the wound. The puncture is made on the opposite side and at the same distance. The next time the injection and puncture are carried out, the distance from the edge of the wound is already 0.5 cm. The threads are tied only after all the sutures have been applied, thus making it easier to manipulate in the very depths of the wound. The use of the Donatti suture makes it possible to suture wounds with large diastasis.

In order for the result to be cosmetic, during any operation, primary surgical treatment of wounds must be carefully carried out, and the types of sutures must be selected correctly. If you do not carefully align the edges of the wound, this will result in a rough scar. If you apply excessive force when tightening the first knot, ugly transverse stripes will appear along the entire length of the scar.

As for tying knots, all are tied with two knots, while synthetic and catgut knots are tied with three.

Types of surgical sutures and methods of applying them

When applying any type, and there are many of them used in surgery, it is extremely important to strictly follow the technique. How to apply a knotted suture correctly?

Using a needle on a needle holder, first pierce the edges at a distance of 1 centimeter, holding with tweezers. All injections are carried out one opposite the other. The needle is allowed to be passed through both edges at once, but it can be passed alternately, first through one, then through the other. After completion, the end of the thread is held with tweezers and the needle is removed, and the thread is tied, while the edges of the wound should be brought one to the other as close as possible. The rest of the stitches are done in this manner until the wound is completely stitched up. Each seam should be 1-2 cm apart. In some cases, knots can be tied when all the stitches have already been applied.

How to tie a knot correctly

Most often, surgeons use a simple knot to tie the suture material. And they do it like this: after the suture material is threaded into the edges of the wound, the ends are brought together and a knot is tied, and another one above it.

It can be done in another way: they also thread a thread into the wound, take one end with one hand, and the other with the other, and, bringing the edges of the wound closer together, make a double knot, and then a simple knot above it. The ends of the thread are cut at a distance of 1 cm from the knot.

How to properly stitch a wound using metal staples

The types of surgical sutures and methods of their application can be different, which is determined by the location of the wound. One option would be stitching using metal staples.

Staples are metal plates, several mm wide and about a centimeter long, but can be longer. Both of their ends are presented in the form of rings, and from the inside they have a tip that penetrates the tissue and prevents the staples from slipping.

To apply staples to a wound, you should grab its edges with special tweezers, bring them together, place them well, holding it with one hand, and with the other you need to take the staple with another tweezers. After this, apply it to the seam line, squeezing the ends and applying force. As a result of such manipulation, the staple bends and wraps around the edges of the wound. Apply at a distance of 1 cm from each other.

The staples, like the sutures, are removed 7-8 days after they are applied. For this, a hook and special tweezers are used. Once removed, the staples can be straightened, sterilized, and used again to close wounds.

Types of stitches in cosmetology

A cosmetic surgical suture can be made with any of the existing suture materials: silk, catgut, linen thread, fine wire, Michel staples, or horsehair. Among all these materials, only catgut is absorbable, and all the others are not. Seams can be embedded or removable.

According to the application technique in cosmetology, continuous and knotted sutures are used, the latter can also be divided into several types: marine, ordinary female or surgical.

The nodular type has one main advantage over the continuous one: it securely holds the edges of the wound. But a continuous suture is in demand because it is applied faster and is more economical in the quality of the material used. The following types can be used in cosmetology:

mattress;
continuous Reverden suture;
continuous furrier;
tailoring (magical);
subcutaneous (American Halsted suture).

In cases where the patient has strong tissue tension, the doctor can use plate or lead-plate sutures, as well as a suture with rollers, which makes it possible to close large defects and securely hold the tissue in one place.

In plastic surgery, the doctor may also sometimes use an apodactyl suture. Its essence lies in the fact that it is applied and tied only with the help of a special tool: a needle holder, tweezers and a torsion pean.

Horsehair is the best suture material. The types of surgical sutures and knots that exist in cosmetology can be created well with its help. It is often used during ENT operations, because it practically does not become infected, does not irritate the skin and tissues, and there is no suppuration or scars in the places where it is applied. Horsehair is elastic, so unlike silk, it will not cut into the skin.

Use of sutures in dentistry

Dentists also use different types of sutures to stop bleeding or hold the edges of a large wound together. All types of sutures in surgical dentistry are very similar to those that we have already described, the only thing is that there are slight differences in the types of instruments. To apply a suture in the oral cavity, the following are most often used:

needle holder;
eye surgical tweezers;
small two-prong hook;
eye scissors.

It can be difficult to perform operations in the oral cavity, and only a professional will be able to perform this work efficiently, because not only high-quality primary treatment of wounds is important here. It is also important to choose the right type of sutures in dentistry, but most often it is a simple interrupted suture. And it is applied like this:

It is necessary to sequentially pierce both sides of the wound at a sufficient distance from one another, the thread must be pulled out as much as possible, leaving only a small end - 1-2 cm.
The long end of the thread and the needle are held in the left hand, after which they need to wrap the needle holder clockwise 2 times.
Using a needle holder, grab the short tip and pull it through the loop formed - this is the first part of the knot, carefully tighten it, slowly bringing the edges of the wound closer together.
Also, while holding the loop, you need to do the same manipulations, only scroll counterclockwise once.
Tighten the already fully formed knot, be sure to monitor the uniform tension of the thread.
Move the knot from the cutting line, trim the end of the thread, that's all, the seam is ready.

It is also worth remembering that stitches should be applied correctly from the middle of the wound and stitches should not be done too often so as not to disrupt blood circulation in the tissues. In order for healing to proceed steadily, especially for wounds resulting from trauma, it is necessary to install drainage between the sutures for several days.

Types of surgical sutures and methods of applying internal sutures

Not only do the external seams need to be placed correctly, the fabric inside must also be sewn securely. The internal surgical suture can also be of several types, and each of them is designed for stitching certain parts. Let's look at each type to better understand everything.

Suture Aponeurosis

The aponeurosis is the place where the fusion of tendon tissues occurs, which have high strength and elasticity. The classic site of the aponeurosis is the midline of the abdomen - where the right and left peritoneums fuse. Tendon tissues have a fiber structure, which is why their fusion along the fibers increases their divergence; among themselves, surgeons call this effect the saw effect.

Due to the fact that these fabrics have increased strength, a certain type of seam must be used to sew them together. The most reliable is considered to be a continuous wrapping suture, which is made using synthetic absorbable threads. These include "Polysorb", "Biosin", "Vicryl". Thanks to the use of absorbable threads, the formation of ligature fistulas can be prevented. To create such a seam, you can also use non-absorbable threads - "Lavsan". With their help, the formation of hernias can be avoided.

Suture on fatty tissue and peritoneum

Recently, these types of tissues are very rarely sutured, because they themselves provide excellent fusion and rapid healing. In addition, the absence of stitches does not interfere with blood circulation at the site of scar formation. In cases where a suture is unavoidable, the doctor can apply one using absorbable sutures - Monocryl.

Intestinal sutures

Several sutures are used to stitch together hollow organs:

Single-row serous-muscular-submucosal Pirogov suture, in which the node is located on the outer shell of the organ.
Mateshuk's suture, its peculiarity is the fact that when it is created, the knot remains inside the organ, on its mucous membrane.
The single-row Gambi suture is used when the surgeon is working on the large intestine, which is very similar in technique to the Donatti suture.

Liver sutures

Due to the fact that this organ is quite “crumbly” and richly saturated with blood and bile, it can be very difficult to make a suture on its surface even for a professional surgeon. Most often, in this case, the doctor applies a continuous suture without overlap or a continuous mattress suture.

U-shaped or 8-shaped surgical sutures are used on the gallbladder.

Sutures on vessels

The types of surgical sutures used in traumatology have their own characteristics. If you need to sew vessels, then in this case a continuous seam without overlap will help the best, which ensures reliable tightness. Using it often leads to the formation of an “accordion”, but this effect can be avoided if you use a single-row interrupted stitch.

Surgical sutures, the types used in traumatology and surgery, are similar to each other. Each type has its own disadvantages and advantages, but if you approach their application correctly and select the optimal thread option, then any suture will be able to fulfill its tasks and reliably fix a wound or suture an organ. The timing of removal of suture material in each individual case is determined individually, but generally they are removed by 8-10 days.

8334 0

They are used for more accurate comparison of the edges of a skin wound and come in two main varieties: intra- and extradermal.

Intradermal (intradermal) continuous suture

The first stitch of the suture begins in the corner of the wound, advancing the needle in the dermal layer of the skin near its edge by 3-5 mm or more (depending on the thickness of the skin, the size of the needle and other factors). The needle is passed parallel to the surface of the skin, at the same depth, capturing the same amount of tissue with each stitch (Fig. 1 a, b). The high quality of this type of suture is ensured under the condition that the needle puncture site on one edge of the wound is located opposite the needle insertion site on the opposite edge of the wound. In this case, when the thread is pulled, the edges of the wound come closer together, and these two points coincide (Fig. 1 c). If this rule is not followed, then the edges of the wound are not matched accurately, or a gap forms between them.

Rice. 1. Diagram of the thread for a single-row intradermal continuous suture (explanation in the text).

Note that removing a continuous seam from denser fabrics becomes more difficult due to greater fixation of the thread. In general, this suture is applied only with monofilament having a smooth surface, and when stitching the edges of long wounds, the rule of interrupting the suture is used: inside the skin passage of the removed suture is interrupted every 6-8 cm, bringing its next loop to the surface of the skin and passing it over a rubber tube. When removing sutures, the withdrawn section of the thread is crossed and two parts of the continuous suture are removed by pulling in different directions (Fig. 2).

Rice. 2. Scheme of interruption of a long intradermal continuous suture (explanation in the text).

Important advantages of the intradermal removable continuous suture are the absence of pressure on the skin surface and more accurate comparison of the edges of the skin wound. At the same time, this type of seam is technically more complex. It requires high precision in guiding the needle and thread, which can often only be achieved using a binocular loupe.

In addition, the strength of fixation of the edges of the skin wound with this type of suture is not significant, and the edges of the wound can easily diverge during transverse stretching. Therefore, it is advisable to use a removable suture inside the skin only in ideal or favorable conditions for closing the wound, when the tension on its edges is absent or small.

Extradermal continuous (wraparound) suture

It is a simpler type of removable continuous seam. It ensures closeness and good comparison of the edges of the wound (Fig. 3). When applying such a suture, the thinnest suture material (5-6/0 thread) and optical magnification are used.

Rice. 3. Diagram of the suture thread for an extradermal continuous suture.

The extradermal continuous suture is technically simpler (compared to the intradermal continuous suture), is quickly applied, but still compresses the edges of the skin being compared. That is why it is used in the absence of significant tissue tension on the suture line (ideal or favorable conditions for closing the wound), the suture stitches are not allowed to be tightened too tightly, and the suture itself is removed early (5-6 days).

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, it is necessary to cross the muscle fibers 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 a second stitch from the inside of the second edge being 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 creeping of tissues 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 from the outside of one of the edges to be stitched, and the needle is punctured 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 marine 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: the nail phalanx of the thumb in one ring, the distal phalanx of the IV or III finger in the other, the index finger on the 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 a power transformer, a high-frequency current generator, a control pedal, and 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!) from 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.