BANDAGING OF BLOOD VESSELS (vinctura vasorum; synonym: alloying of vessels, deligation on a vessel) — operational reception, the purpose to-rogo constant full closing of a gleam of a blood vessel by means of thread (ligature). The ligature can be replaced cliping of vessels (see) or underrunning by special staplers like UKL (see. Staplers ).
P. to. pages apply most often to a final stop bleedings (see) at operations, an injury of vessels, a gap and an ulceration of a vascular wall; during removal of body or its part (bandaging and crossing pulmonary сосуд#в at a pneumonectomy, renal — at a nephrectomy, gastric — at a resection or an extirpation of a stomach); for reduction of blood loss in the course of operation (e.g., bandaging of an outside carotid artery and its branches before removal of a hemangioma of the person); for the purpose of prevention of arrozivny bleeding from the infected main vessel or a prosthesis (in this case make P. to. page on extents); as method of treatment of inborn defects (e.g., open arterial channel); as a stage of operation at a varicose vein disease of the lower extremities and a posttrombotichesky disease (e.g., bandaging of perforantny veins on Lintona or Kok-kettu); as a measure of prevention of an embolism of a pulmonary artery at acute venous fibrinferments.
Bandaging of the main arteries of extremities creates danger of ischemic gangrene and in urgent cases shall be applied only at impossibility of an angiorrhaphy.
By preparation for planned bandaging of a vessel (e.g., concerning traumatic aneurism) it is necessary to define possibilities of collateral circulation. For this purpose apply Korotkov, Moshkovich, Rusanov, Genle's tests (see. Collaterals vascular ), and also kapillyaroskopiya (see), angiography (see). If time allows, carry out preoperative training of collaterals (see).
For P.'s performance to. pages are necessary styptic clips (see. Clips surgical ), dissectors, scissors, tweezers, a fork for bringing down of ligatures, surgical needles, including atraumatic (see. Eagles medical ), ligatures from a catgut, silks, lavsan, etc. (see. Suture material ). Catgut (see) use for bandaging of small vessels, is more often in hypodermic cellulose. For bandaging of larger vessels use silk (see), and also threads from synthetics, the Crimea give preference since they cause smaller reaction from surrounding fabrics and are not fragmented.
Technology of bandaging
P. to. pages carry out in a wound and on an extent. In a wound larger vessels tie up everyone, small — by imposing of the Z-shaped or purse-string seam taking surrounding fabrics or stop bleeding by diathermocoagulation. In particular, at a laparotomy, thoracotomies and nek-ry other accesses for P. to. pages combine with diathermocoagulation. The item to. the page on an extent most often is forced reception when it is not possible to make P. to. page in a wound. Usually it happens at severe bleedings in a contaminated wound, at an arrosion of a vessel. For an exposure of vessels on an extent use typical accesses, widely bare a vascular bundle. Allocation of vessels is made by means of scissors and the dissector or clips of other type. Previously delete blood from a wound with tampons and napkins or it is better by means of a suction then there is visible a crossed blood vessel.
At typical option P. to. pages take the end of a vessel a clip, without allocating it from surrounding fabrics. The assistant lifts a clip up, and the surgeon brings under it ligature (see), surely having bypassed a ligature the end of a clip (in a deep wound it is sometimes more convenient to bring thread under a styptic clip by means of other clip or the special fork tool), and ties the first node. Then the assistant removes a styptic clip, and the surgeon, having in addition tightened the first node, ties the second. During the use of synthetic thread it is necessary to tie 3 — 5 nodes.
The second option P. to. pages apply, e.g., at a resection of a stomach when it is necessary to cross an omentulum. On the site of an epiploon impose two clips, between to-rymi it cross; vessels together with fabric of an epiploon tie up (more often with underrunning of an epiploon). Ta-tsoy option' P. to. page it is possible at a resection of intestines, etc.
The third option P. to. villages most often use at an alloying of large vessels. In these cases the vessel (a vein or an artery) is previously allocated and under it by means of the dissector bring (fig. 1) and tie two ligatures, between to-rymi a vessel crossed. In the same way the vessel can be crossed between two clips and to tie up its ends. At an alloying of large vessels for reliability it is better to tie up each end two threads, and to impose the second ligature with underrunning by an atraumatic needle. Also other options of bandaging of large vessels are possible. So, bandaging of a thin-walled vessel can be made, having imposed previously by means of an atraumatic needle the P-shaped or simple seam taking an outside cover of a vessel. In cases when the vascular wall is sharply thinned and the ligature can easily cut through it, at retroclusion apply laying from teflon felt.
At injury of an aorta or large main vessels are applied vascular seam (see), imposed by means of an atraumatic needle, and reconstruction of vessels. In case of the expressed calcification of a vessel stitches are put through an outside cover and on all circle of a vessel, then tied. If it is impossible to perform these operations at roughing-out of a wound, the patient needs to be transported in specialized vascular department, having used the temporary vascular shunt (see. Shunting of blood vessels ).
The described options P. to. pages are suitable for bandaging both an artery, and a vein. However during the bandaging of the main vein put an atraumatic stitch more often, and for hollow and other large veins support an atraumatic seam with laying. In the absence of teflon or other synthetic laying with the same purpose pieces of a fascia or a muscle can be used.
Rather rare pristenochny P. to. the page (is more often on veins) produce hl. obr. at a separation of lateral branches of a vessel. In such cases the vascular wall in the place of defect is taken a clip and impose a thin ligature; at the wrong performance of this operation narrowing of a vein (fig. 2) is possible. At the same defect of an artery or large vein use only a vascular seam. At simultaneous injury of the main artery and vein carry out reconstruction both arteries, and veins.
In field conditions when bandaging of the main artery can be the unique means of a stop of bleeding, for prevention of a so-called wine drainage Oppel's operation which well proved during war can be applied, at a cut along with an artery also the vein of the same name ties.
For the purpose of prevention of ischemic frustration in an extremity during operation in the peripheral end of an artery transfuse blood, make a desimpatization of the central end and a circular section of an outside cover near a ligature across Rusanov. It is necessary to consider also that bandaging of nek-ry arteries (the general sleepy, femoral in a zone of the bringing channel, subnodal), is especially fraught with serious ischemic frustration up to gangrene therefore its level shall be defined by existence of collateral branches. So, bandaging of a femoral artery it is reasonable to make distalny otkhozhdeniye of a deep femoral artery; bandaging of a popliteal artery — with preservation of lateral and medial upper knee arteries; bandaging of a humeral artery — distalny collateral (average, beam and upper elbow) arteries.
The postoperative period
At big operations (thoracotomies, a torakofrenolyum-botomiya, etc.) for control of a hemostasis and removals of the accumulating hemorrhagic liquid enter drainages into a cavity (see. Drainage ). The drainage gives the chance to check P.'s care to. page within the first two days after operation.
After bandaging of the main vessels it is important to support normal a hemodynamics (considering indicators of the ABP, the central venous pressure, volume of the circulating blood, etc.), acid-base equilibrium and other indicators homeostasis (see). For a spasmolysis of peripheral vessels it is reasonable to use spasmolysants (a papaverine, Nospanum, etc.), peridural anesthesia (see. Anesthesia local ). Apply infusion of a reopoliglyukin, Persantinum, curantyl to improvement of microcirculation and rheological properties of blood. The symptoms of ischemia of an extremity caused by bandaging of the highway serve as the indication to use of novocainic blockade lumbar (or cervical) sympathetic gangliyev.
Krom of the phenomena ischemia (see), secondary bleedings in the early and late postoperative periods are possible. If bleeding considerable, then urgent repeated operation is shown. At insignificant bleedings the compressing bandage, imposing of additional seams, etc.
See also can be used Blood vessels .
Bibliography: Zakharova G. N., Losev R. 3. and - Gavrilov V. A. Treatment of damages of the main blood vessels of extremities, Saratov, 1979; Lytkin M. I. and To ache ets V. P. Acute injury of the main blood vessels, L., 1973; Petrovsky B. V. and Milonov of O. B. Hirurgiya of aneurisms of peripheral vessels, M., 1970; Pokrovsky A. V. Clinical angiology, M., 1979; Shalimov A. A. and D r yu to N. F. Hirurgiya of an aorta and the main arteries, Kiev, 1979.
A. V. Pokrovsky.