From Big Medical Encyclopedia

INTESTINAL SEAM — the method of recovery of damages of an intestinal wall, and also connection of various departments went. - kish. a path after a resection of intestines or for the purpose of imposing of bypass soustiya (gastro-, entero-, esophagojejuno - holetsistoentero-, enteroentero-, ileotransverzo-and kolokoloanastomoza). Still the doctor Praksagor (mentions 431 BC an intestinal seam).

Except various ways and options of a manual seam, the mechanical seam by means of various found considerable distribution in surgical practice staplers (see).

Irrespective of a method of imposing To. the mode providing optimal conditions of healing is necessary for highway after operation. This mode is defined by features of each operation and a disease, apropos to-rogo the patient is operated.

The manual seam remains by the main method which has practically no contraindications to use whereas use of staplers is not always possible (at cicatricial and infiltrative changes of walls of a gut, with a different width of a gleam of the sewed pieces of intestines and so forth). It is necessary to add to it that some staplers (P KS-25, KTs-28, NZhKA) provide imposing only of metal skobochny seams of the same kind and most of surgeons for the purpose of peritonization impose after that the second row of seams in the manual way.

Manual seams distinguish on depth of capture of fabrics of a wall of a gut (through everything. layers, serous and muscular and gray and serous), by quantity of rows (one - two - and three-row), on material of threads (a catgut, silk, synthetic monofilny and polifilny knitted or twisted fibers, etc. — see. Suture material ), by a technique of imposing (separate noose sutures or continuous blanket, with a vvorachivaniye of edges, haemo static, etc.) and on use of usual or atraumatic needles.

Fig. 1. The diagrammatic representation of two consecutive stages of imposing of a one-row intestinal suture on Lambera: and — imposing of the serous and muscular seam taking a serous cover (1) and a muscular layer (2), thread it is carried out in a submucosa (3), without affecting a mucous membrane (4); — the seam is tied, surfaces of serous covers of the sewed walls of a gut closely adjoin.

Basic value has A. Lamber (1826) proposal to sew edges of a wound of an intestinal wall, taking serous or its serous and muscular layer (fig. 1). At the same time the recommendation of the author to enter a needle at distance of 5 — 8 mm and to bring her at distance of 1 mm from edge of a wound of an intestinal wall, and to occupy other region of a wound upside-down is important. During the setting of such seam of edge of a mucous membrane remain in a gleam of a gut and quite well adjoin to each other.

Fig. 2. The diagrammatic representation of three consecutive stages of imposing of a two-row seam on Common people: and — imposing of a serous and muscular seam on Lambera; — Lamber's (first row) seam is tightened, the same stitch of the second row from above is put; in — a seam on Common people in the finished look (lamberovsky seams of both rows are tied, the mucous membrane is not sewed); 1 — a serous cover of a gut, 2 — a muscular layer, 3 — a submucosa, 4 — a mucous membrane.
Fig. 3. The diagrammatic representation of a two-row intestinal seam according to Albert. The first row of seams takes howling layers of a wall of a gut, including a mucous membrane, the second row passes through a serous cover, a muscular layer and a submucosa of a gut; 1 — a serous cover, 2 — a muscular layer, 3 — a submucosa, 4 — a mucous membrane, 5 — a seam of the first row, 6 — a seam of the second row.

Common people (V. Czerny, 1880) Albert put two rows of lamberovsky stitches (fig. 2), and (E. Albert) imposed the first row of seams through all layers of an intestinal wall and peritonized their gray and serous seams (fig. Z). One of philosophy of modern surgery was as a result developed went. - kish. a path — need of peritonization of the line of an anastomosis. Comparison of serous covers of the sewed bodies leads to bystry pasting in the area of seams at the expense of the dropping-out fibrin, provides tightness of an anastomosis and a hemostasis.

Most of surgeons recognizes necessary to put a two-row stitch as the most reliable and rational. An internal number of seams, having executed the functions at a wound repair, in 15 — 30 days or a little later it is cut through and torn away in a gleam of a gut. From silk or synthetics surgeons began to apply to reduction of negative influence on healing of an intestinal wound of not resolving threads a usual catgut in the beginning long ago, and then chrome-plated, differing from usual in the bigger durability and smaller speed of a rassasyvaniye.

Fig. 4. The diagrammatic representation of the one-row intestinal suture across Gambi taking all layers of a wall of a gut.

Cushing (H. W. Cushing, 1889), V. P. Mateshchuk (1945), Gambi (L. Gambee, 1951), V. S. Savelyev with sotr. (1976) with success used a one-row suture, considering that it breaks blood supply of the sewed sites of an intestinal wall (fig. 4) less. I. D. Kirpatovsky (1964), etc. uphold a three-row seam at a large intestine operations, proceeding from anatomic features of this body and big danger of infection of an abdominal cavity. However most of surgeons prefers to apply on a large intestine a two-row seam, but surely nodal.

Went to surgeries. - kish. a path are widespread also continuous sutures, and is more often continuous thread put an inside weld (usually a catgut), and outside of nodal or also continuous silk or synthetic thread. Imposing of a continuous suture reduces duration of operation a little, but is followed by a sborivaniye of fabrics and slightly narrows a gleam of an anastomosis. The continuous suture promotes a bigger necrosis of the sewed fabrics in the area of an anastomosis therefore during the imposing most dangerous concerning insufficiency of soustiya with a large intestine preference is given to two rows of noose sutures.

The continuous suture is quite admissible during the formation gastroentero-and enteroenteroanastomoz.

Fig. 5. The diagrammatic representation of the blanket intestinal stitch (2) put on all layers of a back wall of an interintestinal anastomosis after gray and serous seams (1).
Fig. 6. The diagrammatic representation of imposing of the continuous rolling suture on Shmidena: the stitch (1) on through defect in a wall of a gut is put (2); at immersion of a mucous membrane in a gleam of a gut of a surface of serous covers of the sewed sites densely adjoin with each other.

There are several techniques of imposing of internal continuous (usually catgut) seam. Are applied usual blanket (fig. 5), the furrier's and rolling seam on Shmidena (fig. 6). In need of sewing up of cross crossed gut usually use a continuous blanket suture a catgut with the subsequent immersion of a stump purse-string or a number of noose sutures from silk (or synthetic) threads. It is better to use seams on atraumatic needles, especially at a large intestine operations, having a thin wall with poorly expressed muscular layer.

Fig. 7. The diagrammatic representation of imposing of the gray and serous purse-string seam allowing to invaginate a stump of a gut in its gleam.
Fig. 8. The diagrammatic representation of the invaginating gray and serous Z-shaped seam allowing to carry out peritonization of not through defect of a wall of a gut.

The gray and serous seams invaginating purse-string (fig. 7) and Z-shaped (fig. 8) serving for sewing up of the small wounds of a gut which are not getting into its gleam and also for peritonization of a stump of a gut at its resection or a worm-shaped shoot at appendectomy were widely adopted.

Mechanical seam with use of metal brackets has a number of merits among which it should be noted the inertness of a suture material (tantalum, etc.) causing small reaction of the sewed fabrics, a smaller possibility of formation of granulomas. Staplers usually provide good adaptation of the sewed fabrics, tightness and speed of stitching. However each device is counted on work in the conditions of a certain standardization of elasticity, density, thickness of fabrics, etc. that not always meets at the expressed pathological changes.

V. S. Mayatom with sotr. the wide experience of use of mechanical seams at a resection of a stomach and a gastrectomy is accumulated.

Expediency of use of mechanical seams (UKL, UO, NZhKA) at cross crossing in typical conditions at a small and large intestine operations does not raise doubts. The line of mechanical seams shall be a peritonizirovana a gray and serous manual seam.

Bibliography Kalinin T. V. and Kasulin V. S. Use of the devices PKS-25 and KTs-28 in surgical practice, M., 1968, bibliogr.; Kirpatovsky I. D. Intestinal seam and its theoretical bases, M., 1964, bibliogr.; Mait V.S., etc. Resection of a stomach and gastrectomy, M., 1975; P y and x A. N. The atlas of operations on direct and thick guts, M., 1968; Fedorov V. D. and d river. Interintestinal anastomosis, Owls. medical, No. 2, page 32, 1975, bibliogr.; L e m b e of t A. MGmoire sur l’ent^roraphie, avec la description d’un proced6 nouveau pour pra-tiquer cette operation chirurgicale, R£pert. g6n. anat. physiol, path., t. 2, p. 100, 1826.

V. D. Fedorov.