SEAMS SURGICAL — the most widespread way of compound of biological fabrics by means of a suture material. Unlike sewing together of fabrics (a bloody method) there are anemic methods of their connection without use of a suture material (see), napr * by tightening of a wound an adhesive plaster (see), pastings, a svarivaniye by means of ultrasound, etc. (see. Seamless connection).
Highway x. were applied still in the ancient time (see Surgery). Them it is mentioned in the most ancient literary monument to India — to Ayurveda (cm *)',
to-ry carry to 3 — 2 millennium BC. Different types of III. x. are brought in Hippocrates, Prak-sagor, A. Tsels's works, etc. In «The instruction made by N. L. Bidloo for studying of surgery in dissecting room» (1710) there is a detailed description of types of surgical seams, indications to their use, ways of imposing and removal. D Depending on terms of imposing of III. x. distinguish: primary
seam (see), to-ry is imposed on a wound directly after primary surgical treatment or on a fresh wound; the delayed primary seam (impose in terms from 24 watch up to 7 days after operations before development of granulations at absence in a wound of initial signs of a purulent inflammation); provisional seam — a version from -
Fig. 1. The diagrammatic representation of imposing of a simple noose suture on a linear skin wound.
srochenny primary seam (threads through fabrics perform operations in time, and tie them several days later); the early secondary seam (see), to-ry is imposed on the wound granulating, cleared of pus and nekrotizirovanny fabrics 8 — 15 days later after its emergence; a late secondary seam (impose on a wound
of Fig. 2. The diagrammatic representation of comparison by two surgical tweezers of edges of a skin wound during the imposing of a simple noose suture.
15 — 30-day and bigger after development in it cicatricial fabric which is previously excised).
Highway x. can be removable when the suture material is deleted after an union of fabrics, and submersible — do not delete the suture material imposed on deep fabrics or a wall of hollow body. In the latter case the suture material resolves or encapsulated in fabrics or cut through in a gleam of hollow body. The stitches put on a wall of hollow body can be through or pristenochny (not getting into a gleam of body).
Depending on the applied tools and technology of performance distinguish manual and mechanical surgical seams. For imposing of manual seams use needles (see Eagles medical), needle holders, tweezers, etc. (see. Surgical tools). As a suture material use resolving and nerassasy-vayushchiyesya threads biological or
Fig. 3. The diagrammatic representation of setting of the first loop of a node according to Moroz (at short units): and — on a tip
of a needle to its vykalyvaniye from fabrics the loop of thread which free end is spent under the site it crossing a wound is outlined; — after a vykol of a needle the loop is tightened.
synthetic origin, metal wire, etc. The mechanical seam is carried out by means of staplers (see) in which a suture material are metal brackets from tantalum or cobalt alloys.
Depending on technology of underrunning of fabrics and fixing of a node manual Sh. x. subdivide on simple nodal and continuous. Simple noose sutures (fig. 1) on skin are put usually with intervals in 1 — 2 cm, sometimes more often, and with risk of suppuration — is more rare. Edges of a wound carefully compare tweezers (fig. 2). Seams are tied surgical, sea or simple (women's) nodes (see the Ligature). In order to avoid weakening of a node at manual suture it is necessary to hold threads in the tense state at all stages of formation of loops of a seam. During the setting of fine or short end it is reasonable to use the reception offered by M. A. Moroz — on a tip of a needle to its vykalyvaniye from fabrics outline a loop, for -
Fig. 4. Diagrammatic representation of a tool (apodaktilny) way of setting of a surgical node: and —
after a vykol of a needle a long collum of thread will wrap the needle holder which occupy the short unit; — after tightening of the first loop the long unit is wrapped around the needle holder in an opposite direction (the needle holder fixed the short unit for tightening of the second node).
tyagivy it at removal of thread (fig. 3).
For setting of a node, especially superfine ends at plastic and microsurgeries, apply also tool (apodaktilny) way. After a puncture of fabric pass through thread so that over fabrics there was its short end 2 — 4 cm long, then keep the long unit
the left hand and turn around the needle holder, the Crimea occupy the short unit and tighten the first loop (fig. 4, a). After that the long unit is wrapped around the needle holder in an opposite direction in relation to the previous turns of a node and, having captured by him the short end, tighten the second loop (fig. 4, b).
Fig. 5. The diagrammatic representation of imposing of the rolling intra noose suture on a wall of a gut across Pirogov — to Mateshu-k: 1 — a mucous
membrane and a muscular layer of a wall of a gut; 2 — a serous cover of a gut; 3 — sutural thread is carried out through serous and muscular covers; 4 — the node is created from a mucous membrane.
Silk threads are tied two nodes, catgut and synthetic — three and more. Tightening the first node, try to obtain comparison of the sewed fabrics without excessive effort in order to avoid eruption of a seam. Correctly put simple noose suture strongly connects fabrics, without leaving in a wound of cavities and without breaking blood circulation in fabrics that provides optimal conditions for a wound repair.
In addition to simple noose sutures, apply also other options of a noose suture. So, during the imposing of layer-by-layer seams on a wall of hollow bodies quite often as the first row of seams use the rolling intra noose sutures across Pirogov — to Mateshuk when knot from a mucous membrane
(fig. 5). Apply looped noose sutures to the prevention of eruption of fabrics — P-shaped (U-shaped) turning out and rolling (fig. 6, and, b) and
Fig. 6. Diagrammatic representation of options of looped noose sutures: and —
the P-shaped turning-out seam; — the P-shaped rolling seam; in — a 8-shaped seam.
8-shaped (fig. 6, c). For the best comparison of edges of a skin wound use the noose adapting sutures — a P-shaped (loop-shaped) seam across Donati (fig. 7, a); mnogostezh-
Fig. 7. The diagrammatic representation of options of the noose adapting sutures: and —
a P-shaped (loop-shaped) seam across Donati; — a mnogosteshkovy blanket seam across Struchkov and sotr.; in — the noose adapting suture according to Gil a fox.
a kovy blanket seam according to V. I. Struchkov with sotr. (fig. 7, b); the noose adapting suture across Dzhi l a fox at which epidermis is pierced directly at edge of a wound, and der -
Fig. 8. Diagrammatic representation of a simple (linear) blanket continuous suture and its options: and — a simple blanket seam; ■ — a blanket seam on Multa-novsky; in — a matratsny seam.
mu and hypodermic cellulose with a fascia take more widely (fig. 7, c).
At continuous Sh.' imposing x. thread is held all the time tense that the previous stitches did not weaken. Hold double thread in the last stitch, to-ruyu later vykalyvaniye of a needle connect with the free unit. Continuous Sh. x. have many options depending on their appointment. Often apply a simple (linear) blanket seam (fig. 8, a), a blanket seam across Multanovsky (fig. 8, b) and a matratsny seam (fig. 8, c). These seams turn out edges of a wound if they are imposed outside, napr, during the mending of a vessel (see. A vascular seam) also roll if they are imposed from within body, napr, during the formation of a back wall of an anastomosis on bodies went. - kish. a path (see. Intestinal seam). During the formation of a front wall of an anastomosis during stomach and intestines operation widely use the rolling Shmiden's seam (see fig. 6 to St. Intestinal seam, t. 10, Art. 422). On skin continuous Sh. x. impose usually for obtaining the best cosmetic effect. Apply a one-row intradermal continuous suture on Holsteda to mending of superficial wounds (fig. 9, a), a deep — a two-row continuous suture on Holsteda — to Zoltan (fig. 9, b).
Along with linear continuous III. x. apply different types of circular seams. Treat them: the circular seam aiming at fixing of bone fragments, napr at a fracture of a patella with discrepancy of fragments (see the Patella); a so-called cerclage — a fastening a wire or thread of bone fragments at a slanting or spiral change or fixing of bone transplants (fig. 10, a); the block polyspast seam for rapprochement of edges used during the mending of a wound of a chest wall (fig. 10, b); simple purse-string seam (fig. 10, c) and its versions —
S-shaped across Rusanov (fig. 10, d) and Z-shaped on Saltena (fig. 10, e), the stumps of a gut applied to sewing up after its section, immersion of a worm-shaped shoot, plastics of an umbilical ring, etc.; the circular or circular stitch put in various ways at recovery of a continuity of completely crossed tubular body — a vessel, a gut, an ureter, etc. At partial crossing of body put to a floor a circular or side stitch, and orient a suture line so that it went in the transverse or slanting direction in relation to body in order to avoid narrowing in this place.
During the mending of wounds and formation of an anastomosis can be nalo-
Fig. 9. Diagrammatic representation of imposing of continuous intradermal sutures:
and — a one-row suture on Holsteda (sutural thread is carried out through a derma and a top coat of hypodermic cellulose); — a two-row seam on Holsteda — to Zoltan (a deep number of seams is carried out through a fascia and
a sublayer of hypodermic cellulose).
wives one number of seams — single-row (one-storey, single-layer) a seam, but put stitches layer-by-layer more often — in two, three, four tiers with use of different types of seams. E.g., during the mending of a wound of an abdominal wall usually impose: on a peritoneum — simple continuous sutures, muscles — 8-shaped, an aponeurosis — P-shaped or simple nodal, on a fascia with a fatty tissue, and also skin — simple nodal.
Highway x. along with connection of edges of a wound provide also a stop of bleeding, specially haemo static seams are for this purpose offered: the continuous chain (cutting-away) suture on Geydengayna (fig. 11, a) and nodal chain on Geydengayna — to Gakker (fig. And, b), to-rye imposed on soft tissues of the head before their section at a craniotrypesis. Option nodal tse-
Fig. 10. Diagrammatic representation of circular seams: and — a cerclage —
knitting at a slanting fracture of a bone; — a block polyspast seam for rapprochement of edges; e — a simple purse-string seam; — a S-shaped purse-string seam across Rusanov; d — the Z-shaped purse-string seam on Saltena,
a pochny seam is the gemostatiche-sky seam across Ogshel used at wounds of a liver (see). At liver operations apply also haemo static blokovidny seam across Zamoshin (fig. 11, c).
Technology of imposing of Sh. x. depends on the used operational receptions. E.g., at radical operation for hernia (see) and in other cases when it is required to receive a strong hem, resort to doubling (duplikatura) of an aponeurosis P-shaped seams or seams according to Girard — to Zeke (fig. 12, a). After eventration (see) when layer-by-layer mending of a wound is complicated, or at deep wounds apply removable 8-shaped seams across Spasokukotsky (fig. 12, c). During the mending of wounds of irregular shape can be used temporary (on -
Fig. 11. Diagrammatic representation of options of haemo static seams: and — the continuous chain (cutting-away) suture across Geydengay - well; — a noose chain suture on Geydengayna — to Gakker; in — the blokovidny seam across Zamoshin applied at liver operations.
pravlyayushchy) seams, to-rye impose for rapprochement of edges of a wound in places of the greatest tension. After imposing of constant seams they can be removed. In cases when seams are given up on skin a big tension or assume them to leave on a long term, apply the so-called lamellar (plastinochny) P-shaped seams tied on plates, buttons, rubber tubes, gauze balls, etc. (fig. 13) to prevention of eruption. With the same purpose it is possible to use secondary and provisional seams when on skin put more frequent noose sutures, and tie them through one, leaving other threads neza-vyazanny; when eruption of the tightened seams begins, tie provisional, and the first remove.
Skin seams remove most often on 6 — the 9th days after them nalozhe-
Fig. 12. The diagrammatic representation of suture according to Girard — to Zeke for doubling of an aponeurosis (a) and removable 8-shaped seams across Spasokukotsky (c).
the niya, however terms of removal can vary depending on localization and the nature of a wound. Earlier (4 — the 6th days) seams remove from skin wounds in places with good blood supply (on a face, a neck), later (9 — the 12th days) from skin wounds in places with a bad krovosnabzheniyekhm (on a shin and foot). Terms of leaving of seams increase at a considerable tension of edges of a wound, the lowered angenesis as a result of disturbances of protein metabolism, the general intoxication of an organism, etc.
Seams are removed, having tightened a node so that over skin there was a part of thread hidden in the thickness of fabrics, to-ruyu cross scissors (fig. 14) and all thread is extended for a node. In some cases (a long wound, a considerable tension of its edges) seams
are removed Chala's dream through one, postponing removal of other seams until a full wound repair.
At Sh.'s use x. there can be a number of complications. From traumatic complications it is possible to note accidental punctures a needle of a vessel or carrying out a seam through a gleam of hollow body during the imposing of a pristenochny seam. Bleeding from the punctured vessel usually stops during the setting of a seam, in rare instances it is necessary to put the second stitch in the same place, having taken in it the bleeding vessel; at a puncture of the main vessel need for an angiorrhaphy can arise a rough cutting needle. If the accidental through puncture of hollow body, napr, a caecum is found at annular pication during appendectomy, in this place in addition put noose sutures for the prevention of formation of intestinal fistula. At suture refer bad combination (adaptation) of edges of a wound of soft tissues, lack of effect of a vvorachivaniye to technical mistakes at intestinal and a reversing at a vascular seam, narrowing and deformation of an anastomosis, etc. These defects can result
in insolvency of seams of an anastomosis, developing of bleeding, peritonitis, intestinal, bronchial, uric fistulas (see) etc. Suppuration of a wound, education naruzh-
GIS. 10 «jlstashchsipis
tinchaty P-shaped seams: and — on buttons; — on gauze balls.
Fig. 14. Diagrammatic representation of a stage of removal of a noose skin suture: the pandiculation for a node to a surface brought the site of thread which was under skin which is crossed scissors.
ny and internal alloyed aos-tsess and alloyed fistulas arise owing to disturbance of an asepsis at sterilization of a suture material or during operation. Not - the resolving ligatures, sagging in a gleam of bilious or uric ways, promote formation of concrements. Complications in the form of allergic reactions of the slowed-down type (see the Allergy) arise at use of catgut more often, is much more rare — silk and synthetic threads.
See also Nervous seam, the Tendinous seam.
Bibliography: B and d l about about N. D. Manual for studying surgery in dissecting room, the lane from Latinas., M., 1979; Blochin H. H. Skin plastics, M *, 1955; Zoltan Ya. of Cicatrix optima, the Operational equipment and conditions of optimum healing of wounds, the lane with Wenger., Budapest, 1977; To and r p and t about in -
with to and y I. D. Intestinal seam and its theoretical bases, M., 1964; To r e-
N and r And. Plastic surgery in gynecology, the lane from Czeches., Prague, 1980; V.'s Pods, And., Grigo
ryan A. V. and about with t and shch e in V. K * the Purulent wound, M., 1975; Gillies and, Millard D. R. The principles and art of plastic surgery * Boston — Toronto, 1957. S. V. Lokhvitsky.