SECONDARY SEAM — connection of edges of the granulating wound after the end of process of its biological clarification.
Distinguish V. Highway early, imposed before formation of the hems interfering rapprochement of edges of a wound, and V. Highway late, applied in cases when edges of a wound are already fixed by cicatricial fabric. Early V. Highway can be applied on 8 — the 15th day after clarification of a wound, late — after 2 weeks and more. Both views of V. Highway are among the interventions accelerating healing of the granulating wound.
Mentioning of V. Highway is available for T. Kokher in the textbook on operational surgery. Delorm wrote about secondary connection of edges of the granulating wound (E. Delorme) in 30 years prior to World War I. For the first time by V. Highway of fighting wounds it was applied in fr. army in World War I after the works of A. Karrel and his employees studying a bacterial flora of the wounds got during military operations. On the basis of these works And. Karrel suggested «to prepare» previously a wound by means of chemical antiseptic agents by irrigation it within 4 — 20 days and after bacterial, control Fr. surgeons did not want to impose V. Highway wide experience of use of V. Highway at treatment of bullet wounds. So, Tyuffye (Th. Tuffier) imposed V. Highway of 121 times, R. Lerish — 142 times. Lenorman (Ch. Lenormant) and M. Shevassyu reported that it after the end of World War I V. Highway was forgotten by fr. surgeons. Surgeons of other warring states B. of highway almost did not apply.
Domestic surgeons (H. N. Burdenko, A. E. Rauyer, A. M. Zablu of dovskiya, 3. A. Landers, D. A. Entin, L. M. Ballon, etc.) began to apply V. Highway also during World War I. However mass use of V. Highway took place only during the Great Patriotic War. By 1943 H. N. Burdenko had material in 9520 cases, B. D. Do-bychin — in 13 350 cases, I. V. Krivorotoye — in 12 163, H. N. Elansky — in 22 000 cases. According to T. Ya. Aryev, received as a result of development of materials of the Great Patriotic War, by V. Highway it was imposed not less than in 8% of all wounds of soft tissues. In most cases by V. Highway it was imposed without bacterial, control, and healing of wounds proceeded without any complications threatening health or life of wounded. Thus, the priority of mass use of V. Highway completely belongs to surgeons of medical service of the Soviet Army.
On materials of the Great Patriotic War of 80% of V. Highway it was imposed at wounds of soft tissues and only 20% at fire fractures of bones. The best results were received during the imposing of V. Highway on wounds of integuments, soft tissues and wound surfaces after the made amputations. The current and healing of wounds after imposing of V. Highway to a nek-swarm of degree depend on their localization: best of all wounds of a face and soft covers of a skull heal; wounds of distal sites of the lower extremities heal worse proximal — it is better than a wound of upper extremities, than lower.
the Considerable size of a wound owing to what healing by its second intention proceeds it is very long, as a rule, with formation of the extensive hems breaking function.
Existence in a wound of pockets, the gyrose courses, a plentiful purulent discharge, the sluggish, covered with a fibrinous plaque granulations, not sawn-off necrotic fabrics, hypostasis of granulations inflamed and edematous edges of a wound, a pyoderma around a wound, existence of a limfangiit, lymphadenitis. The impossibility to pull together edges of a wound without considerable tension also serves as a contraindication to imposing of V. Highway. It is not necessary to impose V. Highway at the serious condition of the patient which is followed by considerable decline of food and the lowered regenerative ability of fabrics (anemia, a nutritional dystrophy, avitaminosis, widespread tuberculosis and so forth).
Before imposing of V. Highway bacterial, control of microflora of a wound is desirable. The impossibility to produce bacterial, a research does not serve as an obstacle to suture since clinical indicators allow to judge rather surely absence of an active infection in a wound. For preparation of wounds for imposing of V. Highway numerous medicamentous means, in particular proteolytic enzymes are offered (V. I. Struchkov and soavt.; 1967). Generally preparation of wounds is carried out under the laws adopted in surgery: provide drainage of a wound, protect its edges from maceration, delete the nekrotizirovanny fabrics interfering normal process of regeneration from a wound apply the means stimulating growth of granulations, and the means possessing bactericidal and bacteriostatic action on microflora (see. Wounds , wounds).
Operation of imposing V. Highway demands a strict asepsis and shall be carried out in the operating room. In most cases it makes under a local anesthesia and only by way of exception under anesthetic. By preparation of a surgery field of granulation do not process iodine. During the processing of various layers of a wound change tools. Bleeding is stopped the imposing of thin catgut ligatures and tampons moistened with hot saline solution. For V. Highway use silk, capron, is more rare a thin bronze and aluminum or silver wire.
During the imposing of early V. Highway. granulations do not delete, refresh only edges of a skin wound. Stitches are put at distance 1 — 2 cm from each other, otstupya on 1 — 1,5 cm from edge of a skin wound, taking sidewalls and its bottom, not puncturing granulations. Only after imposing of all seams they are consistently tied, since corners of a wound. In early stages of healing apply a method of anemic rapprochement of edges of a wound situational kleolovy (fig. 1) and adhesive bandages. A. Charukovsky applied such method of rapprochement of edges of a wound at the beginning of 19 century, calling it «a dry seam», unlike «bloody seams».
Imposing of late V. Highway. make after excision of skin, granulations and mobilization of edges of a wound. Before imposing of V. Highway in especially late terms (in 2 months and more) the wound is excised completely with removal of all cicatricial fabric (fig. 2). In all cases of imposing of V. Highway it is necessary to care for that stitches were put without tension of fabrics since the smooth wound repair is provided to these. If it is impossible to avoid completely a tension, then it is necessary to refuse and close a wound from imposing of usual seams lamellar seams (see. Seams surgical ).
For prevention of an infection after imposing of V. Highway the general and topical administration of antibiotics (an infiltrirovaniye of fabrics around a wound is recommended during operation, at extensive wounds periodic irrigation of a wound in the first 3 — 4 days after operation through the drainage entered into it) taking into account sensitivity of microflora. If the wound is located on an extremity, then the last after operation is immobilized.
The result of imposing of V. Highway
Is available the following data on the general result of imposing of V. Highway in days of the Great Patriotic War: primary healing — 54%, incomplete (partial) discrepancy of seams — 37% and full discrepancy of seams — 9%. It should be noted that in process of accumulation of experience and acquisition of technical skills in use of highway of method B. primary healing of wounds reaches higher rates in comparison with the provided data. So, e.g., E. L. Berezov received 86% of primary healing, H. N. Elansky — 87%, M. I. Kuslik — 88%, A. N. Bakulev, E. I. Zakharov, B. D. Do-bychin, etc. — higher percent.
Experience of the Great Patriotic War showed that V. Highway can be applied not less than at 24% of all wounded, and at a half of them treatment comes to an end in terms less than a month, in general use of V. Highway cuts the term of treatment of wounds by half.
The vastest experience of use of V. Highway at treatment of wounds in the years of war with success is used in surgical practice of peace time. It concerns treatment of extensive open damages when after surgical treatment of the fragmentary hurt wound imposing of primary seams for one reason or another is impossible or it is contraindicated. V. Highway is used also for acceleration of healing of the granulating wounds formed after opening of abscesses, phlegmons and other purulent processes if there is a full confidence that pyoinflammatory process ended and there was a rejection of all necrotic fabrics.
Effective use of V. Highway in peace time is promoted: 1) treatment of patients in specialized to lay down. institution or separation of hospital from the beginning of a disease before recovery; 2) a possibility of production bacterial, control of a wound during the periods of an incubation, distribution and localization of an infection with the characteristic of microflora and its sensitivity to various antibiotics; 3) use of antibiotics of a broad spectrum of activity and proteolytic enzymes for preparation of a wound for imposing of V. Highway, use of antibiotics during operation and in the postoperative period.
The combined use of V. Highway and antibiotics reduces terms of treatment of patients with a severe open injury and with the extensive granulating wounds.
Bibliography: Burdenko H. H. Collected works, t. 2, page 267, M., 1951; Vishnevsky A. A. and Schreiber M. I. Field surgery, M., 197 5; Voskresensky L. N. A secondary seam, a late seam, the delayed seam, a deaf seam, M., 1942; Kamayev M. F. Contaminated wound and its treatment, M., 1970, bibliogr.; L of e r and sh River. How to arrive after excision of the muscular wounds given by military shells: primary seam, plaster bandage or secondary seam? in book: Notes on the soldier. - field hir., under the editorship of S. S. Yudin, page 131, M., 1943; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 1, page 145, M., 1951; Pods V. I., Grigoryan A. V. and Gostishchev V. K. Purulent wound, M., 19 75, bibliogr.; R e b e r H. Infektionshospitalismus, Chi-rurg, S. 154, 1967, Bibliogr.; Rostock P. Die Wunde, B., 195u; Schmitt W., Mulier G. u. Richter E. Altes Krankenhaus und of «moderner» Hos-pitalismus, Zbl. Chir., S. 2940, 1967.