VASCULAR SEAM — the surgical stitch put on a vascular wall. NL can be circular, or circular, and side, can be imposed by means of the angiorrhaphy device (mechanical hardware by NL) or hands (manual NL).
Emergence of NL is connected with a name of the English doctor Hallo-wel, to-ry in 1759 successfully put a stitch on a humeral artery. Attempts of other doctors to execute NL terminated in failure. Only in 1877 N. V. Epp managed, using NL, to successfully create a porto-caval anastomosis in an experiment. In 1882 Mr. of Shede (M. of Schede) defect of the femoral vein injured during operation took in at the person. Bryan and Shabule (E. Brian, M. of Jaboulay) in 1896 put a noose P-shaped circular suture on a carotid artery of a dog. The principle of adaptation (comparison) of an internal cover of a vessel developed by them by its reversing found the embodiment in many subsequent modifications of a vascular seam. In 1897 Murphy (J. Century of Murphy) offered invaginatsionny NL, to-ry Deynis altered further (Danis, 1912).
In experimental and a wedge, development of NL the big role belongs to the Russian scientists to A. A. Jasinowski (1889), P. I. Tikhova (1894), I. To F. Sabaneev (1895) and N. I. Napalkov (1900). The equipment circular NL was especially successfully improved by A. Narrel (1902). Despite nek-ry distinctions, almost everything sovr. methods manual NL are in a varying degree modifications of a seam of Kar-relya, at Krom in the beginning the ends of the sewed vessels stitch through all layers three directing seams which are located equally spaced. During the setting of these seams and a tension for the ends of threads the vessel takes the form of an equilateral triangle in cross-section. Then vascular walls between the directing seams handles are sewed a continuous blanket suture. For achievement of the best contact of an internal cover of the sewed vessels Insen (Insen, 1903) suggested to use not simple nodal, but P-shaped seams as seams handles.
The considerable event in vascular surgery should be considered development mechanical hardware NL (see. Staplers ).
Qualitatively new stage in development of technology of NL was development of microsurgical connection of vessels (see. Microsurgery ). In recent years there were messages on seamless connection of vessels by means of special glue (see. Seamless connection ), ultrasound (see), beams laser (see). Tsianokrilatny glue (MK-6, MK-7) is successfully used by surgeons as addition to the sutural equipment. With its help it is possible to pressurize and to considerably strengthen NL.
Pilot studies and a wedge, observations allowed to formulate at the beginning of 20 century philosophy of NL, to-rye fully kept the value and so far: Shall be NL tight; shall not cause narrowings of a vessel; it needs to be carried out by a through puncture of a vascular wall, whenever possible with its minimum injury; the sewed vessels shall adjoin in the area of seams a smooth internal cover.
Indications and Contraindications
Indications to performance of NL are very extensive. They arise at various damages of vessels and their effects: aneurisms, arteriovenous fistulas, occlusions, during the performance of various reconstructive operations on an aorta, arteries, veins, during creation of an inter-vascular anastomosis, at organ transplantation, change of skin, musculocutaneous and bone fragments on the feeding vascular leg. Microsurgical NL is widely used at replantations (see) akhmputiro bathing fingers, a brush, it is irreplaceable during the formation of a limfovenozny anastomosis, reconstruction of intracranial vessels. Need of the emergency performance of NL most often arises at operative measures concerning wounds of the vessels, at replantation amputated as a result of an injury of extremities and fingers during operations for acute thromboses and embolisms of the main vessels.
A contraindication to performance of NL is existence of a purulent wound, in conditions a cut imposing of NL, as a rule, comes to an end with arrozivny bleeding or thrombosis of the sewed vessel.
The preparation for surgery
the Preparation for surgery with imposing of NL shall be carried out taking into account a number of the moments. In particular, at wound of vessels it is necessary to liquidate effects blood losses (see), at sharply expressed hypercoagulation — whenever possible to skorrigirovat indicators coagulant system of blood (see), considerable to carry out by the weakened patient fortifying treatment, etc.
During the performance of operations on vessels use special surgical instruments and atraumatic needles (see. Eagles medical ). Tools for performance of operations on vessels are issued the domestic industry in special sets. Clips (for an aorta, arteries, veins), scissors, dissectors, tweezers, rakes, needle holders, etc. enter them various form (see. Surgical tools ). Except the listed tools, rubber or handles made of cloth, balloon catheters like Fogarti are necessary (see. Fogarti catheter ) and catheters for intraoperative dilatation of vessels (see. X-ray endovascular surgery ).
Performance of NL by microsurgical methods requires additional special equipment: operative microscope (see) or a magnifying glass points (see. Points ), microsurgical tools, a special suture material (see. Microsurgery ).
In quality suture material (see) for performance of NL use atraumatic needles with fine ends from silk, nylon, a Dacron, metal. The best suture material consider a monofilament yarn from nylon on an atraumatic needle now. In recent years the threads made of polypropylene, possessing a surface of high smoothness, an absolute nesmachivaye-most that provides good comparison of vascular walls were offered. The ratio of caliber of a vessel and diameter of the used thread shall correspond to 100 approximately: 1. So, for sewing together of vessels to dia. 5 — 10 mm suit thread to dia. 5/0 — 6/0 (5 — 6 zero); for vessels in caliber of 2 — 4 mm — thread to dia. 7/0 (7 zero), 55 microns thick; for smaller vessels — thread to dia. 8/0 — 10/0 (8 — 10 zero), up to 25 microns thick.
Anesthesia during the imposing of NL shall provide quiet performing surgery even in difficult anatomic conditions. At the same time it is necessary to consider that operation can last several hours and be followed by considerable blood loss. The choice of a method of anesthesia, finally, is defined by a state and age of the patient, localization of a vessel and weight of an estimated operative measure. At large and long operations it is better to apply an endotracheal anesthesia (see. Inhalation anesthesia ). Local anesthesia (see. Anesthesia local ) it is shown at operations on superficially located vessels of extremities.
Equipment of an angiorrhaphy
Circular (circular) vascular seam. The most widespread is the vascular seam of Karrel (fig. 1) modified by A. I. Morozova (1909) now.
By this technique impose only two fixing threads — on back and front walls of an anastomosis, and then during the imposing of a continuous suture in an operational wound turn serially one and other semi-circle of a vessel. At the same time thread of a continuous suture is used as the third seam handle, the Crimea delay a vascular wall.
B. V. Petrovsky (1964) described the simplified technique circular by NL. For the ends of the sewed vessels impose atraumatic clips (fig. 2, a). Then clips together with the ends of a vessel turn in horizontal position and carry out a simple blanket seam of the semi-circle of a vessel turned up (fig. 2, b). After that clips together with the ends of a vessel turn to the opposite side (on 180 °) and make sewing together of other semi-circle of a vessel (fig. 2, c). Before tightening of the last seam and binding of threads clips on the peripheral and central ends of the sewed vessel slightly open for removal of the possible blood clot formed in a vessel during manipulations on it.
In some cases, when there are difficulties at sewing together of a hardly accessible back wall of this or that anastomosis, is successfully used continuous P-obraz-ny or blanket NL with the delayed tightening of thread.
Circular NL sometimes apply Dorrance's method to imposing. Its essence is that for the ends of the sewed vessels at first put a continuous P-shaped suture (fig. 3, a), to-ry then supplement continuous blanket (fig. 3, b). This way finds application at aorta operations for the purpose of the prevention of eruption of seams and their maximum sealing.
In practice quite often the difficulties connected with discrepancy of diameters of the sewed vessels meet. N. A. Dobrovolskaya (1912) offered for these cases, and also for operations on small vessels (diameter less than 2 mm) a way of artificial expansion of perimeter of a vessel: on the ends of a vessel do slanting, scrappy or scalloped cuts. In a crust, time this way of NL is applied very seldom.
The circular «rantovidny» seam of Sapozhnikov (1946) is of a certain interest, to-ry is in fact a double P-shaped seam.
At connection of vessels of different diameters, in particular when a vessel of inflow already of a vessel of outflow (at organ transplantation, switching of vessels from one vascular pool in another) it is possible to use an invaginatsionny way of sewing together of vessels. Technically this NL is quite simple, does not demand special tools. At sewing together of vessels of equal caliber, especially small, this seam is applied seldom since it causes considerable narrowing of an anastomosis.
In experimental conditions the kanyulny (prosthetic) method of connection of vessels on Payra (1904) with use of the resolving tubule from magnesium (for production of similar cannulas used also silver, ivory, chrome, steel, vitalium, tantalum, polyethylene, teflon, polyvinyl chloride and other materials) kept the value. By this method one end of a vessel is spent through a gleam of a magnesian tubule, turned out on its end outside an internal cover and strengthened a ligature. Then the end of a vessel which is turned out on a prosthesis is entered into a gleam of the peripheral end of a vessel and also fixed to a prosthesis a ligature. Advantage of a method consists in its simplicity and bystry performance; the possibility of a necrosis of a vascular wall from pressure a ligature belongs to its shortcomings that can lead to bleeding or thrombosis of an anastomosis.
A peculiar modification of a kanyulny (prosthetic) method is offered by D. A. Donetsky (1957) for circular to NL. The central end of a vessel is entered into a gleam of a special metal ring with four thorns and turned out on a ring so that edges of a vessel were punctured with thorns through. Then this end of a vessel together with a ring is entered into a gleam of the peripheral end of a vessel, a wall to-rogo also after a puncture fixed by thorns. The method is used for connection of vessels the end in the end and a side sideways. Its shortcoming is close contact of a vascular wall with the rigid not pulsing metal ring which is a foreign body.
By means of mechanical hardware NL is possible to achieve good sealing and exact adaptation of an internal cover of a vessel, and also to avoid narrowing of an anastomosis. Now use several models of angiorrhaphy devices (see. Staplers ), to-rye allow to connect vessels with a diameter from 1,3 to 20 mm, it is necessary to refer need of allocation of the sewed ends of a vessel throughout 15 — 20 mm To the shortcomings of it of NL considerably limiting use of angiorrhaphy devices in a wedge, practice, difficulty of a manipulation with the device in a deep wound and, at last, lack of a possibility of its use at the expressed sclerosis of the sewed vessels.
The side vascular seam by a technique of performance essentially does not differ from circular. It can also be continuous, separate nodal, blanket, P-shaped, combined. There are special odnoskrepochny angiorrhaphy devices, with the help to-rykh it is possible to take in side defects of a vessel tantalic paper clips. Side NL whenever possible should impose in transverse direction that gives the chance substantially to prevent narrowing of a vessel in the field of a seam.
Postoperative period after performance of NL usually proceeds favorably. In some cases, at danger of developing of acute thrombosis in the field of NL, it is necessary to appoint heparin on 5000 PIECES in 4 — 6 hours, but not earlier than in 8 — 12 hours after operation.
The main serious complications after imposing of NL are bleeding (see), acute thrombosis of the sewed vessel (see. Thrombosis ) and suppuration of a wound. Postoperative bleeding is usually caused by eruption of the stitches put on a vascular wall, or insufficiently good adaptation of walls of the sewed vessels. Can be and other origins of postoperative bleeding, in particular excess introduction to time of operation of heparin or massive hemotransfusion, to-rye can lead to hypocoagulation. Narrowing of a vessel as a result of disturbance of the equipment of stitching is the main reason for acute thrombosis in the field of NL. Suppuration of a wound in the field of NL, especially often observable after operations for traumatic damages of vessels and quite often leading to dangerous arrozivny bleeding or acute thrombosis of the sewed vessel belongs to heavy postoperative complications.
Improvement of the surgical equipment and use of modern tools allowed to improve considerably in recent years results of various operative measures, to-rye demand imposing of NL. In specialized departments passability of vessels after imposing of NL on them is not broken more than in 90% of cases.
The vascular seam at stages of medical evacuation
the Frequency of wounds of large arteries in wartime considerably fluctuates depending on a type of hurting weapon, character and localization of damage. In days of the Great Patriotic War of 1941 — 1945 of wound with damage of the main vessels made, according to army and army areas, 1,2%, in the front area were registered at 2,3% struck. In the American army in World War II of wound of vessels were observed at 0,95% of wounded.
Much attention throughout all history of field surgery was paid to research of the most rational ways of a stop of bleeding at wounds of the main vessels. The alloyed method of a stop of bleeding according to A. Paré (1570) owing to the simplicity, availability and reliability remained classical and was applied in armies of the warring countries in World War II approximately in 90% of cases. However bandaging of the main vessel in a wound or on an extent came to an end often with amputation of an extremity. By experience of the Great Patriotic War of 1941 — 1945 after bandaging of the general femoral artery at 50% of wounded it was necessary to make amputation of an extremity. According to local wars of the last time, thanks to broader and early use of recovery operations at wounds of vessels the number of amputations was reduced, napr, during the war in Korea to 13%, and in Vietnam — to 8%.
In a crust, time consider that to NL in field conditions it is shown at threat of developing of gangrene of an extremity after bandaging of the main artery. At the same time consider a condition of collateral circulation and expressiveness of ischemia.
Classification ischemia (see) extremities according to V. A. Kornilov (1969) provides allocation of three forms: compensated, noncompensated and irreversible. The ischemia compensated for the account of collateral circulation is characterized by safety of movements of an extremity and all types of sensitivity distalny wounds. At the compensated ischemia of an extremity the final stop is shown bleedings (see) way of bandaging of a vessel in a wound or on an extent. At noncompensated ischemia the leading symptom is absence or weakening of active movements of an extremity and disturbance of its sensitivity, to-rye appear within the first hour after wound. In this case recovery operations on vessels are shown (see. Blood vessels, operations ). Irreversible ischemia of the injured extremity is characterized by a cadaveric spasm of her muscles; at the same time only amputation of an extremity is shown (see. Amputation ).
NL can be imposed at a stage of the qualified surgical help, in MSB (in a favorable situation), in time surgical treatment of a wound (see). However the final stop of bleeding at this stage of medical evacuation is carried out by hl. obr. by bandaging of both ends of the damaged vessel in combination with a fasciotomy for reduction of posttraumatic hypostasis of an extremity. For the prevention of acute ischemia of an extremity after bandaging of the main artery enter paravazalno or into the peripheral end of a vessel of 40 — 50 ml of 1% of solution of novocaine. Sometimes for the prevention of a gangrenosis of an extremity, at noncompensated ischemia and impossibility of recovery of passability of a vessel by means of NL make temporary shunting (connection) of the ends of the damaged vessel a plastic endovazalny prosthesis (see. Shunting of blood vessels ), what allows to keep blood circulation in an extremity during the transportation of the victim in specialized to lay down. establishment. If at noncompensated acute ischemia it is impossible to impose the temporary shunt, then it is better to alloy a vessel (see. Bandaging of blood vessels ), since ischemic frustration on the periphery of an extremity develop more slowly, than at the imposed styptic plait.
Recovery operations on vessels make in MSB extremely seldom, only at their side damage.
At a stage of the specialized medical help first of all operate wounded with the renewed bleeding, with the imposed plaits, the pulsing hematoma, and also with the phenomena of noncompensated ischemia after an alloying of a vessel and at the temporary shunt of a vessel imposed at the previous stage of evacuation. In the absence of contraindications impose manual or (more rare) mechanical to NL
of NL it is contraindicated at frailty of an extremity and its irreversible ischemia, infectious complications of a wound, a serious general condition of the wounded, big defects of soft tissues.
By experience of the Great Patriotic War of 1941 — 1945 only 1,2% of wounded with damage of vessels had no complications. The most frequent complications were shock (see), acute blood loss, wound fever (see), ischemic frustration. Among the reasons of lethal outcomes is after wound of vessels 45% were the share of cases of blood loss and a mephitic gangrene. Frequency of development of aneurisms of vessels after an angiorrhaphy during World War II was reduced from 65,6% (at the beginning) to 9,15% (at the end).
According to M. I. Lytkin and V. P. Kolomiyts (1973) data, the result of imposing of NL in the conditions of war is close to the results achieved in peace time at an acute injury of the main vessels. The most frequent complications of operations with imposing of NL are bleeding, thrombosis and a purulent infection of a wound. For prevention of such complications it is offered to use in the first days after operation anticoagulants (see) and antibacterial agents.
Bibliography: Androsov P. I. A mechanical seam in surgery of vessels, M., 1960; Burdenko N. N. The main installations of the modern doctrine about gunshot wounds of arteries, M., 1942; Kornilov V. A. About recovery of the injured main arteries of extremities at acute ischemia, Surgery, No. 6, page 30, 1969; Lys and c y K. M. N and To about x and E. P N. Principles of treatment of damages of the main vessels of extremities, in the same place, No. 6, page 84, 1978; JI y shopping mall and M. I. N and To about l about m and e V. P's c. Acute injury of the main blood vessels, L., 1973; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 10, page 393, M., 1964, bibliogr.; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 19, page 15, etc., M., 1955; Petrovsky B. V. and Krylov of V. S. Mikrokhirurgiya, M., 1976; With y h e N and-kov I. A. Shov and plastics of arteries, M., 1980, bibliogr.; The emergency surgery of vessels, under the editorship of M. D. Knyazev, page 70, 99, M., 1975; Herz und herznahe Gefasse, hrsg. at. H. G. Borst u. a., B. — N. Y., 1978.
O. S. Belorusov; K. M. Lisitsyn (soldier.).