The concept of "intestinal suture" is collective and implies the elimination of wounds and defects of the esophagus, stomach and intestines. Even during the Crimean War, Pirogov Nikolai Ivanovich used special sutures for suturing hollow organs. They helped save the injured organ. Over the years, more and more new modifications of the intestinal suture have been proposed, the advantages and disadvantages of its various variations have been discussed, which indicates the importance and ambiguity of this problem. This area is open to research and experimentation. Perhaps in the near future there will be a person who will offer a unique technique for joining tissues. And it will be a breakthrough in suture technique.
Basic requirements for intestinal suture
In surgery, there are a number of conditions that an intestinal suture must meet in order to be used in abdominal operations:
- First of all, tightness. This is achieved by precise matching of the serous surfaces. They stick to each other and tightly solder, forming a scar. A negative manifestation of this property are adhesions, whichmay obstruct the passage of the contents of the intestinal tube.
- The ability to stop bleeding while maintaining enough blood vessels to supply the suture and heal it as soon as possible.
- The seam should take into account the structure of the walls of the digestive tract.
- Significant strength throughout the wound.
- Healing edges by primary intention.
- Minimal trauma to the digestive tract (gastrointestinal tract). This includes avoiding entwining sutures, using atraumatic needles, and limiting the use of surgical forceps and clamps that can damage the wall of the hollow organ.
- Prevention of necrosis of the membranes.
- Clear juxtaposition of intestinal tube layers.
- Use absorbable material.
The structure of the intestinal wall
As a rule, the wall of the intestinal tube has the same structure throughout with minor variations. The inner layer is a mucous tissue, which consists of a single-layer cubic epithelium, on which there are villi in certain areas for better absorption. Behind the mucosa is a loose submucosal layer. Then comes the dense muscle layer. The thickness and arrangement of the fibers depends on the section of the intestinal tube. In the esophagus, the muscles go circularly, in the small intestine - longitudinally, and in the thick muscle fibers are located in the form of wide ribbons. Behind the muscle layer is the serous membrane. This is a thin film that covers the hollow organs and ensures their mobility relative to each other. The presence of this layer must be taken into account whenintestinal suture is applied.
Properties of the serosa
A useful property for surgery of the serous (i.e., outer) shell of the digestive tube is that after comparing the edges of the wound, it is firmly glued together for twelve hours, and after two days the layers are already quite tightly fused. This ensures the tightness of the seam. To get this effect, you need to apply stitches often enough, at least four per centimeter.
To reduce tissue trauma in the process of suturing the wound, thin synthetic threads are used. As a rule, muscle fibers are sutured to the serous membrane, giving the suture greater elasticity, which means the ability to stretch when the food bolus passes. Capture of the submucosal and mucosal layer provides good hemostasis and additional strength. But it is important to remember that infection from the inner surface of the intestinal tube through the suture material can spread throughout the abdominal cavity.
Outer and inner sheath of the alimentary canal
For the practice of the surgeon, it is extremely important to know about the sheath principle of the structure of the walls of the alimentary canal. Within the framework of this theory, outer and inner cases are distinguished. The outer case consists of the serous and muscular membranes, and the inner case consists of the mucosa and submucosa. They are mobile relative to each other. In different parts of the intestinal tube, their displacement during damage is different. So, for example, at the level of the esophagus, the inner case is reduced more, and if the stomach is damaged -outer. In the intestine, both cases diverge evenly.
When the surgeon sews up the wall of the esophagus, he injects the needle in an oblique-lateral direction (to the side). And the perforation of the stomach wall will be sutured in the opposite, oblique-medial direction. The small and large intestines are stitched strictly perpendicularly. The distance between the stitches should be at least four millimeters. Decreasing the pitch will lead to ischemia and necrosis of the wound edges, while increasing it will lead to leakage and bleeding.
Border seams and edge seams
Intestinal suture can be mechanical and manual. The latter, in turn, are divided into marginal, marginal and combined. The former pass through the edges of the wound, the latter retreat from its edge not a centimeter, and the combined ones combine the two previous methods.
Edge seams are single-case and double-case. It depends on how many shells are connected at once. The Bir suture with knots along the outer wall and the Mateshuk suture (with knots inward) are one-stage, since they capture only the serous and muscular membranes. And Pirogov's three-layer intestinal suture, with which not only the outer case, but also the submucosal layer is stitched, and the through suture of Jelly are double-case.
In turn, through connections can be made both in the form of a nodal and in the form of a continuous seam. This last one has several variations:
- twist;
- mattress;
- Reverden stitch;- Schmiden stitch.
Coastal also have their own classification. So, the Lambert seam is isolated,which is a two-stitch knotted stitch. It is applied to the outer (serous-muscular) case. There is also a continuous volumetric, purse-string, semi-purse-string, U-shaped and Z-shaped.
Combination stitches
As the name implies, combined seams combine elements of edge and edge seams. Allocate "registered" surgical sutures. They are named after the doctors who first used them for abdominal surgery:
- Cherny's suture is a connection of the marginal and marginal serous-muscular suture.
- Kirpatovsky's suture is a combination of marginal submucosal suture and seromuscular suture.
- The Albert stitch includes two more specific stitches: Lambert and Jelly.
- Tupe's seam begins as a marginal through seam, the knots of which are tied into the lumen of the organ. Then a Lambert suture is placed on top.
Classification by number of rows
There is also a division of seams not only by authors, but also by the number of rows superimposed one above the other. The intestinal wall has a certain margin of safety, so the mechanism for suturing wounds was designed in such a way as to prevent tissue eruption.
Single-row sutures are difficult to apply, this requires a specific precision surgical technique, the ability to work with an operating microscope and thin atraumatic needles. Not every operating room has such equipment, and not every surgeon can handle it. Most commonly useddouble seams. They fix wound edges well and are the gold standard in abdominal surgery.
Multi-row surgical sutures are rarely used. Mainly due to the fact that the wall of the organ of the intestinal tube is thin and delicate, and a large number of threads will cut through it. As a rule, operations on the large intestine, such as appendectomy, end with the imposition of multi-row sutures. The surgeon first applies a ligature to the base of the appendix. This is the first, inner seam. Then comes a purse-string suture through the serous and muscular membranes. It tightens and closes at the top with a Z-shaped, fixing the intestinal stump and providing hemostasis.
Comparison of intestinal sutures
In order to know in what situation it is advisable to use a particular seam, you need to know their strengths and weaknesses. Let's take a closer look at them.
1. The gray-serous Lambert suture, for all its lightness and versatility, has a number of disadvantages. Namely: does not provide the necessary hemostasis; rather fragile; does not compare mucous and submucosal membranes. Therefore, it must be used in combination with other stitches.
2. Marginal single- and double-row sutures are strong enough, provide a complete comparison of all layers of tissues, create optimal conditions for tissue healing without narrowing the lumen of the organ, and also exclude the appearance of a wide scar. But they also have disadvantages. The seam is permeable to the internal microflora of the intestine. Hygroscopicity leads to infection of tissues around it.
3. Serous-muscular-submucosal sutures have significant mechanical strength, meet the principles of sheath structure of the intestinal wall, provide complete hemostasis and prevent narrowing of the lumen of the hollow organ. It was this seam that Nikolay Ivanovich Pirogov suggested at the time. But in his variation, he was single-row. This modification also has negative qualities:
- a rigid line of tissue connection;- an increase in the size of the scar due to swelling and inflammation.
4. Combined sutures are reliable, easy to perform, hemostatic, airtight and durable. But even such a seemingly ideal suture has its drawbacks:
- inflammation along the line of tissue connection;
- slow healing;
- formation of necrosis;
- high probability of adhesions;- infection of the threads when passing through the mucosa.
5. Three-row sutures are used mainly for suturing defects of the large intestine. They are durable, provide good adaptation of the wound edges. This reduces the risk of inflammation and necrosis. Among the disadvantages of this method are:
- infection of the threads due to flashing two cases at the same time;
- slowdown in tissue regeneration at the wound site;
- high probability of adhesions and, as a result, obstruction;- tissue ischemia at the suture site.
It can be said that each technique for suturing wounds of hollow organs has its own advantages and disadvantages. The surgeon needs to focus on the end result of his work - what exactly he wants to achieve with this operation. Of course, the positive effect must always prevail over the negative, butthe latter cannot be completely leveled.
Suture cutting
Conventionally, all seams can be divided into three groups: those that erupt almost always, erupt rarely and practically do not erupt. The first group includes the Schmiden suture and the Albert suture. They pass through the mucous membrane, which is easily injured. The second group includes sutures located near the lumen of the organ. These are the Mateshuk seam and the Beer seam. The third group includes sutures that do not come into contact with the intestinal lumen. For example, Lambert.
It is impossible to completely exclude the possibility of eruption of the suture, even if it is applied only to the serous membrane. Under equal conditions, a continuous seam will cut through with a greater probability than a nodal one. This probability will increase if the thread passes close to the lumen of the organ.
Distinguish between mechanical thread cutting, suture rejection along with necrotic masses and eruption as a result of a local reaction of damaged tissues.
Modern absorbable materials
To date, the most convenient material that can be used to perform an intestinal suture is absorbable synthetic threads. They allow you to connect the edges of the wound for a sufficiently long time and not leave foreign materials in the patient's body. Particular attention is paid to the mechanism of removal of threads from the body. Natural fibers are exposed to tissue enzymes, and synthetic fibers are broken down by hydrolysis. Since hydrolysis destroys body tissues less, it is preferable to useartificial materials.
In addition, the use of synthetic materials makes it possible to obtain a durable inner seam. They do not cut through the fabric, therefore, all the troubles that this may entail are also excluded. Another positive quality of artificial materials is that they do not absorb water. This means that the suture will not deform and the intestinal flora, which can infect the wound, will also not get from the lumen of the organ to its outer surface.
When choosing a suture and material for suturing the wound, the surgeon must be guided by the observance of biological laws that ensure tissue fusion. The desire to unify the process, reduce the number of rows or use unproven threads should not be the goal. First of all, the patient's safety, his comfort, reduction of postoperative recovery time and pain sensations are important.
