In their work, surgeons use surgical sutures, there are different types of them, this is one of the most common methods used to connect biological tissues: the walls of internal organs, wound edges, and others. They also help stop bleeding, the flow of bile, all thanks to the right suture material.

Recently, the main principle of creating any type of suture is considered to be careful attitude to each edge of the wound, regardless of its type. The suture should be applied so that the edges of the wound and each of the layers of the internal organ that requires suturing are exactly matched. Today, these principles are combined under the term "precision".

Depending on which tool is used to create the seam, as well as the execution technique, two types can be distinguished: manual and mechanical seams. For overlay method use conventional and traumatic needles, needle holders, tweezers and other devices. For stitching, absorbable threads of synthetic or biological origin, metal wire or other materials can be chosen.

A mechanical seam is applied with a special apparatus, where metal staples are used.

During the stitching of wounds and the formation of anastomoses, the doctor can suture both in one row - single-row, and in layers - in two or even four rows. Along with the fact that the sutures connect the edges of the wound together, they are also excellent at stopping the bleeding. But what types of suture material exist today?

Classification of surgical sutures

As we have already said, seams can be both manual and mechanical, but there are several more classes of their separation:

• according to the technique of their imposition, they are nodal, as well as continuous;
• if you divide them by shape - simple, nodal, in the shape of the letter P or Z, purse-string, 8-shaped;
• according to their functionality, they can be divided into hemostatic and screwing;
• by the number of rows - from one to four;
• according to the period of stay inside the tissue - removable and immersed, in the first case, the seams are removed after a certain time, and in the second case they remain in the human body forever.

It is also worth mentioning that surgical sutures, their types are divided depending on the material used: they can be absorbable if catgut is used - this is a biological species and vicryl, dexon - these are synthetic. Erupting into the lumen of the organ - this type of suture is superimposed on hollow organs. Permanent - these are the types of sutures that are not removed, they remain in the body forever and are surrounded by a connective tissue capsule.

Types of raw materials for suturing

Suture material includes a variety of materials used to ligate vessels by applying surgical sutures. The types of material for suturing tissues and skin have changed greatly every year, depending on how surgery has developed. What surgeons just did not use in order to connect the tissues of internal organs and skin:

• tendons of mammals;
• fish skin;
• threads obtained from the tails of rats;
• nerve endings of animals;
• hair taken from the mane of horses;
• the umbilical cord of a newly born person;
• strips from vessels;
• hemp or coconut fibers;
• rubber tree.

But, thanks to modern developments, synthetic threads have now become popular. There are also cases when metal can also be used.

Certain requirements apply to any suture material:

• high strength;
• Smooth surface;
• elasticity;
• moderate stretch;
• high level of slip on tissues.

But one of the important criteria that apply to the suture material is compatibility with the tissues of the human body. The currently known materials used for seams have antigenic and reactogenic properties. There are no absolute species according to these characteristics, but their degree of expression should be minimal.

It is also very important that the suture material be sterilizable and retain it for as long as possible, while its main characteristics should remain original. The suture thread may consist of one or more fibers that are connected together by twisting, knitting or weaving, and to ensure their surface is smooth, they are coated with wax, silicone or Teflon.

Currently, absorbable and non-absorbable types of suture material are used in surgery. The classification of surgical sutures, most of it involves the use of absorbable threads - catgut, which is made from the muscle membrane of the small intestine of a sheep, and the submucosal layer can also be used to create it. Today there are 13 sizes of catgut, which differ in diameter from each other.

The strength of the seam material increases with size. So, for example, the strength of the three-zero type is about 1400 g, but the sixth size is 11500 g. This type of thread can dissolve from 7 to 30 days.

From non-absorbable suture material in surgery, silk, cotton, linen and horsehair threads are used.

Types of seams

When suturing, be sure to take into account how deeply the wound is cut or torn, its length and how far its edges have diverged. The location of the wound is also taken into account. The most popular in surgery are such surgical sutures, the photos in the article will show how they look:

This will help to understand which methods of applying surgical sutures are most often used when suturing an external wound.

Continuous intradermal type

It has recently been used most often, providing the best cosmetic result. Its main advantage lies in the excellent adaptation of the wound edges, excellent cosmetic effect and minimal disruption of microcirculation when compared with other types of sutures. The thread for stitching is carried out in the layer of the actual plane of the skin parallel to it. However, for easier thread pulling, it is better to take a monofilament material.

After the types of sutures are performed, various types can be selected, but often doctors prefer absorbable suture material: biosin, monocryl, polysorb, dexon and others. And from threads that do not dissolve, monofilament polyamide or polypropylene are perfect.

knotted seam

This is another of the popular types of outer seam. When creating it, the skin is best pierced with a cutting needle. If you use it, then the puncture looks like a triangle, the base of which is directed towards the wound. This shape of the puncture allows you to securely hold the suture material. The needle is inserted into the epithelial layer as close as possible to the edge of the wound, retreating only 4 mm, after which it is carried out obliquely in the subcutaneous tissue, while slightly moving away from the edge, as far as possible.

After reaching one level with the edge of the wound, the needle is turned towards the midline and injected into the deepest point of the wound. The needle in this case passes strictly symmetrically into the tissue on the other side of the wound, only in this case the same amount of tissue will fall into the suture.

Horizontal and vertical mattress suture

The types of surgical sutures and knots are selected by the surgeon depending on the severity of the wound, if there are slight difficulties in matching the edges of the wound, then it is recommended to use a U-shaped mattress suture running horizontally. If a nodal primary surgical suture is applied to a deep wound, then in this case a residual cavity can be left. It can accumulate something that is separated by a wound and leads to suppuration. This can be avoided by applying a seam in several floors. This method of suturing is possible with both nodal and continuous types.

In addition, a Donatti suture (vertical mattress suture) is often used. In its implementation, the first puncture is carried out 2 cm from the edge of the wound. The puncture is made on the opposite side and at the same distance. At the next injection and injection, the distance from the edge of the wound is already 0.5 cm. The threads are tied only after all the sutures have been applied, thus, manipulations in the very depth of the wound can be facilitated. The use of the Donatti suture makes it possible to suture wounds with large diastasis.

In order for the result to be cosmetic, during any operation, the primary surgical treatment of wounds must be carefully carried out, the types of sutures must be selected correctly. If the edges of the wound are inaccurately compared, then as a result this will lead to a rough scar. If you apply excessive force when tightening the first knot, then ugly transverse stripes will appear, located along the entire length of the scar.

As for tying knots, everyone is tied with two knots, and synthetic and catgut with three.

Types of surgical sutures and methods of their application

When applying any and they are used in surgery a lot, it is extremely important to strictly observe the execution technique. How is a knotted suture applied correctly?

Using a needle on a needle holder, first pierce the edges at a distance of 1 centimeter, holding with tweezers. All injections are carried out one opposite the other. The needle is allowed to be passed immediately through both edges, but it can be passed alternately, then through one, then through the other. After completion, the end of the thread is held with tweezers and the needle is removed, and the thread is tied, while the edges of the wound should be brought one to the other as close as possible. So do the rest of the seams and until the wound is completely sewn up. Each seam should be 1-2 cm apart. In some cases, knots may be tied when all sutures have been placed.

How to tie a knot correctly

Most often, surgeons use a simple knot to tie the suture. And they do it like this: after the suture material is threaded into the edges of the wound, the ends are brought together and a knot is tied, and another one above it.

It can be done in another way: they also thread the thread into the wound, take it with one hand at one end, and with the other after the other, and, having brought the edges of the wound together, make a double knot, and already over it a simple one. The ends of the thread are cut at a distance of 1 cm from the knot.

How to stitch a wound properly using metal staples

Types of surgical sutures and methods of their application may be different, which is determined by the location of the wound. One option would be to staple it with metal staples.

Staples are metal plates, the width of which is several mm, and the length is about a centimeter, but may be more. Both of their ends are presented in the form of rings, and from the inside they have a point that penetrates the tissues and prevents the staples from slipping off.

To put brackets on the wound, you should grab its edges with special tweezers, bring them together, put them well, holding it with one hand, with the other you need to take the bracket with another tweezers. After that, put it on the seam line, squeezing the ends, applying force. As a result of such manipulation, the staple bends and wraps around the edges of the wound. Apply at a distance of 1 cm from each other.

Staples are removed, as well as sutures, after 7-8 days after their application. For this, a hook and special tweezers are used. Once removed, the staples can be aligned, sterilized, and reused for suturing wounds.

Types of seams in cosmetology

Cosmetic surgical suture can be made with any of the existing suture materials: silk, catgut, linen thread, fine wire, Michel staples or horsehair. Among all these materials, only catgut is resorbable, and all the rest are not. The seams are immersed or removable.

According to the overlay technique in cosmetology, continuous and knotted sutures are used, the latter can also be divided into several types: marine, ordinary female or surgical.

The knotted look has one major advantage over the continuous look: it securely holds the edges of the wound. But the continuous seam is in demand because it is applied faster and more economically as a material used. In cosmetology, the following types can be used:

• mattress;
• continuous Reverden seam;
• continuous furrier;
• tailor (magic);
• subcutaneous (American Halsted suture).

In cases where the patient has strong tissue tension, the doctor can use plate or lead-plate sutures, as well as a suture with rollers, thanks to which it is possible to close large defects and securely hold the tissues in one place.

In plastic surgery, too, the doctor may sometimes use an apodactyl suture. Its essence lies in the fact that it is applied and tied only with the help of a special tool: a needle holder, tweezers and a torsion paean.

Horse hair is the best suture material. It is good to create types of surgical sutures and knots that exist in cosmetology with its help. It is often used in ENT operations, because it practically does not become infected, does not irritate the skin and tissues, and there are no suppurations and scars in the places of its application. Horsehair is elastic, so unlike silk, it will not cut into the skin.

The use of sutures in dentistry

Dentists also use different types of stitches to stop bleeding or to seal the edges of a large wound. All types of sutures in surgical dentistry are very similar to those that we have already described, the only thing is that there are slight differences in the types of instruments. For suturing in the oral cavity, the most commonly used:

• needle holder;
• eye surgical tweezers;
• small two-pronged hook;
• eye scissors.

It can be difficult to perform operations in the oral cavity, and only a professional in their field will be able to do this work efficiently, because not only high-quality primary wound treatment is important here. It is also important to choose the right types of sutures in dentistry, but most often it is a simple interrupted suture. And it's laid out like this:

1. Consistently it is necessary to pierce both sides of the wound at a sufficient distance from one another, the thread must be stretched as much as possible, leaving only a small end - 1-2 cm.
2. The long end of the thread and the needle are held in the left hand, after which they need to wrap the needle holder clockwise 2 times.
3. Using a needle holder, grab the short tip and pull it through the loop formed - this is the first part of the knot, gently tighten it, slowly bringing the edges of the wound closer together.
4. Also, while holding the loop, you need to do the same manipulations, only scroll counterclockwise once.
5. Tighten an already fully formed knot, be sure to monitor the uniformity of the thread tension.
6. Move the knot off the cut line, cut off the end of the thread, that's all, the seam is ready.

It is also worth remembering that it is necessary to properly suture from the middle of the wound and stitches should not be done too often so as not to disrupt blood circulation in the tissues. In order for healing to proceed stably, especially for wounds resulting from trauma, it is necessary to install drainage between the sutures for several days.

Varieties of surgical sutures and methods for applying internal sutures

Not only do the outer seams need to be applied correctly, the inside fabrics also need to be sewn securely. The internal surgical suture can also be of several types, and each of them is designed to stitch certain parts together. Let's look at each of the types to better understand everything.

Seam of the Aponeurosis

The aponeurosis is the place where the fusion of tendon tissues occurs, which have high strength and elasticity. The classic place of aponeurosis is the middle line of the abdomen - where the right and left peritoneum are fused. Tendon tissues have a fiber structure, which is why their splicing along the fibers increases their divergence, among themselves surgeons call this effect the saw effect.

Due to the fact that these fabrics have an increased strength, it is necessary to use a certain type of seams for stitching them. The most reliable is considered a continuous twisting seam, which is made using synthetic absorbable threads. These include "Polysorb", "Biosin", "Vikril". Through the use of absorbable threads, the formation of ligature fistulas can be prevented. Also, to create such a seam, you can use non-absorbable threads - "Lavsan". With their help, the formation of hernias can be avoided.

Seam on adipose tissue and peritoneum

Recently, these types of tissues are very rarely sewn together, because they themselves provide excellent adhesion and rapid healing. In addition, the absence of sutures does not interfere with blood circulation at the site of scar formation. In those cases, if a suture cannot be dispensed with, the doctor can apply it using absorbable threads - "Monocryl".

Intestinal sutures

To stitch hollow organs, several sutures are used:

• Pirogov's single-row serous-muscular-submucosal suture, in which the node is located on the outer shell of the organ.
• The seam of Mateshuk, its feature is the fact that the knot, when it is created, remains inside the organ, on its mucous membrane.
• The single-row Gumby suture is used when the surgeon is working on the large intestine, which is very similar in technique to the Donatti suture.

Seams of the liver

Due to the fact that this organ is rather "friable" and abundantly saturated with blood and bile, it can be very difficult to make a seam on its surface even for a professional surgeon. Most often, in this case, the doctor applies a continuous suture without overlap or a continuous mattress suture.

On the gallbladder, U-shaped or 8-shaped surgical sutures are used.

Seams on vessels

The types of surgical sutures used in traumatology have their own characteristics. If you need to sew vessels, then in this case, a continuous seam without overlap, which ensures reliable tightness, will help as well as possible. Using it often leads to the formation of an "accordion", but this effect can be avoided if a single-row interrupted suture is used.

Surgical sutures, types used in traumatology and surgery are similar to each other. Each of the types has its drawbacks and advantages, but if you correctly approach their imposition and choose the best version of the thread, then any seam will be able to fulfill its tasks and securely fix the wound or sew the organ. The timing of the removal of suture material in each individual case is determined individually, but basically they are removed already on the 8-10th day.

Surgical sutures

the most common way to connect biological tissues (edges, walls of organs, etc.), stop bleeding, bile leakage, etc. using suture material. In contrast to the stitching of tissues (bloody method), there are bloodless methods of their connection without the use of suture material (see. Seamless connection of tissues) .

Depending on the timing of Sh. x. distinguish: primary, which is applied to an accidental wound immediately after the primary surgical treatment or to an operating wound; delayed primary is applied until the development of granulations in terms of 24 h up to 7 days after surgery in the absence of signs of purulent inflammation in the wound; provisional suture - a delayed primary suture, when the threads are carried out during the operation, and they are tied after 2-3 days; an early secondary suture, which is applied to a granulating wound cleared of necrosis after 8-15 days; a late secondary suture is applied to the wound after 15-30 days or more with the development of scar tissue in it, which is previously excised.

The sutures may be removable when removed after fusion, and immersed, which remain in the tissues, absorbing, encapsulating in the tissues, or erupting into the lumen of a hollow organ. The sutures placed on the wall of a hollow organ can be through or parietal (not penetrating into the lumen of the organ).

Depending on the tools used and the execution technique, manual and mechanical seams are distinguished. For manual sutures, ordinary and atraumatic needles, needle holders, tweezers, etc. are used (see Surgical instruments) , as a suture material (Suture material) - absorbable and non-absorbable threads of biological or synthetic origin, metal wire, etc. A mechanical suture is performed using staplers, in which metal staples are the suture material.

Depending on the technique of stitching fabrics and fixing the knot, manual Sh. x. subdivided into nodal and continuous. Simple knotted sutures ( rice. 1 ) is usually applied to the skin at intervals of 1-2 cm, sometimes more often, and with the threat of suppuration - less often. The edges of the wound are carefully compared with tweezers ( rice. 2 ). The sutures are tied with surgical, marine or simple (female) knots. To avoid loosening the knot, keep the threads taut at all stages of the formation of seam loops. For tying a knot, especially ultrathin threads during plastic and microsurgical operations, an instrumental (apodactyl) method is also used ( rice. 3 ).

Silk threads are tied with two knots, catgut and synthetic - with three or more. By tightening the first one, the stitched tissues are compared without excessive force in order to avoid cutting through the seams. A properly applied suture firmly connects the tissues without leaving cavities in the wound and without disturbing blood circulation in the tissues, which provides optimal conditions for wound healing.

In addition to simple knotted sutures, other types of knotted sutures are also used. So, when suturing the wall of hollow organs, Pirogov-Mateshuk screw-in sutures are used when they are tied under the mucous membrane ( rice. 4 ). To prevent tissue eruption, looped interrupted sutures are used - U-shaped (U-shaped) eversion and screw-in ( rice. 5, a, b ), and 8-shaped ( rice. 5, in ). For a better comparison of the edges of the skin wound, a nodal adaptive U-shaped (loop-shaped) suture according to Donati is used ( rice. 6 ).

When applying continuous seams, the thread is kept taut so that the previous stitches do not weaken, and in the last one they hold a double thread, which, after being punctured, is tied to its free end. Continuous Sh. x. have different options. Often a simple (linear) twist stitch is used ( rice. 7, a ), twisting seam according to Multanovsky ( rice. 7b ) and mattress seam ( rice. 7, in ). These sutures invert the edges of the wound if they are applied from the outside, for example, when suturing a vessel, and they are screwed in if they are applied from the inside of the organ, for example, when forming the posterior wall of the anastomosis on the organs of the gastrointestinal tract.

Along with linear, various types of circular seams are used. These include: a circular suture, which aims to fix bone fragments, for example, in case of a fracture of the patella with a divergence of fragments; the so-called - fastening with a wire or thread of bone fragments with an oblique or spiral fracture or bone grafts ( rice. 8, a ); block pulley suture for bringing the ribs together, used when suturing a chest wall wound ( rice. 8, b ), a simple purse-string suture ( rice. 8, in ) and its varieties - S-shaped according to Rusanov ( rice. 8, g ) and Salten Z-shaped ( rice. 8, d ) used for suturing the stump of the intestine, immersing the stump of the appendix, plastics of the umbilical ring, etc. A circular suture is applied in various ways when restoring the continuity of a completely crossed tubular organ - a vessel, intestine, ureter, etc. With a partial intersection of the organ, a semicirculatory or lateral suture is performed.

When suturing wounds and forming anastomoses, sutures can be applied in one row - a single-row (one-story, single-tier) suture or in layers - in two, three, four rows. Along with the connection of the edges of the wound, the sutures also provide a stop of bleeding. For this purpose, specially hemostatic sutures are proposed, for example, a continuous chain (chopping) suture according to Heidenhain - Hacker ( rice. 9 ) on the soft tissues of the head before their dissection during craniotomy. A variant of the interrupted chain suture is the Oppel suture for liver injuries.

Overlay technique Sh. x. depends on the operating methods used. For example, in hernia repair and in other cases when it is required to obtain a strong one, they resort to doubling (duplicating) the aponeurosis with U-shaped sutures or Girard-Zik sutures ( rice. 10, a ). When suturing eventration or for deep wounds, removable 8-shaped sutures are used according to Spasokukotsky ( rice. 10, b, c ). When suturing wounds of complex shape, situational (guide) sutures can be used, which bring the edges of the wound together in places of greatest tension, and after permanent sutures are applied, they can be removed. If the seams are tied on the skin with great tension or they are supposed to be left for a long time, the so-called lamellar (lamellar) U-shaped seams are used to prevent eruption, tied on plates, buttons, rubber tubes, gauze balls, etc. ( rice. eleven ). For the same purpose, secondary provisional sutures can be used, when more frequent interrupted sutures are applied to the skin, and they are tied through one, leaving the other threads untied: when the eruption of the tightened sutures begins, provisional sutures are tied, and the first ones are removed.

Skin sutures are removed most often on the 6-9th day after their application, however, the timing of removal may vary depending on the location and nature of the wound. Earlier (4-6 days) sutures are removed from skin wounds in areas with good blood supply (on the face, neck), later (9-12 days) on the lower leg and foot, with a significant tension of the wound edges, reduced regeneration. The sutures are removed by pulling the knot so that the part of the thread hidden in the thickness of the tissues appears with the skin, which is crossed with scissors ( rice. 12 ) and the entire thread is pulled by the knot. With a long wound or a significant tension of its edges, the sutures are removed first after one, and the rest in the following days.

When applying III. X. various types of complications may occur. Traumatic complications include an accidental vessel needle or a suture through the lumen of a hollow organ instead of a parietal suture. from a punctured vessel it usually stops when a suture is tied, otherwise it is necessary to apply a second suture in the same place, capturing the bleeding one into it; when a large vessel is punctured with a coarse cutting needle, it may be necessary to apply a vascular suture. If an accidental through hollow organ is found, this place is additionally peritonized with serous-muscular sutures. Technical errors in suturing are poor alignment () of the edges of the skin wound or the ends of the tendons, the lack of the effect of screwing in with an intestinal and eversion with a vascular suture, narrowing and deformation of the anastomosis, etc. Such defects can lead to suture failure or obstruction of the anastomosis, bleeding, peritonitis, intestinal, bronchial, urinary fistulas and other wounds, the formation of external and internal ligature fistulas and ligature abscesses occurs as a result of aseptic disorders during sterilization of the suture material or during surgery. Complications in the form of delayed-type allergic reactions (see Allergy) often occur with the use of catgut threads, much less often with silk and synthetic threads.

Rice. 8. Schematic representation of circular sutures: a - cerclage - fastening of bone fragments with an oblique fracture; b - block pulley seam for convergence of ribs; in - a simple purse-string suture; g - S-shaped purse-string suture according to Rusanov; e - Z-shaped purse-string suture according to Salten.

Rice. 4. Schematic representation of the screwing suture according to Pirogov - Mateshuk, superimposed on the intestinal wall: 1 - and the muscular layer of the intestinal wall; 2 - intestines; 3 - suture thread passed through the serous and muscular membranes; 4 - the knot is tied from the side of the mucous membrane.

Rice. Fig. 3. Schematic representation of the instrumental (apodactyl) method of tying a surgical knot: a - after the needle is punctured, the needle holder is wrapped with the long end of the thread, which captures the short end of the thread; b - after tightening the first loop, the long end of the thread is wrapped around the needle holder in the opposite direction.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

• - I Muscles (musculi; synonymous with muscles) Functionally distinguish between involuntary and voluntary muscles. Involuntary muscles are formed by smooth (non-striated) muscle tissue. It forms the muscular membranes of hollow organs, the walls of blood vessels ... Medical Encyclopedia

I The esophagus (esophagus) is the part of the digestive tract that connects the pharynx with the stomach. Takes part in swallowing food, peristaltic contractions of the P.'s muscles ensure the promotion of food into the stomach. The length of P. of an adult is 23 30 cm, ... ... Medical Encyclopedia

ABOMASOTOMY- (from Novolat. abomasum abomasum and Greek tome dissection), the operation of opening the abomasum. It is used in sheep to remove bezoars, U cr. horn. livestock in case of inversion and displacement of the abomasum or its blockage with dense fodder masses. A. in sheep is produced under ... ...

BURSITIS- Rice. 1. Precarpal bursitis in a cow. Rice. 1. Precarpal bursitis in a cow. bursitis, inflammation of the synovial sac (bursa). Cattle (Fig. 1) and horses are more often affected. Along the course of B. there are acute and chronic, by nature ... ... Veterinary Encyclopedic Dictionary

GASTROTOMY- (from the Greek. gastēr stomach and tomē incision), the operation of opening the lumen of the stomach. More often produced in dogs, cats and less often in piglets to extract foreign bodies from the stomach or from the initial part of the esophagus. Apply general anesthesia after ... ... Veterinary Encyclopedic Dictionary

aboiazotomy- (from Novolat. abomasum abomasum and Greek tomē; dissection), the operation of opening the abomasum. It is used in sheep to remove bezoars, in cattle when the abomasum is twisted and displaced or blocked by dense fodder masses. A. in sheep ... ... Veterinary Encyclopedic Dictionary

Devices for mechanical connection of organs and tissues during surgical operations. Their use reduces the time of suturing, simplifies the suturing process and increases the asepsis of the operation, reduces blood loss and tissue trauma, ... ... Medical Encyclopedia

COLONOTOMY- (from the Greek kólon large intestine and tomē incision, dissection), the operation of opening the colon in a horse when it is clogged with intestinal stones. K. is performed 45 days after the displacement of intestinal stones into the gastric extension ... Veterinary Encyclopedic Dictionary

SURGICAL OPERATION- (from lat. operatio action), a set of manual and instrumental techniques used to eliminate patol. process (therapeutic O. x.), clarification of the diagnosis (diagnostic O. x.), restoration of tissue continuity (plastic, restore. O. x.), ... ... Veterinary Encyclopedic Dictionary

Surgical sutures are the most common way to connect biological tissues (wound edges, organ walls, etc.), stop bleeding, bile leakage, etc. using suture material.

The most general principle for performing any suture is to respect the edges of the wound to be sutured. In addition, the suture should be applied, trying to accurately match the edges of the wound and the layers of the organs to be sutured. Recently, these principles have been commonly referred to as "precision".

Depending on the tools used and the execution technique, manual and mechanical seams are distinguished. For manual sutures, ordinary and atraumatic needles, needle holders, tweezers, etc. are used, and absorbable and non-absorbable threads of biological or synthetic origin, metal wire, etc. are used as suture material. are metal brackets.

When suturing wounds and forming anastomoses, sutures can be applied in one row - a single-row (one-story, single-tier) suture or in layers - in two, three, four rows. Along with the connection of the edges of the wound, the sutures also provide a stop of bleeding.

When applying a skin suture, it is necessary to take into account the depth and extent of the wound, as well as the degree of divergence of its edges. The most common types of seams are:: nodular dermal, subcutaneous nodular, subcutaneous continuous, intradermal continuous single-row, intradermal continuous multi-row.

Continuous intradermal suture is currently the most widely used, as it provides the best cosmetic result. Its features are good adaptation of the wound edges, good cosmetic effect and less disturbance of microcirculation compared to other types of sutures. The suture thread is carried out in the layer of the skin itself in a plane parallel to its surface. With this type of seam, to facilitate thread pulling, it is better to use monofilament threads. Absorbable sutures are often used, such as Biosyn, Monocryl, Polysorb, Dexon, Vicryl. From non-absorbable threads, monofilament polyamide and polypropylene are used.

No less common simple knotted seam. The skin is most easily pierced with a cutting needle. When using such a needle, the puncture is a triangle, the base of which faces the wound. This shape of the puncture holds the thread better. The needle is injected into the epithelial layer at the edge of the wound, retreating from it by 4-5 mm, then obliquely carried out in the subcutaneous tissue, moving further and further away from the edge of the wound. Having reached the same level with the base of the wound, the needle turns in the direction of the midline and sticks at the deepest point of the wound. The needle must pass strictly symmetrically and in the tissues of the other edge of the wound, then the same amount of tissue enters the seam.

If it is difficult to match the edges of the skin wound, it can be used horizontal mattress U-shaped seam. When applying a conventional interrupted suture to a deep wound, it is possible to leave a residual cavity. In this cavity, wound discharge can accumulate and lead to wound suppuration. It is possible to avoid suturing the wound in several floors. Floor-by-floor suturing of the wound is possible with both nodal and continuous sutures. In addition to floor suturing of the wound in such situations, it is used vertical mattress suture (according to Donatti). In this case, the first injection is made at a distance of 2 cm or more from the edge of the wound, the needle is inserted as deep as possible to capture the bottom of the wound. The puncture on the opposite side of the wound is done at the same distance. When the needle is held in the opposite direction, the injection and injection are performed at a distance of 0.5 cm from the edges of the wound so that the thread passes through the layer of the skin itself. Threads should be tied when suturing a deep wound after all sutures have been applied - this facilitates manipulations in the depth of the wound. The use of the Donatti suture makes it possible to compare the edges of the wound even with their large diastasis.

The skin suture must be applied very carefully, since the cosmetic result of any operation depends on it. This largely determines the authority of the surgeon in patients. Inaccurate comparison of the edges of the wound leads to the formation of a rough scar. Excessive efforts when tightening the first knot are the cause of ugly transverse stripes located along the entire length of the surgical scar.

Silk threads are tied with two knots, catgut and synthetic - with three or more. By tightening the first knot, the stitched tissues are matched without excessive force to avoid cutting through the seams. A properly applied suture firmly connects the tissues without leaving cavities in the wound and without disturbing blood circulation in the tissues, which provides optimal conditions for wound healing. For suturing postoperative wounds, a special suture material with microprotrusions has been developed - APTOS Suture, due to the specific nature of the threads themselves, there is no need to apply interrupted sutures at the beginning and end of the wound, which shortens the time for suturing and simplifies the entire procedure.

Skin sutures are removed most often on the 6-9th day after their application, however, the timing of removal may vary depending on the location and nature of the wound. Earlier (4-6 days) sutures are removed from skin wounds in areas with good blood supply (on the face, neck), later (9-12 days) on the lower leg and foot, with a significant tension of the wound edges, reduced regeneration. The sutures are removed by pulling the knot so that a part of the thread hidden in the thickness of the tissues appears above the skin, which is crossed with scissors and the entire thread is pulled out by the knot. With a long wound or a significant tension of its edges, the sutures are removed first after one, and the rest in the following days.

Any damage to the body is associated with a violation of the integrity of the skin. A scar is a healed wound and its condition is affected by the nature of the traumatic agent (mechanical, thermal, chemical or radiation damage). The use of APTOS Suture thread allows to reduce the length of the wound by moderately gathering its edges, as a result of which the scar remains much smaller and less noticeable compared to the use of ordinary suture materials.

The company "Volot" produces a wide range of suture material for use in various types of operations, the quality and properties of threads, needles are evaluated by many clinics in the country.

A) Single seam. For many patients, a skin suture is a brand name. The principle underlying all skin sutures is to achieve healing by first intention and with minimal scarring. A prerequisite for this is an exact alignment of the edges of the skin and subcutaneous tissue without tension.

The edges of the skin should be well supplied with blood; formation of cavities and pockets should be avoided. The general rule is that the distance between the seams should correspond to the width of the fabric in the seam (that is, the distance between the seams and the width of the seam should form a square). Single sutures are the most commonly used and are the simplest of all threading techniques. The thread is sequentially passed through the edges of the wound, held by tweezers.

To do this, the needle is passed perpendicularly through the skin and obliquely through the subcutaneous tissue. The distance from the injection to the edge of the wound and the depth of the stitch should be the same on both sides of the wound. The threads should be tied with slight tension to avoid ischemia of the tissues (the tissues under the suture should not turn pale).

b) continuous seam. A continuous suture saves time, but is technically more difficult because it requires good matching of the wound edges and suture guidance by an assistant. A continuous seam can be applied as a simple Kirchner seam (a) or as a "marine" seam with an overlap (b).

V) . The mattress suture gives excellent matching of wound edges.

In the Donati vertical mattress suture, the thread is visible on both sides of the wound. However, the best match is achieved only when the width and depth of the forward and reverse stitches are absolutely symmetrical, and if all four injection and injection points lie on the same straight line perpendicular to the wound. The closer to the skin surface the reverse stitch is, the better the closure of the wound.

G) . With this modification of the mattress suture, the thread is visible only on one side of the wound. On the other hand, the thread captures the subcutaneous layer and part of the skin. Thus, in order to achieve a good cosmetic result, the same conditions are necessary as for the Donati suture. However, removing this suture is more difficult, especially if the puncture and puncture sites are close enough to each other, and the thread is tied too tight.

e) Continuous subcutaneous suture. With a continuous subcutaneous suture, the thread enters the skin only at the beginning and at the end of the wound. The suture goes completely into the skin and gives excellent matching by a precise butt-joining suture through both edges of the wound. At each end of the wound, the thread is fixed with a plastic clip.

Video lesson of imposing a mattress seam

e) Individual subcutaneous sutures. Separate subcutaneous sutures with 5-0 or 6-0 PGA suture give good skin matching, especially in children. Removal of stitches is not required. However, it is recommended that these sutures be relieved of any tension on the wound by the additional application of surgical self-adhesive tapes.

and) Surgical adhesive tapes (Steri-Strips). Modern surgical tapes are able to match wound edges and hold them together without tension. They are rarely indicated as a stand-alone wound closure, as they easily peel off when wet. Most often they are used as an additional measure for superficial wounds.

h) . To remove stitches, the thread is slightly lifted with a clamp, cut close to the skin on one side, and then removed. This prevents the contaminated outer part of the thread from being pulled through its subcutaneous canal. The best time to remove sutures is determined by the condition of the wound, as well as the location of the suture.

Skin sutures on the face and neck can be removed on day 5, while skin sutures in other areas of the body should be left in place for 6 to 14 days, depending on their location.

And) . The fastest way to close a wound is to use an automatic staple device that inserts and bends square metal staples at the wound margins. The edges of the wound should be symmetrically grasped by the clamps with teeth and slightly twisted at the moment the bracket is applied. The imposition of such a suture requires good interaction between the surgeon and the assistant.

To) Removing brackets. The brackets are removed with appropriate special forceps, which bend the closed brackets in the shape of the letter M, as a result of which their subcutaneous parts release the scar.

Stitches on the cervix superimposed with ruptures of the cervix during the examination of the birth canal, which is performed immediately after childbirth. Ruptures most often occur in typical places: at 3 and 9 "hours" (if the cervix, as is customary for obstetricians and gynecologists, is presented as a watch dial). Suturing such gaps does not require anesthesia - after childbirth, the cervix is ​​insensitive to pain. The most commonly used absorbable suture material is biological material. catgut (made from the small intestine of cattle or sheep) or semi-synthetic threads: Vicryl, PGA, Caproag. Stitches can be single (a series of short threads, each of which is fixed with a knot) or continuous, where the knot is tied only at the beginning and end of a linear break. These sutures do not require special care in the postoperative period and do not cause concern.

Stitches in the vagina superimposed with ruptures of the vaginal wall. Absorbable materials are also used for single sutures or continuous sutures. This is a more painful operation that requires anesthesia - local (NOVOCAINE, LIDOCAINE) or general (short-term intravenous anesthesia). Seams do not require special care. Sutured vaginal tears may be moderately painful for a couple of days after they are applied.

Seams at the crotch superimposed in case of perineal ruptures during childbirth or its artificial dissection.

There are ruptures of the perineum of three degrees (Fig. 1): I - rupture of only the skin of the posterior commissure of the vagina; II - rupture of the skin and muscles of the pelvic floor and III - rupture of the skin, muscles and walls of the rectum.

Perineotomy (Fig. 2a) is the dissection of the perineum along the midline from the posterior commissure of the vagina towards the anus. Episiotomy (Fig. 2b) - the same dissection, originating from the posterior commissure, but at an angle of approximately 45 ° C to the right or left (usually to the right).

Perineal incision can be performed under local anesthesia NOVOCAINOM or LIDOCAINE, or maybe without anesthesia, given that there are numerous physiological mechanisms that protect the perineum from the pain of childbirth. In the surgical sense, the incision has numerous advantages over perineal rupture: the incision has smooth edges (and the scar, as a result, is more aesthetic), the incision is made to the desired depth and relatively rarely spontaneously extends to nearby organs.

Perineal ruptures are sutured in layers: first, the wall of the rectum is sutured with a special row of sutures (unless, of course, this is required). Then with absorbable suture (catgut, vicryl, PGA) connect the muscles of the perineum and only then - the skin. The skin is usually sutured with non-absorbable material - silk, nylon or nikantha (nylon impregnated with antibiotic GENTAMICIN or tetracycline). The same principle is observed when restoring the integrity of the perineum after perineotomy or episiotomy.

Techniques for suturing. If the edges of the incision are sufficiently even, it is possible to apply a cosmetic intradermal suture. This seam came to surgery from cosmetology. The essence of the technique of its application is that the thread passes through the thickness of the skin in a zigzag manner, going out only at the beginning and end of the incision. As a result, the scar turns out to be thinner and devoid of such a specific accessory of the surgical suture as marks from needle punctures and punctures that accompany the “normal” suture on both sides.

A technique is also used in which one thread stitches both the muscles and the skin at once. This technique allows you to compare tissues well, the healing process is the least painful. Such a suture is applied with absorbable material.

Healing period. Healing of a perineal suture is somewhat more problematic than sutures in the cervix and vagina. For any wound to heal well, several conditions are required, important among which are rest and asepsis (that is, maximum protection against pathogens). A few decades ago, after a rupture or incision of the perineum, patients kept bed rest for several days, which greatly contributed to good wound healing. Currently, due to the ubiquity of the joint stay of mothers and babies in the postpartum ward, ensuring complete rest of the perineum is problematic.

It is also difficult to provide aseptic conditions necessary for healing. Constant contact with postpartum secretions (lochia), as well as the inability to fix a sterile dressing on the wound, are factors that create some difficulties in the treatment of perineal wounds.

To help your body overcome these difficulties, you must first of all strictly monitor the cleanliness of the area concerned. Sanitary pads should be changed every 2 hours. In a hospital setting, the treatment of sutures with antiseptic solutions is usually carried out by staff on a gynecological chair or on a bed once a day. After each urination and defecation, it is necessary to wash with warm water or a weak solution of manganese, and then dry the seam area with a clean towel with blotting movements. This is recommended to be done both in the maternity hospital and at home within 1.5-2 months after childbirth.

If there are stitches on the perineum, mechanical sparing (rest) is necessary for the muscles and skin of the corresponding area. Although complete immobilization of the puerperal is usually not possible, movement should be minimal and careful. A postpartum woman with sutures should not sit down for 10 days after childbirth; failure to follow this recommendation may lead to divergence of the seams. For the convenience of young mothers, postpartum departments are equipped with "buffet" tables for eating while standing, you can eat lying in bed, also on a special bedside table. Within 2-3 days after childbirth, it is not recommended to consume bread and other products made from flour and cereals in order to delay the onset of stool as much as possible (although after an enema in the generic department of the stool, there will not be day 2 or 3 anyway).

Sutures made of non-absorbable material are usually removed on the 6-7th day after they are applied. If the puerperal has already been discharged from the hospital, the stitches are removed in the conditions of the antenatal clinic. This is a simple and painless procedure. But even after it, you must continue to strictly observe the rules of hygiene. Only not earlier than 10 days after childbirth, a woman in labor can sit, and at first on a hard chair and only then on soft sofas and armchairs.

The trip home from the hospital will be associated with certain difficulties. To avoid trouble, you should take a reclining position in the back seat of the car. Warn relatives that in addition to young parents and a baby, only one person can ride in the car, because only the front seat will be free.

Stitches after caesarean section

A caesarean section is an extensive abdominal operation, during which many different soft tissues are dissected, which are successively connected with sutures.

Stitch on the uterus. Suturing the uterus is an important step in the caesarean section. Currently, the most common caesarean section in the lower segment of the uterus is a transverse incision. The incision length is 11-12 cm. Such an incision creates optimal conditions for wound healing on the uterus and minimizes surgical blood loss, but if for some reason this particular incision direction is difficult, a “classical” or “corporal” cesarean section is performed with a longitudinal incision body of the uterus of the same length.

Over the years of the development of obstetric science, a great many opinions have been expressed about how and with what to suture the uterus in order to create optimal conditions for carrying subsequent pregnancies. Now the uterus is most often sutured with a single-row or double-row continuous suture using absorbable materials with a long period of complete absorption (i.e., actual resorption) - 70-120 days (vicryl, monocryl, dexon, caproag). Sometimes the imposition of special individual sutures is also used. However, any of these techniques, when carefully performed, gives excellent results, and preference in practice, as a rule, is given to the technique that is most developed in a particular obstetric institution.

In recent years, in domestic clinics, dissection of the uterus with the help of the American apparatus of the company "Auto Suce" ("AutoSuture"). With the help of this device, an incision is made on the uterus with simultaneous application of absorbable material staples to the edges of the wound, which can significantly reduce the amount of blood loss.

After suturing the wound on the uterus and revision of the abdominal organs, the peritoneal cover, muscles of the anterior abdominal wall, tendons and subcutaneous fat are sequentially sutured. For this, absorbable semi-synthetic threads or ordinary catgut are used.

Stitches in the skin. The choice of method for suturing the skin wound after caesarean section depends on the direction of the skin incision. There are quite a few surgical accesses for caesarean section, but in modern obstetrics, three types of skin incisions are most common:

• Lower median laparotomy (dissection of the anterior abdominal wall). The incision is made vertically, along the midline between the womb and the navel, 12-15 cm long (Fig. 3a). Its main advantage is speed and convenience, so this type of skin incision is almost always used in emergency situations, when a few minutes can be crucial (for example, with massive bleeding).
• Laparotomy according to Joel-Cohen. A transverse incision, which is made 2-3 cm below the middle of the distance between the womb and the navel. This is a convenient and fast enough operative access for caesarean section.
• Pfannenstiel laparotomy. A transverse incision of an arcuate shape is made along the suprapubic skin fold (Fig. 3b). It is this circumstance - the best cosmetic effect - that determines the widespread use of this type of intervention. Being in a skin fold, a thin skin scar merges with it and sometimes becomes generally indistinguishable. In addition, both transverse incisions create favorable conditions for the intradermal suture, which we discussed above. The longitudinal incision is always sutured with separate silk (or other non-absorbable material) sutures, because in this case the sutures are under conditions of greater mechanical stress; accordingly, higher requirements are placed on the mechanical strength of the skin suture.

Healing period. The first one or two days after the operation, the suture area is quite painful and requires medical anesthesia. The source of pain is, of course, not only the skin wound - pain is caused by all soft tissues intersected during the operation. Despite this, it is very useful to get up early (one day after the operation). Sometimes, especially when the subcutaneous tissue of the abdomen is developed, wearing a postpartum bandage brings relief, limiting the mobility of the soft tissues of the abdomen and thereby providing more complete rest to the skin wound.

The seams on the skin are treated with antiseptic solutions every other day or every day with the application of a sealed sterile bandage. Self-adhesive bandages sold in pharmacies are very convenient. If the sutures are silk, they are removed on the 7th day, before discharge.

After discharge, self-care for skin sutures, as a rule, is not necessary - general hygiene measures are sufficient. The seam can be washed with soap and water, refraining only from strong pressure on it and the use of hard sponges and washcloths.

Absorbable materials have a different mechanism of resorption, they lose strength in different ways, and are absorbed after a different amount of time. This may determine the features of the postpartum period.

So, threads of natural origin dissolve under the action of enzymes produced in the liver, which is accompanied by a pronounced reaction of the surrounding tissues - redness may occur, a transparent discharge leaks from the injection sites. Since catgut is a natural biological material, it can cause allergic reactions. This circumstance complicates healing, possible divergence of the seams.

Synthetic threads (vicryl, PDS) are absorbed as a result of hydrolysis, i.e. dissolve under the action of body fluids when water penetrates the fibers of the thread. Compared to the mechanism of resorption of natural threads, hydrolysis causes a less pronounced reaction of the body. The time of resorption of the suture material on average is:

• Catgut completely resolves within 30 days, but loses strength after 7 days, that is, if there are catgut sutures on the perineum, the “threads” are separated on the 7th day.
• Vicryl completely resorbed in 60-90 days. This material is widely used in caesarean section.
• PDS (maxon) completely absorbed by the 210th day. PDS is used to connect tendons after a caesarean section.

In conclusion, one cannot fail to say a few words about the psychological consequences of birth trauma and caesarean section. It would seem difficult to find a young woman who is completely indifferent to the appearance of scars on her body. However, none of the serious researchers involved in the psychological problems of puerperas, does not name the presence of a skin scar among the significant reasons for negative emotions in the postpartum period. For example, young mothers after a caesarean section are much more worried about the fact that the spouse saw the child earlier than she did, rather than the presence of some kind of skin scar. Let the seams and scars remain an insignificant episode in the history of your birth. And doctors and modern medical technologies will help you with this.