Intestinal seam: species. Ways of connecting the intestinal wall

The concept of "intestinal seam" is collective and implies the removal of wounds and defects of the esophagus, stomach and intestines. Even during the Crimean War, Pirogov Nikolai Ivanovich used special sutures for sewing hollow bodies. They helped to save the injured body. For many years, new modifications of the intestinal suture were proposed, the advantages and disadvantages of its various variations were discussed, which points to the importance and ambiguity of this problem. This area is open to research and experiments. Probably, in the near future there will be a person who will offer a unique method of connecting tissues. And this will be a breakthrough in the technique of stitching.

Basic requirements for intestinal suture

In surgery, there are a number of conditions that the intestinal suture must match in order that it can be used in abdominal operations:

1. First of all, tightness. This is achieved by an accurate comparison of serous surfaces. They stick to each other and densely weld together, forming a scar. A negative manifestation of this property are spikes, which can make it difficult to pass the contents of the intestinal tube.
2. The ability to stop bleeding, while retaining enough blood vessels to supply the suture and its early healing.
3. The seam should take into account the structure of the walls of the digestive tract.
4. Significant strength throughout the wound.
5. Edge healing with primary tension.
6. Minimal trauma of the digestive tract (gastrointestinal tract). This implies the rejection of the sutures, the use of atraumatic needles, and the limited use of surgical tweezers and clamps that can damage the wall of the hollow organ.
7. Prevention of necrosis of membranes.
8. A clear comparison of the layers of the intestinal tube.
9. Use of absorbable material.

The structure of the intestinal wall

As a rule, the wall of the intestinal tube has the same structure all along with insignificant variations. The inner layer is a mucous tissue, which consists of a single-layered cubic epithelium, in which in certain areas there are villi for better absorption. Behind the mucosa is a loose submucosal layer. Then comes a tight muscular layer. The thickness and location of the fibers depends on the intestinal tube. In the esophagus the muscles go circularly, in the small intestine - longitudinally, and in the thick muscular fibers are arranged in the form of wide bands. The muscle layer is followed by a serous membrane. This is a thin film that covers the hollow organs and ensures their mobility with respect to each other. The presence of this layer is necessarily taken into account when an intestinal seam is applied.

Serous membrane properties

A useful property for surgery is the serous (i.e., outer) envelope of the digestive tube, which, after matching the edges of the wound, is firmly adhered for twelve hours, and after two days the layers are already sufficiently tightly adhered. This ensures tightness of the seam. To get this effect, you need to apply stitches quite often, at least four on one centimeter.

To reduce the traumatization of the tissue, thin synthetic fibers are used in the process of suturing the wound. As a rule, the muscle fiber is sewn to the serous membrane, giving the seam a great elasticity, which means that the ability to stretch when passing through the food lump. Capture of the submucosal and mucous layer provides good hemostasis and additional strength. But it is important to remember that infection from the internal surface of the intestinal tube through the suture material can spread throughout the abdominal cavity.

Outer and inner case of digestive canal

For the practical work of a surgeon, it is extremely important to know about the fleshy principle of the structure of the walls of the digestive canal. Within the framework of this theory, the outer and inner cases are distinguished. The outer case consists of serous and muscular membranes, and the inner case is made of mucous and submucosa. They are mobile relative to each other. In different parts of the intestinal tube, their displacement during damage is different. For example, at the level of the esophagus, the inner case is shrunk, and if the stomach is damaged, the outer case is cut. In the intestine, both cases disperse uniformly.

When the surgeon sutures the esophagus wall, he injects the needle in an oblique-lateral direction (in the side). A perforation of the wall of the stomach will be sutured already in the reverse, oblique-medial direction. Thin and large intestines are stitched strictly perpendicular. The distance between the stitches must be at least four millimeters. Reducing the step will lead to ischemia and necrosis of the edges of the wound, and an increase to insufficiency and bleeding.

Edge seams and edge seams

The intestinal seam can be mechanical and manual. The latter, in turn, are divided into edge, edge and combined. The first pass through the edges of the wound, the second retreat from its edge is not a centimeter, and the combined combine the two previous methods.

The marginal sutures are one-frontal and two-frontal. It depends on how many shells are connected simultaneously. The seam according to Biru with nodes along the outer wall and the Mateshuk's seam (with nodes inward) refer to one-stage ones, since they seize only the serous and muscular membrane. A three-layered intestinal suture Pirogov, which is stitched not only the outer case, but also the submucosa, and the through seam of Gel are two -fold.

In turn, end-to-end joints can be made both in the form of a nodal, and in the form of a continuous seam. This latter has several variations:

- Accurate;
- mattress;
- seam of Reverden;
- Schmiden's seam.

Prikraevye also have their own classification. Thus, the Lambert seam is distinguished, which is a two-stitch nodal suture. It is applied to the outer (serous-muscular) case. There is also a continuous volumetric, pouch, half-cassette, U-shaped and Z-shaped.

Combined seams

As is clear from the title, combined seams combine elements of edge and edge. Allocate "nominal" surgical sutures. They are named after doctors who first used them for surgery on the abdominal organs:

1. The Cervi stitch is a joint of the marginal and marginal serous-muscular suture.
2. Kirpatovsky's seam is a combination of an edge submucosal suture and a serous-muscular suture.
3. Albert's seam includes two more specific seams: Lambert and Jelly.
4. The Toupe seam begins as an end-to-end suture, the knots of which are tied in the lumen of the organ. Then the Lambert seam is superimposed on top.

Classification by number of rows

There is also a seam separation not only by the 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 of suturing the wounds has been designed in such a way as to prevent tissue from erupting.

Single-row seams are superimposed, it requires a specific precision surgical technique, the ability to work with an operating microscope and thin atraumatic needles. Such equipment is not in any operating room, and not every surgeon can cope with it. The most common are double-row seams. They well fix the edges of the wound and are the gold standard in cavitary surgery.

Multiple surgical sutures are used extremely rarely. Basically, because the wall of the intestinal tube organ is thin and tender, and a large number of threads will penetrate it. Typically, the imposition of multi-row sutures end operations on the large intestine, for example appendectomy. The surgeon first ligatures the base of the appendix. This is the first, internal seam. Then comes the suture through the serous and muscular membrane. It is tightened and closed on top of the Z-shaped, fixing the stump of the intestine and providing hemostasis.

Comparison of intestinal sutures

In order to know in which situation it is expedient to apply this or that seam, it is necessary to know their strengths and weaknesses. Let us consider them in more detail.

1. Gray-serous Lambert seam for all its lightness and versatility has a number of drawbacks. Namely: does not provide the necessary hemostasis; Rather fragile; Does not match mucous and submucosal membranes. Therefore, it is necessary to use it, combining it with other seams.

2. The marginal one- and two-row seams are sufficiently strong, provide a complete comparison of all layers of tissues, create optimal conditions for tissue healing, while not narrowing the lumen of the organ, and also exclude the appearance of a wide scar. But they have drawbacks. The seam is permeable to the internal microflora of the intestine. Hygroscopicity leads to infection of tissues near it.

3. Serozno-muscular-submucosal sutures possess considerable mechanical strength, they correspond to the principles of corpuscle structure of the intestinal wall, provide complete hemostasis and prevent the narrowing of the lumen of the hollow organ. This is the seam suggested by Pirogov Nikolai Ivanovich. But in his variation he was single-handed. This modification has also negative qualities:
- rigid line of tissue connection;
- increase in the size of the rumen due to edema and inflammation.

4. Combined seams are reliable, simple in execution, hemostatic, tight and durable. But even this seemingly ideal seam 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 stitches are used mainly for suturing the defects of the large intestine. They are strong, they provide good adaptation of the edges of the wound. This reduces the risk of inflammation and necrosis. Among the shortcomings of this method are:
- Infection of threads due to sewing two cases simultaneously;
- slowing the regeneration of tissues in the wound site;
- a high probability of adhesions and, as a consequence, obstruction;
- tissue ischemia in place of suturing.

It can be said that each technique of suturing the wounds of hollow organs has its advantages and disadvantages. The surgeon needs to focus on the final result of his work - what exactly he wants to achieve this operation. Of course, the positive effect should always prevail over the negative, but the latter will not be completely leveled.

Seaming

Conditionally, all the seams can be divided into three groups: those that erupt almost always, erupt rarely and hardly penetrate. The first group is the Schmiden's seam and the seam of Albert. They pass through the mucous membrane, which easily traumatizes. The second group includes seams, located near the lumen of the organ. This is the seam of Mateshuk and the seam of Bira. The third group includes seams that do not come into contact with the gut lumen. For example, Lambert.

Completely eliminate the possibility of a throat opening, it is impossible, even if it is superimposed only on the serous membrane. With equal conditions, the continuous seam will cut through with a greater probability than the nodal seam. This probability will increase if the thread passes close to the lumen of the organ.

There are mechanical threading, seam rejection along with necrotic masses and eruption as a result of local reaction of damaged tissues.

Modern absorbable materials

To date, the most convenient material that can be performed by the intestinal seam is absorbable synthetic threads. They allow you to connect the edges of the wound for a sufficiently long time and not leave foreign material 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 filaments are cleaved by hydrolysis. Since hydrolysis less destroys the tissues of the body, it is preferable to use artificial materials.

In addition, the use of synthetic materials makes it possible to obtain a strong internal seam. They do not penetrate 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 seam will not deform and the intestinal flora, which can infect the wound, also does not get out of the lumen of the organ on its outer surface.

When choosing a seam and material, which the wound will be sutured with, the surgeon should be guided by the observance of the biological laws that ensure the intergrowth of the tissues. The desire to unify the process, reduce the number of rows or apply unapproved threads should not be the goal. First and foremost, the patient's safety, comfort, reduction of postoperative recovery time and painful sensations are important.