Surgical sutures: an art that does not require sacrifices, but helps to avoid them

Sutures are used in surgery during operations to connect skin tissue during incisions, as well as the walls of internal organs. They are also used in traumatology - when treating wounds resulting from injuries. Applying sutures stops bleeding and prevents infection. Depending on the damaged organs, tissue characteristics, depth of the wound and other nuances, different techniques, materials, and technologies can be used.

It would seem that innovation always wins. And new technological methods of connecting tissues during surgery should slowly replace manual sutures.

For example, connecting the edges of a skin wound using titanium staples. Or, as this method is also called, skin stapler. There is also a special device for removing these paper clips. Paper clips that dissolve by themselves are also used.

Special endoscopic stapling devices are also used. Some of them allow you to carry out all manipulations literally with one hand. All these technologies significantly reduce the time of operations and make the work of surgeons and assistants easier.

But the use of expensive equipment and materials is not always available and cannot always replace traditional suture material. The surgeon's hands are a universal and reliable device. An experienced doctor will always select the ideal needle and thread for each specific case and tie the knots correctly. All this affects the outcome of the operation. Moreover, the negative results of an unprofessionally executed seam can be felt both immediately and after a long time.

Therefore, the manual suturing technique is still the main one.

Seam: beautiful or reliable?

If we talk about the sutures that connect the edges of the wound, then there are several ways. Skin sutures always have cosmetic consequences for the patient's appearance. And doctors usually take this into account.

A continuous intradermal cosmetic suture is considered the most gentle in terms of preserving the skin.

Metal staples are often used - they do not leave transverse stripes on the skin during healing.

To connect the tissues of internal organs, for example, tendons, blood vessels, liver, etc., there are special sutures. Interestingly, they differ in technique depending on the type of organ.

Based on the location of the suture, the characteristics of the tissue and organ, as well as the importance of appearance for the patient, the surgeon chooses a specific technique.

Knot for memory

A securely tied knot is not just the final point in the operation. This is a large part of her success. The professionalism of the surgeon in performing this technique determines how well the tissues will heal and how safe the recovery process will be.

There can be any number of knots on one seam. The more there are, the higher the reliability. If the thread breaks in one place, other stitches will remain and hold the fabric tightly.

It is important not to overtighten the tissue at the junction to prevent necrosis from developing. But at the same time ensure the necessary density.

The knot must be tightened the first time, otherwise the wound will rip apart.

Surgical threads: a variety that needlewomen would envy

There are now a lot of types of surgical threads. They vary in both brands and characteristics. There are several classifications:

1) Absorbable and non-absorbable

Absorbable

These include materials made from polymer and metal threads. Advantages of the material:

— strength that remains in tissues for a long time;

- good manipulative qualities;

— manufacturability;

- inexpensive price.

They are eliminated from the body by themselves and are used if the tissues grow together in a short time - up to 120 days. Or to connect internal organs. But again, in the case when long-term or even eternal fastening of tissues is not required.

Non-absorbable

These materials include threads made from both synthetic and natural fibers. For quite a long time, threads based on polyglycolic acid and a copolymer of lactide and glycolide with a resorption period of up to 90 days have been used in surgery. They are much stronger than catgut and can cause a minor inflammatory reaction in the body. However, Vicryl and Dexon are less elastic compared to non-absorbable materials. Such materials are not recommended for use in cases where long-term preservation of the strength of the seams is advisable.

One of the modern suture materials is polysorb. Its structure: braided composite threads based on polyglycolic acid using a polymer coating. Comparative assessment of the material:

It is not inferior to silk in terms of handling characteristics.
Polysorb is pulled through fabrics with graceful ease, just like monofilament thread.
Strength indicators are higher than those of vicryl.
Another plus is the increased reliability of the node.

2) Natural and synthetic

Natural threads made of silk, flax, cotton and catgut, as practice has shown, have many disadvantages.

Rice. Catgut thread

Rice. Silk thread

In synthetic fabrics, the time of biodegradation is more accurately determined - the ability to be independently excreted from the body. It is important to know exactly how long a given material can hold tissue in a tight state. If the thread weakens or breaks before the tissues heal, it can be extremely dangerous. Catgut, for example, is unpredictable in this regard. But linen and cotton, due to their naturalness, can be conductors of microbes in the fabric, so they, too, have practically ceased to be used.

Synthetic suture material can also be of several types, depending on the material. There are polyamide (nylon), polyester (lavsan), polypropylene, polymer, fluoropolymer, etc. As with techniques, the surgeon chooses the thread depending on the situation and personal preference. This choice is usually not discussed with the patient.

Rice. Nylon thread

Rice. Dacron thread

3) According to their structure, threads are divided into monofilament (monofilament) and braided. Simply put, braided threads are several threads connected together using twisting or weaving. Monofilament is more gentle on fabrics, but less durable. A rope or braid is stronger, but tougher.

Rice. Monofilament

Interestingly, new technologies are leading the way when it comes to materials selection, in contrast to innovative suturing techniques. Doctors are actively switching to modern types of suture material, realizing their obvious advantages, safety and reliability.

Hot topic - surgical needles

When most people hear the word “needle,” they think of a straight, shiny tailor’s needle. But in surgery, most needles are curved to some degree. More curved needles are used to stitch tissue deep in the wound. The sharpness and shape of the needle tip depends on the application. For example, needles for connecting vascular tissues are especially sharp and require special sharpening.

An interesting fact is that black needles are sometimes found. This way, during long-term operations, the load on the doctor’s eyes is less.

In the 80-90s of the last century, atraumatic suture material appeared. A thread rolled into the tip of a needle does not injure tissue as it passes, since its thickness coincides with the thickness of an eyeless needle. Also the thread does not fold. This invention was a real breakthrough in surgery.

A good suture is a sterile suture

Along with the innovation of materials and technologies, simple rules for observing antiseptic and aseptic requirements play a huge role in the success of suturing. All surgical procedures must take place in facilities where routine aseptic preparation is performed on a regular basis.

Most materials and instruments arrive in surgery sterilized and are intended for single use. All this significantly reduces the risk of infection when applying and processing sutures.

The last chord - removing the seams

If there are no complications, the stitches are removed by a paramedic or nurse. The presence of a surgeon is not required. Usually the sutures are removed a week and a half after the operation. In older people, this period may last longer, since the tissues do not heal as well.

The seam is pre-treated with disinfectants, for example, iodine. The thread is cut and pulled out, after which the seam is processed again.

This procedure is not entirely painless. The sensations may vary depending on the type and complexity of the operation, and how well the wound has healed.

It is important to carefully monitor the suture after surgery and removal of threads. If the patient seems that something is going wrong, that the wound is not healing so quickly, if it has begun to fester, he should not hesitate and be sure to consult a doctor again.

SURGICAL SUTURES

Surgical sutures

- the most common method of connecting biological tissues using suture material. In contrast to stitching tissues (bloody method), there are bloodless methods of connecting them without the use of suture material (see), for example, by tightening the wound with an adhesive plaster (see), gluing, welding using ultrasound, etc. (see Seamless connection).

Surgical sutures have been used since ancient times (see Surgery). They are mentioned in the oldest literary monument of India - Ayurveda (cm), which dates back to the 3rd-2nd millennium BC. Various types of surgical sutures are given in the works of Hippocrates, Praxagoras, A. Celsus and others. Compiled by N.L. Bidloo “Instructions for the study of surgery in the anatomical theater” (1710) contains a detailed description of the types of surgical sutures, indications for their use, methods of application and removal. Depending on the timing of surgical sutures, they are distinguished: primary suture (see), which is applied to the wound immediately after primary surgical treatment or to a fresh wound; delayed primary suture (applied from 24 hours to 7 days after surgery until granulation develops in the absence of initial signs of purulent inflammation in the wound); provisional suture - a type of delayed primary suture (threads are passed through the tissue during surgery, and they are tied a few days later); early secondary suture (see), which is applied to a granulating wound that has been cleared of pus and necrotic tissue 8-15 days after its occurrence; late secondary suture (applied to a wound 15-30 days old or older after the development of scar tissue in it, which is previously excised).

Surgical sutures can be removable, when the suture material is removed after tissue fusion, and submersible - suture material applied to deep tissues or the wall of a hollow organ is not removed. In the latter case, the suture material is absorbed or encapsulated in the tissue or cut into the lumen of a hollow organ. 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 instrumentation and technique used, manual and mechanical surgical sutures are distinguished. To apply manual sutures, needles are used (see Medical needles), needle holders, tweezers, etc. (see Surgical instruments). Absorbable and non-absorbable threads of biological or synthetic origin, metal wire, etc. are used as suture material. Mechanical suture is performed using stitching machines (see), in which the suture material is metal staples made of tantalum or cobalt alloys.

Rice. 1. Schematic illustration of applying a simple interrupted suture to a linear skin wound. Rice. 2. Schematic representation of the comparison of the edges of a skin wound with two surgical tweezers when applying a simple interrupted suture. Rice. 3. Schematic representation of tying the first loop of a knot according to Moroz (with short ends of the thread): a - a loop of thread is thrown onto the tip of the needle before it is punctured from the tissue, the free end of which is drawn under the section that crosses the wound; b - after the needle has been punctured, the loop is tightened.

Depending on the technique of stitching tissue and fixing the knot, manual surgical sutures are divided into simple interrupted and continuous. Simple interrupted sutures (Fig. 1) are usually applied to the skin at intervals of 1 - 2 cm, sometimes more often, and if there is a risk of suppuration - less often. The edges of the wound are carefully aligned with tweezers (Fig. 2). The sutures are tied with surgical, naval or simple (female) knots (see Ligature). To avoid loosening of the knot when manually applying sutures, the threads should be kept taut at all stages of the formation of suture loops. When tying a thin or short thread, it is advisable to use the technique proposed by M. A. Moroz - a loop is placed on the tip of the needle before it is pricked out of the tissue, tightening it as the thread is withdrawn (Fig. 3).

Rice. 4. Schematic representation of the instrumental (apodactyl) method of tying a surgical knot: a - after puncturing the needle, the long end of the thread is wrapped around the needle holder, which is used to grasp 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 (the short end of the thread is fixed with the needle holder to tighten the second knot).

For tying a knot, especially ultra-thin threads during plastic and microsurgical operations, the instrumental (apodactyl) method is also used. After puncturing the tissue, the thread is pulled so that its short end, 2-4 cm long, remains above the tissue, then the long end of the thread is held with the left hand and wrapped around the needle holder, which is used to grab the short end of the thread and tighten the first loop (Fig. 4, a). After this, the long end of the thread is wrapped around the needle holder in the opposite direction in relation to the previous turns of the knot and, having grabbed the short end with it, the second loop is tightened (Fig. 4, b).

Silk threads are tied with two knots, catgut and synthetic ones - with three or more. By tightening the first knot, the fabrics to be sewn are aligned without excessive force to avoid cutting through the seam. A correctly applied simple interrupted suture firmly connects the tissues without leaving cavities in the wound and without disrupting blood circulation in the tissues, which provides optimal conditions for wound healing.

Rice. 5. Schematic representation of the application of a screw-in intranodal suture on the intestinal wall according to Pirogov - Mateshuk: 1 - mucous membrane and muscular layer of the intestinal wall; 2 - serous membrane of the intestine; 3 — the suture thread is passed through the serous and muscular membranes; 4 - the node is formed from the side of the mucous membrane. Rice. 6. Schematic representation of options for looped interrupted sutures: a - U-shaped everting suture; b - U-shaped screw-in seam; c - 8-shaped seam. Rice. 7. Schematic representation of options for interrupted adapting sutures: a - U-shaped (loop-shaped) suture according to Donati; b - multi-stitch stitch according to Struchkov and co-workers; c - interrupted adapting suture according to Gillis.

In addition to simple interrupted sutures, other types of interrupted sutures are also used. Thus, when applying layer-by-layer sutures to the wall of hollow organs, screw-in intranodal sutures according to Pirogov-Mateshuk are often used as the first row of sutures, when the knot is tied from the side of the mucous membrane (Fig. 5). To prevent tissue eruption, looped interrupted sutures are used - U-shaped (U-shaped) everting and inverting (Fig. 6, a, b) and 8-shaped (Fig. 6, c). To better compare the edges of the skin wound, interrupted adapting sutures are used - a U-shaped (loop-shaped) suture according to Donati (Fig. 7, a); multi-stitch stitch according to V.I. Struchkov and co-workers (Fig. 7, b); interrupted adapting suture according to Gillies, in which the epidermis is pierced directly at the edge of the wound, and the dermis and subcutaneous tissue with fascia are captured more widely (Fig. 7, c).

Rice. 8. Schematic representation of a simple (linear) continuous continuous seam and its variants: a - simple continuous seam; b - twisted seam according to Multanovsky; c - mattress seam.

When applying continuous surgical sutures, the thread is kept taut at all times so that the previous stitches do not loosen. In the last stitch, a double thread is held, which, after the needle is pricked out, is tied to the free end of the thread. Continuous surgical sutures have many options depending on their purpose. A simple (linear) wrapping seam (Fig. 8, a), a wrapping seam according to Multanovsky (Figure 8, b) and a mattress seam (Figure 8, c) are often used. These sutures invert the edges of the wound if they are applied from the outside, for example, when suturing a vessel (see Vascular suture) and are turned in if they are applied from the inside of an organ, for example, when forming the posterior wall of an anastomosis on the organs of the gastrointestinal tract (see Intestinal suture). When forming the anterior wall of the anastomosis during surgery on the stomach and intestines, the Schmiden screw-in suture is widely used (see Fig. 6 to Art. Intestinal suture). Continuous surgical sutures are usually placed on the skin to obtain a better cosmetic effect. To suture superficial wounds, a single-row intradermal continuous suture according to Halstead is used (Fig. 9, a), and for deep wounds, a double-row continuous suture according to Halstead-Zoltan is used (Fig. 9, b).

Rice. 9. Schematic representation of the application of continuous intradermal sutures: a - single-row Halstead suture (the suture thread is passed through the dermis and the upper layer of subcutaneous tissue); b - double-row suture according to Halstead-Zoltan (a deep row of sutures is passed through the fascia and the lower layer of subcutaneous tissue). Rice. 10. Schematic representation of circular sutures: a - cerclage - fastening of bone fragments in an oblique bone fracture; b - block chain suture to bring the ribs closer together; c - simple purse-string suture; d — S-shaped purse-string suture according to Rusanov; d - Z-shaped purse-string suture according to Salten

Along with linear continuous surgical sutures, various types of circular sutures are used. These include: a circular suture, which aims to fix bone fragments, for example, in case of a fracture of the patella with divergence of the fragments (see Patella); the so-called cerclage - fastening bone fragments with a wire or thread in case of an oblique or spiral fracture or fixing bone grafts (Fig. 10, a); block pulley suture for bringing the ribs together, used when suturing a wound of the chest wall (Fig. 10, b); simple purse-string suture (Fig. 10, c) and its varieties - S-shaped according to Rusanov (Fig. 10, d) and Z-shaped according to Salten (Fig. 10, e), used for suturing the intestinal stump after its dissection, immersion vermiform appendix, umbilical ring plastic surgery, etc.; a circular or circular suture applied in various ways to restore the continuity of a completely crossed tubular organ - vessel, intestine, ureter, etc. When the organ is partially crossed, a semi-circular or lateral suture is applied, and the suture line is oriented so that it runs in a transverse or oblique direction along in relation to the organ to avoid narrowing in this place.

When suturing wounds and forming anastomoses, one row of sutures can be applied - a single-row (one-story, single-tier) suture, but more often the sutures are applied in layers - in two, three, four tiers using various types of sutures. For example, when suturing a wound of the abdominal wall, they usually apply: simple continuous sutures to the peritoneum, 8-shaped muscles, U-shaped or simple knotted aponeurosis, simple knotted sutures to the fascia with fatty tissue, as well as the skin.

Rice. 11. Schematic representation of options for hemostatic sutures: a - continuous chain (puncture) suture according to Heidenhain; b - interrupted chain stitch according to Heidenhain - Hacker; c — block-shaped suture according to Zamoshin, used in liver surgery.

Surgical sutures, along with connecting the edges of the wound, also provide stopping bleeding; for this purpose, specially hemostatic sutures have been proposed: a continuous chain (puncture) suture according to Heidenhain (Fig. 11, a) and an interrupted chain suture according to Heidenhain-Hacker (Fig. 11, b), which applied to the soft tissues of the head before their dissection during craniotomy. A variant of the interrupted chain suture is the hemostatic suture according to Ogschel, used for liver injuries (see). During liver operations, a hemostatic block suture according to Zamoshin is also used (Fig. 11, c).

Rice. 12. Schematic representation of sutures according to Girard-Zick for doubling the aponeurosis (a) and removable 8-shaped sutures according to Spasokukotsky (b, c). Rice. 13. Schematic representation of lamellar U-shaped seams: a - on buttons; b - on gauze balls.

The technique of applying surgical sutures depends on the surgical techniques used. For example, during radical surgery for a hernia (see) and in other cases when it is necessary to obtain a durable scar, they resort to doubling (duplication) of the aponeurosis with U-shaped sutures or Girard-Zick sutures (Fig. 12, a). After eventration (see), when layer-by-layer suturing of the wound is difficult, or for deep wounds, removable 8-shaped sutures according to Spasokukotsky are used (Fig. 12, b, c). When suturing wounds of complex shape, temporary (guide) sutures can be used, which are applied to bring the edges of the wound closer together in places of greatest tension. Once permanent sutures have been placed, they can be removed. In cases where the sutures are tied on the skin with great tension or are intended to be left for a long period of time, to prevent eruption, so-called lamellar (plate) U-shaped sutures are used, tied on plates, buttons, rubber tubes, gauze balls, etc. (Fig. . 13). For the same purpose, you can use secondary provisional sutures, when more frequent interrupted sutures are applied to the skin, and they are tied through one, leaving the other threads untied; when the tightened seams begin to cut through, provisional ones are tied, and the first ones are removed.

Skin sutures are most often removed 6-9 days after their application, however, the timing of removal may vary depending on the location and nature of the wound. Earlier (4 - 6 days) the sutures are removed from skin wounds in places with good blood supply (on the face, neck), later (9 - 12 days) from skin wounds in places with poor blood supply (on the lower leg and foot). The length of time for leaving sutures increases with significant tension on the edges of the wound, decreased tissue regeneration as a result of protein metabolism disorders, general intoxication of the body, etc.

Rice. 14. Schematic representation of the stage of removing an interrupted skin suture: by pulling the knot, a section of thread located under the skin is brought to the surface, which is crossed with scissors.

The sutures are removed by tightening the knot so that a part of the thread hidden in the thickness of the tissue appears above the skin, which is crossed with scissors (Fig. 14) and the entire thread is pulled out by the knot. In some cases (a long wound, significant tension on its edges), the sutures are removed first after one, postponing the removal of the remaining sutures until the wound has completely healed.

When using surgical sutures, a number of complications can arise. Traumatic complications include accidental punctures of a vessel with a needle or passing a suture through the lumen of a hollow organ when applying a parietal suture. Bleeding from a punctured vessel usually stops when a suture is tied; in rare cases, it is necessary to place a second suture in the same place, capturing the bleeding vessel; when a major vessel is punctured with a rough cutting needle, it may be necessary to apply a vascular suture. If an accidental through puncture of a hollow organ, for example, the cecum, is detected when a purse-string suture is applied during appendectomy, interrupted sutures are additionally placed in this place to prevent the formation of an intestinal fistula. Technical errors when applying sutures include poor alignment (adaptation) of the edges of the soft tissue wound, lack of inversion effect with intestinal and eversion with vascular sutures, narrowing and deformation of the anastomosis, etc. These defects can lead to failure of the anastomotic sutures, bleeding, peritonitis, intestinal , bronchial, urinary fistulas (see), etc. Wound suppuration, the formation of external and internal ligature abscesses and ligature fistulas occur due to violation of asepsis during sterilization of suture material or during surgery. Non-absorbable ligatures, sagging into the lumen of the biliary or urinary tract, contribute to the formation of stones. Complications in the form of delayed allergic reactions (see Allergy) more often occur when using catgut, and much less often when using silk and synthetic threads.

Skin suture from the general surgeon's point of view

It's no secret that quite often our patients evaluate the quality of the surgeon's work, even after the most complex abdominal interventions, by the appearance of the skin scar. Yes, we do not engage in aesthetic surgery – “surgery of pleasure”; we restore people’s health and, often, life. However, the common phrase that “when you lose your head you don’t cry for hair” is often not enough for today’s overly demanding patients to explain the appearance of a rough, deformed scar on the abdominal wall. And such cases, as we know, are not uncommon. Of course, some wounds heal by secondary intention. But this accounts for no more than 10% of all laparotomies. What's the matter? It may be that we pay significantly less attention to the skin suture at the end of the operation than it deserves. Or we generally entrust its application to novice surgeons: where else can they learn to work with tissue and a needle. The most interesting thing is that, according to fellow plastic surgeons, the skin is a very “grateful” tissue, whose healing is disrupted only by very serious errors in surgical technique. The violation of reparative processes in the skin is understood not so much as its divergence after the removal of sutures (this is an easily removable problem), but rather the occurrence of hypertrophic scars. Hypertrophic scars consist of dense fibrous tissue in the area of damaged skin. They are formed due to excess collagen synthesis. Scars are usually rough, tight, raised above the surface of the skin, have a reddish tint, are hypersensitive and painful, and often cause itching. Hypertrophic scars are divided into two main categories. 1. A normal hypertrophic scar corresponds to the boundaries of the previous wound and never extends beyond the damaged area. The leading role in the development of hypertrophic scars is played by the following factors: large size of the healing wound defect, ischemia of the skin in the suture area, prolonged healing and constant trauma to the scar. After 6–12 months, the scar usually stabilizes, acquires a clear outline, demarcated from the atrophic part of the scar and intact skin, and somewhat decreases and softens. 2. Keloid is a scar that penetrates into the surrounding normal tissues that were not previously involved in the wound process. Unlike hypertrophic scars, keloids often form in functionally inactive areas. Its growth usually begins 1–3 months after epithelization of the wound. The scar continues to enlarge even after 6 months and usually does not shrink or soften. There is typically no parallelism between the severity of the injury and the severity of keloid scars; they can occur even after minor injuries (puncture, insect bite) and often after a IIIA degree burn. Stabilization of the keloid scar usually occurs 2 years after its appearance. It is characteristic that keloid scars almost never ulcerate. The pathogenesis of keloids is unknown. Some authors regard them as benign tumors. Apparently, the most correct idea is that the formation of keloids is caused by a violation of the development of connective tissue. Auto-aggression is possible due to excess content of biologically active substances in tissues. The role of endocrine disorders, individual predisposition to the development of keloids, and the predominance of young and middle-aged patients with such scars cannot be excluded. Hypertrophic scars are difficult to treat. Excision of the scar can lead to its re-development. Injections of steroids into the scar area (and/or injections following excision), as well as close-focus radiation therapy, can prevent scar recurrence.

We in no way call for giving excessive importance to the aesthetic aspects of the skin suture on a laparotomy wound - the main field of activity and manifestation of the skill of abdominal surgeons is hidden from prying eyes. However, in addition to the “substrate for cosmetic effect,” the skin is also part of the surgical wound of the anterior abdominal wall, which requires no less care in forming skin sutures than when suturing the aponeurosis. Moreover, the skin suture does not require some incredibly complex technical and time costs (as they talk about this too often in specialized institutions...).

When forming a skin suture, you should:

- adhere to precision technology with precise comparison of the epidermal and dermal layers;

- strive to evert the edges of the skin; inversion (screwing the edges of the skin into the wound) is unacceptable;

- use minimally traumatic suture material (monofilament or complex threads of size 3/0-0 on an atraumatic cutting or reverse-cutting needle in ½ circle);

- use atraumatic tweezers or single-pronged hooks for skin traction;

— avoid tension of the skin with thread (only apposition and immobilization);

— eliminate cavities and pockets in the subcutaneous fat layer;

- form the suture in such a way that each thread passes through the skin only once, minimizing cross-infection along the entire suture line;

- use removable or absorbable threads;

- do not interfere with the natural drainage of the wound in the first two to three days of the postoperative period;

- leave the minimum possible amount of suture material in the wound.

It should be noted that the presence of some special “cosmetic seam” is just a common misconception. Any skin suture that meets the above requirements can be fully considered cosmetic. Currently, several types of sutures are most common for suturing skin wounds.

A simple interrupted suture is a single suture applied in a vertical plane, most common for apposition and immobilization of the edges of a skin wound, due to the ease of application, hemostatic effect, and the possibility of good adaptation of the wound edges.

The nuances of forming a simple interrupted skin suture include the following mandatory technical points:

— injection and puncture are made strictly perpendicular to the surface of the skin;

- the injection and puncture must be strictly on the same line, perpendicular to the length of the wound;

— the distance from the edge of the wound to the injection site should be 0.5-1 cm, which depends on the depth of the wound and the severity of the tissue layer;

— the thread is carried out to capture the edges, walls and, of course, the bottom of the wound to prevent the formation of cavities in the wound;

- if the depth of the wound is significant and it is impossible to apply a separate suture to the subcutaneous tissue, multi-stitch sutures should be used (for example, Struchkov’s suture);

- the distance between the seams on the skin of the anterior abdominal wall should be 1-1.5 cm; more frequent stitches lead to impaired microcirculation, more rare stitches lead to the appearance of diastasis of the wound edges;

- in order to avoid microcirculatory disorders and unsatisfactory cosmetic effect (transverse lines on the scar), the tightening of the seam should not be excessive, with the formation of a pronounced “roller” over the skin, the thread should only ensure a tight juxtaposition of the skin layers;

— the formed knot should be located on the side of the line of the sutured wound, but not on it.

The McMillen-Donati suture is a single vertical U-shaped interrupted suture with massive capture of the underlying tissue and targeted adaptation of the wound edges. Effectively used for suturing deep wounds with large diastasis of the edges. Apply using a large cutting needle. The injection is made at a distance of 2 cm or more from the edge of the wound, then it is injected so as to capture as much as possible and carried out to the bottom of the wound, where the needle is turned towards the midline of the wound and punctured at its deepest point. Then, on the side of the puncture, along the screed, a few mm from the edge of the wound, the needle is again injected and withdrawn into the thickness of the dermis on the opposite side, the needle is passed in the same way in the opposite direction. When the knot is tightened, homogeneous tissues are juxtaposed. The disadvantages of the seam include an unsatisfactory cosmetic result due to the formation of rough transverse stripes.

A slightly modified version of the McMillen-Donati suture is the Allgower suture, characterized in that the thread is not passed through the surface of the skin on the contralateral side. Single interrupted skin sutures have both advantages and disadvantages. The advantages of single interrupted sutures include their relative simplicity and low time costs for their application, the presence of natural drainage of the cavity of the sutured wound in the first days of the postoperative period through the spaces between the sutures, the possibility of limited opening of the wound when removing one or more sutures. The disadvantages of single sutures include the insufficient cosmetic effect when using them, even if they are formed technically correctly. The fact is that single sutures are removable, and for proper scar formation it is necessary to immobilize the edges of the skin wound for as long as possible. In addition, when forming individual seams, the appearance of transverse stripes or scars at the points of needle insertion is inevitable. Based on the requirements for a cosmetic effect, J. Chassaignac and W. Halstedt proposed the formation of a continuous intradermal suture along the entire length of the wound.

The Chassaignac-Halsted suture is a continuous internal adapting suture. The suture thread passes through the dermis, in a plane parallel to the surface of the skin. The needle is inserted on one side of the incision, passing it only intradermally. After this, they move to the other side of the incision. On both sides, the same amount of dermis is captured into the seam (0.5 - 1 cm). In essence, this seam is a continuous horizontal U-shaped one. At the end of the suture, the needle is poked into the skin, 1 cm away from the corner of the wound. The thread is fixed either with knots directly above the wound, or with special anchor devices.

The formation of the Halstead suture ensures complete adaptation of the epidermal and dermal layers of the skin and, accordingly, the best cosmetic effect. When forming this suture, particularly careful hemostasis is required, preliminary elimination of the residual cavity by suturing the subcutaneous tissue and the absence of skin tension. In the case of a large wound (over 8 cm), theoretically, difficulties may arise when removing a long non-absorbable thread, therefore, when applying such a suture, it is recommended to puncture the surface of the skin every 8 cm in order to be able to subsequently remove the threads in parts.

As already noted, a prerequisite for the use of a continuous intradermal suture is careful comparison of the subcutaneous fat tissue. In addition to the hemostatic effect and prevention of residual cavities, suturing the tissue helps to bring the edges of the skin wound together and makes it possible to apply a skin suture without tension. In this regard, J. Zoltan proposed an improved version of the intradermal suture.

The Halsted-Zoltan suture is a continuous two-row stitch. The first row is applied approximately in the middle of the subcutaneous base, the second - intradermally. The first needle injection is made near the end of the wound, at a distance of 2 cm from one of the edges. Then the needle is injected and punctured alternately in one and the other wall of the wound, passing it only along the middle of the thickness of the subcutaneous tissue in the horizontal plane (continuous U-shaped suture). Having completed the formation of a deep row of seams, the thread is brought to the surface of the skin. Both ends of the thread are pulled, thus bringing the edges of the wound closer together. To form the second row, the tip of the needle is brought into the dermis. Continue to sew in such a way that the puncture and puncture points are located symmetrically relative to the cut line, as with a regular Halsted seam. Until the surface suture is completed, the threads are kept taut, then a knot is formed by tying the ends of the threads to the skin.

An indispensable condition for the formation of a continuous intradermal suture is the use of only a monofilament thread of size 3/0 - 2/0 on a cutting or, better, reverse-cutting needle. The question of the preference for using absorbable (non-removable) or non-absorbable (removable) monofilament thread for a continuous intradermal suture remains open today: some surgeons remain staunch supporters of Prolene, while others invariably use Monocryl.

To achieve the best cosmetic effect, which is largely associated with trauma to the skin when threading, combined methods of closing the skin wound are used. Recently, a method that includes, as one of the components, the use of an adhesive application to immobilize the skin after reduction and protect the wound from exposure to the external environment, has become increasingly popular. In this case, Dermabond is used as a means of immobilization and protection - a medical glue based on 2-ocycyanoacrylate and a violet dye for contrasting with the skin. After application to the skin, Dermabond, due to contact with air, passes from the liquid phase into the elastic-elastic gel phase with exceptionally strong adhesion to the skin within 30-60 seconds. At the same time, a durable film is formed on the skin, preventing diastasis of the wound edges and protecting the edges and walls of the wound from contamination by microorganisms (the use of glue eliminates the need to use aseptic dressings on the postoperative wound). Dermabond provides immobilization of the edges of the skin wound for up to 7-8 days and after this time it independently fragments and is removed from the skin. Mandatory conditions for the use of Dermabond glue are thorough hemostasis and tight closure of the wound edges with a suture of subcutaneous tissue: it is possible to use a continuous suture or separate sutures with absorbable material. That is why this method of closing a skin wound is combined - suture and glue. It can be assumed that the introduction into clinical practice of connecting the edges of a skin wound using an adhesive application in itself indicates the direction of evolution of methods for connecting tissues in surgery: from threads to polymer adhesive materials.

Caring for cosmetic sutures in the postoperative period

Caring for a cosmetic suture in the postoperative period does not differ from that when applying a conventional surgical suture. An important condition for successful healing is compliance with the rules of asepsis and antisepsis, as well as careful treatment of the wound. The bioabsorbable suture material used for this type of suture dissolves itself, which reduces the risk of infection when removing the thread. Also, in the early stages of healing, anti-inflammatory ointments may be recommended, and in a later period, agents that reduce scar formation.

Technical features of performing a cosmetic seam

The main task of a cosmetic seam is to achieve the maximum aesthetic effect. In this regard, to apply this type of sutures, the thinnest threads made of biodegradable materials, as well as atraumatic needles, are used.

When applying a cosmetic suture, the thread should pass intradermally for better adaptation of the wound edge and for less disruption of microcirculation.

The cosmetic suture is applied according to the natural tension lines of the skin, so that the final result on the skin looks like a wrinkle or fold. Cosmetic suture: • main types of cosmetic sutures in surgery; • suture material used for cosmetic sutures; • cosmetic suture care in the postoperative period.

The main types of cosmetic sutures in surgery

In modern surgery, several types of cosmetic sutures are used, among which the most commonly used are: • continuous intradermal suture, which helps to preserve microcirculation as much as possible; • vertical mattress suture - considered cosmetic, since punctures are made as close as possible to the edge of the wound, ensuring minimal trauma to the skin.

Extensive operations with a wide wound require reliable fixation, which a cosmetic suture cannot provide. In this case, preference is given to a stronger surgical suture, and subsequently scar plastic surgery is performed.

Suture material used for cosmetic stitching

Applying a cosmetic suture requires the use of special suture material. Preference is given to atraumatic needles and self-absorbing threads.

Biodegradable suture materials are of organic origin (catgut) and synthetic (MedPHA - threads made on the basis of polyhydroxyacetylic acid).

To reduce trauma to the skin, manufacturers usually apply a film coating of absorbable polymer to threads made of synthetic materials. The main advantage of synthetic suture material is the high reliability of the surgical knot and the strength of the suture.

Skin glue or threads: how to get the most invisible suture after surgery?

The process of wound healing in plastic surgery is one of the most important stages towards obtaining an aesthetically attractive result. If for general surgery the most important requirement for suture material is to ensure better healing, then for aesthetic surgery, in addition to this, there is also a requirement to minimize the consequences of postoperative wounds, that is, the desire for a complete absence of scars.

Modern suture materials include absorbable and non-absorbable sutures based on synthetic materials such as polydiaxonone, polyglycolic acid, polyglycolic acid, polyglycolic acid, glycolide copolymer, epsilon-caprolactone and others. Natural materials (catgut) are also used, which are made from the tissues of large and small livestock. This suture material is used mainly only when suturing internal organs, mucous membranes, muscles and tendons, and last but not least for suturing external wounds. Because catgut consists almost entirely of connective tissue, it can contribute to the formation of unattractive, large scars.

There is a third type of suture material, which, although relatively new in comparison with threads, is nevertheless widely used today in the work of plastic surgeons in Russia and abroad. We are talking about cyanoacrylate adhesives. Initially, these adhesives were to be used as an alternative to threads for surgery of internal organs and mucous membranes. However, studies have shown that the glue reacts with body fluids and, when disintegrating, turns out to be toxic. At the same time, the glue showed itself in the best and safest way when stitching external postoperative wounds.

Plastic surgery patients are well aware of the troubles they face in the first few days after surgery. In addition to the restriction of movements or the need to sleep only in a certain position, which most patients can easily endure, there are many other unpleasant moments that cause much more significant discomfort - not taking a shower, changing bandages at certain intervals, and finally, removing stitches, which causes many people considerable stress.

Taking this into account, Russian and foreign scientists have conducted a number of studies on how the rehabilitation process proceeds when stitching wounds in the traditional way - with staples or threads and when applying glue, and most importantly, how the final cosmetic effect will differ. Differences also appeared at the stage of the operation, when closing wounds, since working with glue turned out to be less energy-intensive and took less time than suturing, which ultimately did not require additional anesthesia.

It is worth noting that when working with skin glue, traditional suture material is still applied to the skin, but only to stitch the edges of the wound; the glue itself is applied to the main part of it. The whole process doesn't take even five minutes. The first layer of glue dries, after which the doctor applies a second one. For the applied substance to completely harden, you need to wait about 2-3 minutes.

When the wound is closed in the traditional way, that is, with the help of threads, the doctor first applies a suture and then applies special strip stickers that provide better skin tension.

The biggest advantage of glue from the point of view of the patients themselves is that they have relative freedom - for example, they can take a shower without fear of getting the suture area wet, which is impossible when stitching a wound with threads - they cannot take a shower, since the wound area must remain as dry as possible .

In addition to the above, according to research by specialists, patients usually do not show any skin reactions to the glue. The exception is allergic reactions, however, this is specified and determined in advance. However, some patients have a skin reaction to strip stickers.

The most important advantage of the glue, according to surgeons, is that the bacteriological protection of the glue is 95%, and it remains so for 72 hours after surgery - the most dangerous time in terms of wound infection. Then it starts to decline. In addition, the glue does not involve applying any gels or ointments to the wound, which is necessary when stitching the wound with threads.

As for the main criterion - the aesthetic result. So far, the opinions of scientists do not provide an objective and unambiguous answer. Their research shows approximately the same results using both glue and creating traditional seams. Scars 12 or more months after surgery remain similar, provided the initial ones are the same. True, some experts draw conclusions in favor of glue, noting that after a long period after surgery, scars healed with its help look better than those that were traditionally sewn up with threads.

One way or another, it can be stated with certainty that the use of cyanoacrylate glue for closing wounds has significantly improved the postoperative rehabilitation period for patients and made it more comfortable.

You can learn more about plastic surgery in the “Body plastic surgery” section.