The concept of "intestinal suture" is collective and involves the elimination of wounds and defects of the esophagus, stomach and intestines. Even during the Crimean War, Pirogov Nikolai Ivanovich used special stitches for suturing hollow organs. They helped to preserve the affected organ. Over the years, newer modifications of the intestinal suture have been proposed, the advantages and disadvantages of its various variations were discussed, which indicates the importance and ambiguity of this problem. This area is open to research and experimentation. Perhaps in the near future there will be a person who will offer a unique technique for combining tissues. And this will be a breakthrough in the stitching technique.
Basic requirements for intestinal suture
In surgery, there are a number of conditions that the intestinal suture must meet in order to be used in abdominal operations:
- First of all, tightness. This is achieved by accurately matching serous surfaces. They stick to each other and tightly solder, forming a scar. A negative manifestation of this property are adhesions, which can impede the passage of the contents of the intestinal tube.
- The ability to stop bleeding, while maintaining enough blood vessels for blood supply to the suture and its early healing.
- The seam should take into account the structure of the walls of the digestive tract.
- Significant strength throughout the wound.
- Healing the edges by primary intention.
- Minimal trauma to the digestive tract (gastrointestinal tract). This implies the rejection of twisting sutures, the use of atraumatic needles, as well as the limited use of surgical tweezers and clamps, which can damage the wall of a hollow organ.
- Prevention of necrosis of the membranes.
- A clear comparison of the layers of the intestinal tube.
- Use of absorbable material.
The structure of the intestinal wall
As a rule, the wall of the intestinal tube has the same structure throughout with minor variations. The inner layer is the mucous tissue, which consists of a single-layer cubic epithelium, in which in certain areas there are villi for better absorption. A loose submucosal layer is located behind the mucosa. Then comes the dense muscle 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 muscle fibers are arranged in the form of wide ribbons. Behind the muscle layer is the serous membrane. This is a thin film that covers the hollow organs and ensures their mobility relative to each other. The presence of this layer is necessarily taken into account when an intestinal suture is applied.
Properties of the serous membrane
A useful property for surgery in the serous (i.e., outer) lining of the digestive tube is that after matching the edges of the wound, it sticks tightly for twelve hours, and after two days the layers are already quite tightly fused. This ensures a tight joint. To get this effect, you need to sew stitches often enough, at least four on one centimeter.
To reduce tissue trauma during the suturing process, thin synthetic threads are used. As a rule, muscle fibers are sutured to the serous membrane, giving the suture greater elasticity, which means the ability to stretch when passing the food lump. Capture of the submucosal and mucous layers provides good hemostasis and additional strength. But it is important to remember that infection from the inner surface of the intestinal tube through the suture material can spread throughout the abdominal cavity.
The outer and inner case of the digestive canal
For the practical work of the surgeon, it is extremely important to know about the case-like principle of the structure of the walls of the digestive canal. In the framework of this theory, the outer and inner cases are distinguished. The outer case consists of serous and muscle membranes, and the inner one consists of mucous and submucous membranes. They are mobile relative to each other. In different parts of the intestinal tube, their displacement during damage is different. So, for example, at the level of the esophagus, the inner case is reduced more, and if the stomach is damaged, the outer one. In the intestines, both cases diverge evenly.
When the surgeon sutures the wall of the esophagus, it injects the needle in an oblique-lateral direction (sideways). And perforation of the wall of the stomach will be sutured already in the opposite, oblique-medial direction. The small and large intestines are stitched strictly perpendicularly. The distance between the stitches should be at least four millimeters. A decrease in pitch will lead to ischemia and necrosis of the wound edges, and an increase will lead to insolvency and bleeding.
Edge seams and edge seams
Intestinal suture can be mechanical and manual. The latter, in turn, are divided into regional, marginal and combined. The former pass through the edges of the wound, the latter recede from its edge not a centimeter, but combined ones combine the two previous methods.
Edge seams are single-sided and two-sided. It depends on how many shells connect simultaneously. A seam along Bir with knots on the outer wall and a suture of Mateshuk (with knots inward) belong to the instantaneous, since they capture only the serous and muscular sheath. And the three-layer intestinal suture of Pirogov, which is used to stitch not only the outer case, but also the submucosal layer, and the through suture of Jelly, are two-sided.
In turn, through connections can be made in the form of a nodal or in the form of a continuous seam. This last one has several variations:
- entwined;
- mattress;
- Reverden's seam;
- Schmiden’s seam.
The marginal ones also have their own classification. So, the Lambert seam is distinguished, which is a two-stitch nodal seam. It is applied to the outer (serous-muscular) case. There is still a continuous volumetric, purse-string, half-purse, U-shaped and Z-shaped.
Combined seams
As the name implies, combined seams combine elements of the regional and marginal. Allocate "nominal" surgical sutures. They are named after the doctors who first used them for surgery on the abdominal organs:
- Suture Cherni is a combination of the marginal and marginal serous-muscular suture.
- Kirpatovsky suture is a combination of the marginal submucosal suture and serous-muscular.
- Albert's seam includes two more specific seams: Lambert and Jelly.
- The seam of Tupe begins as an edge through seam, the nodes of which are tied into the lumen of the organ. Then, a Lambert suture is placed on top.
Row classification
There is also a separation of seams 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, therefore, the mechanism of suturing wounds was designed in such a way as to prevent the eruption of tissues.
Single-row sutures are difficult to apply, for this a specific precision surgical technique, the ability to work with an operating microscope and thin atraumatic needles are required. Such equipment is not in every operating room, and not every surgeon can cope with it. Two-row seams are most commonly used. They fix well the edges of the wound and are the gold standard in abdominal surgery.
Multi-row surgical sutures are extremely rare. Mainly due to the fact that the wall of the organ of the intestinal tube is thin and delicate, and a large number of threads will penetrate it. As a rule, multi-row sutures end operations on the large intestine, such as appendectomy. The surgeon first ligates to the base of the appendix. This is the first, inner seam. Then comes a purse string suture through the serous and muscular sheath. It is delayed and closed from above by a Z-shaped, fixing the stump of the intestine and providing hemostasis.
Comparison of intestinal sutures
In order to know in which situation it is advisable to apply one or another seam, it is necessary to know their strengths and weaknesses. Let's consider them in more detail.
1. Lambert's gray-serous suture, with all its lightness and versatility, has several disadvantages. Namely: does not provide the necessary hemostasis; rather fragile; does not compare mucous and submucous membranes. Therefore, it is necessary to use it by combining with other seams.
2. Edge single- and double-row seams are strong enough, provide a complete comparison of all tissue layers, 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 also have disadvantages. The seam is permeable to the intestinal microflora. Hygroscopicity leads to infection of the tissues near it.
3. Serous-muscular-submucosal sutures have significant mechanical strength, meet the principles of the plutonic structure of the intestinal wall, provide complete hemostasis and prevent narrowing of the lumen of the hollow organ. It was such a seam that Pirogov Nikolai Ivanovich suggested at the time. But in his variation he was single-row. This modification has negative qualities:
- rigid line of tissue connection;
- An increase in the size of the scar due to edema and inflammation.
4. Combined joints are reliable, easy to perform, hemostatic, airtight and durable. But even this seemingly perfect seam has its drawbacks:
- inflammation through the connection of tissues;
- slow healing;
- formation of necrosis;
- high probability of adhesions;
- infection of the threads when passing through the mucous membrane.
5. Three-row sutures are used mainly when suturing defects of the large intestine. They are durable, provide a good adaptation of the edges of the wound. This reduces the risk of inflammation and necrosis. Among the disadvantages of this method are:
- infection of the threads by flashing two cases at the same time;
- slowing down tissue regeneration at the wound site;
- high likelihood of adhesions and, as a consequence, obstruction;
- tissue ischemia at the site of suturing.
We can say that each technique for suturing wounds of hollow organs has its advantages and disadvantages. The surgeon needs to focus on the end result of his work - what exactly does he want to achieve with this operation. Of course, a positive effect should always prevail over a negative one, but the latter cannot be completely leveled.
Teething
Conventionally, all seams can be divided into three groups: those that almost always erupt, rarely erupt and practically do not erupt. The first group includes the Schmiden seam and the Albert seam. They pass through the mucous membrane, which is easily injured. The second group includes sutures located near the lumen of the organ. This is the seam of Mateshuk and the seam of Beer. The third group includes sutures that do not touch the intestinal lumen. For example, Lambert.
It is impossible to completely exclude the possibility of eruption of the suture, even if it is superimposed only on the serous membrane. Under equal conditions, a continuous seam will be cut through with a greater probability than a nodal joint. This probability will increase if the thread passes close to the lumen of the organ.
There are mechanical teething, suture rejection along with necrotic masses and teething as a result of a local reaction of damaged tissues.
Modern absorbable materials
To date, the most convenient material with which the intestinal suture can be made is absorbable synthetic threads. They allow you to connect the edges of the wound for a sufficiently long time and not leave foreign materials in the patient's body. Particular attention is paid to the mechanism of removing threads from the body. Natural fibers are exposed to tissue enzymes, and synthetic fibers are cleaved by hydrolysis. Since hydrolysis destroys body tissues less, it is preferable to use artificial materials.
In addition, the use of synthetic materials makes it possible to obtain a durable inner seam. They do not cut through the fabric, therefore, all the troubles that this may entail are also excluded. Another positive quality of artificial materials is that they do not absorb water. This means that the suture will not be deformed and the intestinal flora, which can infect the wound, will also not get out of the lumen of the organ onto its outer surface.
Choosing the suture and the material that will be used to wound the wound, the surgeon should be guided by the observance of biological laws that ensure tissue fusion. The desire to unify the process, reduce the number of rows or apply unproven threads should not be the goal. First of all, the patient’s safety, convenience, reduction of postoperative recovery time and pain are important.