Indication. When it is not possible to stop the bleeding at the wound site, the vessel is ligated along its length. Sometimes the vessel is ligated throughout to prevent possible bleeding during surgery.
Operation technique. Vascular ligations are usually performed under local anesthesia. The vessel to be ligated is isolated from the surrounding tissues using a Deschamps needle, a silk or catgut ligature is placed under it, depending on the caliber, and the vessel is ligated. To ligate any artery, it is necessary to know its projection line and, guided by it, make an incision in the skin and soft tissues; The location of the artery can also be determined by pulsation.
^ Ligation of the radial and ulnar arteries (a. a. radialis, ulnaris)
Indications: bleeding when the hand and lower third of the forearm are wounded in the area of distribution of one or another artery.
The patient's position on the table is on the back, the arm is moved to the side and placed on the side table.
The projection line of the radial artery runs from the middle of the elbow to the styloid process of the radius or from the inner edge of the biceps muscle to the pulse point of the radial artery (Fig. 11).
Operation technique. The artery can be exposed at any level with an incision made along the projection line.
The skin, subcutaneous tissue, and own fascia are dissected; incision 5–6 long cm. Under the fascia, the radial artery is usually located between the brachioradialis muscle (m. brachiora-diale) on the outside and the radial flexor (m. flexor curpi radialis) on the inside. The fascia is cut through the probe, the artery is isolated and ligated.
Rice. N. Ligation of the radial artery.
1 - projection
line; 2
- an incision to expose the artery in the upper third; 3 -
incision to expose the artery in the lower third.
Rice. 12. Ligation of the ulnar artery.
/ and 2-projection line of the ulnar artery; 3 and 4 timescuts for artery ligation.
The projection line of the ulnar artery for ligation of its upper third runs from the middle of the cubital fossa to the inner surface of the forearm, at the border between its upper and middle third. The projection line of the ulnar artery in the middle and lower third of the forearm runs from the inner epicondyle of the shoulder to the outer edge of the pisiform bone.
Typically the artery is ligated in the middle or lower third of the forearm. In the middle third, the incision is made along a projection line length
6-7 cm(Fig. 12). The skin, subcutaneous tissue, and superficial fascia are dissected. On 1 cm outward from the skin incision, directly above the superficial flexor digitorum (m. flexor digitorum superficialis), the proper fascia of the forearm is dissected along the probe. Having widened the wound with blunt hooks, they penetrate into the gap between the ulnar flexor of the hand (m. flexor curpi ulnaris) and the superficial flexor of the fingers and bluntly release the inner edge of the latter muscle. The superficial flexor digitorum is pulled outward, behind it under
The deep layer of fascia contains the ulnar nerve and artery. The artery lies medially to the nerve.
If the ulnar artery is detected in the lower third of the forearm, the incision is made along a projection line measuring 5–6 cm(see Fig. 12). The skin, subcutaneous tissue, and superficial fascia are opened. The fascia of the forearm is dissected strictly along the projection lines. The flexor ulnaris tendon is pulled inward with a blunt hook, then the sheet of fascia enveloping the flexor digitorum superficialis on the medial side is dissected along the probe. Under the fascia is the ulnar artery with two veins, medial to it lies the ulnar nerve.
^ Ligation of the brachial artery (a. brachialis)
Indications: bleeding in the upper third of the forearm and in the lower third of the shoulder.
The patient's position on the table is on his back, with his arm abducted as far as possible.
The projection line runs along the medial groove of the biceps muscle (Fig. 13).
Operation technique. The artery is usually ligated in the middle third of the shoulder. For dressing, an incision 5–6 long cm
^ Rice. 13. Ligation of the brachial artery,
The dotted line is the projection line; The solid line is the location of the incision.
is carried out along the convexity of the abdomen of the biceps muscle (i.e. biceps brachii), i.e., somewhat outward and anterior to the projection line. The skin, subcutaneous tissue, and superficial fascia are dissected, the anterior wall of the biceps muscle vagina is opened using a probe, its edge is isolated and the muscle is pulled outward. Through the back wall of its moisture-
The median nerve (p. medianus), lying in this area directly on the brachial artery, is visible through the ligament. The posterior wall of the vagina is opened, the nerve is retracted medially with a blunt hook, the brachial artery, which is accompanied by two veins, is isolated and ligated.
^ Ligation of the axillary artery (a. axillaris)
Indications: bleeding in the middle and upper third of the shoulder.
The position of the patient on the table is on his back, with his arm abducted as far as possible,
Rice. 14. Topography of the axillary and brachial artery according to Schmieden.
1st brachial artery; ^ 2- biceps; 3- triceps;
4 - median nerve; 5 - ulnar nerve; 6 - radial nerve; 7 - axillary artery; 8- axillary vein; 9 - coracohumeral
Rice. 15. Exposure of the axillary artery (according to M. A. Sreseli).
1 - coracobrachialis muscle and short head of the biceps muscle; 2-axillary artery; ^ 3 - median nerve (pulled with a hook); 4 - ulnar nerve; 5 - axillary vein.
Operation technique. It is better to ligate this artery not along the line of projection of the artery, but in the so-called roundabout way through the sheath of the coracobrachialis muscle (m. coracobrachialis).
Cut 7–8 long cm is done along the convexity of the coracobrachialis muscle, starting from the level of the intersection of this muscle with the lower edge of the pectoralis major muscle (m. pectoralis major) and to the deepest point of the armpit. The skin, subcutaneous tissue, and superficial fascia are cut, then the fascial sheath of the coracobrachialis muscle and the short head of the biceps muscle (m. biceps brachii) is dissected. Both muscles are exposed bluntly and, together with the short head of the biceps muscle, are pulled anteriorly. The median nerve is visible through the sheet of fascia that forms the posterior wall of the muscle sheath. A sheet of fascia is dissected along the probe. The artery lies behind the median nerve. The vein remains medial to the artery. The artery must be isolated extremely carefully so as not to injure the vein. Injury to the latter may result in an air embolism. The musculocutaneous nerve (n. musculo cutaneus) remains outside the artery, the ulnar nerve (n. ulnaris) and cutaneous nerves of the shoulder and forearm (n. cutaneus antibrachii et brachii med.) are located medially, and the radial nerve is posterior to the artery (Fig. 14, 15).
^ Ligation of the subclavian artery (a. subclavia)
Indications: bleeding in the upper third of the shoulder and in the armpit.
A cushion is placed under the shoulders and the arm is retracted.
The subclavian artery is projected along the middle of the clavicle (Fig. 16).
Operation technique. An incision 7–8 long cm is carried out parallel to the clavicle, at 1 cm below it, so that the middle of the incision corresponds to the line of projection of the artery. The proper fascia of the pectoralis major muscle is dissected, its clavicular part (pars clavicularis) is crossed transversely. The back wall of her vagina is opened. Here the external superficial vein (v. cephalica) is usually found; it is retracted downwards and inwards with a blunt hook. The fascia is dissected along the upper edge of the pectoralis minor muscle (m. pectoralis minor), followed by a neurovascular bundle deep in the loose tissue. Lymph nodes, branches of the anterior thoracic nerve (p. thoracalis ant.), small branches of arteries and veins can be found here. By bluntly pushing the tissue apart and ligating the small vessels encountered, they form access to the subclavian
Arteries. The subclavian vein (v. subclavia) runs slightly anteriorly and inwardly from it; the brachial plexus (plexus brachialis) is located outward and upward from the artery.
c - ligation of the subclavian artery: 1st projection line; 2 - incision line to expose the artery above the collarbone; ^ 3 - incision line to expose the artery under the collarbone; 6 - topography of the subclavian artery: 1 - subclavian vein; 2 - subclavian artery; 3 - brachial plexus.
^ Ligation of the anterior tibial artery (a. tibialis anterior)
Indications: bleeding from the dorsum of the foot and the anterior surface of the lower and middle thirds of the leg.
The patient's position on the table is on his back, the lower leg is rotated slightly inwards.
The projection line of the anterior tibial artery runs from the middle of the distance between the head of the fibula and the tuberosity of the tibia (tuberositas tibiae) to the middle of the distance between the ankles (Fig. 17).
Operation technique. The artery can be ligated in any part of the projection line. Cut 7–8 long cm. The skin, subcutaneous tissue, superficial fascia are opened; the wound is spread apart with hooks and an intermuscular gap is found between the anterior tibialis muscle (m. tibialis anterior) and the long extensor digitorum (i.e. extensor digitorum longus), which is visible through the proper fascia of the leg. The aponeurosis is repented over the gap, they bluntly penetrate into the depths and find the artery, which is accompanied by veins and the deep peroneal nerve (n. peroneus profundus), lying on the interosseous membrane.
^
Ligation of the posterior tibial artery (a. tibialis posterior)
Rice. 17. Ligation of the anterior tibial artery.
1-projection line; 2, 3
And 4 -
incisions for ligating the artery.
Rice. 18. Dressing
Posterior tibial artery.
1
- projection line; 2, 3 and 4 cuts for artery ligation.
Indications: bleeding from the plantar surface of the foot and the back surface of the lower and middle thirds of the leg.
The position of the patient on the table is on his back,
The leg is slightly bent at the knee and hip joints and rotated outward.
The projection line in the middle and lower thirds of the leg starts from a point one transverse finger inward from the inner condyle of the tibia to the middle of the distance between the inner malleolus and the Achilles tendon (Fig. 18).
Operation technique. The artery can be ligated in any area along the projection line. Skin incision 7-8 long cm along the projection line. The skin, subcutaneous tissue, superficial fascia are dissected, and the proper fascia of the leg is cut. The edge of the calf muscle (m. gast-
rochemius), is pulled back, the soleus muscle lying on two wounds (m. soleus) is cut with a knife; the blade of the latter should be aimed at the bone. The soleus muscle is pulled posteriorly, under it a deep plate of the tibia's own fascia is visible, through which the neurovascular bundle passing in the intermuscular canal is visible. Using a grooved probe medially from the nerve, a canal is opened, the artery is isolated and ligated.
^ Ligation of the popliteal artery (a. poplitea)
Indications: bleeding in the upper third of the leg. The patient's position on the table is on his stomach. Projection line along the middle of the popliteal fossa (Fig. 19).
Rice. 19. Projection of the popliteal artery.
1 - projection line; 2-incision for ligation of the artery.
Fig. 20. Topography of the popliteal artery,
1 - popliteal artery; 2 -
popliteal vein; .3 - tibial nerve; 4
- common peroneal nerve; 5 -
small saphenous vein; 6
and 7 - semimembranosus and semitendinosus muscles; 8 -
biceps femoris muscle; 9 -
head of the gastrocnemius muscle.
Operation technique. Cut length 7–10 cm along the projection line, i.e., in the middle of the distance between both femoral condyles. The skin, subcutaneous tissue and superficial fascia are dissected. The own fascia, having been cut in one place, is opened using a probe so as not to injure the nerve, then the
The neurovascular bundle is isolated in this way. The nerve will be first, then the vein, the artery lies deep near the bone (remember "NeVA"), the Artery is isolated and ligated (Fig. 20).
^ Ligation of the femoral artery (a. femoralis)
Indications: bleeding from the knee area, lower and middle thirds of the thigh, high hip amputation.
The patient's position on the table is on his back.
The projection line runs from the middle of the Pupart ligament to the inner femoral condyle (Fig. 21). This line protrudes only when the limb is rotated outward and bent at the knee and hip joints.
Technique of operation. The artery can be ligated in any area. It is important to distinguish between dressings above and below the origin of the deep
Rice. 21. Projection line of the femoral artery and incision sites (/).
Rice. 22. Isolation of the femoral artery at various levels.
1-pupart's ligament; ^
2
-femoral vein; 3 -
great saphenous vein; 4
- oval fossa; 5 - sartorius muscle; 6
- internal cutaneous nerve; 7 - femoral artery; 8 -
vastus internus; 9 -
abductor magnus tendon.
Coy artery of the thigh (a. profunda femoris), through which collateral circulation can be restored.
Ligation of the femoral artery above the origin of the deep femoral artery is usually performed directly under the Pupart ligament. The cut starts at 1 cm taller than Poupart's
ligaments and continue according to the projection line for a length of 8–9 cm. The skin, subcutaneous tissue and superficial fascia are incised. Focusing on the lower edge of the Poupart ligament and the area of the foramen ovale, the superficial plate of the fascia lata is dissected using a grooved probe and the artery is bluntly isolated. The femoral vein passes medial to the artery; in order not to damage the vein, the Deschamps needle and ligature should be inserted from the side of the vein (Fig. 22).
Rice. 23. Projection line (/) of the pupart ligament and incision line (2) for ligation of the iliac artery.
Rice. 24. Topography of the external iliac artery.
1 - femoral nerve; 2-lumbar muscle; 3 - external iliac artery; 4
- external iliac vein.
To ligate the femoral artery below the origin of the deep femoral artery, the incision is made along a projection line measuring 8–9 cm, starting at 4–5 cm below the poupart ligament. The skin, subcutaneous tissue, and superficial fascia are opened. The fascia lata is exposed along the medial edge of the translucent sartorius muscle. The sartorius muscle is pulled outward. Vessels are visible through the posterior layer of the vagina of this muscle. The posterior wall of the muscle sheath is carefully cut through the probe, the femoral artery is isolated and ligated below the origin of the deep femoral artery. The latter departs from the outer wall of the main trunk of the femoral artery at 3–5 cm below the poupart ligament.
^ Ligation of the external iliac artery (a. iliaca externa)
Indications: high amputation of the femur, exerticulation of the femur, bleeding from the femoral artery directly under the ligament of the femur.
The patient's position on the table is on his back.
cm parallel to the Pupart ligament by 1 cm taller than her. The middle of the incision should approximately correspond to the middle of the Poupart ligament (Fig. 23). The inner end of the cut should end short of 3–4 cm to the pubic tubercle to avoid damage to the spermatic cord.
The skin, subcutaneous tissue, and superficial fascia are opened, and the aponeurosis of the external oblique muscle is dissected. Along the course of the incision, the vessels are intersected and ligated. The internal oblique (m. obliquus internus abdominis) and transverse abdominal muscles (m. transversus abdominis) are pulled upward (Fig. 24). The underlying transverse fascia is dissected using a grooved probe; behind it is a loose layer of fatty tissue; the tissue is bluntly pushed apart and the external iliac artery is found; a vein lies inward of the artery. The artery is isolated and ligated. The Cooper needle must be passed from the side of the vein so as not to injure it.
^ Ligation of the hypogastric artery (a. iliac interna)
Indications: bleeding from the gluteal region, injury to the superior or inferior gluteal arteries (a. a. glutei sup. and inf.). If there is bleeding from the gluteal region, ligation of the gluteal arteries can be performed. However, the operation to expose the gluteal arteries is more cumbersome, and finding the short trunk of the superior gluteal artery is much more difficult; in these cases it is always more advantageous to ligate the hypogastric artery.
The patient's position on the table is on the healthy side, with a bolster under the lower back.
Operation technique. Cut length 12–15 cm starts from the end of the 11th rib downwards and inwards to the outer edge of the rectus abdominis muscle, the incision is somewhat arched, convex outward (Fig. 25).
The skin, subcutaneous tissue, superficial and deep fascia, external oblique, internal oblique and transverse abdominal muscles are dissected. The adjacent transverse fascia is carefully dissected along the probe and the peritoneal sac is bluntly pushed inward. When cutting the transverse fascia, you can accidentally open the peritoneum; if the latter is opened, it must be immediately sewn up with a continuous seam. After abduction
B 
ruffles in the depths of the wound in the retroperitoneal tissue, vessels, the common iliac artery and vein (a. iliaca communis and v. iliaca communis) are found, the place of division of the common iliac artery is found, the hypogastric artery is highlighted. The latter is located on the side wall of the pelvis, behind it lies the vein of the same name, and in front of it is the external iliac vein, so the hypogastric artery must be isolated with extreme caution so as not to damage the adjacent veins.
Rice. 25. Incision to expose the hypogastric artery according to Pirogov.
1-projection line and section line.
. As the cut progresses, the dissected vessels are immediately ligated, otherwise the accumulating blood at the bottom of the wound will interfere with orientation. Particular care must be taken when isolating vessels in the retroperitoneal tissue; the crossed veins must be ligated. An intersection is made between two ligatures. In the small pelvis, the ureter passes above the hypogastric artery (crossing it). When isolating the hypogastric artery, care must be taken to ensure that it is not damaged or caught in the ligature.
^ Ligation of the internal thoracic artery (a. thoracica interna)
Indications – bleeding from a chest injury in the area of passage of a. thoracica interna, as a preliminary stage for thoracotomy, as one of the surgical methods for treating angina pectoris.
The patient's position on the table is on his back.
Operation technique. An incision 5–6 long cm produced almost parallel to the edge of the sternum, at 1 cm stepping away from it, it is more convenient to make the incision somewhat obliquely from the edge of the sternum V in the lateral direction, so that the middle of the incision corresponds to the level of vessel ligation.
The skin, subcutaneous tissue, superficial fascia, pectoralis major muscle and deep layer of fascia are incised. In the medial corner of the wound, white shiny bundles of tendons stand out, under them lie oblique fibers of the internal intercostal muscle (m. intercostalis int.). The muscle fibers are bluntly separated, the artery lies underneath them, and the vein of the same name lies outside the artery. The artery is isolated and ligated.
A. thoracica interna can be bandaged in any intercostal space along its course, but it is more convenient in the second or third, since the latter are wider.
^ Ligation of the carotid arteries (a. a. carotis externa and interna)
Indications: bleeding from the branches of the carotid arteries, both external and internal.
Position the patient on the table - a cushion is placed under the shoulders, the head is thrown back and turned in the opposite direction.
Rice. 26. Topography of the carotid arteries.
^ 1 - common facial vein; 2 - internal jugular vein; 3 - sternocleidomastoid muscle; 4 - superior thyroid artery; 5 - common carotid artery; 6 - descending branch of the hypoglossal nerve; 7 - superior thyroid vein.
Operation technique. Cut 7–8 long cm is carried out along the anterior edge of the sternocleido-mastoideus muscle (m. sternocleido-mastoideus), starting from the level of the lower jaw. The skin, subcutaneous tissue, and platysma are dissected. The external jugular vein (v. jugularis externa) is moved to the side. After dissecting the vagina, the anterior edge of the sternocleidomastillary muscle is exposed, the muscle is bluntly peeled off and pushed outward. The posterior wall of the vaginal muscle is opened, preferably with a probe, and the neurovascular bundle is exposed. The common facial vein (v. facialis) is isolated and pulled upward. At the level of the upper edge of the thyroid cartilage
The place where the common carotid artery divides is located; in this area, the superior thyroid artery (a. thyreoidea superior) departs from the external carotid artery. It is most convenient to ligate the external carotid artery slightly above the origin of the superior thyroid artery (Fig. 26).
The external carotid artery lies more anterior and medially from the internal carotid artery, the latter in this area does not have branches extending from it, while branches extend from the external one. Ligation of the internal carotid artery is performed extremely rarely; usually the common carotid artery is ligated. Isolation of the artery should be done extremely carefully, only bluntly. Lateral to the artery lies the internal jugular vein (v. jugularis interna), and the vagus nerve (n. vagus) between them. The descending branch of the hypoglossal nerve (n. hypoglossus) is located on the surface of the artery; it must be moved to the side. The vagus nerve should also be carefully separated from the artery. The artery is ligated in the usual way.
Ligation of the common carotid artery and the internal one can be accompanied by serious consequences as a result of softening of the brain due to the onset of anemia, so it must be resorted to in exceptional cases.
In order to determine whether bleeding occurs from the branches of the external carotid artery or from the branches of the internal artery, a provisional ligature is applied to the external artery and the artery is tightened with this ligature. If the bleeding has stopped, then you can limit yourself to ligation of the external carotid artery; if bleeding continues, then it is necessary to ligate the common carotid artery.
Avoiding errors and dangers
When a vascular bundle is roughly separated, an artery or vein can be injured; when an artery is separated from a vein, the venous branches extending from the vein can be torn. Bleeding occurs, complicating the operation. Therefore, when isolating vessels, one must act extremely carefully; one must use only anatomical tweezers. The use of surgical tweezers is unacceptable.
When performing a ligature with a Deschamps and Cooper needle under an artery, the adjacent vein can be injured, which is especially dangerous, since an air embolism may occur. To prevent this, the needle is always inserted from the side of the vein. To improve blood circulation after ligation of the great vessels on the lower limb, some (V.A. Oppel) suggest ligating the vein of the same name simultaneously with the artery; a delay in blood outflow somewhat reduces the development of anemia in the limb.
^ BLOOD TRANSFUSION,
BLOOD REPLACEMENT AND ANTI-SHOCK SOLUTIONS
Currently, blood transfusion and blood-substituting solutions are quite widely used in surgical practice. Not a single major operation is complete without blood transfusion or infusion of various blood-substituting solutions, therefore, each surgical department must have the equipment necessary for this, and surgical department workers must be proficient in the technique of blood transfusion and infusion of blood-substituting solutions.
Sometimes blood replacement solutions can come from institutions that prepare these solutions, but more often it is necessary to organize the preparation of solutions on site. Therefore, every surgeon heading a surgical department needs to know the composition of solutions and the technique for their preparation.
^ Composition of blood replacement and antishock solutions
Quite a few different recipes for blood replacement and anti-shock solutions have been proposed. The most common are 5% glucose solution and saline solution. Various other substances are added to these basic solutions in order to enhance the effect of the solution on various systems of the patient's body. Alcohol is often used as an antishock agent, so a good antishock solution is a 10% solution of alcohol in a 5% glucose solution or saline solution. This solution can be used in weakened patients as a basic anesthesia. Intravenous administration 300–500 ml This solution induces light sleep, which allows even long operations to be performed under local anesthesia.
Here are recipes for some of the most common solutions that are easy to prepare on site.
Liquid by V. I. Popov
Glucose 150.0 Bicarbonate of soda. . 4.0
Sodium chloride. . . 15.0 Wine alcohol 95°. 100.0
» calcium. . 0.2 Distilled
» potassium... 0.2 water 1000.0
Liquid by I. R. Petrov
Sodium chloride. . . 12.0 Glucose 100.0
» calcium... 0.2 Wine alcohol 95°. 50.0
» potassium.... 0.2 Sodium bromide. . 1.0
Bicarbonate of soda... 1.5 Distilled water 1000.0
Anti-shock solution No. 43 Leningrad Institute of Blood Transfusion
Sodium chloride... 8.0 Veronal. . . . . . . 0.8
Glucose 50.0 Methylene blue. 0.002
Wine alcohol 95°. 50.0 Distilled water 1000.0
Calcium chloride... 2.0
Saline infusion CIPC
Sodium chloride... 8.0 Sodium carbonate, . 0.8
» potassium.... 0.2 Phosphate
» calcium. . . 0.25 sodium 0.23
Magnesium sulfate. . 0.05 Distilled water 1000.0
TsIPK liquid (according to N.A. Fedorov’s recipe)
Sodium chloride. . » 15.0 Eucodal 0.08
» calcium... 0.2 Ephedrine 0.2
Distilled water 1000.0
When preparing solutions, you have to pay special attention both to the preparation of the solutions themselves and to the preparation of the dishes in which the solutions are stored. Solutions should be prepared using good quality distilled water. To do this, it is necessary to ensure the thorough cleanliness of the distillation cube, cooling system and pipeline. Solutions should be prepared using fresh distilled water. Water that has stood for 6 hours or more should not be used for preparing solutions.
Salts and other organic preparations used for the preparation of solutions must meet the chemical and pharmaceutical requirements for intravenous drugs.
The resulting fresh distilled water is boiled again and only then the appropriate drugs are diluted in it. The solution is filtered through a sterile paper filter containing sterile absorbent cotton wool. The vessel with the solution is closed with a sterile regular or cotton-gauze stopper, and the neck is tied at the top with wax. The solution prepared in this way is subjected to sterilization.
All utensils used for solutions are washed with soap and soap powder, then washed with a 0.25% solution
Hydrochloric acid, washed twice with distilled water and dried.
Solutions should be prepared in a special box; The person preparing the solution must wear a sterile mask.
The solution for intravenous infusion must be absolutely transparent. If the solution contains flakes, threads, or any suspension at all, then such a solution should not be used. If a vessel with a solution has been opened and not all of the solution has been used, then, after closing the vessel with a stopper, the solution must be boiled for at least 10 min, to kill microorganisms that accidentally entered the vessel when opening the stopper. The boiled solution can stand for several days; before use, it should be boiled again.
Recently, various protein hydrolysates have been widely used: L-103, aminopeptide, aminokrovin, polyglucin, etc. These solutions are the best blood replacement solutions, as they contain protein components. They are best administered intramuscularly or subcutaneously.
^ Preparation of equipment
New glassware, glass and rubber tubes require special treatment. Rubber tubes should be made of good material, smooth and elastic (from the rubber used to make gastric tubes and catheters).
All glassware is washed with running water. When washing, rubber tubes are carefully rubbed between your fingers. Then the dishes and pipes are boiled 10 min in an alkaline solution and 10 min in distilled water, after which they are dried in an oven at a temperature of 100°.
New Dufault needles are thoroughly wiped off from grease, washed with water from a rubber can, then thoroughly cleaned with cotton wool placed on a mandrin and moistened with ammonia, then with cotton wool moistened with ether or alcohol, after which the lumen of the needle is wiped with dry cotton wool on a mandrin. The needles cleaned in this way are immersed in 96° alcohol for 12 hours, then dried with ether. The processed needles and separately processed mandrins are stored in a 3% solution of paraffin in ether, with their points up, in a jar with a ground stopper. Before use, needles are usually checked with a mandrin.
Blood transfusion equipment must be carefully checked to ensure the correct fit of all parts, especially where rubber and glass tubes are connected. The rubber tubes must be well stretched over the glass tubes, and
In these places, even under strong pressure, liquid should not leak out and air should not pass through.
Thoroughly washed equipment is sterilized in a conventional autoclave; for sterilization, it is wrapped in special wide towels or placed in special bags.
Sometimes after a blood transfusion or infusion of solutions, complications are observed in the form of fever and chills. These complications can arise as a result of improper preparation of the equipment. Therefore, special attention should be paid to the preparation of equipment that has already been in use.
After a blood transfusion, all equipment is immediately washed with a stream of water and immediately boiled or sterilized, after which it is wrapped in a sterile towel and stored until the next transfusion.
If this is not done immediately, then microorganisms that accidentally remain in the joints of rubber and glass tubes can multiply during storage of the equipment and give rise to entire colonies.
Sterilization before transfusion will kill bacterial colonies, but their bodies will remain and give rise to a pyrogenic reaction. Therefore, the equipment must be sterilized immediately after a blood transfusion to kill any bacteria remaining in it. If the blood transfusion is not done immediately, then the equipment must be sterilized again before the transfusion.
After use, the needles are thoroughly washed under the tap, cleaned with a mandrin, dried with a soft towel, blown and placed with the mandrin removed in absolute alcohol for at least 12 hours, and then placed in a 3% solution of paraffin in ether.
Blood transfusion equipment should be stored sterile in a bag, or wrapped in a sterile sheet, or placed in a sterile bag, labeled with the date of sterilization.
To organize blood and solution transfusions, the following items are needed:
Indoor glacier 1
Blood transport box... 1
Siphon tubes 10 pcs.
Rubber tubes ^ 2 kg
Glass tubes 500 G
Droppers 10 pcs.
Flasks with a capacity of 1 l different shapes. . 15 >
Glass funnels 3 »
Screw terminals 5"
Dufault needles 20 »
Glass cannulas 10"
A wooden or metal stand for strengthening ampoules with blood and for
Installations of flasks with solutions 2 »
Syringes of various sizes 5 pcs.
Needles for syringes of various thicknesses. . 10"
Frank's needle 1"
Slides 10 »
Flat plates 2 »
Eye pipettes 5 »
Storage box for standard products
rotok 1 »
Vidalevsky test tubes 10 »
Richardson cylinders 2 »
Bags for sterilizing equipment. . 20"
The remaining necessary items will always be found in every surgical department.
When ligating the subclavian artery, a. subclavia , collateral circulation develops through anastomoses between the transverse artery of the neck, a. transversa colli , and suprascapular artery, a. suprascapularis , with the posterior and anterior surrounding arteries of the shoulder, ah. circumflexa humeri anterior et posterior , and the artery surrounding the scapula , a. circumflexa scapulae, as well as anastomoses between the internal and lateral thoracic arteries, a. thoracica interna And a. thoracica lateralis.
Two networks are formed in the circumference of the shoulder joint - the network of the scapula, rete scapulae , and supra-shoulder network, rete acromiale .
When ligating the axillary artery, a. axillaris , collateral circulation is carried out through the scapular network, rete scapulae , or scapular arterial circle, through anastomoses between the branches of the subclavian artery - the transverse artery of the neck ,a . transversa colli, infrascapular artery, a. suprascapularis; with branches of the axillary artery - the thoracodorsal artery, a. thoracodorsalis , and surrounding scapular artery , a. circumflexa scapulae.
Around the surgical neck of the humerus, by anastomosis of the anterior and posterior circumflex arteries, a. circumflexa humeri anterior et posterior , the axillary artery forms the brachial plexus rete humere . This plexus provides blood supply to the shoulder joint and adjacent muscles.
Collateral circulation during ligation of the brachial artery, a. brachialis , develops through anastomoses between the branches of the deep brachial artery, a. profunda brachii, middle and radial bypass arteries, a.collaterales radialis et media, superior and inferior ulnar bypass arteries, a. collateralis ulnaris superior et interior , with recurrent branches of the radial and ulnar arteries, ah. reccrrens radialis et ulnaris .
In the circumference of the elbow joint, the network of the elbow joint, rete articulare cubiti , which separately considers the olecranon network, rete olecrani . Both of them are formed by the branches of the superior and inferior ulnar bypass arteries (branches of the brachial artery), the middle and radial bypass arteries (branches of the deep artery) of the shoulder on one side and the branches of the recurrent radial arteries (branch of the radial artery), recurrent ulnar arteries (branches of the ulnar artery) and the recurrent interosseous artery (a branch of the posterior interosseous artery) on the other side.
On the palmar surface there is a palmar network of the wrist, rete carpi palmare , formed from the carpal palmar branches, rami carpei palmares , radial and ulnar arteries, as well as the anterior interosseous artery, a. interossea anterior.
On the dorsum of the hand, in the area retinaculum extensorum , lies the dorsal network of the wrist, rete carpi dorsale . It divides into the superficial dorsal carpal network, rete carpi dorsale superficiale , located under the skin and deep dorsal network of the wrist, rete carpi dorsale profundum , – on the bones and ligaments of the wrist joints. Formed from anastomoses of the dorsal carpal branches, rami carpei dorsales, radial and ulnar arteries and posterior interosseous artery, a. interossea posterior.
Arteries of the trunk, arteriae trunci
Thoracic aorta , aorta thoracica , has a length of about 17 cm, its diameter is from 2.1 to 3.8 cm. It is located to the left of the bodies of the V-VIII and in front of the bodies of the IX-XII thoracic vertebrae. Through hiatus aorticus The aorta penetrates the abdominal cavity from the diaphragm. The thoracic aorta lies in the posterior inferior mediastinum, directly on the spinal column. To the left of the aorta is the hemizygos vein, v . hemiazygos , in front – the pericardial sac and the left bronchus. On the right is the thoracic lymphatic duct, ductus thoracicus , and azygos vein, v. azygos. At the level of the IV-VII thoracic vertebrae, the aorta lies to the left of the esophagus, at the level of the VIII-IX vertebrae - behind and at the level of the X-CP - to the right and behind it. Two types of branches arise from the thoracic aorta, splanchnic or visceral branches, rr. viscerales, and parietal or parietal branches, rr. parietales.
Internal branches of the thoracic aorta, rr. viscerales:
1. Bronchial branches , rr. bronchiales , 3-4 pieces enter the gates of the right and left lungs and supply blood to the bronchi, connective tissue stroma of the lung, peribronchial lymph nodes, pericardial sac, pleura and esophagus;
2. Esophageal branches , rr. esophagei, from 3 to 6 pieces supply blood to the esophagus;
3. Mediastinal branches , rr. mediastinales, numerous branches supplying blood to the connective tissue and lymph nodes of the mediastinum;
4. Pericardial branches , rr. pericardiaci, directed to the posterior surface of the cardiac sac.
Parietal branches of the thoracic aorta , rr. parietales:
1. Superior phrenic arteries , ah. phrenicae superiores, in the amount of two, they supply blood to the lumbar part of the diaphragm;
2. Posterior intercostal arteries , ah. intercostales posteriores, in the amount of 9-10 pairs. Nine of them lie in the intercostal spaces, from the third to the eleventh inclusive, the lowest ones go under the XII ribs and are called the subcostal arteries, a. subcostalis ; in each of the intercostal arteries a dorsal branch is distinguished, r. dorsalis , to the deep muscles and skin of the back and spinal branch, r. spinalis , to the spinal cord and its membranes.
The superior intercostal arteries supply blood to the chest wall; branches extend from the IV-VI intercostal arteries to the mammary gland, the lower three supply blood to the abdominal wall and diaphragm.
abdominal aorta, aorta abdominalis , is a continuation of the thoracic aorta. It begins at the level of the XII thoracic vertebra and reaches the IV-V lumbar vertebra. Located to the left of the midline, its length is 13-14 cm, diameter 17-19 mm. The abdominal aorta then divides into two common iliac arteries, ah. iliacae communes dextra et sinistra . From the place of division of the aorta, a thin branch extends downwards, being its continuation, lying on the anterior surface of the sacrum - the median sacral artery, a. sacralis mediana.
Two types of branches arise from the abdominal aorta: parietal branches, rr. parietals , and internal branches rr. viscerales.
Parietal branches of the abdominal aorta, rr. parietales:
1. Inferior phrenic artery , a. phrenica inferior , departs immediately after the exit of the aorta through the diaphragmatic opening at the level of the XII thoracic vertebra and is directed to the lower surface of the tendon part of the diaphragm. The right artery passes behind the inferior vena cava, the left - behind the esophagus. Supplies blood to the diaphragm, gives off to the superior adrenal arteries, aa. suprarenales superiores .
Rice. 2.14. Branches of the abdominal aorta (diagram).
1 – colon transversum; 2 – truncus coeliacus; Z – a. gástrica sinistra; 4 – a. splenica (Henaus); 5 – cauda pancreatis; 6 – v. henaus; 7 – a. mesenterica superior; 8 – aa. jejunales et ileales; 9 – a. cólica sinistra; 10 – a. mesenterica inferior; 11 – a. sigmoidea; 12 – a. iliaca communis; 13 – a. rectalis superior; 14 – rectum; 15 – colon sigmoideum; 16 – a. appendicularis; 17 – caecum; 18 – a. ileocaecalis; 19 – a. colica dextra; 20 – a. colica media; 21 – v. mesenterica superior; 22 – v. mesenterica inferior; 23 – v. porta hepatitis; 24 – caput pancreatis; 25 – duodenum; 26 - hepar; 27 – vesica felae; 28 – a. hepatica communis.
2. Lumbar arteries, ah. lumbales , in the amount of 4-5 branches, depart at the level of the bodies of the I-IV lumbar vertebrae, running parallel to the posterior intercostal arteries. The two upper branches pass behind the kidneys and diaphragm, the two lower ones lie behind m. psoas major . Having reached the transverse processes of the vertebrae, each lumbar artery divides into spinal and dorsal branches, r. spinalis et r. dorsalis . They supply blood to the muscles and skin of the back, the spinal cord with its membranes.
3. Median sacral artery , a. sacralis mediana , is a continuation of the abdominal aorta at the site of its division into two common iliac arteries. Supplies blood to the sacrum, surrounding muscles and rectum.
Internal branches of the abdominal aorta, rr. viscerales , divided into paired and unpaired.
Unpaired visceral branches:
1. Celiac trunk, truncus coeliacus . The vessel is 1-2 cm long, departs at the level of the XII thoracic - upper edge of the body of the I lumbar vertebra, is divided into three branches:
1.1. Left gastric artery, a. gastrica sinistra , approaching the cardial part of the stomach, it gives off esophageal branches, rr. esophagei , then goes between the leaves of the lesser omentum along the lesser curvature of the stomach from left to right, sending branches to the anterior and posterior walls of the stomach;
Rice. 2.15. Arteries of the stomach, duodenum, pancreas
and spleen. The stomach is turned upward.
1 – a. gastrica sinistra; 2 – a. splenica; 3 – a. gastroepiploica sinistra; 4 – aa. gastricae breves; 5 – a. gastroepiploica sinistra; 6 – a. caude pancreatis; 7 – a. pancreatica magna; 8 – a. pancreatica inferior; 9 – a. pancreatica dorsalis; 10 – a. pancreaticoduodenalis inferior; 11 – a. pancreaticoduodenalis anterior inferior; 12 – a. pancreaticoduodenalis posterior inferior; 13 – a. pancreaticoduodenalis anterior superior; 14 – a. pancreaticoduodenalis posterior superior; 15 – a. pancreaticoduodenalis anterior superior; 16 – a. gastroduodenalis; 17 – a. gastroepiploica dextra; 18 – a. hepatica propria; 19 – a. gastrica dextra; 20 – a. hepatica communis; 21 – truncus coeliacus.
1.2. Common hepatic artery, a. heratica communis , is located behind and parallel to the pyloric part of the stomach, enters the thickness of the lesser omentum and is divided into two branches:
1.2.1.Gastroduodenal artery, a. gastroduodenalis , which goes downwards, behind the pyloric part of the stomach, crossing it from top to bottom, and is divided into two vessels:
Superior pancreaticoduodenal artery, a. pancreaticoduodenalis superior , which is located between the head of the pancreas and the descending part of the duodenum and gives off branches to the head of the pancreas, rr.pancreatici , to the duodenum, rr . duodenales.
Right gastroepiploic artery, a. gastromentalis dextra , passes along the greater curvature of the stomach between the leaves of the greater omentum and gives off branches: the anterior and posterior surfaces of the stomach, rr. gastrici , as well as to the greater omentum, rr.omentales .
1.2.2. Proper hepatic artery a. hepatica propria , goes to the gate of the liver in the thickness lig. hepatoduodenal , to the left of ductus choledochus and somewhat in front of v. portae . Approaching the gate of the liver, the proper hepatic artery divides into the right, r. dextra , and left r. sinistra, branches . They depart from it:
Right gastric artery a. gastrica dextra , heading towards the lesser curvature of the stomach, it goes between the leaves of the lesser omentum from right to left, where it anastomoses with the left gastric artery.
Biliary artery , A. cystica, arises from the right branch of the proper hepatic artery.
1.3. Splenic artery, a. lienalis, passes behind the stomach along the upper edge of the pancreas. Having reached the tail of the pancreas, it enters the gastrosplenic ligament, lig. gastroliennale , and at the gate of the spleen it is divided into 3–6 branches. The splenic artery gives branches:
1.3.1. To the body and tail of the pancreas, rr. pancreatici ;
1.3.2. Short gastric arteries ah. gastricae breves , to the back wall of the stomach;
1.3.3. Left gastroepiploic artery, a. gastromentalis sinistra , the largest branch, located between the leaves of the greater omentum along the greater curvature of the stomach, runs from left to right and anastomoses with the right gastroepiploic artery.
2. Superior mesenteric artery , a. mesenterica superior , originates at the level of the first lumbar vertebra. Its beginning is located between the head of the pancreas and the horizontal part of the duodenum, then it passes into the gap between the lower edge of the pancreas and the ascending part of the duodenum, enters the root of the mesentery of the small intestine at the level of the II lumbar vertebra, forming an arch convexly facing to the left, and reaches the right iliac fossa.
From the superior mesenteric artery arise:
2.1. inferior pancreaticoduodenal artery, a. pancreaticoduodenalis inferior, which runs along the anterior surface of the pancreas, goes around its head, where it anastomoses with the superior pancreatic-duodenal artery. Gives branches to the pancreas and duodenum.
2.2. Skinny arteries, aa. jejunales , and ileum, aa. ilei , in the amount of 16-20, extend between the layers of the mesentery of the small intestine. They run fan-shaped, connecting with each other by 3-4 arterial arches. They supply blood to the small intestine and its mesentery.
2.3. Ileocolic artery, a. ileocolica . Supplies blood to the cecum and terminal ileum. Gives off the artery of the vermiform appendix, a.appendicularis , which is located in the mesentery of the process.
2.4. Right colon artery, a. Colica dextra , supplies blood to the ascending colon. Gives ascending and descending branches.
2.5. Middle colic artery, a. colica media , goes deep into the mesentery of the transverse colon, supplies the intestine with blood, giving off right and left branches.
3. Inferior mesenteric artery , a. mesenterica inferior .
It arises from the aorta at the level of the lower edge of the third lumbar vertebra. Gives the following branches:
3.1. Left colic artery, a. colica sinistra , located retroperitoneally, in front of the left ureter and left testicular (ovarian artery). Divided into ascending and descending branches, it supplies blood to the descending colon. All colon arteries form anastomoses with each other (riolan arches).
3.2. Sigmoid arteries, aa. sigmoideae , supply blood to the sigmoid colon, are located first retroperitoneally, and then between the layers of its mesentery.
3.3. superior rectal artery, a. rectalis superior , supplies blood to the upper third of the rectum.
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93. Exposure and ligation of the axillary artery.
Projection of the axillary artery: along the line on the border between the anterior and middle third of the width of the armpit or along the anterior border of hair growth in the armpit (according to Pirogov).
Technique for exposure and ligation of the axillary artery:
1. Position of the patient: on the back, the upper limb is moved to the side at a right angle and laid on a side table
2. An incision of the skin, subcutaneous fat, superficial fascia 8-10 cm long, slightly anterior to the projection line, corresponding to the convexity of the belly of the coracobrachialis muscle
3. Using a grooved probe, we dissect the anterior wall of the vagina of the coracobrachialis muscle.
4. We retract the muscle outward and, carefully, so as not to damage the axillary vein associated with the fascia, we dissect the posterior wall of the vagina of the coracobrachial muscle (which is also the anterior wall of the vascular sheath)
5. We stretch the edges of the wound, highlight the elements of the neurovascular bundle: in front the axillary artery (3) is covered by the median nerve (1), laterally - by the musculocutaneous nerve (2), medially - by the cutaneous medial nerves of the shoulder and forearm (6), by the ulnar nerve , behind - the radial and axillary nerve. The axillary vein (5) and cutaneous nerves of the shoulder and forearm are displaced medially, the median nerve is displaced laterally and the axillary artery is isolated.
6. The artery is ligated with two ligatures (two for the central section, one for the peripheral) BELOW THE ORIGIN tr. thyrocervicalis ABOVE THE ORIGIN of the subscapular artery (a.subscapularis). Collateral circulation develops due to anastomoses between the suprascapular artery (from the thyrocervical trunk of the subclavian artery) and the circumflex scapular artery (from the subscapular artery - a branch of the axillary artery), as well as between the transverse artery of the neck (a branch of the subclavian artery) and the thoracodorsal artery (from the subscapular artery - branches of the axillary artery).
94. Exposure and ligation of the brachial artery.
P 
projection of the brachial artery defined as a line from the apex of the axilla along the internal groove of the shoulder to the middle of the distance between the medial condyle of the humerus and the tendon of the biceps brachii muscle.
Exposure and ligation of the brachial artery is possible in:
a) in the middle third of the shoulder:
1. Patient position: on the back, arm extended to the side on the extension table
2. By palpation we determine the medial edge of the biceps brachii muscle, then 2 cm outward from the projection line along the convexity of the abdomen of this muscle, we make a 6-8 cm long incision in the skin, subcutaneous fatty tissue, and superficial fascia.
3. We stretch the edges of the skin wound and cut the anterior wall of its fascial sheath along the medial edge of the biceps muscle.
4. We pull the biceps muscle laterally and, using a grooved probe, we dissect the posterior wall of the fascial sheath of the muscle (which is also the anterior wall of the vascular sheath)
5. Determine the brachial artery (the median nerve is located most superficially at the edge of the biceps muscle, the brachial artery passes under it)
6. We ligate the axillary artery below the origin of the a.profunda brachii (then collateral circulation develops through anastomoses between the deep brachial artery and the a.collateralis ulnaris superior with the recurrent branches of the radial and ulnar arteries)
b 
) in the cubital fossa:
1. Position of the patient: on the back, the artery is abducted at a right angle and fixed in a supination position
2. A skin incision 6-8 cm long in the middle third of the projection line from a point 2 cm above the medial condyle of the shoulder through the middle of the elbow to the outer edge of the forearm.
3. The v.mediana basilica is crossed between the two ligatures, taking care not to damage the internal cutaneous nerve of the forearm in the medial corner of the wound
4. The thin fascia and shiny fibers of the trapezoidal ligament of Pirogov (aponeurosis m. bicipitis brachii), coming from the biceps tendon obliquely downward and medially, are incised with a scalpel and then cut along the grooved probe along the line of the skin incision
5. We stretch the wound, at the medial edge of the biceps tendon we find the brachial artery, and slightly inward from it - the median nerve.
6. We ligate the brachial artery (collateral circulation in this area is well developed due to anastomoses between the branches of the brachial artery and the return vessels of the radial and ulnar arteries)
95. Vascular suture (manual Carrel, mechanical suture). Operations for injuries of large vessels.
1912, Carrel - first proposed the vascular suture technique.
Vascular suture is used to restore main blood flow in the treatment of:
a) traumatic and surgical damage to blood vessels
b) aneurysms of limited extent, segmental occlusions, thrombosis and vascular embolism.
Materials: non-absorbable synthetic monofilament threads (from prolene - gold standard, mersilene, ethylone, etibond) and atraumatic cutting-stabbing curved needles ("penetrating" tip-point and thin round body).
Tools: special instruments are most often used: vascular clamps (Satinsky lateral push-up, straight and curved bulldogs), dissector scissors, anatomical tweezers.
Types of vascular suture:
A. hand stitch
a) circular (circular): 1. continuous (twisting) 2. nodal
b) lateral: 1. continuous (twisting) 2. nodal; 1. transverse 2. longitudinal
B. mechanical suture – applied with vaso-suturing devices
The main provisions of the vascular suture technique:
1. Sufficient mobilization of the vessel being sutured (up to 1-2 cm)
2. Thorough bleeding of the surgical field (clamping of the lumen of the vessel with rubber glove strips - tourniquets, a finger or stubble in the wound, Hoepfner forceps, etc.)
3. The suture is placed through all layers of the vessel wall
4. The ends to be stitched must touch the intima
5. The needle is inserted approximately 1 mm from the edge of the vessel; the interval between stitches is 1-2 mm.
6. The seams must be sufficiently tightened, the vascular suture must be airtight both along the line of contact of the vessel walls and in the places where the threads pass.
7. Blood flow is restored by first removing the distal and then the proximal clamps.
8. Vascular surgery is performed under hypocoagulation conditions (injection of heparin into a vein - 5000 units and locally - 2500 units of heparin dissolved in 200 ml of physiological solution)
Method of applying a circular continuous (wrap) Carrel suture
(currently used only in microsurgery for suturing small-diameter vessels):
1. When a vessel is injured, the intima and media contract and move proximally, so it is necessary to carefully excise the excess adventitia.
2. Place three stay sutures at an equal distance from each other (120), bringing the edges of the vessel to be sewn together. To do this, we stitch both ends of the vessel with three atraumatic threads through all layers (one from the adventitia side, the other from the intimal side), at a distance of 1.0 mm from the edge. We bring the edges of the vessels together and tie the threads. When stretched by the ends of the threads, the lumen of the vessel acquires a triangular shape, which ensures that the needle does not catch the opposite wall when applying an enveloping suture between the holders.
3
. The edges are sutured sequentially, each time connecting the main ligature with a thread-holder.
Scheme for applying a circular Carrel suture:
a – application of stay sutures; b – bringing the edges of blood vessels closer together; c – suturing of individual edges of the vessel; d – completed seam of the vessel.
A.I. Morozova’s technique (now used in surgery of medium and large vessels):
1
. Instead of three stay sutures, two are used. The role of the third holder is assigned to the main thread.
2. An enveloping suture is applied to one (front) wall of the vessel, after which the clamps with the vessel are turned 180 and the other semicircle of the vessel is stitched.
Errors and complications when applying a vascular suture:
1. Narrowing of the lumen of the vessel (stenosis) – occurs most often due to the capture of excess tissue. Elimination of the defect: excision of the edges of the vessel along the suture line and application of a new end-to-end anastomosis with a circular end-to-end and transverse side suture or application of a lateral venous patch with a longitudinal side suture.
2. Bleeding along the suture line – occurs more often due to insufficient tightening of the thread, weakness of the vascular wall due to inflammation, thinning, or cutting through the suture. Elimination: applying tampons, hemostatic gauze to the vessel, applying single U-shaped or interrupted sutures, fibrin glue.
3. Vascular thrombosis– occurs due to errors in suture application, temporary clamping of the vessel, tucking of the intima and adventitia. Elimination: dissection of the artery and removal of the thrombus, inspection of the vessels using balloon catheters.
Method of applying a mechanical suture.
The ends of the vessel are beaded and fixed on the bushings of the stapler and thrust parts of the stapler (Gudov, Androsov), the latter are connected and, using a special lever, the walls of the vessel are stitched with tantalum staples (clips).
The main advantages of a mechanical seam: speed of anastomosis; absolute tightness of the anastomosis; lack of suture material (clip) in the lumen of the vessel; the possibility of developing stenosis is excluded.
Operations for injuries of large vessels:
1. Access to the vessels is carried out in those places where they are located most superficially (carotid triangle for the common carotid arteries, Ken’s line (from the spina iliaca anterior superior to the medial femoral condyle) for the femoral artery, etc.)
2. Main types of operations performed:
a) applying a side suture to the wound
NB! If two walls of a large vessel are damaged at once (for example, with a bullet wound), the wound of the front wall of the vessel should be expanded, the wound of the rear wall should be sutured from the lumen of the vessel, and the wound of the front wall should be sutured.
b) application of a circular suture (when crossing vessels)
c) vascular prosthetics (if it is impossible to tighten the walls of the vessel; prostheses made of polytetrafluoroethylene, lavsan, dacron, homo- and xeno-bioprostheses are more often used)
d) ligation of the artery - performed as a last resort in case of:
1. the presence of extensive defects and damage to blood vessels, when the victim requires resuscitation measures
Ligation of damaged arteries saves the victim’s life, but leads to ischemia of varying severity. Ligation of the iliac arteries, femoral artery, popliteal artery, common and internal carotid arteries, and axillary artery is especially dangerous.
96. Suture of tendon (Cuneo) and nerve.
Tenorrhaphy- suturing tendons.
Requirements for tendon sutures:
1. The seam must be simple and technically feasible
2. The suture should not significantly disrupt the blood supply to the tendons
3. When applying a suture, it is necessary to ensure that the smooth sliding surface of the tendon is maintained and limit the use of threads to a minimum
4. The seam should firmly hold the ends of the tendons for a long time and prevent them from becoming fibered.
Indications for applying a tendon suture:
a) fresh wounds with tendon damage
b) suturing of tendons in a delayed period to restore the function of flexors and extensors
Classification of tendon sutures (according to V.I. Rozov):
1. sutures with knots and threads located on the surface of the tendon (U-shaped Brown suture for flat tendons)
2. intra-trunk sutures with knots and threads located on the surface of the tendon (Lange suture)
3. intra-trunk sutures with knots immersed between the ends of the tendon (Cuneo suture)
4. other sutures (Kirschner method - using fascia to wrap and connect the tendon)
T 
Cuneo tendon suture technique:
1. Both ends of a long silk thread are threaded onto two straight thin needles.
2. First, a thin puncture is made through the tendon, 1-2 cm away from its end, then the tendon is pierced obliquely with both needles. As a result, the threads intersect.
3. This technique is repeated 2-3 times until the end of the tendon segment is reached.
4. Then they begin to stitch another section of tendon in the same way.
5. When the threads are tightened, the ends of the tendon touch.
The nerve suture was first developed by Nelaton (1863) and put into practice by Langer (1864).
The main purpose of the suture: precise comparison of the excised bundles of the damaged nerve with minimal trauma to both it and the surrounding tissues, because excessive trauma enhances degenerative phenomena in the nerve trunk and promotes the development of scar tissue in its circumference.
Indications for nerve suturing:
a) complete anatomical break of the nerve trunk
According to the method of application, there are 1. epineural and 2. perineural nerve sutures.
Technique for applying epineural suture:
1. Isolation from the side of the unchanged portion of the proximal end of the nerve in the direction of the damage zone
2. The ends of the nerve or neuroma are excised within the unchanged tissue with a very sharp blade so that the cutting line is extremely smooth
3. The epineural suture is applied with a thread on a cutting needle.
4. The epineurium is mobilized around the circumference of the nerve, the ends of the nerve are compared. The alignment of the ends should not be too tight (diastasis 0.5-1 mm).
5. At a distance of 1 mm from the edge of the nerve, a needle is inserted perpendicular to its surface, making sure that it passes only the epineurium
6. The needle is intercepted with a needle holder and inserted into the opposite end of the nerve from the inside.
7. The knot is tied, leaving the end of the thread 3 cm long.
8. Similarly, a second guide suture is applied at an angle of 180 relative to the first.
9. The epineurium is stretched and another 1-2 sutures are placed on the anterior semicircle of the nerve.
10. Intermediate epineurial sutures are placed between the stay sutures, preventing the epineurium from being turned inward.
11. The stitched nerve is placed in a bed prepared within the unchanged tissues
T 
Technique for applying a perineural suture:
1. The nerve is isolated as when applying an epineural suture. The epineurium is removed 5-8 mm from both ends of the nerve to open access to the bundles.
2. Using a thread on a cutting needle behind the perineurium, each group of bundles is sewn separately (2-3 sutures for each group). Restoring the integrity of the bundles begins with the deepest located bundles.
97. Shoulder amputation.
The shoulder amputation technique has features depending on the level of its implementation:
A) in the lower third.
1. Analgesia: usually general anesthesia.
2. Before amputation, a hemostatic tourniquet is applied.
3. Using a medium amputation knife, a circular incision is made in the skin to the proper fascia
4. In front, on the flexor surface, due to the high contractility of the skin, the incision is made 2 cm more distal than in the back (skin contractility above the anterior-inner surface is 3 cm, on the postero-outer surface 1 cm)
6. Having pulled back the skin and muscles, cut the muscles to the bones a second time. It is important not to forget to cut the radial nerve located on the posterior outer surface.
7. The periosteum is cut 0.2 cm above the intended cut and peeled off downwards. They saw the bone.
8. The brachial artery, deep brachial artery, superior ulnar collateral artery are ligated, and the median, ulnar, radial, lateral and medial cutaneous nerves of the forearm are cut off high.
9. Having removed the tourniquet, apply a ligature to small vessels.
1
0. Sew the own fascia and apply skin sutures with drainage for the 2nd day.
b) in the middle third– performed using a two-flap fasciocutaneous method
1. The skin and its own fascia are dissected in the form of two (anterior long and posterior short) flaps. The flaps are separated upward.
2. At the level of the base of the separated flaps, the muscles are crossed. In this case, the biceps brachii muscle is crossed distal to the others.
3. Slightly proximal to the site of the intended bone cut, the periosteum is cut and slightly moved downward, and then the bone is sawed through.
4. In the stump, the brachial artery, deep brachial artery, superior ulnar collateral artery are ligated, and the median, radial, ulnar, musculocutaneous and medial cutaneous nerves of the forearm are crossed.
5. The edges of the transected fascia are connected with interrupted sutures. Sutures are placed on the skin with drainage.
V) in the upper third– amputation is performed with the formation of a stump from two musculocutaneous flaps, if possible preserving the deltoid muscle and the head of the humerus (for cosmetic and functional benefits; provides the ability to carry weight on the shoulder, improves the conditions for prosthetics):
1. Cut out the first flap, including the deltoid muscle with the skin covering it, preserving the axillary nerve.
2. A second musculocutaneous or fasciocutaneous flap is cut out on the medial surface of the shoulder
3. Cover the cut of the humerus with the first flap, connecting it with sutures to the second flap.
4. After the operation, the shoulder stump is fixed in the position of abduction by 60-70% and flexion by 30% to prevent adductor contracture of the shoulder.
Medicine and veterinary medicine
Artery of the forearm The radial artery arises from the brachial artery in the cubital fossa and goes into the lateral canal of the forearm, the radial groove, where it passes accompanied by the superficial branch of the radial nerve. Next, the ulnar artery passes behind the brachial head of the pronator teres and the median nerve downwards and lies medially in the middle third of the forearm in the medial canal of the forearm, approaching the ulnar nerve passing in the canal. The medial canal of the forearm is limited medially by the flexor carpi ulnaris and laterally by the superficial...
Arteries of the forearm. Arterial collaterals of the elbow region. Ligation of the radial and ulnar arteries.
Artery of the forearm
The radial artery departs from the brachial artery in the cubital fossa, goes to the lateral canal of the forearm (radial groove), where it passes accompanied by the superficial branch of the radial nerve.
The ulnar artery, having left the brachial artery in the cubital fossa between the heads of the pronator teres, gives off the common interosseous artery. The common interosseous artery between the flexor digitorum profundus and the flexor pollicis longus reaches the bony membrane, where it divides into two branches: the anterior interosseous artery and the posterior interosseous artery. Next, the ulnar artery passes behind the brachial head of the pronator teres and the median nerve downwards and medially, lies in the middle third of the forearm in the medial canal of the forearm, approaching the ulnar nerve passing in the canal. The medial canal of the forearm is limited medially by the flexor carpi ulnaris, laterally by the flexor digitorum superficialis, anteriorly by the fascia propria of the forearm, and posteriorly by the flexor digitorum profundus. In addition to the interosseous artery, the ulnar artery gives off muscular branches to the forearm.
The anterior interosseous artery is located on the anterior surface of the interosseous membrane. The artery accompanying the median nerve departs from the anterior interosseous artery. In the lower third of the forearm, the anterior interosseous artery passes behind the pronator quadratus and passes through the hole in the interosseous membrane into the posterior muscle bed. The anterior interosseous artery is of great importance for roundabout circulation during ligation of the radial and ulnar arteries.
The posterior interosseous artery goes to the back of the forearm through a hole in the interosseous septum.
Arterial collaterals of the ulnar region
The largest number of collaterals begin to function when blood flow is disrupted in the area between the origin of the brachial arterya. collateralis ulnaris inferiorand the site of division of the artery into the radial and ulnar.
The branches directly anastomosing with each other are presented below.
Top: Bottom:
a. collateralis radialis -> a. recurrent radialis
a. collateralis media -> a. interossea recurrences
a. collateralis ulnaris superior<->ramus posterior a. recurrens ulnaris
a. collateralis ulnaris inferior<->ramus anterior a. recurrens ulnaris
The most unfavorable is the cessation of the main blood flow in the area above the deep brachial artery.
Ligation of the radial and ulnar artery
- Ligation of the radial artery The projection line of the radial artery connects the middle of the elbow with the pulse point. The hand is in a supinated position. A skin incision 6 x 8 cm long is made along the projection of the vessel. The proper fascia is opened using a grooved probe and the radial artery with its accompanying veins is found. In the upper half of the forearm it passes between m. brachioradialis (outside) and m. pronator teres (inside) accompanied by the superficial branch of the radial nerve, in the lower half of the forearm in the groove between the rn. brachioradialis and rn. flexor carpi radialis. A ligature is applied to the isolated artery.
- Ligation of the ulnar artery The projection line goes from the internal condyle of the humerus to the pisiform bone. This line corresponds to the course of the ulnar artery only in the middle and lower third of the forearm. In the upper third of the forearm, the location of the ulnar artery corresponds to the line connecting the middle of the elbow with a point located on the border of the upper and middle third of the medial edge of the forearm. The hand is in a supinated position. A skin incision 7 x 8 cm long is made along the projection line. After cutting the own fascia of the forearm, the flexor carpi ulnaris muscle is pulled inward with a hook and entered into the gap between this muscle and the superficial flexor digitorum muscle. The artery lies behind the deep layer of the own fascia of the forearm. It is accompanied by two veins, and the ulnar nerve is located outside the artery. The artery is isolated and ligated.
- Nerves of the forearm. Median, ulnar, radial nerves.
The superficial branch of the radial nerve in the middle third of the forearm accompanies the radial artery, in the lower third of the forearm it deviates from the radial artery laterally, passes under the tendon of the brachioradialis muscle and passes to the dorsum of the forearm, and then penetrates the hand, where it innervates two and a half fingers on the radial side.
The ulnar nerve in the forearm passes between the two heads of the flexor carpi ulnaris muscle and lies in the medial canal of the forearm in the middle third of the forearm, the ulnar artery approaches it. In the lower third of the forearm, a dorsal branch departs from the ulnar nerve, which, under the flexor carpi ulnaris tendon, bends around the ulna, pierces the fascia of the forearm and, in the subcutaneous tissue, reaches the back of the hand, where it innervates two and a half fingers on the ulnar side. The ulnar neurovascular bundle reaches the wrist along the medial canal of the forearm and through the ulnar canal the carpal canal passes to the hand.
The median nerve penetrates the forearm between the brachial and ulnar heads of the pronator teres and then lies strictly in the middle of the forearm between the superficial and deep flexor digitorum muscles. From the median nerve between the heads of the pronator teres, the anterior interosseous nerve of the forearm departs, which, accompanied by the vessels of the same name, passes between the flexor digitorum profundus and the flexor pollicis longus, lies on the anterior surface of the interosseous membrane and goes down behind the pronator teres, giving off branches to the nearest muscles. In the lower third of the forearm, the median nerve laterally bends around the flexor digitorum superficialis and, at the border with the wrist, lies between the tendons of the flexor carpi radialis laterally, the flexor digitorum superficialis medially, the palmaris longus muscle in front and the deep flexor digitorum muscle behind. Next, the median nerve, together with the tendons of the three muscles, passes to the hand through the carpal tunnel
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OPERATIVE SURGERY
LIMBS
OPERATIONS ON VESSELS
Operations on arterial, venous and lymphatic vessels constitute a large branch of modern surgery and in many cases are organ-preserving. That is why every doctor, and especially a novice surgeon, must be armed with knowledge of the topographic anatomy of blood vessels and the basic surgical techniques used to stop bleeding and restore blood supply.
The current stage of development of vascular surgery is characterized by wide diagnostic capabilities due to the advent of perfect (selective) vasography with determination of speed, volume of blood flow and level of occlusion, the use of ultrasound, radioisotope and tomographic methods, as well as the development of various types and methods of prosthetics and bypass surgery of arteries and veins. The development of microsurgery, which makes it possible to restore blood flow even in vessels with a diameter of 0.5-3 mm, should be considered a great achievement.
The history of vascular surgery begins in ancient times. With names Antilusa And Filagrius(III-IV centuries) classical methods of operations for vascular aneurysms are associated. Ambroise Pare in the 16th century he was the first to perform ligation of arteries throughout. In 1719 L. Geister proposed a method for isolated ligation of arteries and veins, and in 1793 Deschamps designed a special needle for passing a ligature under a blood vessel, later called the needle Deshana. The first surgeon to stitch the vascular wall was Hellowel(1759), and the development of the modern vascular suture belongs to the Frenchman A. Carrel(1902).
VESSEL LIGATION
At the present stage of development of surgery, ligation of a large blood vessel can be used as a forced operation, often indicating the powerlessness of the surgeon. Ligation of the main artery, even in a relatively favorable place from the point of view of the development of collateral circulation, is always dangerous and is accompanied by necrosis or, at best, severe ischemic syndrome, called “ligated vessel disease.”
278 * TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY O- Chapter 4
Rice. 4-1. Scheme of incisions for ligation of arteries throughout. 1 - common carotid artery, 2, 3 - subclavian artery, 4 - axillary artery, 5 - brachial artery, 6 - radial artery, 7 - ulnar artery, 8 - iliac artery, 9,10 - femoral artery, 11,12 - posterior and anterior tibial artery. (From: Komarov B.D.
When operatively accessing vessels, it is necessary to be guided by projection lines (Fig. 4-1).
When opening the vaginal vessel, the artery is isolated from the accompanying veins. From the side of the gap between the vein and artery with a needle De-shana Two ligatures (central and peripheral) are placed alternately under the vein at a distance of 1.5-2 cm from one another (Fig. 4-2). Between the peripheral and central ligatures, the venous vessel is crossed at a distance of 0.5 cm from the central one.
When ligating a large arterial trunk, first the central end of the vessel is ligated with a surgical knot, then the peripheral end. Then 0.5 cm distal to the central
Rice. 4-2. General principles of ligation of venous vessels.
Rice. 4-3. General principles of ligation of large arterial vessels with suturing. The arrow indicates the direction of blood flow, the dotted line indicates the intersection of the vessel.
After each ligature, a stitching ligature is applied to avoid possible slippage of the ligature due to the resulting “club” (Fig. 4-3).
After ligation, the arterial trunk is transected in order to interrupt the sympathetic nerves passing through the adventitia of the vessel, which gives the effect of its desympatization. This manipu- | lation creates better conditions for the development of collateral circulation.
The possibilities of restoring blood circulation along the roundabout routes after ligation of large arteries depend on the level of ligation of these; vessels and the degree of development of collateral circulation. Collateral circulation is carried out mainly due to existing anastomoses between the branches of various arterial trunks, while newly formed collaterals begin to function only after 60-70 days.
OPERATIONS ON ARTERIES
Among arterial diseases subject to surgical treatment, five main groups can be distinguished.
1. Malformations and anomalies: coarctation of the first aorta, patent arterial (botal- I fishing) duct, combined defects of the I heart and blood vessels, vascular tumors (those I mangiomas).
2. Aortoarteritis: a disease Takayasu, disease Raynaud, obliterating endarteritis, thrombus angiitis (disease Burger).
3. Atherosclerosis and its consequences: ischemic heart disease, ischemic brain disease, gangrene of the extremities, thrombosis and arterial aneurysms.
Operative surgery of the extremities ♦ 279
4. Injuries: vascular injuries, traumatic aneurysms.
5. Occlusions: acute and chronic, embolism and thrombosis.
PROJECTION LINES
AND LIGATION OF LARGE VESSELS
Exposure and ligation of the brachial artery (a.brachialis) on the shoulder
The projection line for exposing the brachial artery throughout the shoulder runs from the apex of the axilla along sulcus bicipitalis medialis to the middle of the distance between the biceps tendon and the internal epicondyle of the humerus (Fig. 4-4).
Rice. 4-4. Projection line of the brachial artery.(From: Kalashnikov R.N., Nedashkovsky E.V., Zhuravlev A.Ya. A practical guide to operative surgery for anesthesiologists and resuscitators. - Arkhangelsk, 1999.)
Dressing a. brachialis must be carried out below the level of departure from it a. profunda brachi. Collateral circulation develops between branches a. profunda brachii And a. collateralis ulnaris superior with recurrent branches of the radial and ulnar arteries (a. reccurens radialis And ulnaris).
Exposure and ligation of the brachial artery (a. brachialis) in the cubital fossa
An incision to expose the brachial artery in the cubital fossa is made in the middle third of the projection line drawn from a point located 2 cm above the internal epicondyle.
Rice. 4-5. Projection line to expose the brachial artery in the cubital fossa.
ka humerus, through the middle of the elbow to the outer edge of the forearm (Fig. 4-5).
Ligation of the brachial artery in the ulnar fossa rarely leads to circulatory disorders of the forearm, since there are well-developed anastomoses between the branches of the brachial artery and the return vessels of the radial and ulnar arteries, forming around the elbow joint rete cubiti.
Exposure of the radial artery (a. radialis)
The projection line of exposure of the radial artery runs from the medial edge of the biceps brachii tendon or the middle of the cubital fossa to the pulse point of the radial artery or to a point located 0.5 cm inward from the styloid process of the radius (Fig. 4-6).
Rice. 4-6. Projection lines to expose the radial and ulnar arteries on the forearm.(From: Elizarovsky S., Kalashnikov R.N. Operative surgery and topographic anatomy. - M., 1967.)
280 < ТОПОГРАФИЧЕСКАЯ АНАТОМИЯ И ОПЕРАТИВНАЯ ХИРУРГИЯ ♦ Глава 4
Exposure of the ulnar artery (a.ulnaris)
The projection line of the ulnar artery runs from the inner epicondyle of the humerus to the outer edge of the pisiform bone (os pisiforme)(See Figure 4-6).
Exposure and ligation of the femoral artery (a. femoralis)
Projection line (line Cache) passes from top to bottom, from the outside to the inside from the middle of the distance between the superior anterior iliac spine (spina iliaca anterior superior) and pubic symphysis (symphisis pubis) to the adductor tubercle of the femur (tuberculum adductorium ossis femoris)(Fig. 4-7).
Rice. 4-8. Choosing the location of the ligature on the popliteal artery, a-projection line of the popliteal artery, 6-branches of the popliteal artery. Light circles indicate the most favorable zones for ligation of the anterior and posterior tibial arteries. The dotted line indicates the joint space and places of unwanted ligatures. 1 - femoral artery, 2 - descending genicular artery, 3 - superior lateral genicular artery, 4 - popliteal artery, 5 - superior medial genicular artery, 6 - inferior lateral genicular artery, 7 - anterior tibial recurrent artery, 8 - inferior medial genicular artery , 9 - anterior tibial artery, 10 - peroneal artery, 11 - posterior tibial artery. (From: Lytkin M.I., Kolomiets V.P. Acute injury of the main blood vessels. - M., 1973.)
WAYS TO STOP BLEEDING
Stopping bleeding using a ligature was described at the beginning of our era. Celsus.
Rice. 4-7. Projection line of the femoral artery along To Kan. (From: Kalashnikov R.H., Nedashkovsky E.V., Zhuravlev A.Ya. A practical guide to operative surgery for anesthesiologists and resuscitators. -Arkhangelsk, 1999.)
When dressing a. femoralis it is necessary to remember the level of discharge a. profunda femoris, ligation of the artery is carried out distal to its origin. Collateral circulation when ligating the femoral artery is restored through anastomoses between a. glutea inferior And a. circumflexa femoris lateralis, a. Pudenda externa And a. Pudenda interna, a. obturatoria And a. circumflexa femoris medialis.
Exposure and ligation of the popliteal artery (a. poplitea)
The projection line can be drawn vertically through the middle of the popliteal fossa, slightly moving away from the midline to the side so as not to injure the v. saphena parva(Figure 4-8).
Classification
Methods to stop bleeding are divided into two groups: temporary and final. Methods to temporarily stop bleeding
include raising and maximum flexion of the limb in the joint, applying a pressure bandage and tight tamponade of the wound Mikulich-Radetsky. If the bleeding is arterial in nature, you can resort to pressing the blood vessel above the wound site to certain anatomical structures [for example, pressing the external carotid artery (a. carotis externa) to the carotid tubercle of the VI cervical vertebra; rice. 4-9].
Minor bleeding on the extremities can be controlled by elevating the extremity and packing the wound with gauze or a pressure bandage. To temporarily stop bleeding in the absence of a fracture,
Operative surgery of the extremities -O- 281
Rice. 4-9. Places of digital pressure of arteries.(From: Komarov DB. Emergency surgical care for injuries. - M., 1984.)
change the maximum flexion of the limb in the joint above the wound site.
Using finger pressure, bleeding can be stopped for a short period of time, and is used only in emergency cases before applying clamps to a wounded vessel.
A rubber tourniquet is applied above the site of arterial bleeding, mainly on the shoulder or thigh. Soft tissue is placed on the skin to prevent unnecessary trauma. The tourniquet is applied so that the pulsation of the arteries below the site of its application stops. Too little compression with a tourniquet does not achieve the goal; excessively tight tightening is dangerous, since nerves and blood vessels are compressed, as a result of which paralysis may develop in the future or the intima of the vessel may be damaged, and this may lead to the formation of a blood clot and gangrene of the limb. Application of a tourniquet is used not only for bleeding, but also to prevent blood loss during surgery. However, this method should not be used for temporary
new lesions in the elderly with pronounced atherosclerosis and in inflammatory diseases (diffuse purulent process, lymphangitis, anaerobic infection). The tourniquet is kept on the limb for no more than 1-2 hours. After applying the tourniquet, a note is recorded under its tourniquet, which indicates the time of application of the tourniquet.
When large vessels are damaged, it is difficult to temporarily stop bleeding with tamponade or a bandage. In such cases, hemostatic clamps are used. Peana, Kochera or “mosquito”, with which a bleeding vessel is captured in a wound and bandaged, or a bandage is applied over the clamp, followed by delivery of the patient to a medical institution, where the final stop is carried out.
However, due to the rapid fatigue of the fingers and the inability to deeply press the arterial trunks, it is better to use a rubber tourniquet, proposed in 1873, to temporarily stop bleeding. Esmar-hom. It is also possible to apply a hemostatic clamp to the vessel in the wound.
Methods to finally stop bleeding divided into mechanical (application of hemostatic clamps, etc.), physical (for example, the electrocoagulation method), chemical (use of hydrogen peroxide, wax paste to stop bleeding from diploic veins) and biological (use of a hemostatic sponge, omentum, etc.).
Surgical interventions on large vessels, if they are damaged, can be divided into two groups. The first group includes methods of ligating a vessel throughout or in a wound, the second group includes methods of restoring impaired blood flow through the use of a vascular suture and angioplasty.
Vessel ligation
Ligation of a vessel in a wound. The procedure is performed in emergency cases for injuries or gunshot wounds (Fig. 4-10). Ligation of a vessel in a wound is the most common method of stopping bleeding; its goal is to close the lumen of the vessel at the site of injury.
Ligation of the vessel throughout. Throughout, the artery is most often ligated as a preliminary step before removing an organ or body part. Vessel ligation
282 <■ TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY ♦ Chapter 4
Tying small-caliber vessels is sometimes replaced by twisting them.
Rice. 4-10. Scheme for stopping bleeding using a hemostatic clamp left in the wound, with additional tight tamponade Mikulich-Radetzko-
mu.(From: A short course of operative surgery with topographic anatomy / Ed. V.N. Shevkunenko. - L., 1947.)
throughout, they are performed proximal to the site of injury to reduce blood flow to the damaged part of the organ or limb. . Indications
1. Impossibility of ligating a vessel in a wound with severe tissue damage.
2. The danger of exacerbation of the infectious process as a result of manipulations in the wound.
3. Presence of traumatic aneurysm.
4. The need to amputate a limb due to an anaerobic infection, when applying a tourniquet is contraindicated.
5. Danger of erosive bleeding. Operational access. When ligating the artery along its length, direct and indirect approaches are possible. With direct access, soft tissues are dissected along the projection lines; with indirect access, skin incisions are made at a distance of 1-2 cm from the projection line of the artery.
In some cases, ligation of a vessel along its length is performed to temporarily turn off blood circulation in a particular area, when large blood loss is expected (for example, when removing a sarcoma, the thighs are ligated a. iliacae ext.). The ligature is applied for the duration of the operation and then removed.
Sometimes, instead of the usual method of ligating the vessel, they resort to the so-called continuous cutting suture along Heidenhain(see chapter 6). Needling is used when conventional dressing is unreliable due to the depth of the captured vessel or the danger of the ligature slipping. To avoid leaving many foreign bodies in the wound in the form of immersion ligatures, re-
Vascular suture
An important prerequisite for the development of vascular surgery was the teaching N.I. Pirogov about the patterns of arrangement of the vessels of the extremities in relation to the surrounding tissues, outlined in the work “Surgical anatomy of arterial trunks and fascia” (1837).
I law - all main arteries with a joint
existing veins and nerves are enclosed in | fascial sheaths or vaginas.
II law - the walls of these cases are formed by their own fascia, covering the adjacent muscles.
III law - on a section, vascular sheaths I have the shape of a triangle, the base tsh which is facing outwards. The apex of the vagina is certainly fixed to the bone “directly or indirectly.” Patterns of vascular location
nerve bundles of the extremities dictate the need for surgical access to them to select the edge of a particular muscle forming one of the sides of the intermuscular space as a guide for the incision. In order to better navigate, both during operations on blood vessels and during preparation, one should remember the projection lines of the blood vessels. Ligation of large arterial trunks often causes severe circulatory disorders, ending in gangrene of the limb. Therefore, for a long time, surgeons have sought to develop operations that make it possible to restore the continuity of blood flow in a damaged artery.
Lateral and circular vascular sutures were developed (Fig. 4-11). The side suture is used for parietal wounds, and the circular suture is used for complete anatomical wounds | interruption of the vessel.
Stages of applying a vascular suture
1. Mobilization of the vessel.
2. Inspection of soft tissues, vessels, nerves, bones and primary surgical treatment of the wound.
3. Preparing the ends of the vessel for suturing (rubber tourniquets or vascular clamps are placed on the ends of the vessels).
4. Direct suture.
Rice. 4-11. Methods for treating vascular damage, A-
application of a side suture, 6 - resection of the damaged section of the artery, c - application of a circular suture, d - artery replacement. (From: Emergency surgery of the heart and blood vessels / Edited by M.E. De-Beiki, B.V. Petrovsky. - M.,
5. Starting blood flow through the vessel, checking the tightness of the suture and the patency of the vessel. Basic requirements for vascular sutures
1. The sutured ends of the vessels should touch along the suture line with their smooth inner surface (endothelium).
2. Application of a vascular suture should be carried out without injuring the endothelium of the vessels being sutured.
3. The connection of the edges of the damaged vessel should be with minimal narrowing of its lumen.
4. Creation of absolute tightness of the vascular wall.
5. Prevention of blood clots: the material used for suturing blood vessels should not be in the lumen and in contact with blood.
An important condition is sufficient mobilization of the vessel, thorough bleeding of the surgical field with temporary clamping of the proximal and distal parts of the vessel. The suture is applied using special instruments and atraumatic needles, which
Operative surgery of the extremities -O- 283
ensures minimal trauma to the vessel wall, especially its inner lining (intima).
When applying a vascular suture, the inner membranes of the vessels are ensured to adhere to each other. There should be no suture materials or sections of the middle or outer shell in the lumen, as they can cause thrombosis. The stitched ends of the vessel are washed with heparin and periodically moistened. Avoid getting blood on the suture material.
Unlike an arterial suture, a venous suture is applied with less thread tension when tightening individual stitches. When suturing the vein, sparser stitches are used (approximately 2 mm apart). The thicker the walls of the vessel, the sparser the seams, the tighter the vessel can be ensured.
A suture is placed through all layers of the vessel wall. The ends of the vessels being stitched must be in contact along the suture line with their inner membrane. The needle is inserted approximately 1 mm from the edge of the vessel, the suture stitches are placed at a distance of 1-2 mm from each other. With pathologically altered walls, there is a tendency to cut through seams and therefore, when suturing large-diameter vessels, more tissue is captured into the seam and the distance between individual stitches is increased. The vascular suture must be sealed both along the line of contact between the vessel walls and at the points where the threads pass. This is ensured by sufficiently tightening the seams. When applying a suture, an assistant constantly maintains tension on the thread. Tightness control is carried out after applying a suture by removing the distal clamp. If there is no significant bleeding, remove the central clamp and apply a tampon moistened with warm saline to the vessel for several minutes to stop bleeding along the suture line.
Prevention of thrombus formation in a vessel during temporary clamping consists of local injection of heparin into the afferent and efferent segments of the vessel or into the general bloodstream, into a vein 5-10 minutes before clamping the vessel. When clamping a vessel for a long time, it is advisable to slightly open the distal and proximal clamps before applying the last sutures in order to remove any possible
284 ♦ TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY « Chapter 4
blood clots may form. After applying a suture and freeing the artery from clamps or tourniquets, you should make sure that there is pulsation in the peripheral part of the vessel. Classification of vascular sutures. IN Currently, more than 60 modifications of manual vascular suture are known. They can be divided into four groups.
Group I - the most widely used
wrap seams Carrel, Morozova etc.; An anastomosis between segments of vessels is created with a continuous suture.
Group II - everting sutures; a continuous mattress suture makes it possible to achieve better intimate contact.
III group - intussusception sutures proposed Murphy in 1897
Group IV - various methods of strengthening anastomoses using absorbable prostheses.
Vascular suture Carrel. After mobilization and exclusion of the proximal and distal parts of the vessel from the bloodstream using special clamps, both ends of the latter are sutured through all layers with three guide sutures-stays, located at an equal distance from each other. When applying a vascular suture, the stay sutures are stretched so that the line of contact between the ends of the vessels has the shape of a triangle. In the intervals between fixed sutures, the adjacent edges of the vessel are sutured
Rice. 4-12. Vascular suture technique Carrel. a - edges with a continuous entwining suture, c - suturing of the vessel of aneurysms of peripheral vessels. - M., 1970.)
continuous continuous seam. Continuous suture stitches are carried out at a distance of 1 mm from each other through all layers with a slight gripping of the edges of the vessel along the entire circumference so that after tightening the seams the threads do not protrude into its lumen (Fig. 4-12).
Seam Carrel has some disadvantages.
The suture encloses the vessel with a thread in the form of a stubborn ring.
Often the threads protrude into the lumen of the vessel.
The seam does not always provide a complete seal
tity.
Offer Carrel, undoubtedly played an important role in the development of vascular surgery, although the introduction of the vascular suture into clinical practice did not occur for many years, since surgeons at that time did not have the means to combat postoperative thrombosis. Anticoagulants appeared only 30 years after the first publication Carrel.
Vascular suture Morozova. When applying the first vascular suture, two dermal sutures are used instead of the three proposed Carrel. I The ends of the vessel are connected by two interrupted sutures I with stays placed on opposite sides. Between the applied sutures, a continuous wrapping suture is applied, and the suture thread should be constantly kept in tension so that it acts as a third fixing suture, increasing the lumen of the vessel.
tsa are brought together by three stay sutures, b - stitching with sucking sutures. (From: Surgery
Vascular suture Henkina. Very sparse intermediate interrupted sutures are placed between the stay sutures. Then the line of seams is wrapped with a sleeve cut from the wall of the autovein. The sleeve is sutured to the vessel behind the adventitia with three sutures on top and three on the bottom. This modification reduces the number of intermediate sutures and, therefore, reduces the likelihood of thrombus formation and vessel narrowing.
Vascular suture Sapozhnikova. After excision of the central and peripheral segments of the damaged artery (if the defect is no more than 4 cm), its adducting end is mobilized. On the ends cut with a blade along the side surfaces, sharp scissors make cuts about 2 mm long so that all layers are cut at the same level. This makes it possible to twist the vessel wall in the form of a cuff. The cuffs formed at the central and peripheral ends are brought together and stitched with a continuous suture through all layers.
Thus, after stitching, the inner lining of the vessel segments is in close contact, ensuring sealing of the vascular suture. The advantage of this modification is that the lumen of the vessel at the site of the anastomosis is wider than the adductor and efferent segments. This creates good conditions for blood circulation, especially in the first days, when postoperative edema narrows the lumen of the vessel.
Vascular seamPolyantseva. Stay sutures are applied in the form of U-shaped sutures that evert the inner wall of the vessel. After stretching the applied sutures, a continuous continuous suture is used.
Vascular seamJeboli-Grossa. The everting U-shaped suture can be made using interrupted and mattress sutures, as well as a continuous mattress suture.
Everting vascular sutures. The basic requirements for vascular sutures are also met by everting sutures (Fig. 4-13).
To suture the posterior wall of the proximal and distal ends of the vessel, an interrupted mattress suture is first applied to the corner without tightening the stitches. Only after stitching the entire back wall do they bring the ends of the vessel together, simultaneously tensioning the threads, and thereby achieving a tight seam line. The first interrupted suture is tied. The end is tied to him
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Rice. 4-13. Method of applying an everting mattress vascular suture.(From: Petrovsky B.V., Milanov O.B.
continuous seam. The second corner of the vascular wound is sutured with another interrupted mattress suture, to which the end of the thread of a continuous suture is connected. The front wall is stitched with one continuous mattress suture. The mattress stitch has some disadvantages.
1. May lead to narrowing of the anastomotic area.
2. Prevents the growth and expansion of the artery.
Other vascular sutures
For incomplete, especially patchwork, wounds of the vessel, you can use a U-shaped or loop-shaped suture, then reinforced with several knotted stitches.
For longitudinal linear or small perforated wounds, a series of interrupted sutures can be applied. The narrowing of the lumen that occurs is subsequently leveled out if it does not reach too great a degree and does not exceed 2/3 of the diameter of the vessel.
For minor lateral wounds, especially veins, you can limit yourself to applying a parietal ligature.
If the size of the lateral defect in the arterial wall is so large that excessive narrowing of the lumen may occur when applying the linear suture described above, the defect can be closed using a patch from the wall of a nearby vein, a flap from which is sutured to the arterial wall with a frequent interrupted or continuous suture. With full anatomical
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When the vessel is broken and it is impossible to bring its ends together without tension, a section of the vein is transplanted to the site of the defect. For plastic surgery, the saphenous vein is usually used. The vein must be turned over and sewn with the peripheral end into the central end of the artery so that the valves do not interfere with the flow of blood. Subsequently, the vein wall is functionally transformed and, upon histological examination, resembles the artery wall.
When applying any sutures, the ends of the vessel should touch without tension. To do this, excision of the vessel should be done sparingly, and the limbs should be placed in a position in which the approximation of the ends would be maximum (for example, bending at the knee joint when suturing the popliteal artery). It is necessary to ensure that the assistant correctly and evenly stretches the ends of the fixing threads, since otherwise the opposite wall may get caught in the seam. A vascular suture is applied only if there is complete surgical treatment of the wound. If suppuration of the wound is possible, application of a vascular suture is contraindicated.
SEAMLESS METHODS FOR CONNECTING VESSELS
These methods involve the use of structures external to the vessel (for example, a ring Donetsk), at
with the help of which one end of the vessel is invaginated into the other with the walls of the vessel being fixed to the solid outer frame.
INVAGINATING VASCULAR SURE
Rings Donetsk
One of the known modifications of the everting suture to avoid narrowing of the anastomosis is connecting the vessel using metal rings Donetsk(1957) of different calibers, with special spikes on the edge.
Technique. The central end of the vessel is inserted into the lumen of the ring and turned out with tweezers in the form of a cuff so that its edges are pierced through with spikes. Then the central end of the vessel, put on a ring, is inserted into the lumen of the peripheral end of the vessel, the walls of the latter are also placed on the spikes with tweezers (Fig. 4-14).
Intussusception suture Murphy
The essence of the intussusception suture according to the method Murphy consists in the fact that a peripheral segment of the vessel is put on the inverted central end of the vessel, as a result of which intimate contact of the internal membranes of the vessel occurs, ensuring
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Rice. 4-14. Sewing a vessel using rings Donetsk, a - ring, b - end to end stitching, c - end to side stitching, d - side to side stitching. (From: Petrovsky B.V., Milanov O.B. Surgery of peripheral vascular aneurysms. - M., 1970.)
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tightness of the anastomosis and preventing the exit of threads into the lumen of the vessel. The intussusception method is most convenient in cases where arteries of different calibers have to be sutured and when the diameter of the central segment of the artery is smaller than the peripheral one.
