Surgical treatment of wounds. Types of seams. Primary surgical treatment of the wound Secondary late suture

SECONDARY SEAM- connecting the edges of a granulating wound after completing the process of its biological cleansing.

There are V. sh. early, applied before the formation of scars that prevent the edges of the wound from approaching each other, and V. sh. late, used in cases where the edges of the wound are already fixed with scar tissue. Early V. sh. can be applied on the 8-15th day after cleansing the wound, late - after 2 weeks. and more. Both types of V. sh. are among the interventions that accelerate the healing of granulating wounds.

Story

Mention of V. sh. available in T. Kocher's textbook on operative surgery. Delorme (E. Delorme) wrote about the secondary connection of the edges of a granulating wound 30 years before the First World War. For the first time V. sh. battle wounds were used in the French. army in the First World War after the work of A. Carrel and his colleagues, who studied the bacterial flora of wounds received during hostilities. Based on these works, A. Carrel proposed to pre-prepare the wound using chemicals. antiseptics by irrigating it for 4-20 days and after bacterial control, apply V. sh. Franz. surgeons did not have much experience in using V. sh. in the treatment of gunshot wounds. Thus, Tuffier (Th. Tuffier) ​​imposed V. sh. 121 times, R. Leriche - 142 times. Lenormand (Ch. Lenormant) and M. Chevassu reported that after the end of the First World War, V. sh. the French was forgotten. surgeons Surgeons of other warring states V. sh. almost never used.

Domestic surgeons (N. N. Burdenko, A. E. Rauer, A. M. Zabludovsky, Z. A. Landers, D. A. Entin, L. M. Ballon, etc.) began to use V. sh. also during the First World War. However, the massive use of V. sh. took place only during the Great Patriotic War. By 1943, N. N. Burdenko had material in 9,520 cases, B. D. Dobychin - in 13,350 cases, I. V. Krivorotoe - in 12,163, N. N. Elansky - in 22,000 cases. According to T. Ya. Ariev, obtained as a result of the development of materials from the Great Patriotic War, V. sh. was applied in at least 8% of all soft tissue injuries. In the vast majority of cases, V. sh. was applied without bacterial control, and wound healing proceeded without any complications threatening the health or life of the wounded. Thus, the priority of mass use of V. sh. completely owned by medical surgeons. service of the Soviet Army.

Based on materials from the Great Patriotic War, 80% V. sh. was applied for soft tissue injuries and only 20% for gunshot bone fractures. The best results were obtained when applying V. sh. on wounds of the skin, soft tissues and wound surfaces after amputations. The course and healing of wounds after applying V. sh. to some extent depend on their location: wounds of the face and soft integument of the skull heal best; wounds of the distal parts of the lower extremities heal worse than the proximal ones, wounds of the upper extremities - better than the lower ones.

Indications

The wound is a significant size, due to which its healing by secondary intention takes a very long time, usually with the formation of extensive scars that impair function.

Contraindications

The presence in the wound of pockets, convoluted passages, copious purulent discharge, flaccid granulations covered with fibrinous plaque, unrejected necrotic tissue, swelling of granulations, inflamed and edematous edges of the wound, pyoderma around the wound, the presence of lymphangitis, lymphadenitis. The inability to bring the edges of the wound closer together without significant tension also serves as a contraindication to the application of V. sh. V. sh. should not be applied. in the serious condition of the patient, accompanied by a significant decline in nutrition and reduced regenerative ability of tissues (anemia, nutritional dystrophy, vitamin deficiency, widespread tuberculosis, etc.).

Methodology

Before applying V. sh. Bacteriol, control of wound microflora is desirable. The inability to produce bacteria, the study does not serve as an obstacle to suturing, since clinical indicators make it possible to confidently judge the absence of active infection in the wound. To prepare wounds for applying V. sh. Numerous medications have been proposed, in particular proteolytic enzymes (V.I. Struchkov et al., 1967). Basically, wound preparation is carried out according to the laws accepted in surgery: they ensure drainage of the wound, protect its edges from maceration, remove necrotic tissue from the wound that interferes with the normal regeneration process, use agents that stimulate the growth of granulations, and agents that have a bactericidal and bacteriostatic effect on the microflora ( see Wounds, wounds).

Operation of applying V. sh. requires strict asepsis and must be performed in the operating room. In the vast majority of cases, it is performed under local anesthesia and only as an exception under general anesthesia. When preparing the surgical field, granulations are not treated with iodine. When treating different layers of the wound, instruments are changed. Bleeding is stopped by applying thin catgut ligatures and tampons soaked in hot saline solution. For V. sh. they use silk, nylon, and less often thin bronze-aluminum or silver wire.

When applying early V. sh. granulations are not removed, only the edges of the skin wound are refreshed. Sutures are placed at a distance of 1-2 cm from each other, 1-1.5 cm away from the edge of the skin wound, capturing the side walls and bottom of it, without piercing the granulations. Only after all the sutures have been applied are they tied sequentially, starting from the corners of the wound. In the early stages of healing, the method of bloodless rapprochement of the wound edges with situational cleol (Fig. 1) and adhesive bandages is used. A. Charukovsky used this method of bringing the edges of a wound closer together at the beginning of the 19th century, calling it a “dry suture”, in contrast to “bloody sutures”.

Overlay of the late V. sh. produced after excision of the skin, granulation and mobilization of the wound edges. Before applying V. sh. at a particularly late date (after 2 months or more), the wound is excised completely, removing all scar tissue (Fig. 2). In all cases of application of V. sh. care must be taken to ensure that the sutures are applied without tension on the tissue, as this ensures smooth healing of the wound. If it is impossible to completely avoid tension, then conventional sutures should be abandoned and the wound should be closed with plate sutures (see Surgical Sutures).

To prevent infection after applying V. sh. General and local use of antibiotics is recommended (infiltration of tissue around the wound during surgery, for extensive wounds, periodic irrigation of the wound in the first 3-4 days after surgery through a drainage inserted into it) taking into account the sensitivity of the microflora. If the wound is located on a limb, the latter is immobilized after surgery.

Outcomes of applying V. sh.

The following data are available on the general outcomes of V. sh. during the Great Patriotic War: primary healing - 54%, incomplete (partial) suture dehiscence - 37% and complete suture dehiscence - 9%. It should be noted that as experience is accumulated and technical skills are acquired in using the V. sh. primary wound healing reaches higher rates compared to the given data. So, for example, E. L. Berezov received 86% of primary healing, N. N. Elansky - 87%, M. I. Kuslik - 88%, A. N. Bakulev, E. I. Zakharov, B. D. Do-bychin and others - an even higher percentage.

The experience of the Great Patriotic War showed that V. sh. can be used in no less than 24% of all wounded, and in half of them treatment ends in less than a month; in general, the use of V. sh. reduces wound healing time by half.

Rich experience in using V. sh. in the treatment of wounds during the war, it is successfully used in peacetime surgical practice. This applies to the treatment of extensive open injuries, when, after surgical treatment of a lacerated wound, the application of primary sutures is impossible or contraindicated for one reason or another. V. sh. They are also used to accelerate the healing of granulating wounds formed after the opening of abscesses, phlegmons and other purulent processes, if there is complete confidence that the purulent-inflammatory process has ended and rejection of all necrotic tissue has occurred.

Effective use of V. sh. in peacetime they contribute to: 1) treatment of patients in specialized treatment. institution or department of a hospital from the onset of the disease to recovery; 2) the possibility of producing bacteria, monitoring the wound during periods of incubation, spread and localization of infection with characteristics of the microflora and its sensitivity to various antibiotics; 3) the use of broad-spectrum antibiotics and proteolytic enzymes to prepare the wound for the application of V. sh., the use of antibiotics during surgery and in the postoperative period.

Combined use of V. sh. and antibiotics reduces the treatment time for patients with severe open trauma and extensive granulating wounds.

Bibliography: Burdenko N. N. Collected Works, vol. 2, p. 267, M., 1951; Vishnevsky A. A. and Shreiber M. I. Military field surgery, M., 197 5; Voskresensky L.N. Secondary seam, late seam, delayed seam, blind seam, M., 1942; Kamaev M. F. Infected wound and its treatment, M., 1970, bibliogr.; L e r i sh R. What to do after excision of muscle wounds caused by military shells: primary suture, plaster cast or secondary suture? in the book: Notes on military field surgery, ed. S. S. Yudina, p. 131, M., 1943; Experience of Soviet medicine in the Great Patriotic War of 1941 -1945, vol. 1, p. 145, M., 1951; Struchkov V.I., Grigoryan A.V. and Gostishchev V.K. Purulent wound, M., 19 75, bibliogr.; R e b e r H. Infektionshospitalismus, Chi-rurg, S. 154, 1967, Bibliogr.; Rostock P. Die Wunde, B., 195u; Schmitt W., Mulier G. u. Richter E. Altes Krankenhaus und “moderner” Hospitalismus, Zbl. Chir., S. 2940, 1967.

VIEWS

1. Apply the application technique. 1). Knotted sutures, in cases of matching the edges of the wound without tension. 2). Cosmetic intradermal sutures with catgut and atraumatic needles, especially when wounds are localized on the face. 3).“P”-shaped sutures are applied when there is a significant divergence of the edges of the wound and the need for their tension. 4). “P”-shaped tread seams (with various gaskets) are applied with significant tissue tension to prevent their eruption.

2. Based on the time of application, there are 4 types of sutures.

1) Primary suture - the threads are passed and immediately tightened. Used when treating fresh, uncontaminated wounds, when there is confidence in their healing by primary intention.

2) Primary delayed suture, when the threads are passed but not tightened. The wound is packed with antiseptics. If there is no suppuration, the threads are tightened after 2-3 days.

3) Early secondary sutures are applied to wounds cleared of necrosis and granulating wounds, usually on days 7-14, to bring the edges closer together and accelerate healing. Knotty sutures are rarely applied to ensure drainage of exudate. For high tension, “U”-shaped seams are used.

4) Late secondary sutures are applied on days 30-35. Such a wound is excised along with the scar, and cosmetic stitches are applied. Sometimes skin grafting with local tissues is used.

SURGICAL TREATMENT OF THE WOUND - a surgical intervention consisting of a wide dissection of the wound, excision of its edges, walls and bottom along with non-viable tissues, stopping bleeding in order to prevent wound infection and create favorable conditions for wound healing.

There are primary and secondary surgical treatment of wounds. Surgical treatment carried out on the first day after injury is usually called early, 24-48 hours after injury - delayed, and after 48 hours - late.

Surgical treatment of the wound is performed by a doctor under local anesthesia or general anesthesia.

Primary early treatment begins with wound incision. A bordering incision 0.5-1 cm wide is used to excise the skin and subcutaneous tissue around the wound. Next, the fascia and aponeurosis are dissected along the skin incision. After dissection of the wound, scraps of clothing, blood clots, and loose foreign bodies are removed and the excision of crushed and contaminated tissues within healthy tissues is begun, with the restoration of anatomical relationships.

Delayed and late surgical treatment is performed according to the same rules as early, but if there are signs of purulent inflammation, it comes down to the removal of foreign bodies and necrotic tissue, opening of leaks, pockets, hematomas, abscesses, in order to provide good conditions for the outflow of wound fluid. Primary surgical treatment of the wound is completed by drainage or suturing.

The primary delayed suture is applied up to 5-7 days after the initial surgical treatment of the wound until granulation appears, provided that the wound has not become suppurated.

A secondary suture is applied to the granulating wound when the danger of suppuration has passed, in order to speed up healing. An early secondary suture is applied to granulating wounds within 8 to 15 days. If the edges of the wound are mobile, they are not excised. A late secondary suture is applied at a later date (after 2 weeks), when cicatricial changes have occurred in the edges and walls of the wound. The edges are mobilized and scar tissue is excised.

Indications for secondary surgical treatment of wounds are the development of wound infection, purulent-resorptive fever and sepsis caused by purulent leaks, phlegmon, and secondary tissue necrosis. When the inflammatory process is localized along the wound canal, it is opened wide by additional dissection of the wound, the accumulation of pus is removed, and foci of necrosis are excised. Drainage of the wound is carried out using perforated single- and double-lumen tubes, through which the wound is irrigated with antiseptic solutions.

Treatment of wounds after primary and secondary surgical treatment using antibacterial agents, immunotherapy, proteolytic enzymes, sorbents, ultrasound, etc.

80. Principles of treatment of purulent wounds.

There are 3 stages of the course of purulent wounds:

1) stage of inflammation;

2) regeneration stage;

3) stage of scar reorganization.

The inflammation stage is characterized by pain, often jerking in nature, pronounced swelling around the wound, bright hyperemia with blurred edges, increased body temperature and locally around the wound. During its revision: the presence of purulent-necrotic masses, fibrin deposits, and copious purulent discharge is revealed on the bottom and walls, the nature of which depends on the type of microflora. The duration of this stage is 4-5 days (but with pyogenic microflora).

Treatment at this stage should be general and local. Local treatment at this stage includes: frequent dressings, washing with antiseptics, local enzyme therapy, high-quality wound drainage with antiseptics or water-soluble ointments in order to suppress infection and accelerate the rejection of necrosis. Among the physical factors, ultraviolet radiation, laser irradiation, ultrasonic cavitation, hyperbaric oxygenation or gnotobiological methods of oxygen therapy can be used locally.

During the regeneration stage, which is determined by the appearance of granulations, the main goals are to carefully preserve them, suppress residual infection, cleanse the wound from necrosis, bring the walls closer together, and prevent keloid.

Dressings should be carried out only in the first days, until the remnants of necrosis are removed, and should be carried out daily thereafter, as rarely as possible (depending on the extravasation). Wounds are washed with antiseptics, drained with ointment dressings with antiseptics. After cleansing the wound from purulent-necrotic masses, either early secondary sutures are applied, or, if there are no conditions for this, they are carried out using the method of secondary intention, using ointment or aerosol antiseptics containing vitamins “A” and “E” or sea buckthorn oil, which is rich in them.

During the stage of scar reorganization, the walls of the wound are tightened with fibrosing scar tissue from fibroblasts, and it is epithelialized from the edges. The main focus of treatment is to prevent the formation of a keloid scar. Dressings with hyaluronidase preparations and electrophoresis or ultrasound with “Lidase”, preparations containing vitamins “A” and “E” are used. The process is long. When a deforming scar is formed with impaired joint function or when a cosmetic defect is formed, late secondary sutures are applied, i.e., in fact, plastic surgery is performed.

Advantages of suturing: accelerated healing, reduced losses through the wound surface, reduced likelihood of re-suppuration, increased functional and cosmetic effect, easier wound treatment.

Primary. It is applied until granulations form, the wound heals by primary intention. They are applied immediately after surgery or early PSO in the absence of a high risk of developing purulent complications. Removal of sutures after the formation of dense connective tissue (scar) and epithelization.
Primary delayed. It is applied until granulations form, the wound heals by primary intention. Immediately after surgery and delayed PSO, when there is a certain risk of infection. Apply for 1-5 days after inflammation subsides. A variation is provisional sutures, in which sutures are placed, but the threads are not tied, and the edges of the wound are not closed in this way.

Secondary. Apply to granulating wounds, which heal by secondary intention. The meaning is to reduce or eliminate the wound cavity (with all the consequences). Indications: granulating wound after elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. A) Early secondary (6-21 days) and B) Late secondary (after 21 days). They are differentiated because by the 21st day, scar tissue forms, preventing rapprochement and fusion. Therefore, when applying late secondary sutures, the scarred edges of the wound are excised under aseptic conditions, only then a suture is applied and the threads are knitted. To speed things up, tightening the edges of the wound with an adhesive plaster is sometimes used.

· Surgical treatment of the wound. Definition. Indications.

· Types of surgical treatment (primary surgical treatment, repeated surgical treatment of the wound, secondary surgical treatment).

· PSO of wounds. Definition. Principles of PHO. Types of emergency treatment depending on the timing (early, delayed, late).

· Primary surgical treatment. The purpose of primary surgical treatment. Stages of PHO. Wound drainage options.

· Types of surgical sutures. Provisional seams. Primary suture. Delayed primary suture. Secondary suture (early and late).

· For which wounds is primary surgical treatment not performed?

· Stages of medical care and the stage from which PCS begins.

78. Diagnosis and treatment of victims with prolonged crush syndrome at the stages of medical evacuation.

· Long-term crush syndrome (CDS). Pathogenesis (neural pain factor, toxemia, plasma loss). Classification of severity.

· SDR periods (compression phase - period of traumatic shock, decompression phase, early period, intermediate, late - azotemic intoxication, outcome period).

· Diagnostics of SDR. Clinical and laboratory diagnostics.

· Algorithm of actions aimed at reducing the “volley” release of toxins when releasing a compressed limb (tourniquet, release of compression, application of a tourniquet, removal of a tourniquet). General principles of providing care to patients with SDD.

· Compartment syndrome.

· Volumes of assistance at the stages of medical care. evacuation. Treatment of SDR in accordance with the pathogenesis (fighting pain, preventing cardiac arrest, fighting acidosis, immobilization, blockades - types).

· Surgical treatment depending on the clinical picture.

Organization of surgical care for war wounded.

· Stages of medical care.

· Stages of providing surgical care to the wounded (puncture of the pleural cavity, cutting off a limb hanging on a flap, blockades, tracheostomy, primary surgical treatment, craniotomy, drainage of the pleural cavity, laparotomy, fixation with a rod apparatus of the KST-1 set, amputation).

· Medical triage according to surgical indications at the stage of qualified medical care (emergency surgical interventions, for health reasons, urgent surgical interventions, delayed surgical interventions).

· Types of primary surgical treatment (early surgical treatment, delayed surgical treatment, late surgical treatment), their differences.

· Stages of primary surgical treatment (PST) of gunshot fractures.

· Features in PST of gunshot fractures: osteosynthesis, drainage, wound closure.

· Types of surgical sutures: provisional, primary surgical suture, primary delayed, secondary early surgical suture, secondary late.

Features of a gunshot wound associated with the action of a wounding projectile. Mechanism of wound healing.

· Wound ballistics of a gunshot wound (velocity of the wounding projectile, dimensions of the temporary pulsating cavity, cavitation).

· Characteristics of the damaging factors of modern firearms.

· Features of a gunshot wound: wound channel, zone of traumatic necrosis, zone of molecular concussion, zone of secondary necrosis.

· Pathophysiological mechanisms of the wound process, wound healing mechanisms (alteration, exudation, proliferation, vascular disorders as a reaction to injury, wound cleansing, suppuration, regeneration, scarring and regeneration).

· PCS of gunshot wounds.

Anaerobic wound infection, frequency, clinical picture, prevention and scope of assistance at the stages of evacuation.

· Classification of wound infection. Local forms (aerobic (purulent) infection, anaerobic infection - suppuration, abscess, edema, periwound phlegmon, fistulas, thrombophlebitis, lymphadenitis, lymphangitis). Visceral forms. Generalized forms.

· Anaerobic infection. Etiology. Pathogenesis. Pathogens of clostridial infection.

· Classification according to the course of the disease, according to the nature of local changes, according to the depth of the process.

· Classification of anaerobic infection (monoinfection, clostridial cellulitis, myonecrosis, semi-microbial synergistic infections, synergistic necrotizing fasciitis, cellulitis, progressive synergistic bacterial gangrene, chronic perforating ulcer).

· Diagnosis and clinical symptoms of anaerobic infection (pain, local manifestations, signs of endotoxemia, “ligature” symptom).

· Volume of assistance at the stages of medical evacuation. General principles of treatment of anaerobic infection (isolation of patients, surgical treatment, antibiotic therapy, administration of anti-gangrenous serums). Determination of tissue viability during anaerobic infection. Indications for amputation and reamputation. Surgical methods for treating anaerobic infection. Indications, contraindications for surgery (secondary surgical treatment (STS) - indicate the stages, amputation according to the STS type, within healthy tissues).

PRIMARY SEAM- a surgical suture applied immediately after surgery in order to restore the anatomical structure of the tissues, prevent secondary microbial contamination of the wound and create conditions for its healing by primary intention. Option P. sh. is a delayed primary suture, which is applied 3-5 days after surgery (before the appearance of granulations) in the absence of signs of wound suppuration. Delayed primary sutures can be applied as provisional sutures. In this case, the operation is completed by applying sutures to the wound, but they are tightened a few days later, after they are convinced that there is no danger of suppuration of the wound.

Application of P. sh. wounds is inextricably linked with the development of the problem of primary surgical treatment of wounds (see). In surgical practice, such treatment was used in the First World War (1914-1918), and then became widespread in peacetime. P. sh. began to be widely used not only for closing “clean” wounds, but they often completed the primary surgical treatment of gunshot wounds and wounds caused by other types of damaging mechanical factors.

The experience gained during combat operations in the region of Lake Khasan (1938), near the Khalkhin Gol River (1939) and during the Soviet-Finnish conflict (1939-1940) showed that with the increase in the destructive effect of military means and the associated By expanding the area of ​​tissue damage during primary surgical treatment of wounds, radical excision of all non-viable tissue is often impossible. Closing of P. sh. such a wound led to outbreaks of wound infection. Therefore, the indications for applying P. sh. for a gunshot wound were strictly limited. The justification of such a limitation was confirmed by the experience of the Great Patriotic War (1941-1945), when P.sh. It was allowed to be applied only during primary surgical treatment of wounds of the head, face, chest (in the presence of an open pneumothorax), penetrating wounds of the abdomen, large joints (only the synovial membrane was sutured), wounds of the scrotum, and penis.

In connection with the advent of effective antibacterial agents, and primarily antibiotics, indications for the application of P. sh. expanded. In the practice of modern surgery, the application of P. sh. during secondary surgical treatment of festering wounds. But the success of such operations is possible only if the necrotic tissue is completely excised, adequate drainage of the wound is ensured (in some cases through a counter-aperture) with prolonged rinsing with solutions of antiseptics, proteolytic enzymes and rational antibacterial therapy. However, this direction is still under development.

Technique of applying P. sh. ordinary (see Surgical sutures). After surgery with the application of P. sh. Careful monitoring of the wound should be ensured in order to timely identify complications (suppuration, secondary bleeding). If there are no complications, the bandage is changed on the 2nd-3rd day after the operation and the wound is not bandaged until the sutures are removed. In case of secondary bleeding or suppuration of the wound, the sutures are removed partially or completely, the wound is inspected and treatment appropriate to the condition of the wound is applied. Events.