RU2817841C1 - Method of wound closure with continuous cosmetic subcutaneous-intradermal suture - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: subcutaneous fat is sutured. Suture ends are brought out onto the skin, stretched until the wound edges are brought together, while simultaneously pulling the suture ends in different directions, and held in this position. Beginning and end of the suture is tied. Intradermal suture is applied. On the last intradermal stitch, the suture with the needle is brought into the subcutaneous fat and the suture is pulled up to match the wound edges. Subcutaneous fat is sutured to form a suture loop, and a knot is tied with the ends being tightened, achieving a complete alignment of the skin edges, and the knot is fixed. Suture is delivered in the subcutaneous fat beyond the wound and brought out onto the skin at distance of 10–15 mm from the angle of the wound. Suture is pulled until the knot is reduced into the subcutaneous fat and completely cut off, thus threading the fixed knot under the skin; the suture is made with an absorbable suture.

EFFECT: method eliminates the possibility of secondary infection, does not require additional fixation elements and draining, which reduces the length of staying in hospital, provides a good cosmetic effect.

1 cl, 15 dwg, 1 ex

Description

Field of technology to which the invention relates

The invention relates to medicine, in particular to surgery, namely to means for stitching wounds, and can be used for suturing during surgical operations.

State of the art

There is a known method of suturing a wound, presented in clause of the Russian Federation No. 2498782 according to class. A61B 17/04, z. 06/19/2012, op.11/20/2013

The known method is characterized by the following formula:

A method of suturing a wound by applying a longitudinal continuous removable suture, characterized in that layer-by-layer suturing of the wound is performed with a multi-row continuous removable suture starting from a deep layer of tissue; in each row, two counter threads are passed sequentially within one layer of tissue, while the needle is inserted and punctured at the same strictly symmetrical points on the opposite walls of the wound, perpendicular to the layer being stitched, placing the stitches strictly opposite each other; the threads of the first row are inserted and withdrawn onto the skin, 1 cm from the edge of the corresponding side of the wound and 3-5 cm from the corresponding corner of the wound; the threads of each subsequent row are inserted and brought out onto the skin at the same distance from the edge of the corresponding side of the wound and 1-2 cm closer to the corner of the wound than the threads of the previous row; tension of the withdrawn threads is performed with the direction of the force vector along the axis of the wound until complete reduction and adaptation of the wound walls after passing each row of two counter threads in the array of the stitched layer of tissue, insert the ends of the threads of each row into the unloading device and tie them together; The skin is sutured with a continuous intradermal suture using a thread made of absorbable suture material.

The main disadvantages of this method are as follows. Passing two opposing threads within each layer of tissue leads to the accumulation of a large amount of suture material in each layer, which is uneconomical and can lead to a tissue reaction to a foreign body. The threads of all layers are individually brought out onto the skin, which forms a large number of entrance gates for infection, thereby increasing the possibility of infection of the wound and increasing the likelihood of the formation of rough scars at the injection and puncture sites. The removable nature of the suture complicates patient management in the postoperative period and increases the risk of microorganisms penetrating deep into the connected tissues.

The closest in technical essence to the claimed one is the Halstead method of suturing a wound, presented in great detail in the educational manual “Skin Suture” by the authors V.G. Kozlov. and Bolynova A.V. from the Belarusian State Medical University of the Ministry of Health of the Republic of Belarus, Minsk BSMU 2015, and selected as a prototype (see Appendix to the application, page 12, Fig. 11).

The known method is as follows.

When suturing a deep wound, the subcutaneous tissue is first sutured with a continuous suture, capturing in each stitch an amount of tissue that would correspond to the size of the needle and the degree of its curvature. The suture is drawn parallel to the surface of the skin. The stitching and stitching on each side are placed symmetrically. The ends of the thread are brought out onto the skin, pulled until the edges of the wound come together and held in this position. After this, an intradermal (intradermal) suture is applied. The ends of the threads are tied on one side to a ball, plate, roller or button; then, by pulling the ends of the threads at the other end of the wound, they achieve complete alignment of the edges of the skin and also fix the knot.

A continuous (cosmetic) Halstead suture is an excellent completion of any minimally invasive or microsurgical operation. But it has one significant drawback: these are two knots (two rollers, or buttons) on the skin on both edges of the wound, which require removal after 7-10 days. As a rule, during this period the patient needs dressings and observation by a surgeon, as the risk of surgical infection remains. Thus, the time spent by the operated patient on the surgical bed is extended.

Meanwhile, every postoperative day spent in the hospital increases the cost of treating one operated case. In addition, longer periods of patient stay in the hospital cause psychological and emotional discomfort, which negatively affects the process of postoperative rehabilitation.

The goal is to reduce the time the patient spends in the surgical bed.

Disclosure of the invention

The problem is solved by the fact that in the method of suturing a wound with a continuous cosmetic subcutaneous-intradermal suture, which consists in the fact that when suturing a skin wound, the subcutaneous fatty tissue is first sutured, capturing in each stitch such an amount of tissue that would correspond to the size of the needle and the degree of its curvature , the seam is drawn parallel to the surface of the skin, while the injection and puncture of the stitch on each side are placed symmetrically, the ends of the thread are brought out to the skin, pulled until the edges of the wound are brought closer together, while simultaneously pulling the ends of the thread in different directions and held in this position, the beginning and end of the thread are tied , after that, an intradermal suture is applied in the same way and the ends of the thread are brought out onto the skin, according to the invention, at the last intradermal stitch, the thread with a needle is passed into the subcutaneous fatty tissue and the thread is pulled up until the edges of the wound are aligned, then the subcutaneous fatty tissue is stitched, forming a thread loop, and tie a knot with tightening of the ends, achieving complete alignment of the edges of the skin and fix the knot, after which the thread is passed into the subcutaneous fat beyond the wound and brought to the skin at a distance of 10-15 mm from the corner of the wound, then the thread is pulled until the knot is set into the subcutaneous tissue the fatty tissue is cut off completely, thus tucking the fixed knot under the skin, while the suture is made with an absorbable thread.

Rationale for cause and effect

At the last intradermal stitch, inserting a thread with a needle into the subcutaneous fatty tissue and pulling the thread until the edges of the wound are aligned, followed by stitching the subcutaneous fatty tissue, forming a loop of thread, and tying a knot with tightening the ends, achieving complete alignment of the edges of the skin and fixing the knot, in combination with the subsequent passage of the thread in the subcutaneous fatty tissue beyond the wound and bringing it to the skin at a distance of 10-15 mm from the corner of the wound, with further tensioning of the thread until the knot is set into the subcutaneous fatty tissue and cut off, with the thus fixed knot being tucked in under the skin when making a suture with an absorbable thread makes it possible to dispense with the removal of sutures and possible infection of the wound, thereby reducing the patient’s stay in the hospital.

Justification of the invention's compliance with the criteria for patentability

The inventive method is novel in comparison with the prototype, differing from it in such significant features as passing the thread with a needle into the subcutaneous fat at the last intradermal stitch and pulling the thread until the edges of the wound are aligned, subsequent stitching of the subcutaneous fat, forming a thread loop, and tying a knot with tightening the ends to achieve complete alignment of the edges of the skin and fixing the knot, then passing the thread into the subcutaneous fat beyond the wound and bringing it to the skin at a distance of 10-15 mm from the corner of the wound, further pulling the thread until the knot is set into the subcutaneous fat fiber and cutting it, tucking the thus fixed knot under the skin when making a suture with an absorbable thread, which together ensure the achievement of the desired result.

The applicant is unaware of technical solutions that would use the above-mentioned distinctive actions in combination when applying an intradermal suture and a suture in the subcutaneous fatty retina with the formation of a loop of the main thread by tension and subsequent immersion of the nodes under the skin, and therefore, although the use of self-dissolving threads is known in surgery, he believes that the claimed method meets the criterion of “inventive step”.

The inventive method can find wide application in surgery and therefore meets the criterion of “industrial applicability”.

Brief description of drawings

The invention is illustrated:

A) drawings where shown in:

- fig. 1 - removal of the main thread with a needle intradermally from the subcutaneous layer with the cut “tail” of the knot, thread without a needle (on the left - top view, on the right - side view);

- fig. 2 - application of an intradermal continuous suture not reaching 3-7 mm along the opposite edge of the wound and passing the thread into the subcutaneous space (left - top view, right - side view);

- fig. 3- formation of a loop after suturing the intradermal-subcutaneous layer in the opposite wall of the wound (left - top view, right - side view);

- fig. 4- applying the last knot with tensioning the thread and matching the edges of the wound (on the left - top view, on the right - side view);

- fig. 5 - cutting the loop and running the thread subcutaneously, bringing it to the skin 15-20 mm beyond the wound (left - top view, right - side view);

B) photographs showing:

- fig. 6 - placing the last suture on the subcutaneous fatty tissue at one of the edges of the wound, followed by cutting the outer thread without a needle;

- fig. 7 - removal of the main thread with a needle intradermally at a distance of 3-7 mm from the edge of the wound;

- fig. 8 - application of an intradermal continuous suture to the opposite edge of the wound, not reaching 3-7 mm;

- fig. 9 - passing the thread subcutaneously from the opposite side;

- fig. 10 - stitching the inner dermis from the opposite side and forming a loop;

- fig. 11 - wound contraction;

- fig. 12 - subcutaneous application of the knot followed by cutting the loop;

- fig. 13 - passing the needle subcutaneously beyond the wound by 10-15 mm and puncturing and tensioning the thread with immersion of the last knot and subsequent cutting of the thread;

- fig. 14 - final view of the postoperative wound after immersion of the last knot and complete cutting of the thread;

- fig. 15 - dynamics of postoperative wound healing in the early postoperative period (illustration of a clinical example).

Disclosure of the invention

The inventive method is as follows (the method is illustrated schematically in Fig. 1-5 both for applying a suture to the subcutaneous fatty tissue and for applying a suture to the skin).

When suturing a wound, the subcutaneous fatty tissue is first sutured with a continuous suture, capturing in each stitch an amount of tissue corresponding to the size of the needle and the degree of its curvature. In this case, the seam is drawn parallel to the surface of the skin, the injection and puncture of the stitch on each side are placed symmetrically (Fig. 1). At the last stitch, a loop is created, pulled until the edges of the wound come together (Fig. 2, 3) and a fixing knot is tied (Fig. 4). After which the loop is cut off, and the end of the thread is brought to the edge of the wound intradermally (Fig. 5).

Then an intradermal suture is applied. The latter is carried out parallel to the surface of the skin. The injection and puncture of the stitch on each side are placed symmetrically, periodically, by pulling the end of the thread and achieving complete alignment of the edges of the skin. At the last stitch, the thread is brought out subcutaneously and the symmetrically located dermis is stitched, creating a loop. The node is fixed with the final comparison of the edges of the skin wound. The loop is cut off, and the end of the thread is brought out subcutaneously to the surface of the skin at a distance of 10-15 mm from the edge of the wound. The end of the thread is pulled, inserting the fixing knot into the subcutaneous space, and cut. In this case, the suture is made with absorbable thread.

Implementation of the proposed method

In practice, the method of suturing a wound with a continuous subcutaneous-intradermal suture is carried out as described above. In this case, the distinctive feature of the proposed method lies in two points:

1) the primary knot is the last marginal suture on the subcutaneous fatty tissue, which is applied to it, followed by passing the main thread (with a needle) intradermally into the corner of the wound and cutting off the free end (without a needle) (Fig. 6). The first subcutaneous knot is tightened on the opposite the edge of the wound in the subcutaneous fatty tissue by forming a loop of the main thread, followed by cutting it off and bringing the main thread (with a needle) to the skin 10-15 mm from the edge of the wound, pulling and moving the knot under the skin with final cutting of the thread; the main thread (with a needle) is withdrawn intradermally at a distance of 3-5 mm from the edge of the wound (Fig. 7).

2) Then an intradermal continuous suture is applied in accordance with the above. The suture is drawn parallel to the surface of the skin. The injection and puncture of the stitch on each side are placed symmetrically, periodically, by pulling the end of the thread and achieving complete alignment of the edges of the skin on the opposite edge of the wound, not reaching it 3-5 mm (Fig. 8).

Next, the thread is passed subcutaneously from the opposite side of the wound (Fig. 9). Then the inner dermis is stitched from the opposite side and a loop is formed (Fig. 10). The wound is tightened and a knot is applied subcutaneously (Fig. 11) with the loop trimmed (Fig. 12). Then the needle is passed subcutaneously beyond the wound by 10-15 mm, a puncture is made (Fig. 13), the thread is pulled with the last knot immersed and cut. The final view of the postoperative wound is shown in Fig. 14.

Thus, the existing wound is completely sutured and all nodes are hidden under the skin. More than three thousand patients have had their wounds sutured using this method. Wound suturing was performed on the head, face, torso and limbs. This technique is used in Chelyabinsk clinics: CHUZ “Clinical Hospital “RZD-Medicine” Chelyabinsk, GAUZ Regional Clinical Hospital No. 3, Lotus MC. Recently, a self-absorbing thread I-COL 3-0 has been used and in the early postoperative period the wound heals primarily without the formation of rough scars. The patient is ready for discharge on 3-4 days; in the absence of drainage and the need for perioperative antibiotic prophylaxis, discharge is possible on the day of surgery.

There were 2 cases (less than 0.06%) of complications in the late (18 and 21 days) postoperative period: cutting of the last subcutaneous node to the surface. In both cases, the thickness of the thread did not match the thickness of the skin. After removal of the nodes, the wounds healed within 3 days.

Clinical example:

Patient R., 48 years old, diagnosis: Lumbar osteochondrosis. Sequestrated disc herniation L4-L5. L5 root compression syndrome on the right.

Surgery under general anesthesia, prone position. Microsurgical interlaminectomy of L4-L5 on the right was performed, removal of a sequestered disc herniation. When suturing the postoperative wound, the proposed original continuous subcutaneous-intradermal suture according to Halstead-Bastron was used. Discharge from the hospital on the 4th day. A follow-up examination of the patient was performed on days 14 and 28 after surgery.

In fig. Figure 15 shows the dynamics of postoperative wound healing in the early postoperative period.

Thus, in comparison with the prototype, the use of the proposed improved method of suturing a wound with a continuous cosmetic subcutaneous-intradermal suture allows suturing the wound without leaving thread knots on the skin and not using additional special fixation elements (rollers or buttons), as described in the prototype, which require removal after 7-10 days, during which the patient needs dressings and observation by a surgeon, since the risk of secondary surgical infection remains. At the same time, the absence of knots and additional fixation elements on the skin, combined with the use of absorbable thread for suturing, eliminates the possibility of secondary infection of the wound, thereby reducing the time the operated patient spends on the surgical bed.

Claims (1)

A method of suturing a wound with a continuous cosmetic subcutaneous-intradermal suture, which consists in the fact that when suturing a skin wound, the subcutaneous fatty tissue is first sutured, capturing in each stitch an amount of tissue that would correspond to the size of the needle and the degree of its curvature, the suture is drawn parallel to the surface of the skin, in this case, the injection and puncture of the stitch on each side are placed symmetrically, the ends of the thread are brought out to the skin, pulled until the edges of the wound are brought together, while simultaneously pulling the ends of the thread in different directions, and held in this position, the beginning and end of the thread are tied, then applied in the same way intradermal suture and bring the ends of the thread to the skin, characterized in that at the last intradermal stitch the thread with a needle is passed into the subcutaneous fatty tissue and the thread is pulled up until the edges of the wound are aligned, then the subcutaneous fatty tissue is stitched, forming a loop of thread, and a knot is tied with tightening ends, achieving complete alignment of the edges of the skin, and fix the knot, after which the thread is passed into the subcutaneous fatty tissue beyond the wound and brought to the skin at a distance of 10-15 mm from the corner of the wound, then the thread is pulled until the knot is repositioned into the subcutaneous fatty tissue and completely cut, thus tucking the fixed knot under the skin, while the suture is made with an absorbable thread.

Images