Exposure and ligation of the axillary artery. Possible levels of ligation of the main arteries that do not cause acute limb ischemia Ligation of the brachial artery of the path of collateral blood flow

OPERATIONAL SURGERY

LIMB

OPERATIONS ON VESSELS

Operations on arterial, venous and lymphatic vessels constitute a major section of modern surgery and in many cases are organ-preserving. That is why every doctor, and even more so a novice surgeon, must be armed with knowledge of the topographic anatomy of blood vessels and basic surgical techniques that serve to stop bleeding and restore blood supply.

The current stage in the development of vascular surgery is characterized by wide diagnostic possibilities due to the advent of perfect (selective) angiography with the determination of the speed, volume of blood flow and the level of occlusion, the use of ultrasound, radioisotope and tomography methods, as well as the development of various types and methods of prosthetics and bypass arteries and veins. A great achievement should be considered the development of microsurgery, which allows restoring blood flow even in vessels with a diameter of 0.5-3 mm.

The history of vascular surgery begins in ancient times. With names Antelus and Filagrius(III-IV centuries) classical methods of operations for vascular aneurysms are associated. Amb-roise Pare in the 16th century, he was the first to ligate the arteries throughout. In 1719 L. Geister proposed a method of isolated ligation of arteries and veins, and in 1793 Deschamps designed a special needle for holding a ligature under a blood vessel, later called a needle Deschamps. The first surgeon to suture the vascular wall was hellowell(1759), and the development of the modern vascular suture belongs to the Frenchman A. Carrel(1902).

LINAGE OF VESSELS

At the present stage of development of surgery, ligation of a large blood vessel can be used as a forced operation, often indicating the impotence 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, a severe ischemic syndrome, called "ligated vessel disease."

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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 the anterior tibial artery. (From: Komarov B.D.

During operational access to the vessels, it is necessary to be guided by the projection lines (Fig. 4-1).

When opening the vagina of the 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 brought under the vein in turn 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, retreating 0.5 cm from the central one.

When ligating a large arterial trunk, first the central end of the vessel is tied with a surgical knot, then the peripheral end. Then 0.5 cm distal to the central

Rice. 4-2. General principles of venous ligation.

Rice. 4-3. General principles of ligation of large arterial vessels with stitching. The arrow indicates the direction of blood flow, the dotted line - the place of intersection of the vessel.

a piercing ligature is applied in order to avoid possible slippage of the ligature due to the formed “mace” (Fig. 4-3).

After ligation, the arterial trunk is crossed in order to interrupt the sympathetic nerves passing into the adventitia of the vessel, which I gives the effect of its desympathization. This manipu- | Lation creates the best conditions for the development of the first collateral circulation.

The possibilities of restoring blood circulation along the roundabout ways after ligation of large arteries depend on the level of ligation of these; vessels and degree of development of collateral circulation I. 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 the arterial diseases subject to surgical treatment, five main groups can be distinguished.

1. Malformations and anomalies: coarctation of the first aorta, non-closure of the arterial (botal- I fishing) duct, combined malformations of the I heart and blood vessels, vascular tumors (te-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 limbs, thrombosis and arterial aneurysms.

Operative limb surgery ♦ 279

4. Injuries: vascular injuries, traumatic aneurysms.

5. Occlusions: acute and chronic, embolisms and thromboses.

PROJECTION LINES

AND LANDING OF LARGE VESSELS

Exposure and ligation of the brachial artery (a. brachialis) on the shoulder

The projection line for exposing the brachial artery along the length of the shoulder runs from the top of the armpit along sulcus bicipitalis medialis to the middle of the distance between the tendon of the biceps muscle of the shoulder 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 carried out 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 of the humerus, through the middle of the elbow bend to the outer edge of the forearm (Fig. 4-5).

Ligation of the brachial artery in the cubital fossa rarely leads to circulatory disorders of the forearm, since anastomoses are well developed here between the branches of the brachial artery and the recurrent vessels of the radial and ulnar arteries, forming around the elbow joint rete cubity.

Exposure of the radial artery (a. radialis)

The projection line of exposure of the radial artery runs from the medial edge of the tendon of the biceps muscle of the shoulder or the middle of the cubital fossa to the pulse point of the radial artery or to a point located 0.5 cm medially 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.I., 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 internal 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, outside inwards from the middle of the distance between the superior anterior iliac spine (spina iliaca anterior superior) and pubic symphysis (symphisis pubis) to adductor tubercle of femur (tuberculum adductorium ossis femoris)(Fig. 4-7).

Rice. 4-8. The choice of the place of imposition of a ligature on the popliteal artery, a-projection line of the popliteal artery, 6-branches of the popliteal artery. Light circles indicate the most favorable areas for ligation of the anterior and posterior tibial arteries. The dotted line indicates the joint space and places of unwanted ligation. 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 with a ligature was described at the beginning of our era. Celsus.

Rice. 4-7. Projection line of the femoral artery Ken. (From: Kalashnikov PH., 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 departure a. profunda femoris, ligation of the artery should be carried out distal to the place of its discharge. Collateral circulation during ligation of 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 stepping back from the midline to the side so as not to injure v. saphena parva(Fig. 4-8).

Classification

Ways to stop bleeding are divided into two groups: temporary and final. Ways 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 along Mikulich-Radetsky. If the bleeding is arterial in nature, you can resort to pressing the blood vessel above the injury site to certain anatomical formations [for example, pressing the external carotid artery (a. carotis externa) to the carotid tubercle of the VI cervical vertebra; rice. 4-9].

Light bleeding on the extremities can be stopped by elevating the extremity, packing the wound with gauze or pressure bandage. To temporarily stop bleeding in the absence of a fracture,

Operative limb surgery -O- 281

Rice. 4-9. Places of finger pressing of arteries.(From: Komarov BD. Emergency surgical care for injuries. - M., 1984.)

change the maximum flexion of the limb in the joint above the injury site.

Finger pressure can stop bleeding for a short time, and is used only in emergency cases before applying clamps to a wounded vessel.

The imposition of a rubber tourniquet is performed above the site of arterial bleeding, mainly on the shoulder or thigh. A soft cloth is applied to the skin to avoid unnecessary injury. The tourniquet is applied so that the pulsation of the arteries below the site of its application stops. Too weak compression with a tourniquet does not reach the goal, excessively tight tightening is dangerous, as nerves and blood vessels are compressed, as a result of which paralysis may develop in the future or the intima of the vessel may suffer, and this may lead to the formation of a blood clot and gangrene of the limb. A tourniquet is used not only for bleeding, but also for the prevention of blood loss during surgery. However, this method should not be used for temporary

innovations 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 the tourniquet is applied, a note is fixed under its tours, which indicates the time the tourniquet was applied.

If large vessels are damaged, it is difficult to achieve a temporary stop of bleeding with a tamponade or bandage. In such cases, hemostatic clamps are used. Peana, Kochera or “mosquito”, with which a bleeding vessel is captured in the 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 impossibility of deep pressing of 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.

Ways to finally stop bleeding divided into mechanical (imposition 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.).

Operational interventions on large vessels, when they are damaged, can be divided into two groups. The first group includes methods of ligation of the vessel throughout or in the wound, the second group includes methods for restoring impaired blood flow by using a vascular suture and vascular plasty.

Vessel ligation

Ligation of a vessel in a wound. The procedure is performed in emergency cases with injuries or gunshot wounds (Fig. 4-10). Ligation of a vessel in a wound is the most common method of stopping bleeding, its purpose is to close the lumen of the vessel at the site of injury.

Ligation of the vessel throughout. Throughout the artery is ligated most often as a preliminary step before the removal of an organ or body part. Vessel ligation

282 <■ TOPOGRAPHICAL ANATOMY AND OPERATIONAL SURGERY ♦ Chapter 4

the binding of small-caliber vessels is sometimes replaced by their twisting.

Rice. 4-10. Scheme for stopping bleeding with a hemostat left in the wound with additional tight tamponade along Mikulicz-Radetzko-

mu.(From: A short course in operative surgery with topographic anatomy / Under the editorship of V.N. Shevkunenko. - L., 1947.)

throughout, they are produced proximal to the injury site to reduce blood flow to the damaged section of the organ or limb. . Indications

1. The impossibility of ligation of the vessel in the 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 for amputation of a limb against the background of an anaerobic infection, when the application of a tourniquet is contraindicated.

5. Danger of erosive bleeding. operational access. When ligating the artery, direct and roundabout accesses are possible throughout. With direct access, soft tissues are dissected along the projection lines, with roundabout skin incisions are made, stepping back 1-2 cm from the projection line of the artery.

In some cases, the vessel is ligated throughout to temporarily turn off blood circulation in a particular area when a large blood loss is expected (for example, when removing a sarcoma, the hips are bandaged a. iliacae ext.). The ligature is applied for the duration of the operation, and then removed.

Sometimes, instead of the usual method of ligation of the vessel, they resort to the so-called continuous chipping suture along Heidenhain(see chapter 6). Chipping is used when conventional ligation is unreliable due to the depth of the captured vessel or the danger of the ligature slipping. In order to avoid leaving many foreign bodies in the wound in the form of submersible ligatures, re-

Vascular suture

An important prerequisite for the development of vascular surgeons was the teaching N.I. Pirogov about the regularities of the location of the vessels of the extremities I in relation to the surrounding tissues, outlined in the work “Surgical Anatomy of the Arterial Trunks and Fascia” (1837).

I law - all main arteries with conjunctiva

operating veins and nerves are enclosed in | fascial sheaths or sheaths.

Law II - the walls of these cases are formed by I own fascia, covering the adjacent muscles.

III law - in the section, the vascular sheaths I have the shape of a triangle, the base tsh which is turned outward. The top of the vagina is certainly fixed to the bone "directly or indirectly." Patterns of location of vascular-Sh

nerve bundles of the extremities dictate the need for operational access to them as a guideline for the incision to choose the edge of one or another muscle that forms one of the sides of the intermuscular gap. In order to better navigate, both during operations on the vessels, and during preparation, j 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 been striving 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 seam is used for parietal wounds, and the circular one is used for full anatomical | vessel break.

Stages of vascular suture

1. Mobilization of the vessel.

2. Revision of soft tissues, vessels, nerves, bones and primary surgical treatment of the wound.

3. Preparation of the ends of the vessel for suturing (rubber tourniquets or vascular clamps are applied to the ends of the vessels).

4. Direct suture.

Rice. 4-11. Methods for the treatment of vascular injuries, a-

lateral suture, 6 - resection of the damaged section of the artery, c - circular suture, d - artery prosthesis. (From: Emergency surgery of the heart and blood vessels / Under the editorship of M.E. De-Bakey, B.V. Petrovsky. - M.,

5. Starting blood flow through the vessel, checking the tightness of the seam 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. The imposition of a vascular suture should be carried out without injury to the endothelium of the sutured vessels.

3. The connection of the edges of the damaged vessel should be with a minimum narrowing of its lumen.

4. Creation of absolute tightness of the vascular wall.

5. Prevention of blood clots: the material used for suturing vessels should not be in the lumen and come into 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 sections of the vessel. The suture is applied using special instruments and atraumatic needles, which

Operative limb surgery -O- 283

provides minimal trauma to the vessel wall, especially its inner shell (intima).

During the application of the vascular suture, the inner membranes of the vessels are attached to each other. There should be no suture materials in the lumen, nor sections of the middle or outer sheath, as they can cause thrombosis. The sutured ends of the vessel are washed with heparin and moistened periodically. Avoid getting blood on the suture material.

Unlike the suture of the artery, the venous suture is applied with less thread tension during the tightening of individual stitches. At a seam of a vein, more rare stitches are used (approximately with an interval of 2 mm). The thicker the walls of the vessel, the more rare seams can ensure the tightness of the vessel.

A suture is applied through all layers of the vessel wall. The sutured ends of the vessels must be in contact along the line of seams with their inner shell. The needle is injected approximately at a distance of 1 mm from the edge of the vessel, the stitches of the seam are placed at a distance of 1-2 mm from each other. With pathologically altered walls, a tendency to eruption of sutures is noted, and therefore, when suturing large-diameter vessels, more tissue is captured in the suture and the distance between individual stitches is increased. The vascular suture must be airtight both along the line of contact of the walls of the vessel, and in the places where the threads pass. This is ensured by sufficient tightening of the seams. During suturing, the assistant constantly maintains the thread in tension. Tightness control is carried out after suturing by removing the distal clamp. In the absence of significant bleeding, the central clamp is removed and a swab moistened with warm saline is applied to the vessel for several minutes in order to stop bleeding along the suture line.

Prevention of thrombus formation in the vessel during its temporary clamping consists in the local administration of heparin into the adducting and efferent segments of the vessel or into the general bloodstream, into the vein 5-10 minutes before the vessel is clamped. With prolonged clamping of the vessel, it is advisable to slightly open the distal and proximal clamps before applying the last sutures in order to remove air

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possible formed blood clots. After suturing and releasing the artery from clamps or tourniquets, one should make sure that there is a pulsation of the peripheral part of the vessel. Classification of vascular sutures. AT Currently, more than 60 modifications of the manual vascular suture are known. They can be divided into four groups.

Group I - the most widely used

twisted seams Carrel, Morozova and etc.; the anastomosis between the segments of the vessels is created with a continuous suture.

Group II - eversion sutures; Continuous mattress suture achieves better intimal contact.

III group - invaginated sutures proposed Murphy in 1897

Group IV - various ways to strengthen the anastomoses with absorbable prostheses.

Vascular suture Carrel. After mobilization and exclusion from the blood flow of the proximal and distal sections of the vessel with the help of special clamps, both ends of the latter are stitched through all layers with three guiding sutures-holders located at an equal distance from each other. When applying a vascular suture, the holding 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 the fixed sutures, the adjacent edges of the vessel are sutured together

Rice. 4-12. Vascular suture technique Carrel. a - edges and a continuous twisting suture, c - suturing of a vessel of aneurysms of peripheral vessels. - M., 1970.)

twisted continuous seam. The stitches of a continuous suture are carried out at a distance of 1 mm from each other through all layers with a slight capture of the edges of the vessel around the entire circumference so that after tightening the sutures, the threads do not protrude into its lumen (Fig. 4-12).

The seam Carrel has some disadvantages.

The seam covers the vessel with a thread in the form of an unyielding ring.

Often, the threads protrude into the lumen of the vessel.

The seam does not always provide a complete seal

accuracy.

Sentence carrel, undoubtedly played an important role in the development of vascular surgery, although the introduction of a 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 nodal sutures - I with holders superimposed on opposite sides. A continuous twisting suture is applied between the superimposed sutures, I, and the suture thread should be constantly kept in tension so that it acts as the third fixing suture, increasing the light of the vessel.

tsa are brought together by three seams-holders, b - stitching with suction-"Your seams. (From: Surgery

Vascular suture Henkin. Very rare intermediate interrupted sutures are applied between the sutures-holders. Then the suture line 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 above and three below. This modification reduces the number of intermediate sutures and, therefore, reduces the likelihood of thrombus formation and vasoconstriction.

Vascular suture Sapozhnikov. After excision of the central and peripheral sections of the damaged artery (with a defect of no more than 4 cm), its leading end is mobilized. On the ends cut with a blade along the side surfaces, sharp scissors make notches about 2 mm long so that all layers are cut at the same level. This makes it possible to turn the vessel wall in the form of a cuff. The cuffs formed at the central and peripheral ends are brought together and sewn with a continuous seam through all layers.

Thus, after stitching, the inner shell of the segments of the vessel is in close contact, ensuring the 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 adducting and retracting segments. This creates good conditions for blood circulation, especially in the first days, when postoperative edema narrows the lumen of the vessel.

Vascular the seamPolyantseva. Sutures-holders are applied in the form of U-shaped sutures, turning the inner wall of the vessel inside out. After stretching the superimposed sutures, a continuous continuous suture is used.

Vascular the seamJeboli Gross. The eversion U-shaped seam can be made with interrupted and mattress sutures, as well as with a continuous mattress suture.

Eversion vascular sutures. Eversion sutures also meet the basic requirements for vascular sutures (Fig. 4-13).

To stitch the posterior wall of the proximal and distal ends of the vessel, first, an interrupted mattress suture is applied to the corner without tightening the stitches. Only after flashing the entire back wall, the ends of the vessel are brought together, while pulling the threads, and thereby the tightness of the seam line is achieved. Tie the first knotted suture. He is tied to the end

Operative limb surgery ♦ 285

Rice. 4-13. Method of imposing eversion mattress vascular suture.(From: Petrovsky B.V., Milanov O.B.

continuous seam. The second corner of the vascular wound is stitched with another interrupted mattress suture, with which the end of the thread of a continuous suture is connected. The anterior wall is sutured with one continuous mattress suture. The mattress seam has some disadvantages.

1. May lead to narrowing of the anastomotic area.

2. Prevents the growth and expansion of the artery.

Other vascular sutures

With incomplete, especially patchwork, wounds of the vessel, you can use a U-shaped or loop-shaped suture, then reinforcing it with a few nodal stitches.

With longitudinal linear or small perforated wounds, a number of interrupted sutures can be applied. The resulting narrowing of the lumen subsequently levels off if it does not reach too large degrees and does not exceed 2/3 of the diameter of the vessel.

With minor lateral wounds, especially veins, one can limit oneself to applying a parietal ligature.

If the size of the lateral defect of 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 with a patch from the wall of a nearby vein, the flap of which is sutured to the arterial wall with a frequent interrupted or continuous suture. With full anatomical

286 <■ TOPOGRAPHICAL ANATOMY AND OPERATIONAL SURGERY o Chapter 4

interruption of the vessel and the impossibility of reducing its ends without tension, a section of the vein is transplanted to the defect site. For plastics, 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 blood flow. Subsequently, the wall of the vein functionally transforms and, on histological examination, resembles the wall of an artery.

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 given a position in which the convergence of the ends would be maximum (for example, flexion 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, otherwise the opposite wall may get into the seam. A vascular suture is applied only under the condition of a complete surgical treatment of the wound. If suppuration of the wound is possible, the imposition of a vascular suture is contraindicated.

SEAMLESS VESSEL CONNECTION METHODS

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 fixation of the walls of the vessel to a solid outer frame.

INVAGINATION VASCULAR SUTURE

Rings Donetsk

One of the well-known modifications of the eversion suture, which avoids narrowing of the anastomosis, is the connection of the vessel with metal rings. Donetsk(1957) of various 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 the ring, is inserted into the lumen of the peripheral end of the vessel, the walls of the latter are also put on the spikes with tweezers (Fig. 4-14).

Invagination suture Murphy

The essence of the invagination 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 inner shells of the vessel occurs, providing

III EH i

| at: 5J

Rice. 4-14. Stitching the vessel with 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 aneurysms of peripheral vessels. - M., 1970.)

Operative limb surgery ♦ 287

tightness of the anastomosis and excluding the exit of threads into the lumen of the vessel. The invagination method is most convenient in cases where it is necessary to suture arteries of different calibers and when the diameter of the central segment of the artery is less than the peripheral one.

Ligation of the axillary artery
The projection line of the artery runs on the border between the anterior and middle third of the width of the armpit or along the anterior border of hair growth (according to N.I. Pirogov) or is a continuation upward of the medial groove of the shoulder (according to Langenbeck). The hand is in the abduction position. A skin incision 8-10 cm long is carried out above the coracobrachialis muscle, 1-2 cm away from the projection line. Dissect the subcutaneous tissue, superficial fascia.

Own fascia is cut along a grooved probe. The beak-shoulder muscle is moved outward with a hook and the medial wall of the fascial sheath of the muscle is dissected along the probe. The artery lies behind the median nerve or in a fork formed by the medial and lateral crura of the nerve. Outside is n. musculocutaneus, medially - n. ulnaris, cutaneus antebrachii medialis, cutaneus brachii medialis, behind - n. radialis. The axillary vein, the wound of which is dangerous due to the possibility of an air embolism, should remain medially from the surgical wound. The artery is ligated.

Collateral circulation after ligation of the axillary artery is carried out by branches of the subclavian artery (aa. transversa colli, suprascapularis) and the axillary artery (aa. thoracodorsalis, circumflexa scapulae).

Ligation of the brachial artery
The projection line of the artery corresponds to the medial groove of the shoulder, but it is recommended to use a roundabout approach to approach the vessel in order to exclude injury or involvement of the median nerve in the scar. The hand is in the abduction position. An incision 5-6 cm long is made along the medial edge of the biceps brachii muscle, 1-1.5 cm outward and anterior to the projection line. The skin, subcutaneous tissue, superficial and own fascia are dissected in layers. The biceps muscle that appears in the wound is retracted outwards with a hook. After dissection of the posterior wall of the vagina of the biceps muscle located above the artery, the median nerve is pushed inwards with a blunt hook, the brachial artery is isolated from the accompanying veins and tied up.

Collateral circulation is carried out by branches of the deep artery of the shoulder with recurrent branches of the ulnar and radial arteries.

Ligation of the radial artery
The projection line of the radial artery connects the middle of the elbow bend with the pulse point. The hand is in supination position. A skin incision 6-8 cm long is carried out along the projection of the vessel. Own fascia is opened along 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 rn. brachioradialis and rn. flexor carpi radialis. A ligature is applied to the selected artery.

Ligation of the ulnar artery
The projection line goes from the internal condyle of the shoulder 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 bend with a point located on the border of the upper and middle thirds of the medial edge of the forearm. Hand in supination position.

A skin incision 7-8 cm long is carried out along the projection line. After dissection of the own fascia of the forearm, the ulnar flexor of the hand is pulled inwards with a hook and enters the gap between this muscle and the superficial flexor of the fingers. The artery lies behind the deep leaf of the own fascia of the forearm. It is accompanied by two veins, outside of the artery is the ulnar nerve. The artery is isolated and ligated.

Ligation of the femoral artery
The projection line, with an outwardly rotated, slightly bent limb at the knee and hip joints, runs from the middle of the inguinal ligament to the medial femoral condyle. Ligation of the artery can be performed under the inguinal ligament, in the femoral triangle and the femoral-popliteal canal.

Ligation of the femoral artery in the femoral triangle. The skin, subcutaneous tissue, superficial and broad fascia of the thigh are dissected in layers along the projection line with an incision 8-9 cm long. At the top of the triangle, the tailor's muscle is retracted outward with a blunt hook. Cutting the back wall of the sheath of the sartorius muscle along the grooved probe, the femoral vessels are exposed. With a ligature needle, a thread is brought under the artery, which lies on top of the femoral vein, and the vessel is tied up. Collateral circulation during ligation of the femoral artery below the origin of the deep femoral artery from it is carried out by the branches of the latter.

Popliteal artery ligation
The position of the patient is on the stomach. The projection line is drawn through the middle of the popliteal fossa. An incision 8-10 cm long is used to dissect the skin, subcutaneous tissue, superficial and intrinsic fascia. Under the fascia in the fiber passes n. tibialis, which is carefully taken outward with a blunt hook. Under it, a popliteal vein is found, and even deeper and somewhat medially in the fiber near the femur, the popliteal artery is isolated and ligated. Collateral circulation is carried out by branches of the arterial network of the knee joint.

Ligation of the anterior tibial artery
The projection line of the artery connects the middle of the distance between the head of the fibula and tuberositas tibiae with the middle of the distance between the ankles. A skin incision 7-8 cm long is carried out along the projection line. After dissection of the subcutaneous tissue, superficial and own fascia, hooks are removed medially m. tibialis anterior and laterally - m. extensor digitorum longus. In the lower third of the lower leg, you need to penetrate between m. tibialis anterior and m. extensor hallucis longus. The artery with accompanying veins is located on the interosseous membrane. Outside of it lies the deep peroneal nerve. The isolated artery is ligated.

Ligation of the posterior tibial artery
The projection line of the artery runs from a point 1 cm posterior to the medial edge of the tibia (above) to midway between the medial malleolus and the Achilles tendon (below).

Ligation of the posterior tibial artery in the middle third of the leg. A skin incision 7-8 cm long is carried out along the projection line. The subcutaneous tissue, superficial and proper fascia of the lower leg are dissected in layers. The medial edge of the gastrocnemius muscle is retracted posteriorly with a hook. The soleus muscle is cut along the fibers, departing 2-3 cm from the line of its attachment to the bone, and the edge of the muscle is retracted posteriorly with a hook. The artery is found behind a deep sheet of the own fascia of the lower leg, which is dissected along a grooved probe. The artery is separated from the veins accompanying it and the tibial nerve passing outward and bandaged according to the general rules.

Axillary artery exposure technique (roundabout approach).

The skin incision according to Pirogov is carried out along the border between the anterior and middle parts of the armpit. Dissect the subcutaneous tissue and superficial fascia. The fascial sheaths of the coracobrachial muscle and the short head of the biceps brachii are opened, the muscles are peeled off and retracted inwards. The medial wall of the vagina of these muscles is dissected along the grooved probe, the median nerve is determined.

The axillary artery is located in the subcutaneous tissue behind the median nerve. The vessel is isolated using a dessector and taken for a ligature.

Collateral circulation during ligation of the axillary artery in the upper section (proximal to the origin of aa.subscapularis, circumflexae humeri anterioris et posterioris).

Although the axillary artery has a large number of short and wide lateral arches, and collateral circulation in this area can be considered sufficient, there are separate parts of this vessel, the ligation of which is dangerous in terms of the possibility of developing limb gangrene. This is a segment of the artery below the origin of a. circumflexa humeri posterior and above branches a. profunda brachii, i.e. at the junction with the brachial artery.

However, blood flow is restored through the major collateral arches:

• 1* ramus descendens a. transversae colli anastomoses with a. subscapularis (through its branch - a. circumflexa scapulae);
• 2* a. transversae scapule (from a. subclavia) anastomoses with aa. circumflexa scapulae et a. humeri posterior;
• 3* intercostal branches a.mammariae intemae anastomose with a. thoraca lateralis (sometimes a. thoracoacromialis), as well as through local arteries in the adjacent muscles.

Collateral circulation during ligation of the axillary artery in the lower section: is restored by means of collaterals between a. profunda brachii and aa. circumflexae humeri anterior et posterior; and to a lesser extent through numerous intermuscular collaterals. A complete restoration of blood circulation does not occur here, because. less powerful collaterals develop here.

Complications after dressing: injury to the internal jugular vein and v. axillaries when the axillary artery is exposed can lead to air embolism, the use of a roundabout approach when it is exposed eliminates this danger. Limb necrosis during ligation of the axillary artery occurs in 28.3%.

3. Brachial artery (a. brachialis) begins at the level of the lower edge of the pectoralis major muscle, is located medially to the biceps of the shoulder (Fig. 56). In the antecubital fossa, the brachial artery lies under the aponeurosis of the biceps brachii and divides into the radial and ulnar arteries. The deep artery of the shoulder, muscular branches, superior and inferior ulnar collateral arteries depart from the brachial artery. Deep artery of the shoulder(a. profunda brachii) goes down and backwards, together with the radial nerve goes into the shoulder-muscular canal, spirals around the back of the humerus and continues (after exiting the canal) into the collateral radial artery, which gives branches to the elbow joint. Muscular branches depart from the deep artery of the shoulder (to the triceps muscle of the shoulder), the deltoid branch (to the muscle of the same name); arteries supplying the humerus, and the middle collateral artery (to the elbow joint).

Superior ulnar collateral artery(a. collateralis ulnaris superior) starts from the brachial artery in the middle part of the shoulder, passes in the posterior medial ulnar groove, gives branches to neighboring muscles and to the capsule of the elbow joint. Inferior collateral ulnar artery(a. collateralis ulnaris inferior) begins above the medial epicondyle of the humerus, gives branches to the elbow joint and to adjacent muscles.

Ulnar artery(a. ulnaris) starts from the brachial artery at the level of the neck of the radius, goes under the round pronator, then passes in the ulnar groove on the forearm along with the ulnar veins and nerve and goes to the hand. On the palmar side of the hand, the ulnar artery anastomoses with the superficial branch of the radial artery and forms superficial palmar arch(arcus palmaris superficialis), which is located under the palmar aponeurosis (Fig. 57). Muscular branches, the ulnar recurrent artery, the common interosseous artery, the palmar and dorsal carpal branches, and the deep palmar branch depart from the ulnar artery. Ulnar recurrent artery(a. reccurens ulnaris) departs from the initial part of the ulnar artery, goes up and anastomoses with the inferior ulnar collateral artery (anterior branch) and with the superior ulnar collateral artery (posterior branch). Common interosseous artery(a. interossea communis) departs from the beginning of the ulnar artery and immediately divides into the anterior and posterior interosseous arteries. Anterior interosseous artery(a. interossea anterior) goes along the front side of the interosseous membrane of the forearm, gives off muscle branches and participates in the formation of the anterior network of the wrist. Posterior interosseous artery(a. interossea posterior) perforates the interosseous membrane of the forearm, gives off muscle branches and participates in the formation of the dorsal network of the wrist. dorsal carpal branch(g. carpalis dorsalis) departs from the ulnar artery next to the pisiform bone, participates in the formation of the dorsal network of the wrist. Deep palmar branch(g. palmaris profundus) departs laterally from the ulnar artery at the level of the pisiform bone and goes, anastomosing with the final section of the radial artery, participates in the formation of a deep palmar arch. From the superficial palmar arch distally to the second, third and fourth interdigital spaces depart three common palmar digital arteries(aa. digitales palmares communes).

Rice. 56.

Front view.

• 1 - brachial artery,
• 2 - deep artery of the shoulder,
• 3 - superior ulnar collateral artery,
• 4 - lower ulnar collateral artery,
• 5 - tendon of the biceps muscle of the shoulder,
• 6 - biceps muscle of the shoulder,
• 7 - branches to the skin and muscles,
• 8 - muscle branches,
• 9 - coracobrachialis muscle,
• 10 - pectoralis major muscle.

Rice. 57. Arteries of the forearm and hand. Front view: 1 - lower ulnar collateral artery, 2 - brachial artery,

• 3 - superficial flexor of the fingers, 4 - ulnar recurrent artery, 5 - ulnar artery,
• 6 - anterior interosseous artery, 7 - deep flexor of the fingers, 8 - palmar network of the wrist,
• 9 - deep palmar branch, 10 - deep palmar arch, 11 - palmar metacarpal arteries, 12 - superficial palmar arch, 13 - common palmar digital arteries, 14 - own palmar digital arteries, 15 - thumb artery, 16 - superficial palmar branch, 17 - square pronator, 18 - radial artery, 19 - posterior interosseous artery,
• 20 - common interosseous artery, 21 - radial recurrent artery, 22 - deep branch of the radial nerve, 23 - round pronator, 24 - median nerve.

radial artery(a. radialis) goes down under the fascia and skin, then, rounding the styloid process of the radius, goes to the back of the hand and through the 1st intermetacarpal space penetrates into the palm. The terminal section of the radial artery anastomoses with the deep palmar branch of the ulnar artery and forms a deep palmar arch (arcus palmaris profundus). The palmar metacarpal arteries (aa. metacarpeae palmares) depart from this arc, which flow into the common palmar digital arteries (branches of the superficial palmar arch), (Fig. 58). In the palm of the hand, the radial artery gives off the artery of the thumb (a. princeps pollicis), which gives off branches to both sides of the thumb, and the radial artery of the index finger (a. radialisindicis). The radial recurrent artery (a. reccurens radialis), which anastomoses with the radial collateral artery, departs from the radial artery along its length, the superficial palmar branch (g. palmaris superficialis), which anastomoses in the palm of the hand with the final section of the ulnar artery; the palmar carpal branch (r. carpalis palmaris), which is involved in the formation of the palmar network of the wrist, the dorsal carpal branch (r. carpalis dorsalis), which participates together with the branch of the ulnar artery of the same name and with the branches of the interosseous arteries in the formation of the dorsal network of the wrist. 3-4 dorsal metacarpal arteries depart from this network (aa. metacarpales dorsales), and from them - dorsal digital arteries (aa. digitales dorsales).

Rice. 58.

• 1 - anterior interosseous artery,
• 2 - palmar carpal branch,
• 3 - palmar network of the wrist,
• 4 - ulnar artery, 5 - deep palmar branch of the ulnar artery,
• 6 - deep palmar arch,
• 7 - palmar metacarpal arteries,
• 8 - common palmar digital arteries, 9 - own palmar digital arteries, 10 - artery of the thumb, 11 - radial artery,
• 12 - palmar carpal branch.

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 of exposure and ligation of the axillary artery:

1. The position of the patient: on the back, the upper limb is laid aside at a right angle and laid on a side table

2. An incision of the skin, subcutaneous adipose tissue, superficial fascia, 8-10 cm long, somewhat anterior to the projection line, respectively, of the bulge of the abdomen of the coracobrachialis muscle

3. We dissect the anterior wall of the sheath of the coracobrachialis muscle along the grooved probe.

4. We take the muscle outward and, carefully, so as not to damage the axillary vein associated with the fascia, dissect the back wall of the sheath of the coracobrachialis muscle (which is also the anterior wall of the vascular sheath)

5. We stretch the edges of the wound, select the elements of the neurovascular bundle: in front, the axillary artery (3) is covered by the median nerves (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 the 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 tied with two ligatures (two for the central section, one for the peripheral section) BELOW THE OUTPUT tr. thyrocervicalis ABOVE THE DISCHARGE of the subscapular artery (a.subscapularis). Collateral circulation develops due to anastomoses between the suprascapular artery (from the thyroid cervical trunk of the subclavian artery) and the artery that goes around the scapula (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 thoracic artery (from the subscapular artery - branches of the axillary artery).

Looking for the posterior tibial artery, lying in 3channel of the inner ankle:

Channel 1 (immediately behind the medial malleolus) - posterior tendon tibial muscle;

Channel 2 (posterior to channel 1) - tendon of the long flexor fingers;

3rd channel (behind the 2nd channel) - posterior tibial vessels andtibial nerve lying posterior to them;

4 channel (posterior and outward from channel 3) - tendon of the long flexor of the big toe.

1.10. Access to the anterior tibial artery

The projection line of the anterior tibial artery is drawn from points in the middle of the distance between the head fibula and tibial tuberosity to a point midway between the outer and inner ankles.

a. Access in the upper half of the leg

Skin incision along the projection line from the tibial tuberosity bones down 8-10 cm long;

Subcutaneous adipose tissue and superficial fascia are dissected in layers. The own fascia of the lower leg is carefully examined to detect

connective tissue layer between the anterior tibial muscle and the long extensor of the fingers. The muscles are divided and with the help of blunt hooks are pulled forward and to the sides;

The anterior tibial artery is sought on the interosseous membrane, with the deep peroneal nerve lying outward from it.

b. Access in the lower half of the leg

A skin incision along the projection line 6-7 cm long, the lower edge of which the ligaments should end 1-2 cm above the ankles;

After dissection of the subcutaneous fatty tissue, superficial and proper fascia of the lower leg, the tendons of the anterior tibial muscle and the long extensor of the big toe are bred with hooks;

The anterior tibial artery and the deep peroneal nerve lying medially from it are found on the anterior-outer surface of the tibia.

P. BASIC OPERATIONS

ON THE BLOOD VESSELS

Operations for injuries and vascular diseases are accepted divided into 4 groups (according to):

1. Operations that eliminate the lumen of blood vessels.

2. Operations that restore vascular patency.

3. Palliative operations.

4. Operations on the autonomic nerves innervating the vessels.

2.1. Ligation of vessels (general provisions)

Vascular ligation may be used to temporarily or final stop of bleeding. Pay attention to widespread adoption in health care centers patients with vascular pathology of surgical interventions forrestoration of vascular patency, ligation of the main vessel in order to finally stop bleeding can only be undertaken as a last resort (severe concomitant injury, the impossibility of providing qualified angiological care with a large flow of victims or the absence ofrequired for operational intervention

toolkit). It should be remembered that when the main vessel is ligated, chronic insufficiency of blood flow always develops to one degree or another, leading to the development of functional disorders of various severity, or, in the worst case, gangrene. When performing an operation - ligation of a vessel - a number of general provisions should be strictly adhered to.

Operational access. Operative access should provide a good examination of not only the damaged vessel, but also other components of the neurovascular bundle, with minimal trauma. It is best to use typical projection line incisions to access the great vessels. If the wound is located in the projection of the neurovascular bundle, then access can be made through it. The surgical treatment of the wound performed in this case is reduced to the excision of contaminated and non-viable tissues, as well as to the removal of damaged areas of the vessel. After the neurovascular bundle, together with the fascial sheath surrounding it, is exposed for a sufficient length, it is necessary to “isolate” the damaged vessel, i.e., separate it from other components of the neurovascular bundle. This stage of operational access is carried out as follows: having captured the fascia in the anatomical tweezers, the surgeon releases it from the surrounding tissues by lightly stroking the grooved probe along the vessel. Another technique can be used: a mosquito clamp with closed jaws is installed as close as possible to the vessel wall. Carefully (in order to avoid injury to the vascular wall or rupture of the vessel), spreading the branches along one or the other wall, the vessel is released from the surrounding fascia. For the successful implementation of the surgical technique, it is necessary to isolate the vessel 1-1.5 cm above and below the injury site.

Operational reception. When ligating large and medium-sized arteries, 3 ligatures of non-absorbable suture material should be applied (Fig. 2.1)

color:black;letter-spacing: .05pt">Fig. 2.1

1st ligature - ligature without stitching. The suture thread is brought under the vessel above (in relation to the direction of blood flow) the damaged area. To facilitate this procedure, a Deschamps needle is used with a superficially lying vessel or a Cooper's needle if the vessel to be ligated lies deep.

In order to avoid capturing the nerve in the ligature or damaging the vein, the needle should be wound from the side of the nerve (vein). The thread is tied with a surgical knot;

2nd ligature - ligature with stitching. It is superimposed below the ligature without stitching, but above the injury site. With a piercing needle, approximately in the middle of its thickness, the vessel is pierced through and tied up on both sides. This ligature will prevent the overlying ligature from slipping off without stitching;

3rd ligature - ligature without stitching. It is superimposed below the site of damage to the vessel in order to prevent bleeding when blood enters the damaged vessel through collaterals.

After ligation of the damaged vessel, for the fastest development of collateral blood flow, it is recommended to cross it between the 2nd and 3rd ligatures. Ligation of the vein accompanying the main artery is inappropriate, since it will only impair blood circulation distal to the ligation site.

Surgical reception ends with a thorough examination of the remaining elements of the neurovascular bundle in order to identify possible damage.

Sewing up the surgical wound. If the wound is shallow and there is no doubt about the quality of the surgical treatment, then it is sutured tightly in layers. Otherwise, the wound is sutured with sparse sutures, leaving glove rubber drainage.

2.2. Pathways of collateral blood flow

ligation of large vessels

2.2.1. Collateral blood flow

when ligating the common carotid artery

Roundabout circulation in the region supplied by the ligated artery is carried out:

Through the branches of the external carotid artery on the healthy side, anastomosing with the branches of the external carotid artery on the operated side;

Along the branches of the subclavian artery (the sito-cervical trunk - the lower thyroid artery) from the operated side, anastomosing with the branches of the external carotid artery (superior thyroid artery) also from the operated side;

Through the anterior and posterior communicating arteries of the internal carotid artery. To assess the possibility of a roundabout blood flow through these vessels, it is advisable to determine the cranial index
(CI), because in dolichocephals (CI less than or equal to 74.9) more often,
than brachycephalic (CI equal to or greater than 80.0) one or both
communicating arteries are absent:

CHI \u003d Wx100 / L

where W is the distance between the parietal tubercles, D is the distance between the glabella and the external occipital protrusion.

Through the branches of the ophthalmic artery of the operated side with the terminal branches of the external carotid artery (maxillary and superficial temporal arteries).

2.2.2.

external carotid artery

The ways of development of collateral blood flow are the same as inligation of the common carotid artery, except for branches of the subclavianarteries from the side of the operation. For the prevention of thrombosisinternal carotid artery, if possible,it is desirable to ligate the external carotid artery in the intervalbetween the origin of the superior thyroid and lingual arteries.

2.2.3. Collateral blood flow during ligation
subclavian and axillary artery

Ways for the development of roundabout blood flow during ligationsubclavian artery in its 1st segment (before entering the interscalenespace) to the origin of the transverse artery of the scapula andthere is practically no internal thoracic artery. Onlypossible way of blood supply are anastomoses betweenintercostal arteries and thoracic branches of the axillaryarteries (the artery surrounding the scapula and the dorsal artery of the thoraciccells). Ligation in the 2nd segment of the subclavian artery (ininterstitial space) allows you to participate in a roundabout blood circulation along the above-described path of the transverse arteryscapula and internal mammary artery. Ligation of the subclavian arteries

in the 3rd segment (to the edge of the 1st rib) or dressingaxillary artery in the 1st or 2nd segments (respectively up to pectoralis minor muscle or under it) adds to the roundaboutblood flow, the last source is the deep branch of the transverseneck arteries. Ligation of the axillary artery in the 3rd segment (fromthe lower edge of the pectoralis minor to the lower edge of the pectoralis major muscles) below origin of the subscapular artery leaves no pathfor roundabout blood flow.

2.2.4. Collateral blood flow during ligation

brachial artery

Ligation of the brachial artery above the origin of the deep artery of the shoulder is unacceptable due to the lack of opportunities for the development of bypass circulation.

When ligating the brachial artery below the origin of the deep artery of the shoulder and the superior communicating ulnar artery, up to its division into the ulnar and brachial arteries, the blood circulation distal to the ligation site is carried out in two main ways:

1. Deep artery of the shoulder → middle collateral artery →
network of the elbow joint → radial recurrent artery → radial
artery;

2. Brachial artery (depending on the level of ligation) →
superior or inferior collateral ulnar artery →
network of the elbow joint → anterior and posterior ulnar recurrent
artery -» ulnar artery.

2.2.5. Collateral blood flow during ligation

ulnar and radial arteries

Restoration of blood flow during ligation of the radial or ulnar arteries is carried out due to the superficial and deep palmar arches, as well as a large number of muscle branches.

2.2.6. Collateral blood flow during ligation

femoral artery

When the femoral artery is ligated at the base of the femoral triangle above the origin of the superficial epigastric artery and the superficial artery surrounding the ilium, the development of roundabout blood circulation is possible through these vessels, anastomosing, respectively, with the branches of the superior epigastric artery and perforating branches of the lumbar arteries. However, the main pathway for the development of roundabout blood flow will be associated with the deep femoral arteries:

Internal iliac artery - obturator artery -
superficial branch of the medial artery surrounding the femoral
bone - deep artery of the thigh;

Internal iliac artery - superior and inferior
gluteal artery - ascending branch of the lateral artery
surrounding the femur - the deep artery of the thigh.

When ligating the femoral artery within the femoral triangle below the origin of the deep femoral artery, within the anterior femoral canal, the development of the bypass circulation will be associated with the descending branch of the external artery surrounding the thigh and anastomosing with the anterior and posterior recurrent tibial arteries, arising from the anterior tibial artery .

When ligating the femoral artery within the afferent canal below the place of origin of the descending artery of the knee, along with the roundabout blood circulation developing along the path described above (when ligating the femoral artery below the origin of the deep artery of the thigh), collateral blood flow is also carried out along the anastomoses between the descending artery of the knee and the anterior tibial recurrent artery, arising from the anterior tibial artery.

2.2.7. Collateral blood flow during popliteal artery ligation

Ways of development of roundabout blood circulation during dressingpopliteal artery are similar to the ways in the ligation of the femoral arteries within the adductor canal below the origindescending artery of the knee.

2.2.8. Collateral blood flow during ligation of the anterior and posterior tibial arteries

Restoration of blood flow during ligation of the anterior or posterior tibial arteries occurs due to both muscular branches,and arteries involved in the formation of the vascular network of the outer and inner ankles.

2.3. OPERATIONS THAT RESTORE VASCULAR PERFORMANCE

2.3.1. Temporary restoration of vessel patency (temporary external shunting)

Vascular shunting - this is the restoration of blood flow bypassingmain supply vessel. Basically shuntingused to eliminate ischemia of organs or segmentslimbs with significant (more than 80%) narrowing or complete obstruction of the main vessel, as well as in order to preserve blood supply to tissues during operations on the main vessel. External shunting involves the resumption of blood flowbypassing the affected area.

When a large vessel is injured and it is impossible to providequalified angiological care in the near future, to temporarily stop bleeding and preventischemic tissue damage (especially in regions where there is noor underrepresented pathways for bypass flow), temporary external shunting may be used.

Operation steps:

1. Operational access.

2. Operational reception:

a. Temporary external bypass

Stop bleeding from a damaged vessel by
overlays proximal and distal to the site of damage to the ligatures
or turnstiles;

Introduction first of all into the proximal part of the vesselshunt needles, then, after filling the shunt with blood,proximal (Figure 2.2).

color:black;letter-spacing:.15pt">Fig. 2.2

b. In case of damage to a large-caliber vessel, it is advisable

use for temporary external shunting

siliconized plastic tube:

- tourniquet placement proximal and distal damage;

- introduction of a tube suitable for the diameter of the vessel through the defect invessel wall in the proximal direction and fixing it tovascular wall with a ligature. Then the turnstile is loosened forfilling the tube with blood. Now the free end of the tube is insertedinto the vessel in the distal direction and fixed with a ligature (Fig.2.3). For visual control of the condition of the tube and insertiondrugs part of the tube is displayed on the skin.

In any case, temporary external shunting inin the next few hours, the patient should undergo a restorernaya operation on the vessel.

2.3.2. Final stop bleeding

(recovery operations)

Surgical intervention to restore integrity vessel consists

1. Online access.

2. Operational reception:

font-size:8.0pt;color:black;letter-spacing: .1pt">Fig. 2.3

The imposition of turnstiles above and below the injury site;

Careful revision of vessels, nerves, bones and soft tissuesto identify the nature and extent of damage;

To eliminate angiospasm, infiltration of paravasal tissues with a warm 0.25% solution of novocaine, intravascularthe introduction of vasodilators;

Restoring the integrity of the vessel by applying manualor mechanical vascular suture.

3. Wound closureafter its sanitation (removal of blood clots, non-viable tissues and washing with antibiotics).

The most responsible and difficult moment of the operationalreception is the restoration of the integrity of the vessel, since from the surgeon is required to choose not only the optimal tactical a variant of closing the defect in the vessel in order to avoid its narrowing, but also apply the most appropriate of over 60 (, 1955) vascular suture modifications.

2. 3.3. Technique and basic connection methods

blood vessels

Stages of vascular suture:

1. Vessel mobilization: curved clip highlight itfront, side surfaces and lastly back. The vessel is taken on a holder, bandaged and crossed outgoing from its branches.

Mobilization ends when the endsdamaged vessel can be brought together without significant tension.

2. Approximation of the ends of the vessel: the ends of the vessel are capturedvascular clamps applied in the sagittal planeto facilitate their rotation, at a distance of 1.5-2.0 cm from the edges.The degree of compression of the walls of the vessel by the clamps should be such that the vessel does not slip out, but the intima is not damaged.

3. Preparation of the ends of the vessel for suturing: the vessel is washedwith an anticoagulant solution and excised altered or unevenedges of the wall, excess adventitial membrane.

4. Imposition of a vascular suture: one way or another is applied.imposition of a manual or mechanical seam. Stitches neededapply at a distance of 1-2 mm from the edge of the vessel and observe the samethe distance between them. Before tightening the last seamit is necessary to remove air from the lumen of the vessel. To do this, removetourniquet (usually from the peripheral area) and fill the vessela vessel is filled with blood displacing air or a syringesaline solution through the gap of the last suture that was not tightened.

5. Starting blood through the vessel: first remove the distal and only after that the proximal tourniquets.

Requirements for a vascular suture:

The vascular suture must be airtight;

Should not cause narrowing of the stitched vessels;

The sections to be sewn must be connected internally.shells (intimate);

With the blood passing through the vessel should be in contact asas little suture material as possible.

Vascular suture classification:

Vascular suture

Manual Mechanical

Regional

- invaginative

nodal

Continuous

The most commonly used vascular sutures are:

a. Edge continuous seam Carrel:

- suturing-holders: the ends of the vessel are pierced through the entire thickness of the walls so that the knot is on the sideadventitious sheath. Superimposed at an equal distance two more stitches. When stretching the seams-holders, the wall vessel takes the form of a triangle, which excludesfurther stitching of the opposite wall (Fig. 2.4 a);

- using one of the threads of the sutures-holders, impose continuous twisting seam with a stitch pitch of 0.5-1.0 mm (Fig. 2.4 b). At the end of stitching one side of the triangle thread, used for suturing is tied to one of the suture threads - holders. Sew the rest of the sides in the same way. triangle, rotating the vessel with holders.

Rice. 2.4.

b. Separate seam of Briand and Jabouley:

On the anterior and posterior walls of the vessel impose U-shapedsutures-holders, the knots of which lie on the side of the adventitial shells;

By rotating the vessel by the sutures-holders, separate P-shaped sutures with a step of 1 mm along the entire perimeter of the anastomosis (Fig. 2.5).

This suture does not prevent the growth of the vessel, so its usepreferably in children.

color:black;letter-spacing: .1pt">Fig. 2.5

in. Invagination suture with Solovyov's double cuff:

- the imposition of 4 invaginating sutures-holders on an equal footingdistance from each other in the following way: on the centralend of the vessel, departing from its edge by 1.5 parts of the diameter, twicein a small area, its adventitial membrane is sutured. Thenthe same thread at a distance of 1 mm from the edge of the vessel is stitchedwall through all layers. The peripheral segment of the vessel is stitched withsides of the intima through all layers (Fig. 2.6 a);

- when tying sutures-holders intima of the central segmentturns outward and invaginates into the lumen of the peripheralsegment (Fig. 2.6 b).

Rice. 2.6

In case of insufficient tightness of the seam, separateinterrupted sutures in the cuff area.

d. The seam of the back wall, superimposed when

inability to rotate the vessel, Blalock:

The imposition of a continuous U-shaped seam on the back wallvessel: the needle is injected from the side of the adventitia, and poke out from the side

intima. On another segment of the vessel, the same needle with thread is injected from the side of the intima, and then through the entire wall from the outside to the inside (Fig. 2.7).

color:black;letter-spacing: .1pt">Fig. 2.7

Evenly pulling the threads in opposite directions, the seamtighten until tight contact of the inner shellsstitched segments of the vessel;

Suturing the anterior wall of the continuous suture andtying threads from the seams of the back and front walls.

2.3.4. Tactical techniques for restoring the integrity of the vessel

1. With a complete transverse wound of the vessel, after excision of the altered ends, an end-to-end anastomosis is formed. itpossible with a defect in the tissues of the vessel up to 3-4 cm, but requires moreextensive mobilization.

2. If the defect in the tissues of the vessel is more than 4 cm, then the patency of the arteryrepair with an autovein taken from the great saphenous veinthigh or external vein of the shoulder. Autovenous graft lengthshould be 3-4 cm larger than the replaced defect. In connection withthe presence of a valvular apparatus, the distal end of the autoveinsewn into the proximal (central) segment of the artery and vice versa.

3. With significant defects in the arterial vessels of the largecaliber in the recovery operation, it is advisable to usesynthetic vascular prostheses.

4. With a transverse wound of the vessel wall, a marginal wound is applied the seam.

5. The longitudinal wound of the vessel is sutured with using an autovenous patch (Fig. 2.8) or a patch