Collateral circulation during axillary artery ligation. Operations on the arteries

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 of development of vascular surgery is characterized by wide diagnostic capabilities 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 tomographic methods, as well as the development various kinds and methods of prosthetics and shunting of 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 anterior tibial arteries. (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 ligation of veins.

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 Better conditions for the development of I 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 - I is carried out mainly due to I existing anastomoses between the branches of I different arterial trunks, while I 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.)

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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 bandaging 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 the bleeding for a short time, and is used only in emergency cases before applying clamps to the wounded vessel.

The imposition of a rubber band is carried out above the place arterial bleeding predominantly on the shoulder or hip. 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

new developments in the elderly with pronounced atherosclerosis and with 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

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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 a particular 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, but-

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 thrombosis 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. IN 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 guide 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 drawbacks.

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 - sewing together with 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

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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 when applying the linear suture described above, excessive narrowing of the lumen may occur, 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

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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

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.)

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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.

An unfavorable level of ligation of the arterial trunks on the upper limb is the final section of the axillary artery after the subscapular artery departs and the initial section of the brachial artery before the deep shoulder artery departs (2).

Ligation of the axillary artery above the level of the origin of the subscapular and brachial (1), as well as below the origin of the deep artery of the shoulder and the superior collateral ulnar artery (4) are safe and are not accompanied by the development of acute limb ischemia. The level of ligation of the brachial artery below the origin of the deep artery of the shoulder (3) is acceptable, but it is less safe than the fourth level. Isolated ligation of any other main artery of the arm, as a rule, does not threaten the development of circulatory decompensation in the distal parts of the upper limb.

In the lower extremity, pronounced ischemic disorders are most likely when the femoral artery is ligated above the origin of the deep femoral artery (1) and the popliteal artery along its entire length (4). Ligation of the femoral artery at the apex of the femoral triangle below the origin of the deep femoral artery (2) and in the middle third of the segment (3) is safe and acceptable for injuries of the arterial trunk. Isolated ligation of any of the main arteries of the leg and foot usually does not threaten the development of severe ischemic complications.

In the wounded with uncompensated limb ischemia, if final recovery is impossible, temporary vascular prosthetics should be performed. With compensated ischemia, temporary vascular prosthesis is contraindicated, since the use of this method may be accompanied by complications. If there are signs of venous hypertension during the operation, which is more common in the case of injury to large venous trunks of the lower extremities, temporary prosthetics are indicated not only for arteries, but also for veins. With temporary vascular prosthetics, it is also necessary to perform subcutaneous fasciotomy of the distal limb segment and immobilize. Systolic blood pressure should be maintained at a level not lower than 100-120 mm Hg. Antispasmodics, antiplatelet agents, blood substitutes of rheological action (reopoliglyukin, reogluman) are administered.

The technique of temporary vascular prosthesis for two-stage treatment:

1. An artery is isolated, vascular clamps are applied to it (in their absence, rubber tourniquets), the ends of the artery are freed from excess adventitia, without excising or aligning them.

2. Take a silicone or PVC tube corresponding to the diameter of the damaged vessel and cut off the corresponding part of it. The length of the tube segment is set according to the size of the artery defect by adding another 3-4 cm for insertion into the lumen of the artery (approximately 1-2 cm at each end). The tube is placed in a physiological solution of sodium chloride with heparin (add 2,500 IU of heparin per 200 ml of solution).

3. They are convinced of the patency of the distal end of the artery and introduce a temporary prosthesis into it, for which it is necessary to stretch the walls of the vessel with two thin clamps. If the introduction is difficult, do not force it (danger of detachment of the inner shell!), But cut off the end of the prosthesis obliquely, which will greatly facilitate its introduction; a temporary prosthesis is fixed in the artery with two ligatures.

4. After checking the retrograde filling of the prosthesis with blood, clamp the artery again. Clamps cannot be applied to the prosthesis itself. Then the temporary prosthesis is washed with saline solution with heparin, the prosthesis is inserted into the central (proximal) end of the artery and fixed with one ligature. The clamps are relaxed first at the peripheral, then at the central end of the artery, making sure that there is good blood flow through the temporary prosthesis. The second ligature is applied to the proximal end of the artery around the tube, internal ligatures are connected from both ends of the prosthesis to each other and brought out into the wound. Over the temporary prosthesis, the muscles are sutured with rare sutures, the skin is not sutured.

5. During the re-intervention, the temporary prosthesis is excised along with segments of both ends of the artery during the introduction of the prosthesis.

When using temporary prosthetics, the wounded after being taken out of shock must be urgently evacuated, preferably by air, to a specialized department.

Specialized medical care. The following groups of the wounded are distinguished:

1) Wounded with temporarily stopped or self-stopped primary bleeding, in which the vessels were not restored at the stage of qualified care.

2) Wounded with secondary bleeding.

3) Wounded with pulsating hematomas and aneurysms.

4) Wounded with dead limbs.

5) Wounded with restored or bandaged vessels.

First of all, the wounded are operated on with bleeding, with temporary artery prostheses, and also after unsuccessful restoration or ligation of blood vessels with symptoms of increasing limb ischemia. Restorative operations on blood vessels are contraindicated in the general serious condition of the wounded, with the development of a wound infection, in the period of the peak of radiation sickness. The wounded with aneurysms and arteriovenous fistulas with a healed wound, with chronic arterial and venous insufficiency are sent to vascular centers.

Surgery for vascular injuries can be performed under general and local anesthesia. When using an elastic hemostatic tourniquet to prevent intraoperative bleeding, the vessels are immediately exposed with a wide typical access, regardless of the course of the wound channel and those incisions that will be made for surgical treatment of the wound. If a tourniquet is not used, the artery should be exposed first above the wound. A rubber tourniquet is placed over the artery. Do the same with the artery distal to the wound. Only after that the vessels are exposed at the level of the wound.

Restoration of the vessel is carried out by applying a lateral or circular suture. It is advisable to apply a lateral suture for transverse wounds that make up no more than half the circumference of the vessel, and for longitudinal wounds no more than 1-1.5 cm long. In other cases, it is advisable to cut the artery even with incomplete damage and restore it with a circular suture.

Before applying a vascular suture for gunshot wounds, only clearly macroscopically damaged sections of the artery wall are excised. It is also necessary to remove excess adventitia from the ends of the vessel to be sutured, so that during the suture it does not fall into the lumen of the artery, then moisten the ends of the vessel with heparin. In case of poor blood flow from the peripheral end of the artery, its lumen is preliminarily cleaned of blood clots with a balloon probe.

Circular suture technique. Two or three U-shaped sutures are applied to the vessel with an atraumatic thread at an equal distance from each other. Pulling these sutures brings the ends of the vessel closer, and when they are tied, the intima adapts. Between them impose the usual twisting seams. After relaxation of the tourniquets (first peripheral, then central), bleeding occurs from the suture line, so the vessel should be wrapped with a napkin moistened with saline and wait 4-5 minutes. The use of a vascular stapling apparatus facilitates the imposition of a circular vascular suture and improves its results. At the end of the operation, the area of ​​the vascular suture is covered with muscle tissues.

It is possible to apply an end-to-end vascular suture with defects in the artery wall no more than 2-3 cm long, while it is necessary to mobilize the vessel to the center and to the periphery of the wound by 10 cm, bend the limb in the joint. In the case of more extensive defects, arterial autoplasty is performed using a reversed section of the great saphenous vein of an intact lower limb (the peripheral end of the vein is sutured to the central end of the artery so that the venous valves do not interfere with blood flow).

Indications for the restoration of damaged main veins are signs of venous hypertension, which is more common with injuries of large veins of the lower extremities. If the vein is ligated in this situation, a fasciotomy should be performed. If repair is needed, both the artery and vein are repaired first by the artery. The reverse sequence of actions can lead to thromboembolism of the pulmonary arteries with blood clots that accumulate in the lumen of the damaged vein.

If a vessel injury is combined with a bone fracture, then osteosynthesis is first performed, and then the vessel is restored. To avoid an increase in the duration of ischemia during osteosynthesis in the wounded with signs of uncompensated ischemia, it is advisable to start the operation with a temporary restoration of blood flow. The technique of intraoperative temporary prosthetics has some differences from that described above. The tube corresponding to the diameter of the vessel after insertion into the lumen is fixed with rubber turnstiles that do not damage the vascular wall. In addition, not linear, but long loop-like curved prostheses are used, which allows for safe osteosynthesis and other manipulations.

The primary surgical treatment of a gunshot musculoskeletal wound should be carried out more carefully. According to the indications, resection of the ends of the fragments is allowed. At this stage, preference is given to bone osteosynthesis. With extensive wounds, external osteosynthesis is performed with devices.

During operations against the background of threatening ischemia, a wide subcutaneous dissection of all fascial cases of the ischemic segment is performed using long scissors. Prophylactic fasciotomy during the restoration of the arteries of the extremities is performed according to the following indications: late (more than 4 hours) terms of restoration of blood flow in uncompensated limb ischemia; prolonged (1.5-2 hours) stay on the limb of a hemostatic tourniquet; injury of the accompanying main vein; extensive soft tissue damage and significant limb edema; the serious condition of the wounded with a previous long period of arterial hypotension.

Most often, fasciotomy is used on the lower leg due to the structural features of the osteofascial cases. Its technique consists in opening the anterior and outer cases from one longitudinal incision on the anterior-outer surface of the middle third of the leg 8-10 cm long and opening the superficial and deep posterior cases from the same second incision on the inner surface of the middle and lower third of the leg. The incisions are sutured with rare sutures to eliminate the gate of infection.

In the postoperative period, infusion-transfusion therapy is continued; low molecular weight dextrans, antiplatelet agents, and antispasmodics are administered to eliminate arterial spasm. Anticoagulant therapy in the restoration of blood vessels in the conditions of staged treatment is usually not carried out.

Evacuation of the wounded after restoration or ligation of vessels, if the general condition allows, is possible after 6-12 hours. after operation. From 3-4 to 10 days, evacuation is dangerous due to the possibility of developing secondary bleeding. Before evacuation of all the wounded, regardless of the nature of the intervention on the vessels, the limb is immobilized with transport tires and a provisional tourniquet is applied.

Along with arterial and venous vessels, nerves can be damaged. The most commonly injured are the radial, ulnar, median and sciatic nerves. With gunshot fractures of the shoulder, nerve damage was noted in 35.6% of the wounded, forearm bones - in 30.5%, thigh - in 10.6% and lower leg bones - in 22.2% (K.A. Grigorovich).

The presence of a break in the nerve conductor is determined by the absence of sensitivity in the zone of its innervation and the corresponding function. If the radial nerve is damaged at shoulder level, dorsiflexion of the hand is disturbed and it is impossible to remove the thumb. If the median nerve is damaged at the level of the shoulder or upper third of the forearm, there is no active pronation of the forearm, abduction of the hand to the radial side, opposition and flexion of the thumb, adduction and abduction of the II–III fingers, and flexion of the middle phalanges of all fingers. If the ulnar nerve is damaged, the adduction and abduction of the straightened thumb are disturbed, and the IV and V fingers take a claw-like position.

In case of damage to the brachial plexus, lesions of the upper and lower trunk are distinguished, less often there is a total lesion of the entire plexus. With damage to the upper trunk (C5-C6), the possibilities of shoulder abduction and flexion of the forearm are limited, and with damage to the lower trunk (C5-Th1), the function of flexion of the hand and fingers, as well as the small muscles of the hand, drops out.

Damage to the tibial nerve in the popliteal fossa is accompanied by the impossibility of plantar flexion of the foot and fingers. If the peroneal nerve is damaged, the foot sags, and dorsiflexion is impossible. A complete interruption of the sciatic nerve is accompanied by a violation of active mobility in the foot and fingers.

First aid comes down to stopping bleeding, applying an aseptic bandage and immobilization. Immobilization of the limb is performed in a position in which the nerve experiences the least tension, which prevents sagging of the limb and stretching of the paralyzed muscles (Table ...).

Treatment. In case of fractures complicated by nerve damage, first of all, they provide comparison of fragments and their strong fixation. Fixation is carried out more often by internal osteosynthesis or by the use of compression-distraction devices. In some cases, especially in comminuted fractures of the upper extremities, in the interests of strong fixation of the fragments and suturing the nerve without tension, an economical resection of the ends of the fragments is performed. Under favorable conditions, and especially when the surgeon knows how to suture the nerve, a primary suture is applied.

Table …

Rational immobilization of the limb in case of nerve damage

[according to K. A. Grigorovich]

If there are no favorable conditions, the fracture is treated; after the wound has healed and the fracture has consolidated, reconstructive surgery on the nerves is started.

Primary nerve suture can be performed under certain conditions.

1. There should be no signs of a purulent infection, and after surgical treatment, sutures can be applied to the wound.

2. The surgeon must master the nerve suture technique to perfection.

3. Surgical access should ensure the exposure of the ends of the injured nerve and their mobilization to eliminate tension.

With a sharp razor, damaged areas are economically resected (“refreshing”) and epineural sutures are applied in such a way that the ends of the nerve do not twist, there is no compression, curvature and bending of the bundles. With proper suturing, the transverse sections of both ends are contrasted with the greatest accuracy.

For the suture of the nerve, a thin (8-9/0) thread made of lavsan with a cutting needle is used. Sutures are placed through the epineurium of the central and peripheral segments of the nerves.

Delayed nerve suture. The nerve is isolated from the scars formed around it. Then its bed is opened without disturbing the blood supply up and down to the distance necessary to mobilize the ends of the damaged nerve. The nerve ends are resected and epineural sutures are applied.

After osteosynthesis and suturing of the nerve, plaster immobilization is performed and the wounded is rehabilitated. Currently, for a more effective suture of nerves, a microsurgical technique is used, which allows you to connect individual nerve bundles with microsutures. This is especially important due to the fact that any large multifascicular nerve in a transverse section is 30-70% represented by connective tissue. This is one of the reasons for the often unsatisfactory results of the traditional epineural suture. The second feature of the microsurgical suture of nerves should be considered the possibility of suturing the bundles corresponding to each other after their identification, which significantly reduces the proportion of heterogeneous regeneration of nerve fibers.

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 the 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 at the knee and hip joints of the limb passes from the middle of the inguinal ligament to the medial condyle of the thigh. 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.

When ligating the subclavian artery below the clavicle, an incision is made 2 cm below and parallel to the latter. The skin, subcutaneous tissue and superficial fascia are dissected. The pectoralis major muscle (m.pectoralis major), together with the fascia covering it, is cut from the clavicle obliquely downwards and outwards. Then the sternoclavicular fascia (f. clavipectoralis) is carefully opened and the pectoralis minor muscle (m. pectoralis minor) is exposed. On the upper edge of the latter, the subclavian artery is found, medial to which lies the vein, and lateral to the brachial plexus (Fig. 9).

Figure 9 Exposure of the subclavian artery below the clavicle. 1 - skin with subcutaneous fat; 2 - pectoralis major muscle; 3 - small pectoral muscle; 4 - subclavian vein; 5 - subclavian artery; 6 - trunks of the brachial plexus

Collateral circulation during ligation of the subclavian artery develops through anastomoses a. transversae colli and a. transversae scapulae, with aa. circumflexae humeri anterior et posterior and a. circumflexa scapulae, as well as anastomoses of the branches of a. thoracica interna c a. thoracica lateralis and a. thoracica suprema.

Ligation of the axillary artery (a. axillaris).

Ligation of the axillary artery is performed in two places: at the exit from under the clavicle and in the axillary fossa. The level of ligation of the artery depends on the purpose of the operation. If the ligation is performed due to an injury to the artery, then in order to preserve the nutrition of the limb, one should strive to tie it above the origin of the subscapular artery (a. subscapularis), since a collateral path is created through the system of anastomoses to fill the brachial artery (a. brachialis).

Ligation of the axillary artery at the exit from under the clavicle.

The patient is placed on a roller; his hand is taken away from the chest and somewhat pulled out so that the groove between the deltoid and pectoralis major muscles (sulcus deltoideopectoralis) is more clearly visible. Starting from the clavicle, an oblique incision 8-20 cm long is made along the indicated groove. After opening the skin and subcutaneous tissue, the lateral saphenous vein of the arm (v. cephalica) is exposed. The vein is deflected upwards, penetrates in a blunt way through the tissue between the deltoid (m. deltoideus) and pectoralis major (m. pectoralis major) muscles and reaches the tightly stretched fascia - f.deltoideopectoralis, under which there are vessels. Through this fascia, the thoracoacromial artery (a.thoraco-acromialis) emerges, which is crossed between the ligatures. The fascia is divided in a blunt way, under which lies the pectoralis minor muscle (m. pectoralis minor). On the medial edge of this muscle, the deeper-lying sheet of fascia is stupidly pushed apart, the axillary vein (v.axillaris) is medially found, which is pulled downward, and deeper, posterior to it, lies the artery.

Ligation of the axillary artery in the axillary fossa.

The patient's hand is taken away from the body at an angle greater than the right one, and set in a position intermediate between pronation and supination. The coracobrachialis muscle (m.coracobrachialis), which is straining at the same time, is groped for, which can serve as a conductor, since the axillary artery lies just under this muscle. The medial edge of this muscle corresponds to the anterior border of the scalp of the armpit. A longitudinal incision is made along the border of the middle and anterior third of the armpit, the medial edge of the coracobrachialis muscle is exposed and its fascia is dissected. A thick axillary vein is exposed, which occupies the entire field of operation. Under it, it is easy to detect a thick radial nerve (n. radialis), disappearing in depth. When looking for an artery, it must be remembered that the median nerve (n. medianus) is closely adjacent to the medial edge of the coracobrachialis muscle. To distinguish a nerve from an artery, one must trace it upwards; then it will be seen how it is formed from the medial and lateral trunks of the brachial plexus. Behind the lateral edge of this nerve is a thinner musculocutaneous nerve (n. musculocutaneus.). The ulnar nerve (n. ulnaris) is found by pulling the median nerve outwards. If the ulnar nerve is simultaneously pulled inward, the axillary artery will be exposed (Figure 10).

Rice. 10. Exposure of the axillary artery in the axillary fossa 1- coracobrachialis muscle; 2- axillary artery; 3- median nerve; 4- ulnar nerve; 5- axillary vein.

Collateral circulation during ligation of the axillary artery in its upper section, i.e. central to the origin a. subscapularis, as well as aa. circumflexae humeri anterior et posterior, is restored through distant collateral arches, of which the most important:

1) r. descendens a. transversae colli - a. subscapularis (through its branch - a. circumflexa scapulae);

2) a. transversa scapulae (from a. subclavia) - aa. circumflesae scapulae and humeri posterior;

3) intercostal branches a. thoracica interna - a. thoracica lateralis, sometimes a. thoraco-acromialis, as well as through local arcs enclosed in adjacent muscles.

When the axillary artery is ligated to the periphery from its main branches named above, the chances of a complete restoration of blood circulation are less, since only collaterals between a. profunda brachii and aa. circumflexae humeri ant. and post. and local muscle collaterals, relatively less developed.

Ligation of the brachial artery (a. brachialis).

The ligation of the brachial artery is carried out below the origin of the deep artery of the shoulder (a. profunda brachii), which is the main collateral route.

The patient's arm is retracted in the same way as when ligating the axillary artery. A typical site for arterial ligation is the middle third of the arm.

Ligation of the brachial artery in the middle third of the shoulder.

To expose the brachial artery, an incision is made along the medial edge of the biceps brachii muscle. The skin, subcutaneous tissue, superficial fascia and own fascia of the shoulder are dissected. The biceps muscle of the shoulder (m.biceps brachii) is pulled outward, the artery is isolated from the adjacent nerves, veins and tied up (Fig. 11).

Collateral circulation is well restored with the help of anastomoses of the deep artery of the shoulder with a. recurrens radialis; a.a. collaterales ulnares sup. and inf., c a. recurrens ulnaris and branches of intramuscular vessels.

Fig.11. Exposure of the brachial artery in the shoulder area. 1- biceps muscle of the shoulder; 2- median nerve; 3- brachial artery; 4- ulnar nerve; 5- brachial vein; 6 - medial cutaneous nerve of the forearm.

Ligation of the brachial artery in the cubital fossa.

The hand is taken away from the body and set in a position of strong supination. The tendon of the biceps brachii is felt. An incision is made along the ulnar edge of this tendon. The median vein of the elbow (v. mediana cubiti) enters the incision in the subcutaneous tissue, which is crossed between two ligatures.

Carefully dissecting a thin plate of fascia, the tendon of the biceps muscle is exposed; then becomes visible lacertus fibrosus, going obliquely from top to bottom. This tendon stretch is carefully cut in the direction of the skin incision.

Directly below it lies an artery accompanied by a vein. When looking for an artery, you need to remember that the vessel is quite close under the skin, and therefore you should go slowly, carefully and strictly in layers.

Ligation of the brachial artery in the antecubital fossa is safe, since a roundabout circulation can develop through several anastomotic pathways that make up the arterial network of the elbow (rete cubiti): aa. collateralis radialis, collateralis ulnaris superior et inferior, aa. recurrens radialis, recurrens ulnaris, recurrens interossea. In this case, the collateral arteries anastomose with the corresponding recurrent ones.

Ligation of the radial and ulnar arteries
(a.radialis, a.ulnaris)

Ligation of the ulnar and radial arteries is performed at different levels of the forearm.

Ligation of the radial artery in the muscular region.

Putting the hand in the supination position, an incision is made along the medial edge of the brachioradialis muscle at the border of the upper and middle thirds of the forearm; dissect the dense fascia of the forearm. The brachioradialis muscle is pulled to the radial side, while at the same time moving the flexor group (m. flexor carpi radialis and, in depth, m. flexor digitorum superficialis) to the ulnar side. Here, under a very thin fascial sheet, an artery is easily found, accompanied by its veins.

With the radial artery, a thin superficial branch of the radial nerve (ramus superficialis n. Radialis) passes here, but not directly next to the vessels, but somewhat further to the radial side, being hidden under the brachioradialis muscle (Fig. 12).

Ligation of the radial artery in the tendon section.

A short longitudinal incision is made between the tendons of the ulnar flexor and the tendon of the brachioradialis muscle, the dense fascia is dissected and the radial artery with veins is found; the radial nerve here no longer accompanies the artery.

Rice. 12. Exposure of the radial artery in the middle third of the forearm. 1- radial artery; 2- radial vein; 3- superficial branch of the radial nerve; 4- brachioradialis muscle.

Ligation of the ulnar artery in the muscular region.

To ligate the ulnar artery in the muscular section, an incision is made in the upper third of the forearm along the projection line. The incision has to be made quite long, since the artery lies deep. Dissect the fascia of the forearm, look for the tendon of the ulnar flexor of the wrist, lying

quite far towards the ulnar side. In this case, they often fall into the error of going too close to the midline of the forearm between the muscle bundles of the superficial flexor of the fingers. When the edge of the ulnar flexor is found, pushing the tissues apart, they enter between the ulnar flexor and the superficial flexor of the fingers and find the artery lying on the deep flexor of the fingers and covered by the tender deep fascia. Along the ulnar edge lies a thick ulnar nerve.

Ligation of the ulnar artery in the tendon section.

A short skin incision is made at the radial edge of the ulnar flexor tendon, the ulnar artery is found, and next to it on the ulnar side is the ulnar nerve (Fig. 13).

Rice. 13. Exposure of the ulnar artery in the lower third of the forearm. 1 - ulnar artery; 2 - ulnar nerve; 3 - superficial finger flexor; 4 - elbow flexor of the wrist.

Ligation of the ulnar and radial arteries in the sense of restoring collateral circulation does not threaten any complications.

Ligation of the superficial palmar arch
(arcus palmaris superficialis).

The superficial palmar arch is exposed by an incision, which is made within the middle third of the line connecting the pisiform bone with the lateral end of the palmar-finger fold of the index finger. The skin, subcutaneous tissue and palmar aponeurosis are dissected, under which a superficial palmar arch is found (Fig. 14).

Rice. 14. Exposure of the superficial palmar arch.

EXPOSURE OF THE NERVES OF THE UPPER LIMB

Exposure of the median nerve (n.medianus)

The median nerve on the shoulder runs next to the brachial artery. Therefore, within the shoulder, it is exposed according to the same rules as the artery.

On the forearm, it is exposed by an incision made in the middle of the anterior surface 3-4 cm long, ending at the distal radiocarpal fold. Dissect the skin, subcutaneous fat and fascia. By dissection of the fascia, a nerve is found lying between the tendons of the superficial flexor of the finger (m. flexor digitorum superficialis) and the tendons of the deep flexor of the fingers (m. flexor digitorum profundus) (Fig. 16).

Exposure of the radial nerve (n. radialis)

Since on its way around the humerus it is quite close to it, it is often injured when this bone is damaged.

The patient's arm is bent at the elbow joint and placed on the stomach. Then, below the deltoid muscle (m. deltoideus), they probe the long head of the triceps muscle of the shoulder (m. tricipitis), make an incision along the lateral edge of this muscle, enter the gap between the long and lateral heads of the muscle up to the bone and find the radial nerve here. In the lower half of the shoulder, the incision is made in the groove between the tendon of the biceps muscle of the shoulder and the brachioradialis muscle (m. brachioradialis). In the posterior corner of the wound, the triceps muscle is pulled back and then two muscles become visible in depth, the direction of the fibers of which approximately coincides with the direction of the final incision - this brachioradialis and brachialis muscles. Both muscles are pulled apart in a blunt way, and the nerve located near the bone is exposed.

In the elbow bend, the radial nerve is best exposed by an incision made along the edge of the brachioradialis muscle. Pulling this muscle laterally, find the radial nerve on the surface of m. supinatoris. It is at this point that it divides into its deep and superficial branches (ramus profundus and ramus superficialis) (Fig. 15).

Rice. 15. Exposure of the radial nerve on the shoulder. 1 - deltoid muscle; 2 - radial nerve; 3 - shoulder muscle; 4 - external head of the triceps muscle of the shoulder; 5 - posterior cutaneous nerve of the forearm.

Rice. 16. Exposure of the median and ulnar nerves on the forearm. 1 - superficial finger flexor; 2 - ulnar nerve; 3 - ulnar artery; 4 - median nerve; 5 - deep flexor of the hand; 6 - dorsal branch of the ulnar nerve; 7 - elbow flexor of the wrist.

Exposure of the ulnar nerve (n. ulnaris)

On the shoulder, the ulnar nerve is exposed with an incision passing somewhat posterior to the groove between the biceps of the shoulder (m. biceps) and the medial head of the triceps of the shoulder (m. tricipitis). After dissection of the skin with subcutaneous tissue, a whitish strip of intermuscular fascia is exposed, posterior to which the medial head of the triceps muscle of the shoulder is visible. Stupidly moving inward, they find the ulnar nerve on the anterior surface of this muscle.

In the elbow bend, the incision is made between the ulnar process of the ulna (Olecranon) and the medial epicondyle of the humerus. By dissection of one's own fascia, the ulnar nerve is exposed, easily palpable through the skin.

On the forearm, the ulnar nerve is exposed with the same incision as the ulnar artery (Fig. 16).

TOPOGRAPHICAL AND ANATOMICAL SUBSTANTIATION AND TECHNIQUE FOR PERFORMING NOVOCAINE BLOCKS

Blockade of the brachial plexus according to Kulenkapf.

Indications: refractory neuralgia, during operations on the upper limb and shoulder joint.

Technique: blockade of the brachial plexus can be performed with the patient lying down or sitting. The arm on the injection side is pulled down, the needle, after preliminary anesthesia of the skin, is inserted 1.5 cm above the middle of the upper edge of the clavicle towards the spinous of the third thoracic vertebra to a depth of 3 cm and 20 ml of 2% novocaine solution is injected (Fig. 17). The solution enters the deep cellular space of the external cervical triangle under the 5th fascia of the neck into the fascial cases of the bundles of the brachial plexus and into the sheath of the subclavian artery. Novocain penetrates downward only to the lower edge of the clavicle, where the topography of the trunks of the brachial plexus changes in relation to the subclavian artery. Anesthesia occurs after 30 minutes and lasts for 1.5 - 2 hours. With the introduction of the solution directly into the plexus, as evidenced by the irradiation of pain in the limb, pain relief occurs immediately. With blockade of the brachial plexus, injuries to the dome of the pleura, paralysis of the limb and diaphragm are possible.

Rice. 17. Points of administration of novocaine in case of vago-sympathetic blockade according to A.V. Vishnevsky (A); brachial plexus according to Kulenkanpf (B). The line indicates the projection of the external jugular vein.

Conduction anesthesia of the hand according to Brown-Usoltseva.

Indications: surgical treatment of wounds of the hand, opening of superficial phlegmon of the hand.

Technique: on the back surface of the hand at the level of the border of the middle and proximal thirds of the metacarpal bones, respectively, the interosseous spaces, a thin needle makes an intradermal injection of a 0.25% solution of novocaine (Fig. 18). Then they take a thicker needle and slowly advance it through the interosseous space to the subcutaneous tissue of the palm, sending a 0.5% novocaine solution to advance the needle. In each interosseous space, sequentially, 8-10 ml of novocaine solution is injected, which is distributed in the cellular spaces: subaponeurotic rear of the hand, deep (subtenonous) and superficial (subaponeurotic) of the middle fascial bed of the palm, tener and hypotener. In these cellular spaces, the branches of the ulnar, median, radial nerves innervating the hand pass.

Conduction anesthesia of the finger
according to Oberst-Lukashevich .

Indications: surgical treatment of finger wounds, opening panaritiums in the area of ​​the nail and middle phalanges.

Technique: a tourniquet is applied to the base of the finger, distal to which two injections are made on the sides of the back surface of the main phalanx (Fig. 18). A 1% solution of novocaine (1-2 ml) is injected into the injection area and this produces a blockade of the dorsal nerves of the finger, and then the needle is passed towards the palmar surface and the blockade of the palmar nerves is performed. Anesthesia occurs in 5-10 minutes. The blockade of the nerve trunks of the finger can be carried out without the application of a tourniquet, however, its imposition prevents bleeding from the surgical wound, which allows for an operative reception in more favorable conditions.

Rice. 18. Points of introduction of novocaine in blockades according to Oberst-Lukashevich (a); Brown-Usoltseva (b).

PROJECTIONS OF ARTERIES AND NERVES
LOWER LIMB

BUTTOCKS
(regioglutea)

Superior gluteal vessels and nerve(a., v. et n.glutealis superiores) are projected on the border of the middle and medial third of the line connecting the superior posterior iliac spine with the apex of the greater trochanter. This point coincides with the position of the epipiriform opening (Fig. 19).

Inferior gluteal vessels and nerve(a., v. et v. glutealis inferiores) are projected at a point located slightly below the middle of the line connecting the upper posterior iliac spine with the lateral edge of the ischial tuberosity. This point coincides with the position of the pear-shaped opening (Fig. 19).

Rice. 19. Projection point of the upper gluteal vessels and nerve (a) and lower gluteal vessels and nerve (b).

At the same point, the exit to the gluteal region of the sciatic nerve, the posterior cutaneous nerve of the thigh, the pudendal vessels and the nerve is projected.

The above projections of vessels and nerves define areas that should be avoided during intramuscular injections. safe for intramuscular injections is the upper-lateral square of the gluteal region.

THIGH AREA
(regio femoris)

femoral artery and vein(a.v.femorales) are projected along the line connecting the point, on the border between the middle and medial third of the inguinal fold with the posterior edge of the medial condyle of the femur.

When determining this projection, the limb must be slightly bent at the knee and hip joints and rotated outwards (Fig. 20).

femoral nerve(n.femoralis) is projected onto the anterior surface of the thigh at the border of the outer and middle third of the inguinal fold.

Projection sciatic nerve (n.ischiaticus) runs along a vertical line from a point located midway between the posterior edge of the greater trochanter and the ischial tuberosity, to a point in the middle of the width of the popliteal fossa (Fig. 21).

Projection great saphenous vein of the thigh (v.savena magna) runs along a line running from the posterior edge of the medial condyle of the thigh upward to a point located on the border of the medial and middle third of the inguinal fold.

exit point external cutaneous nerve of thigh (n.cutaneus femoris lateralis) is located medially and below the anterior superior iliac spine. This corresponds to a groove between the sartorius muscle and the muscle that strains the fascia lata.

Exit site under the skin posterior femoral cutaneous nerve (n.cutaneus femoris posterior) is projected in the middle of the gluteal fold.

Fig.20. Projection of the femoral artery and vein (a); femoral nerve

Fig.21. Projection of the sciatic nerve.

KNEE AREA
(regiogenus)

Projection of the neurovascular bundle of the popliteal region ( popliteal artery, vein and tibial nerve ) (a.v. poplitea et n. tibialis) is determined along the line connecting the upper and lower corners of the popliteal fossa.

The place of division of the popliteal artery is located at the lower corner of the popliteal fossa, which corresponds to the tuberosity of the tibia in front (Fig. 22).

Projection common peroneal nerve (n.peroneus communis) corresponds to the length of the posterior-inner edge of the biceps tendon. In the region of the head of the fibula, the nerve departs somewhat from the tendon and lies on the postero-inferior surface of the head of the fibula. At this point, the nerve is palpated in the form of a cord running obliquely from behind down and forward.

Rice. 22. Projection of the popliteal vessels (a); tibial nerve (b).

(v.savena magna et n.savenus) is projected at a point located behind the medial condyle of the femur.

Small saphenous vein(v.savena parva) is projected along a line connecting the lower corner of the popliteal fossa with a point located in the middle of the width of the popliteal fossa, which corresponds to the depression formed by the heads of the gastrocnemius muscle.

SHIN AREA
(regio cruris)

Anterior tibial artery and deep peroneal nerve(a.tibialis anterior et n.peroneus profundus) are projected along a line drawn from a point connecting the middle of the distance between the tuberosity of the tibia and the head of the fibula to a point in the middle of the distance between the ankles (Fig. 23).

Rice. 23. Projection of the anterior tibial artery, deep peroneal nerve (a) and dorsal artery of the foot (b).

exit point superficial peroneal nerve (n.peroneus superficialis) under the skin is located on the border of the middle and lower third of the leg between the long extensor of the fingers and the peroneal muscles.

Posterior tibial artery and tibial nerve(a.tibialis posterior et n.tibialis) are projected along a line connecting the middle of the width of the popliteal fossa with the middle of the distance between the medial malleolus and the Achilles tendon (Fig. 24).

Rice. 24. Projection of the posterior tibial artery and tibial nerve.

peroneal artery(a.peronea) is projected in the middle and lower thirds of the line drawn from the lower angle of the popliteal fossa and the lateral malleolus.

Great saphenous vein and saphenous nerve

Small saphenous vein

Great saphenous vein and saphenous nerve(v.saphena magna et n. saphenus) are projected along a line connecting a point located one transverse finger anterior to the medial malleolus with the posterior surface of the medial condyle of the femur.

Small saphenous vein(v.saphena parva) is projected along the line connecting the lateral edge of the Achilles tendon with the lower angle of the popliteal fossa.

FOOT AREA
(regio pedis)

Projection dorsal artery of the foot (a.dorsalis pedis) is determined by a line connecting the middle of the distance between both ankles with the first interdigital space. The pulsation point of the artery is determined outward from the tendon of the long extensor of the thumb (Fig. 23).

Deep peroneal nerve(n.peroneus profundus) (terminal branch) is projected at the level of the first intermetatarsal space.

Division posterior tibial artery and tibial nerve (a.tibialis posterior et n.tibialis) is projected midway between the posterior edge of the medial malleolus and the calcaneal tubercle.

Internal plantar artery and foot nerve of the same name (a. plantaris medialis et n. plantaris medialis) are projected along a line drawn from the middle of the distance between the posterior edge of the medial malleolus and the calcaneal tuber to the first interdigital space (Fig. 25).

External plantar artery and foot nerve of the same name (a. plantaris lateralis et n.plantaris lateralis) are projected along a line drawn from the middle of the distance between the posterior edge of the medial malleolus and the calcaneal tuber to the fourth interdigital space (Fig. 25).

Rice. 25. Projection of internal (a) and external (b) plantar arteries and veins.

VESSEL AND NERVE EXPOSURE
LOWER LIMB

EXPOSURE AND LINAGE OF VESSELS
LOWER LIMB

Ligation of the external iliac artery ( a. iliaca externa)

An incision 12-15 cm long is made parallel to the pupart ligament, 1 cm above it, so that the middle of the incision coincides with the projection line of the artery. The inner end of the incision, in order to avoid damage to the spermatic cord, should be at a distance of 3 cm from the tuberculum pubicum.

Dissect the skin with subcutaneous tissue, superficial fascia and lamina Thompsoni.

The vasa epigastrica superficialis found in the fiber is cut between two ligatures.

The aponeurosis of the external oblique muscle is dissected along the zholobovatoy probe.

The lower edges of the internal oblique and transverse abdominal muscles are pulled upward with a blunt hook, after which the transverse fascia becomes visible.

The transverse fascia is dissected along a zholobovatoy probe and penetrate into the located loose layer of fatty tissue (tunica adiposa).

In a blunt way, they push apart the fiber and look for the external iliac artery.

On Cooper's ligature needle, above the origin of a. epigastricae inferior and a. circumflexae ilium profunda, a ligature is brought under the artery, being careful not to damage the adjacent vein of the same name (Fig. 26).

Anastomoses between a. epigastric superior et a. epigastric inferior, aa. glutea superior et inferior et a. circumflexa femoris lateralis, a. obturatoria et a. circumflexa femoris medialis.

Ligation of the femoral artery ( a. femorales)

Ligation of the femoral artery is performed: 1) under the inguinal ligament above and below the place of origin of the deep artery of the thigh (a. profunda femoris) 2) in the adductor canal (gunter's canal).

Ligation under the inguinal ligament.

When removing a limb, in order to avoid bleeding from the branches of the deep femoral artery, the femoral artery is ligated above the origin of the deep femoral artery.

Fig.26. Exposure of the external iliac artery

1 - genital-femoral nerve; 2 - external iliac artery;
3 - external iliac vein; 4 - lower epigastric artery;
5 - external iliac lymph node; 6 - aponvosis of the external oblique muscle of the abdomen; 7 - iliac fascia; 8 - internal oblique muscle of the abdomen; 9 - transverse abdominal muscle;
10 - peritoneum; 11- transverse fascia; 12 - Thomson plate.

If you want to save the limb and ligate the artery because of its injury, then you need to ligate the femoral artery below the origin of the deep femoral artery, which is the main collateral route for the blood supply to the underlying part of the limb.

To do this, a longitudinal incision is made 6-8 cm long, which starts from the middle of the inguinal ligament and goes down along the projection line of the artery (Fig. 27). Having cut the skin and superficial fascia, in some cases they immediately fall on the wide fascia and expose its sickle-shaped edge, while in others it is necessary to carefully and gradually move through the layer of subcutaneous fat containing the lymph nodes. Then, the wide fascia of the thigh is dissected downwards in the direction of the skin wound, while opening the vagina of the femoral vessels, located very superficially here.

Rice. 27. Exposure of the femoral artery under the inguinal ligament. 1- femoral artery; 2- femoral vein.

Collateral circulation is restored through anastomoses between a.glutea inferior et a. circumflexa femoris lateralis, a pudenda esterna et a. pudenda interna, a. obturatoria et a. circumflexa femoris medialis, etc.

Ligation of the femoral artery in the Scarpov triangle.

A skin incision 8-9 cm long is carried out along the projection line so that its lower end is 13-15 cm below the pupart ligament. The subcutaneous tissue is dissected in layers and f. superficialis.

F. is cut along the grooved probe. lata. edge m. sartorii is pulled outward with a blunt hook. The posterior wall of the sheath of the sartorius muscle, through which the vessels are visible, is carefully dissected along a grooved probe.

The artery is isolated and the ligature on the Deschamps needle is brought from its inner side, below the origin of a. profundae femoris.

Collateral circulation is restored due to a. profundae femoris.

Projection of the axillary artery: along the line on the border between the anterior and middle third of the armpit width 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 retract the muscle outward and, carefully, so as not to damage the axillary vein associated with the fascia, dissect the posterior wall of the sheath of the coracobrachial 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).