home→Gastritis→ What to do after ligation of the radial artery. Collateral circulation in the shoulder girdle

What to do after ligation of the radial artery. Collateral circulation in the shoulder girdle

Ligation of the axillary artery.

Projection:
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 lower point is in the middle of the elbow bend (the middle of the distance between the lateral and medial epicondyles of the humerus), or a point on the line of the elbow bend at the medial edge of the biceps tendon of the shoulder.

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 lower point is the medial edge of the styloid process of the radius (or 0.5-1 cm medial to the lateral edge of the styloid process).

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 top point is the middle of the elbow bend;
midpoint - on the border of the upper and middle thirds of the projection line of the ulnar nerve;
the lower point is the lateral edge of the pisiform bone.

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 superficial palmar arch
(Arcus palmaris superficialis).
superior point - lateral border of the pisiform bone

The lower point is the lateral end of the palmar-finger fold of the 2nd finger.
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

24-28
dressing femoral artery.

the upper point is on the border between the medial and middle thirds of the length of the inguinal ligament;
the lower point is the medial epicondyle of the femur (tuberculum adductorium)
according to Bobrov A.A.: The point is on the border between the medial 2/5 and lateral 3/5 of the length of the inguinal ligament.

The direction of the vessel corresponds to these lines when the limb is bent at the knee and hip joints and supinated.

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.

Popliteal artery and tibial nerve (projection point) - one transverse finger medial to the middle of the popliteal fossa at the level of the popliteal fold.

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 upper point is the middle of the distance between the lateral edge of the tibial tuberosity and the head of the fibula;
the lower point is 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 upper point is the projection point of the popliteal artery;
the lower point is the middle of the distance between the posterior edge of the medial malleolus and the medial edge of the Achilles tendon.

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.

Ligation of the dorsal artery of the foot (a. dorsalis pedis )
the top point is the average distance between the ankles

The lower point is the first intermetatarsal space (between the heads of the 1st and 2nd metatarsal bones)
A longitudinal incision is made, exposing the tendon of the long extensor thumb. The artery lies in the middle of the rear of the foot at the lateral edge of the said tendon. Slightly higher, directly below the cruciate ligament of the lower leg, the tendon of the long extensor of the thumb crosses the vessel. Next to the artery lies the deep peroneal nerve. The artery has to be separated from the accompanying veins (Fig. 33).

LINAGE OF VESSELS.

Vessels can be tied up in the wound and throughout. For bandaging in the wound, it is expanded with hooks or the incision is lengthened.

the vascular sheath is opened, the vessel is isolated, 2 ligatures are brought under it: above and below the injury site, the vessel is tied up and crossed between the ligatures. As a result, the spasm of its central and peripheral branches is eliminated and the development of collaterals improves. è A clamp is applied to the bleeding vessel, and then the vessel is tied up with a silk ligature. If a large vessel is damaged

Ligatures on large veins should be applied between the nearest tributaries.

outdoor carotid artery- at any level
it is better to apply a ligature not to it, but to the common carotid artery, so that you can count on restoring blood flow through the internal carotid artery due to the formation of collaterals on the opposite side and thyroid vesselsè If the internal carotid artery is damaged
The subclavian artery is ligated at the point where it emerges from under the scalene muscle. (after a branch of the thyroid trunk and a. transversa coli)
The axillary artery is proximal to a branch of the subscapular artery.
Brachial artery - it is better to ligate below a branch of the deep artery of the shoulder.
Arteries of the forearm and hand - at any level.
On the femoral artery, it is preferable to apply ligatures below the origin of the deep femoral artery.
Popliteal artery - bad anywhere
Arteries of the lower leg and foot - at any level.

SUITATION ON VESSELS:

ACCESS:

Access to the vessel should be the simplest and least traumatic, but sufficient to isolate the neurovascular bundle

Before applying, it is necessary to carry out PST of the wound: excise non-viable tissues, carry out osteosynthesis where necessary and ensure thorough hemostasis.

THE ESSENTIAL CONDITION IS THE ABSENCE OF PURULENT INFECTIONS IN THE WOUND.

Before the artery is isolated from the vagina, a 2% solution of novocaine must be injected to block the periarterial sympathetic plexuses. Then dissect the vascular sheath and sever the arteries, veins and nerves with a blunt instrument.

The vessels are exposed at a sufficient distance from the surrounding tissues, without damaging the adventitia. Having isolated the vessel from the surrounding tissues, special vascular clamps - “bulldogs” are applied to its central and peripheral ends. Adventitia is stretched with fingers, its excess is cut off. Before anastomosis is applied, blood clots are washed out with a jet of liquid (novocaine); first from the distal, then from the proximal end of the vessel. To restore patency, a defect, patch, circumferential suture, part replacement, or creation of a bypass graft can be sutured. Lateral suture - superimposed on the artery if its linear wound is less than or equal to half the circumference of the vessel in length. Interrupted sutures are applied in the transverse direction at a distance of 1.5-2 mm. one from the other. If bleeding continues; the suture line can be attached with a flap from one's own fascia/vein.

median nerve:

the top point is on the border of the anterior and middle third of the width of the axillary region;
the lower point is the middle of the distance between the medial edge of the tendon of the biceps brachii muscle and the medial epicondyle of the humerus.

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 dissecting 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)

Ulnar nerve:

the upper point is on the border of the anterior and middle third of the width of the axillary region;
the lower point is the middle of the distance between the medial epicondyle of the humerus and the olecranon of the ulna.

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

Radial nerve:

the top point is the middle of the posterior edge of the deltoid muscle, the line spirals towards the bottom point;
the lower point is the middle of the distance between the lateral epicondyle of the humerus and the lateral edge of the tendon of the biceps muscle of the shoulder or to the anterior lateral ulnar groove (at the level of the elbow bend).

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) probe long head 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)

Sciatic nerve:

the upper point is on the border between the medial and middle thirds of the line drawn from the outer edge of the ischial tuberosity to the apex of the greater trochanter;
the lower point is the middle of the distance between the epicondyles of the femur (or the upper corner of the popliteal fossa).

Exposure of the sudatic nerve in the upper third of the thigh.
An incision is made along the projection line, starting slightly above the ischial fold, going down through thick skin and a thick layer of subcutaneous tissue until they see the lower edge of the large gluteal muscle(m. gluteus maximus).
By dissecting the muscular fascia, the thigh muscles are found and in the incision area the outer edge of the biceps femoris muscle (m.biceps femoris) is found, descending far from the ischial tuberosity, somewhat obliquely and laterally. This muscular edge is pulled inward and under it the sciatic nerve embedded in loose connective tissue is found.

Exposure of the sciatic nerve in the middle third of the thigh.
An incision of the skin, subcutaneous fat and superficial fascia 10-14 cm long is carried out along the projection line in the middle third of the thigh. The edges of the wound are parted and expose the wide fascia of the thigh, between the leaves of which the posterior cutaneous nerve of the thigh (n.cutaneus femoris posterior) passes in the longitudinal direction. The wide fascia is dissected along the grooved probe on the side of the nerve in the direction of the skin incision. After dissection of the fascia, the biceps femoris muscle (m. biceps femoris) adjacent to each other from the lateral side is visible in the wound, and the semitendinosus and semimembranosus muscles (m. semitendinosus et m. semimembranosus) from the medial side. The intermuscular gap is stupidly pushed apart. In the depth of the wound in the form of a whitish band about 1 cm thick, the sciatic nerve is visible, lying on the adductor muscle of the thigh. In a blunt way, the nerve is isolated from the surrounding fatty tissue

Tibial nerve (projection point) - one transverse finger medial to the middle of the popliteal fossa at the level of the popliteal fold.

expose the same incision as the posterior tibial artery (a. tibialis posterior).

Common peroneal nerve:

the top point is the upper corner of the popliteal fossa;
the lower point is the lateral surface of the neck of the fibula.

The common peroneal nerve is exposed at the head of the fibula. An oblique longitudinal incision is made behind the head of the fibula, spirally enveloping the neck of this bone. After dissection of the tendon section at the site of attachment of the long peroneal muscle (m. peroneus longus), the nerve is found between both portions of this muscle quite close to the bone.

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 exfoliated 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: 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 cubital 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, spirally wraps around the humerus behind and continues (after leaving the canal) into the collateral radial artery, which gives off 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 of the hand (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.

When ligating large vessels

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).

External carotid artery

The ways of development of collateral blood flow are the same as in the case of ligation of the common carotid artery, except for the branches of the subclavian artery from the side of the operation. To prevent thrombosis of the internal carotid artery, if possible, it is desirable to ligate the external carotid artery in the interval between the origin of the superior thyroid and lingual arteries.

2.2.3. Collateral blood flow during ligation
subclavian and axillary artery

There are practically no ways for the development of a roundabout blood flow during ligation of the subclavian artery in its 1st segment (before entering the interstitial space) before the discharge of the transverse artery of the scapula and the internal mammary artery. The only possible route of blood supply is anastomoses between the intercostal arteries and the thoracic branches of the axillary artery (the artery surrounding the scapula and the dorsal artery chest). Ligation in the 2nd segment of the subclavian artery (in the interstitial space) allows you to participate in the roundabout blood circulation along the above-described path of the transverse artery of the scapula and the internal mammary artery. Ligation of the subclavian artery

in the 3rd segment (to the edge of the 1st rib) or ligation of the axillary artery in the 1st or 2nd segments (respectively, to the pectoralis minor muscle or under it) adds the last source to the roundabout blood flow - a deep branch of the transverse artery of the neck. Ligation of the axillary artery in the 3rd segment (from the lower edge of the pectoralis minor to the lower edge of the pectoralis major muscle) below the origin of the subscapular artery does not leave any paths for roundabout blood flow.

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.

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.

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).

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.

but. Access in the upper half of the leg

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

The 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 introduction in centers for the provision of medical care 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 ligation of the main vessel always develops to some extent chronic insufficiency blood flow, leading to the development of functional disorders of varying 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;

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.

1. Deep artery of the shoulder → middle collateral artery →
network of the elbow joint → radial recurrent artery → radial
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 ligating the femoral artery 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 afferent 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:

but. 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. 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:

but. 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 apart 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. Thispossible 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