RU2566213C1 - Method for applying double spiral continuous haemostatic liver suture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying a double spiral continuous haemostatic liver suture and covering a wound surface of a liver stump with a vascularised portion of greater omentum. A needle is pricked in unidirectionally from the wound surface within a wound angle closer to a median longitudinal axis of the wound and pricked out on a diaphragmatic surface of the liver. The needle with the same filament is pricked in more than once on the median longitudinal axis of the wound and pricked out on the diaphragmatic surface of the liver covering Ѕ of a parenchyma up to an opposite wound angle. The needle is delivered in the opposite direction through the thickness of the parenchyma onto a visceral surface of the liver. The needle is pricked out and delivered onto the diaphragmatic surface. At 1 cm from the edge, the needle is pricked in through the full thickness of the parenchyma from the diaphragmatic to visceral surfaces. The suturing extends in the same sequence making a way to the wound angle.

EFFECT: reliable homeostasis, simplified technique, reduced suturing time and risk of post-hepatectomy complications of the liver stump.

1 ex, 2 dwg, 2 tbl

Description

The invention relates to medicine, namely to surgery, and can be used when performing a liver resection.

Currently, liver surgery has made great strides. However, despite significant progress in surgical hepatology, a number of problems remained to be resolved. One of them is the treatment of the wound surface during organ resection. It is from the perfection of the methodology and technique of treating the stump of the liver that one or another of the typical complications in the postoperative period depends (V.D. Zatolokin, A.A. Perkov, E.I. Zatolokina. On hemostasis during resection of the left lobe of the liver // Scientific and Practical the journal "Bulletin of Experimental and Clinical Surgery", 2009. - Volume 2, No. 4. - P. 333-334; Alperovich BI, Surgery of the liver and biliary tract. Tomsk: Publishing house of TSU, 1997. 605 p.).

There is a method of final hemostasis during liver resection, which consists in the application of oblique U-shaped hemostatic sutures with a needle puncture above and a puncture below the midline on the wound surface, fixing the omentum along the periphery of the liver stump, along two lines and between them on the wound surface of the liver (patent for invention No. 225674 RU, 2255674 C1, IPC АВВ 17/00. Method of final hemostasis during liver resection / Tutov AS, Perkov AA, Ageev MB, Podymov AN, Ryabchenko DS - No. 2003132890; announced on 11.11.2003; published on July 10, 2005 // 2005. - Bull. No. 19. - 4 pp.) - analogue, it is also totip.

The disadvantages of this method are: nodal U-shaped sutures with a puncture-injection along the midline of the wound surface of the liver do not allow uniform compression on the vascular-bile formation of the liver parenchyma in the manipulation zone; hemming of the omentum used for plastic surgery and its fixation only along the periphery and along the midline of the stump immediately during the application of the suture directly to the liver leads to a weakening of the omentum tension and promotes the formation of residual cavities between the wound surface and the material used for plastic surgery, in which surgery, wound detritus, blood, organ secretions can accumulate, which can lead to suppuration and the development of severe postoperative complications (arrosive bleeding, peritonitis ...). In addition, a distinctive feature of this method is its low profitability, since when applying single U-shaped sutures, the consumption of suture material is significantly higher than when performing continuous sutures with one thread, and the presence of a larger amount of foreign material also increases the likelihood of abscess formation and the formation of a ligature fistula. From the above, the inconvenience associated with the need to constantly reload the needle follows, which is accompanied by a large expenditure of time. It should be taken into account that the known method is notable for a certain complexity of suture formation, which requires a long training and corresponding manual skills, which also increases the time and ultimately the duration of the operation.

The technical result of the invention is the provision of reliable hemostasis along the suture with an increase in the quality of its application, as well as between the elements of the suture within the thickness of the parenchyma, simplification of the technique of suturing with reduction of the time required for this, reduction of possible postoperative complications in the area of the stump of the liver after its resection.

The technical result is ensured by the fact that after complete cutting off of the removed part of the liver, a continuous spiral twisting seam is applied in one direction with a grip ½, in the opposite direction - the entire plane of the wound surface of the liver stump.

The invention is illustrated by drawings.

FIG. 1. Liver stump with stitched and bandaged large vascular-bile formations.

1 - liver stump

FIG. 2. View of the stump of the liver with a double spiral continuous hemostatic hepatic suture.

1 - liver stump

2 - section of a large omentum

The method is as follows.

After complete cutting off of the removed part of the liver, additional hemostasis is performed on large vessels that are clearly visible on the wound surface of the liver stump (Fig. 1). Large vascular-bile formations are stitched and bandaged with lavsan (1). Then a double spiral continuous hemostatic suture is applied (Fig. 2) from the side of the wound surface of the liver (1), injecting with a needle in the corner of the wound closer to the median longitudinal axis of the wound with a puncture on the diaphragmatic surface of the liver, departing from the edge by 1 cm, after which they produce injection with a needle with the same thread on the median longitudinal axis of the wound and injection on the diaphragmatic surface of the liver. And so to the opposite corner of the wound, where through the thickness of the parenchyma they pass to the visceral surface of the liver, making a needle out there. From here, the thread is transferred to the diaphragmatic surface, where, departing from the edge by 1 cm, injected with a needle, passing through the entire thickness of the parenchyma from the diaphragmatic to visceral surface and continue suturing in the same sequence, now stitching the entire thickness of the parenchyma, moving to the corner of the wound from which suturing began. To complete the suture after a puncture on the visceral surface of the liver, an injection is again made next to the suture on the wound surface near the start point of the suture. After that, both free ends of the thread are connected to each other from the side of the wound surface, thereby also compressing the parenchyma (Fig. 2). Each time, the needle is injected in such a way that it emerges on the surface of the liver, departing from the edge of the wound by 1 cm and constantly shifting towards the suture. That is, the needle is directed in depth and to the side, and the suture occurs not in one plane, but simultaneously in several. Also, for convenience, in the process of suturing after puncture on any surface on the thread, a clamp is temporarily applied to prevent the thread tension from loosening; along the seam, this clamp is shifted. When the thread is pulled, the parenchyma is compressed simultaneously in several directions, since the thread is not directed rectilinearly in one plane, this positively affects the quality of hemo- and bile duct. And the degree of compression of the parenchyma is sufficient to clamp medium and small vessels (large ones are ligated to be sutured directly); teething does not occur. After this, the wound surface of the stump of the liver is enveloped in the area of the greater omentum on the leg (2). At the same time, the omentum should be stretched over the entire area of the wound surface of the liver until it is in full contact with it entering the upper and lower surfaces of the liver. The gland is hemmed with interrupted seams. A large omentum is used to achieve several functional goals at once: a combination of complete shelter of the wound surface of the liver and the achievement of final hemostasis, delimitation of the operation zone from the abdominal cavity.

An experimental study was conducted on 24 dogs, it consisted of two groups of experiments. When choosing animals, we took into account that the liver in dogs is significant in size and quite convenient for its resection. The microstructure is quite similar to that of the human liver. Experimental animals were observed for up to 30 days, including blood sampling from the femoral vein for biochemical studies and a liver biopsy to determine the content of lipid peroxidation products (LPO) in the liver tissue homogenate. The determination of the level of transaminases - the activity of alanine aminotransferase (ALT) and aspartate aminotransferase (ACT) in the blood serum - was carried out according to the Reitman-Frenkel method, the concentration of bilirubin - according to the method of Endrashik, cholesterol according to Ilk, β-lipoproteins according to Burshtein, urea - diacetyl monoxym. In addition, the levels of alkaline phosphatase (ALP), total protein, prothrombin index (PTI), fibrinogen were determined by conventional methods, and a thymol test was performed. Indicators of cytolysis syndrome were the activity of ALT, ACT, and LDH. Indicators of cholestasis syndrome are alkaline phosphatase activity, the concentration of bilirubin, cholesterol and β-lipoproteins. Indicators of hepatosuppressive syndrome were the concentration of total protein, fibrinogen content and prothrombin index; mesenchymal-inflammatory syndrome - thymol test. The content of lipid peroxidation products - diene conjugates (DC) and malondialdehyde (MDA) - was determined by the method of I.D. Steel et al. (1977). Before the start of the experiments, all animals had blood taken from the femoral vein for biochemical studies (control).

In the first group, an experimental study was performed on 18 dogs. All surgical interventions were performed from the upper middle laparotomic access under intravenous hexenal anesthesia. The drug was administered at a rate of 30 mg / kg of animal weight. Premedication was performed with atropine 0.1 ml of a 0.1% solution and diphenhydramine 0.2 ml of a 1% solution, which was administered intramuscularly 30 minutes before surgery. In addition, all animals underwent infusion therapy with 5% glucose solution and physiological saline in a volume of 150 to 250 ml. Resection of the left external lobe of the liver with the imposition of a double spiral continuous hemostatic hepatic suture according to our proposed method was carried out as follows. After processing the surgical field with a 1% solution of chlorhexidine bigluconate, a mid-median laparotomy was performed. The elements of the glisson and caval systems of the left external lobe of the liver were ligated. After that, the left triangular ligament intersected with the subsequent separation of the left external lobe of the liver in a blunt and sharp way along the interlobar groove and an elastic clip was applied to the stump of the remaining part of the liver. The left lobe of the liver was completely removed and additional hemostasis was performed on large vascular-bile formations, clearly visible on the wound surface of the liver, which we were stitching and ligated with lavsan. Then a double spiral continuous hemostatic suture was applied from the side of the wound surface of the liver, injecting with a needle in the corner of the wound closer to the median longitudinal axis of the wound with a puncture on the diaphragmatic surface of the liver, 1 cm from the edge, and then injected with a needle with the same thread on the median the longitudinal axis of the wound and puncture on the diaphragmatic surface of the liver. And so to the opposite corner of the wound, where through the thickness of the parenchyma passed to the visceral surface of the liver, making a needle out there. From here the thread was transferred to the diaphragmatic surface, where, departing from the edge by 1 cm, injected with a needle, passing through the entire thickness of the parenchyma from the diaphragmatic to visceral surface and continued suturing in the same sequence, now stitching the entire thickness of the parenchyma, moving to the corner of the wound from which suturing began. To complete the suture after a puncture on the visceral surface of the liver, another injection was made nearby with a puncture on the wound surface near the point of the onset of the suture. After that, both free ends of the thread were connected to each other from the side of the wound surface, thereby also producing compression of the parenchyma. Each time, the needle was injected in such a way that it emerged on the surface of the liver, departing from the edge of the wound by 1 cm and constantly shifting towards the suture. For convenience, a clamp was temporarily applied to the thread in the process of suturing after puncture on any surface on the thread to prevent the thread tension from loosening; along the seam, this clamp was shifted. After that, the wound surface of the stump of the liver was wrapped around the area of the greater omentum on the leg, while pulling the omentum over the entire area of the wound surface of the liver until it was in full contact with the upper and lower surfaces of the liver. The gland was hemmed with interrupted seams. Then hemostasis was controlled and the postoperative abdominal wound was sutured in layers tightly. Blood loss directly during resection was not more than 30 ± 5 ml. Operated animals were observed for 30 days. The postoperative period in all animals was satisfactory. All animals survived the operation.

On the day of the experiment, we took biochemical tests before the operation (before sedation) and 30 minutes after it. The control indicators (in non-operated dogs) were as follows: ALT - 0.76 ± 0.05 mmol / (h · l); ACT - 0.48 ± 0.09 mmol / (h · l); bilirubin - 13.51 ± 0.16 μmol / l; alkaline phosphatase - 2.37 ± 0.24 mmol / (h · l); cholesterol - 3.89 ± 0.35 mmol / l; β-lipoproteins - 0.31 ± 0.06 g / l; fibrinogen - 3.91 ± 0.12 mg / l; IPT - 82.3 ± 1.94%; total protein - 71.4 ± 1.17 g / l; urea - 3.78 ± 0.25 mmol / l; thymol test - 1.46 ± 0.06 units.

When assessing the dynamics of changes in biochemical parameters during the experiment, it is noteworthy that there was a not very pronounced development of the cytolytic syndrome and, to a lesser extent, cholestatic and hepatosuppressive syndromes. Our studies showed that experimental animals showed an increase in the activity of transaminases (ALT, ACT), bilirubin (table 1; units: ALT and ACT - mmol / (h · l), bilirubin - mmol / l, alkaline phosphatase - mmol / (h · l), cholesterol - mmol / l, β-lipoproteins - g / l, fibrinogen - mg / l, IPT -%, total protein - g / l, urea - mmol / l; thymol sample - unit ; p <0.05; n = 24), and the maximum values of these indicators were observed on the third day: ALT and ACT increased by 4.0 and 3.9 times, respectively, bilirubin - 1.7 times compared to the control data. Then they gradually decreased, and these parameters fully normalized by the 30th day after the operation. We also noted a slight decrease in fibrinogen, PTI, total protein and an increase in urea during the first three days after surgery with a full recovery by 14 days. Significant changes in the concentrations of cholesterol, β-lipoproteins, alkaline phosphatase, thymol test were not observed at all periods of observation.

The second group of animals (6 dogs) was used by us to study the recovery processes in the area of the wound surface after resection of the left external lobe of the liver with the application of a double spiral continuous hemostatic hepatic suture according to our method. In this group, biochemical parameters of blood serum were also determined and data were recorded that made it possible to judge the state of hemodynamics. They turned out to be identical to the results obtained in the first group. Animals were withdrawn from the experiment on the day of surgery and on days 1, 3, 7, 14 and 30. An autopsy of the abdominal cavity visually assessed both its condition as a whole and in the area of the operation. Pieces of tissue were also taken for pathomorphological studies.

In this group of experiments, we studied the processes of lipid peroxidation, an indicator of the severity of damage to the cell membranes of hepatocytes. To do this, we determined the content of primary (diene conjugates) and secondary (malondialdehyde) LPO products in the liver tissue homogenate after surgery at the same time as the biochemical parameters of blood serum (table 2; units: DC and MDA - mmol / g; p <0.05; n = 24). The table shows that the maximum increase in these indicators was observed on the third day after the operation: DC increased 1.5 times, and MDA 1.9 times compared with the norm. Two weeks later, there was a significant decrease in these indicators with normalization to the thirtieth day.

Macro and microscopic studies revealed the following.

Macroscopically: With a post-mortem autopsy one day after the operation, a pathological effusion in the abdominal cavity is not determined. The parietal and visceral peritoneum is smooth, shiny. A flap of a large omentum on the leg well covers the wound surface of the liver, it is loosely soldered to its stump, after separation, the stump of the organ is well formed in a blunt way. Adhesions in the area of the stump of the liver are not observed. On the cross section of the liver stump between the flap of the greater omentum and the wound surface there are small blood clots, the latter loosely soldered to the wound surface of the liver. 3 days after the operation, there was also no abnormal effusion in the abdominal cavity. The parietal and visceral peritoneum is smooth, shiny. A flap of a large omentum on the leg well covers the wound surface of the liver, it is loosely soldered to the stump of the liver. Additional adhesions between other organs of the abdominal cavity are not noted. On a cross section of the stump of the liver, it can be seen that the flap of the greater omentum is closely adjacent to the wound surface of the organ. A small portion of the liver (2 to 4 mm thick) adjacent to the omentum flap is slightly darker than the rest of the liver. 7 days after the operation, a pathological effusion in the abdominal cavity is not observed. The parietal and visceral peritoneum are shiny, smooth. A flap of a large omentum on the leg well covers the wound surface of the liver. Adhesive process in the stump area is not available. On the cross section of the stump of the liver, the flap of the greater omentum is closely adjacent to the wound surface of the organ. A small area of the liver (1-2 mm thick) adjacent to the omental flap is slightly darker than the rest of the organ. 14 days after the operation, a pathological effusion in the abdominal cavity is not observed. The parietal and visceral peritoneum are shiny, smooth. The omentum flap well covers the wound surface of the liver. On a transverse section of the stump of the liver, the flap of an uninsulated omentum tightly adheres to the wound surface of the organ. Adhesive process in the area of the stump of the liver is not available. At a later date (30 days), the abdominal cavity without effusion, the peritoneum is smooth, shiny. The stump of the liver is well covered with a flap of a large omentum. Adhesions between the organs of the abdominal cavity are not noted. On a cross section of the liver stump, it was found that an uninsulated omentum is tightly soldered to the surface of the liver. In the resection zone, the omentum flap is somewhat thickened, tightly welded along the edges of the wound surface of the liver with Glisson's capsule.

Microscopically: A histological examination of liver preparations showed that 1 day after the operation, necrosis (marginal zone) and necrobiosis (intermediate zone) are clearly distinguished from each other in the lesion zone. By the end of the first day after surgery, the omentum flap, moderately edematous and full-blooded with minor inflammation, is closely adjacent to the wound surface. In the marginal zone of the liver, necrotic sections of the organ decay and there is plethora of intralobular and interlobular vessels with foci of hemorrhage. In the intermediate zone, the normal lobular structure of the liver as a result of vasodilation and plethora is somewhat disturbed, the borders of hepatocytes are not expressed, their cytoplasm is diffusely colored, part of the hepatocytes are in a state of vacuolization and pycnosis. After 3 days in the area of liver resection and in the area of the greater omentum adjacent to it, areas of hemorrhage are observed. Hemodynamic disturbances in the liver, compared with the first days, decreased slightly. However, intralobular capillaries remain sharply expanded and overflowing with the formed elements of the blood. The inflammatory reaction in the lobules of the liver is insignificant and more pronounced in the interlobular connective tissue. The bile duct epithelium is partially vacuolated. In the intermediate zone, hepatic cells, bile duct epithelium and capillary endothelium are altered. The cytoplasm of hepatocytes is intensely stained with eosin, contains small vacuoles, and the nuclei are pycnotically altered. In some areas of necrobiosis, cells lose contact with each other and lie disconnected. To a lesser extent, the described changes relate to bile duct cells and capillaries. At the same time, on the third day after organ resection, along with destructive processes (necrobiosis, necrosis, etc.), the most dramatic rise in mitotic division of hepatocytes occurs in the area of the wound surface of the liver. The severity of mitotic activity of cells in the areas of necrosis and necrobiosis was not the same. In the latter, the mitotic index (MI) was significantly higher and amounted to 7.24 ± 1.16%. After 7 days, a narrow strip of the leukocyte shaft is defined in the fusion zone of the flap of the uninsulated omentum with the wound surface of the liver, in which along with leukocytes fibroblastic elements and proliferating duct epithelium with the formation of tubules, pycnomorphic cells and hepatocytes in the differentiation stage are determined, that is, necrotic decay and resorption sites and the formation of young connective tissue and blood vessels. In the vessels of the border zone, the phenomena of stasis decreased. In the area of liver tissue adjacent to the wound surface, cells in a state of vacuolization and degeneration. Proliferative processes in the area of damage decreased markedly and MI did not exceed 1.07 ± 0.05%. Our observations showed that cells capable of dividing are localized mainly along the periphery of the lobules and to a lesser extent scattered diffusely. Very rarely dividing cells were found in intact liver lobes. An increase in the number of binuclear cells is noted. On the 14th day after the operation, there is a pronounced fragmentation and organization of necrotic sites in the flap of the greater omentum and in the zone of the wound surface of the liver. Young connective tissue with a large number of cellular elements and blood vessels in places wedge-shaped grows into morphologically unchanged liver parenchyma, causing some disturbance in the structure of lobules in the area of the organ stump. In the forming connective tissue scar, proliferation of epithelial tubes from small to large is noted, epithelial ducts (false bile ducts) and islets consisting of hepatocytes are found in large numbers. 30 days after a liver resection, a formed connective tissue scar is observed in the area of its stump, consisting mainly of collagen fibers, adipose tissue, blood vessels and fibroblasts with single foci of granulation tissue. Between the connective tissue layers are visible neoplasms of the hepatic parenchyma, which occupy significant areas, including blood vessels and numerous epithelial tubes. In areas of the liver remote from the wound surface (up to 1.0 cm), small leukocyte infiltrates are found in places.

Thus, when analyzing macro- and microscopic studies, it can be noted that there was no abnormal effusion in the abdominal cavity at all periods of observation. The parietal and visceral peritoneum remained smooth and shiny, a large omentum covered the stump of the liver well. If in the early periods of observation (up to 7 days) it was still loosely bonded to the surface of the liver stump, then in later periods of observation, both microscopically and macroscopically, a gradual formation of a well-defined connective tissue scar tightly covering the organ stump is observed, and in a large omentum adjacent to to her, large blood vessels are observed. Significant circulatory disorders are not observed, the regeneration of the remaining organ after surgery against the background of the noted morphological changes proceeds quite intensively in the damage zone by mitotic cell division. To a much lesser extent, proliferation of connective tissue takes place, which ultimately does not violate the correct structure of the newly formed hepatic lobules.

All animals of this series throughout the observation period in both groups constantly recorded data that allowed us to judge the state of hemodynamics: recorded the number of heart contractions, which was 114 ± 3.6 beats / min; blood pressure, which was equal to 96 ± 4.5 mm Hg; central venous pressure, which was equal to 76 ± 6.0 cm water; ECG was recorded. The rhythm of the ECG was sinus, correct; teeth and intervals alternated sequentially.

Moreover, directly during liver resection, blood pressure decreased to 67.4 ± 0.7 mm Hg. (29.8%), CVP - up to 43.6 ± 0.5 cm water column (42.6%); Heart rate, on the contrary, increased to 169.0 ± 1.2 beats / min (48.2%). Upon exit from the operation, these indicators quickly returned to their original values. During and after surgery, no significant ECG changes were noted.

To check the reliability of hemostasis when applying a double spiral continuous hemostatic hepatic suture, as well as bringing this technique closer to clinical practice, we additionally used organocomplexes (liver, diaphragm, stomach, duodenum, small, large intestine, and large omentum) of corpses of people whose death was not associated with diseases of the abdominal organs. In 11 organocomplexes, we performed 11 left-sided hemihepatectomies (mainly resected segments II, III, and IV), taking into account all stages of these operations. Before the operation performed on the organocomplex, to verify the completeness of hemostasis, separate cannulation of the biliary and vascular systems of the liver (arterial and venous) was performed according to the method of I.A. Burakova (1979) (a device consisting of Bobrov’s apparatus and pressure gauge). Dyes were injected through cannulas under pressures equal to intravital pressures in each of the liver systems. The method described above was used for resection of the left lobe of the liver, final hemostasis, and plastic surgery of the wound surface of the liver using a large omentum and a double spiral continuous hemostatic hepatic suture. The degree of hemostasis could be judged by the appearance of droplets of colored fluids on the wound surface of the liver. After suturing, the appearance of dyes under a large omentum located on the wound surface of the stump, we did not notice. In addition, during the experiments we found out that the suture remained leakproof not only at normal pressure in the portal vein system, but also when it increased to 130-140 cm water column.

Case Study

Patient T., 46 years old, was admitted to the surgery clinic of the Kursk State Medical University on April 21, 2014 with complaints of aching pain in the right hypochondrium, general weakness. As a result of the examination, the diagnosis was made: echinococcal cyst of the left lobe of the liver. The patient underwent anatomical resection of the left lobe of the liver. For the purpose of final hemostasis, a double spiral continuous hemostatic hepatic suture was applied with cover and fixation to the wound surface of the omentum on the leg. The histological conclusion: echinococcal cyst of the left lobe of the liver. The postoperative period was uneventful, without complications. After the treatment, the patient was discharged on the 17th day after the operation in satisfactory condition. Examined after 1 year: no complaints, satisfactory condition.

Our positive research results, the favorable course of the postoperative period, moderate changes in biochemical parameters - indicators of liver damage syndromes and their transient nature indicate that surgical intervention not only did not lead to irreversible consequences, but also did not have a significant negative impact on the morphofunctional state of the liver and the body as a whole, which, in turn, confirms the effectiveness of the method we used.

Thus, it can be noted that our method of applying a double helical continuous hemostatic hepatic suture is effective, allows uniform compression on the vascular-bile formations of the liver parenchyma in the manipulation zone, significantly reduces the ischemic zone of the liver stump lying distal to the sutures (compared to conventional sutures passing through the entire parenchyma), minimizes the likelihood of developing necrosis of this zone in the postoperative period and significantly reduces the number during the possible residual cavities between the wound surface and hepatic gland. In turn, sheltering the wound surface of the liver with a large omentum on the leg is a good, biologically adequate, convenient way to peritonize the stump of this organ. An uninsulated gland has favorable plastic properties, does not inhibit the proliferation of liver tissue, does not support an inflammatory reaction, does not lead to the formation of a capsule and a coarse connective tissue scar in the area of organ damage. One of the positive aspects is also a significant increase in the speed of suturing compared to many liver sutures, which in a limited time, given the ease of suturing and its good characteristics, can be crucial. The use of a double spiral continuous hemostatic hepatic suture provides reliable hemostasis along the suture with an increase in the quality of its application, as well as between the elements of the suture within the thickness of the parenchyma, simplification of the suturing technique with a reduction in the time required for this, reduction of possible postoperative complications in the area of the liver stump after her resection.

Claims (1)

The method of applying a double spiral continuous hemostatic hepatic suture, including suturing and covering the wound surface of the stump of the liver with a large omentum on the vascular pedicle, characterized in that in one direction from the side of the wound surface in the area of the wound angle closer to the median longitudinal axis of the wound, a needle is inserted with punctured on the diaphragmatic surface of the liver, then injected with a needle with the same thread on the median longitudinal axis of the wound and punctured on the diaphragmatic surface of the liver with capture parenchyma to the opposite corner of the wound, after which in the opposite direction through the thickness of the parenchyma they pass to the visceral surface of the liver, making a puncture there, from here the thread is transferred to the diaphragmatic surface, where, departing from the edge by 1 cm, injected with a needle, pass through the entire thickness of the parenchyma from diaphragmatic to the visceral surface and continue the suture in the same sequence, advancing to the starting point of the suture in the corner of the wound, form a knot with the free ends of the thread, the gland is hemmed with interrupted sutures with access to the upper and lower Yu liver surface.

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