Sewing (medicine)
In medicine, sewing refers to the way in which the tissue is united by means of a needle and thread , whereby the thread ends are usually knotted . It is a fundamental surgical or operative technique that has been indispensable to this day , as a wound heals the fastest without complications when wound layers that belong together lie against one another without tension. This is made possible by various suture techniques and is intended to bridge the period until from the suture by healing a reliable biological scar has formed.
materials
Threads
Sewing is a historically very old form of treatment. The most important advances have been and continue to be made in materials, i.e. needles and threads. Different tasks require different sutures. In the past, for example, natural silk and sheep intestines ( catgut ) were used as sutures. Today, ultra-modern plastics are used almost exclusively.
history
| 3000 BC Chr. | Oldest surgical instruments with an eye needle ( Egypt ). |
| 1500 BC Chr. | Oldest surgical suture (on the belly of a mummy ) (linen, silk threads). |
| 1000 BC Chr. | First use of gut strings bow tendons ( Ayurveda ) |
| 500 BC Chr. | Plant fibers (cotton, linen , hemp , silk), animal tendons, ant sutures , thorns |
| Antiquity | In Greece are animal tendons , fascia and gold wires used in Rome gut strings, human hair , metal clips and textile threads ( linen , wool , silk ). |
| 650 to modern times | Metal (silver, gold, platinum , lead, copper, brass etc.) (alloys), later tantalum , magnesium alloys, chrome-nickel steel , aluminum- bronze |
| 1400 | Quills |
| 16th century | The word "Catgut" appears for the first time in a lexicon (JA Murray). |
| 1852 | The gynecologist J. Marion Sims introduced suturing with silver wire to modern surgery to reduce the risk of infection. |
| 1860 | Introduction of carbolic catgut. |
| Early 20th century | There are around 100 different sterilization methods for catgut. None of these are reliable. |
| 1900 | Silkwormgut → Seidenspinner |
| 1908 | First industrial production of sterilized catguts - Carl Braun , Franz Kuhn , 1907. |
| 1920 | stainless steel |
| 1926 | Collagen thread from horse muscles (Carnofil) |
| 1931 | First synthetic suture material made of polyvinyl alcohol (Synthofil A from B. Braun ). |
| 1939 | Sheathed polyamide filaments (Supramid from BASF ), collagen thread from bovine tendon (Collafil) |
| 1960s | Introduction of skin stapling |
| 1964 | Adhesive of cyanoacrylate approved as a skin adhesive |
| 1968 | First absorbable synthetic suture material polyglycolic acid (polyglycolide) (Dexon) |
| 1968 | First tissue glue (Histoacryl) |
| 1974 | Polyglactin 910 poly ( glycolide - lactide copolymer) PLGA (Vicryl), polyglycolic acid (Safil) |
| 1981 | Polydioxanone (PDS) |
| 1984 | Polyglyconate poly ( trimethylene carbonate-glycolide copolymer) (Maxon) |
| 1987 | Polyglactin 910 (Vicryl rapid) |
| 1992 | Polyglecapron Poly ( Caprolactone -Glycolide-Copolymer) (Monocryl) |
| 1998 | Polyglycolic acid (Serafit) |
| 1999 | Glykomer 631 poly (glycolide-trimethylene carbonate- p -dioxanone copolymer) (Biosyn), lactomer 9-1 poly (glycolide-lactide copolymer) (Polysorb) |
| 2000 | Glyconate poly (glycolide trimethylene carbonate caprolactone copolymer) (Monosyn), polyglycolic acid (Safil quick) |
| 2010 | Hydroxybutyrate (Monomax) |
Nowadays the non-resorbable materials nylon , polyester , PVDF , polytetrafluoroethylene (PTFE) and polypropylene , silk and stainless steel, as well as silver are used.
Absorbable and non-absorbable sutures
First, a distinction is made between absorbable and non-absorbable sutures. As described above, the suture only has a temporary task and suture material unnecessarily remaining in the body poses a risk of inflammation. Therefore, accessible, non-absorbable sutures are removed after a sufficient period of time. This is called “pulling strings” .
For areas in which the threads cannot be reached to pull, for example seams on internal organs or in the subcutaneous fatty tissue, threads are used that are broken down (resorbed) by the body itself. Surgical suture material is differentiated according to the resorption time, according to the time in which it has lost half of its strength, while the dissolution time is the time that elapses until it is completely dissolved.
Resorption is not only a material-specific property, but also a function of time (hyperbola). The modern threads are hydrolytically split by the presence of body water . The size of the surface (and thus the diameter) of the thread therefore play just as important a role as the type of fabric sewn, the moisture content of which is different. Catgut, on the other hand, is broken down by proteolytic enzymes .
Thick and thin threads
Thick threads have the advantage of being able to withstand great forces, since the tensile strength depends, among other things, on the cross-section. Thick threads are often used when sewing under tension. However, thick threads also leave behind thick puncture canals after pulling, which can cause unsightly scars , for example in a skin suture on the face . Therefore, the industry today provides a very large range of different threads from which the operating doctor selects the most suitable thread according to the task and experience.
Monofilament, braided and pseudomonofilament threads
Monofilament (single-thread) plastic threads, like fishing lines, are not pliable. Although they slide easily through the fabric when sewing, they are stubborn to use and their smooth surface prevents a secure knot hold.
By braiding or twisting a thread from several thin threads, a multifilre, braided or twisted thread (a rope ) is created, which is much smoother, easier to knot and the knot is secure. Such threads saw through the tissue and their unsealed surface acts like a wick . This allows pathogens to penetrate the body and promote infections. For this reason, braided threads are no longer considered contemporary for seams on the face. They are ideal for sewing the subcutaneous tissue, for example .
The industry offers pseudomonofilament threads as hybrids . These are braided threads with the mentioned advantages in handling, but the surface of which is smoothed by sheathing, coating, which avoids the sawing and wicking effects.
Sewing needles
The sewing needles are manufactured in different shapes and with special tips for different applications. Today's needles are often coated to increase their lubricity. In the past, needles made of bone, ivory , iron, silver, copper and bronze were used, later steel , nowadays only made of stainless steel.
In the past, threads were often supplied by the meter as sterile , liquid-stored in bottles and, if necessary, clamped into reusable needles with a spring eye, which are only approximately similar to those still used today for sewing fabrics. The latter never had an open spring eye.
Today, needle-thread combinations that can only be used once are common. The needle and thread form a unit, the thread is irreversibly connected to the needle. In addition to the appropriate thread material, the doctor must also select a suitable needle, because there are suitable ones for every situation: large or small, straight, slightly or strongly curved, round or triangular in cross-section with sharp edges and much more.
In the case of atraumatic sutures, the maximum caliber of the needle is identical to that of the thread and is smoothly integrated. This ensures that the thread completely fills the puncture channel and that no blood escapes from the inside of the vessel at the puncture channel, even with vascular sutures. Monofilament or pseudomonofilament suture material is a matter of course. The hollow end of the needle, which surrounds the beginning of the thread, is particularly tricky during manufacture and use. As a rule, the needle is clamped in the needle holder in its rear third and never in the area of the hollow eye .
Special seam shapes
The typical standard is the single button suture (A), in which a point-shaped wound adaptation is created by a thread passed through the tissue in a circle with a multiple knot. Long wounds therefore require several. But long wounds can also be sutured with a continuous thread, whereby different thread guides are possible: overwinding or only in one plane back and forth. In order to avoid skin exit channels, the completely sunk intracutaneous suture was developed .
Special seams can even be made when the fabric is tensioned, such as the vertical backstitch seam, the Donati seam (B). By alternating only one-sided skin pricks at the Allgöwer suture (C), the number of skin exits can even be halved. The paired other side is only grasped intra- and subcutaneously.
Anesthesia
In many cases an anesthetic may be required. Depending on the case, local anesthesia (local anesthesia or regional anesthesia), sedation or analgesia or general anesthesia (general anesthesia) can be used.
node
To close a suture, surgeons use special knotting techniques such as one-handed or two-handed knots. This can be used to tie knots such as the square knot , surgeon's knot or sliding knot such as Röder and Von-Leffern knots .
Needle holder
The earlier guiding of the needle by hand is now only occasionally used with straight needles (optional e.g. for the intracutaneous suture of a panhandle incision after a caesarean section ). Nowadays, in the vast majority of cases , it is pierced through the tissue with a special metal clamp, the needle holder , of which there are basically two different types with many modifications, and thus pulled out again. This has various advantages: The risk of infection for the surgeon from accidental stab wounds is lower and smaller needles can be used. You can also penetrate deeper wound cavities in this way. With surgical gloves, handling the needle holder is easier than guiding the needle by hand.
Even tying the thread can be done with the needle holder in many situations. In other situations, the knot that is put in place by hand and pushed in with the finger is irreplaceable.
Alternatives
There are a number of alternatives for sewing. However, none of these methods achieve the universal applicability and diversity of sewing. Sorted according to the effort, you can name the following:
- Plaster casts - they absorb the forces that make a wound gape, and thus enable tension-free adaptation and healing. Naturally, such techniques are only used externally. There are aseptically produced plasters and sterile plasters in air-tight packaging (Steristrip as the oldest example is mentioned here as a representative).
- Even older is a method already used in the late Middle Ages and known as self-adhesive (from Middle High German haft = suture), in which each wound edge of a cut is stuck with a strip of plaster and these strips are then sutured, allowing the wound edges to come closer to each other.
- Gluing - Inside the body, seams can be sealed with fibrin glue , large wound areas can be sealed in the same way or defects can be closed. The tear strength is limited. Therefore, defects glued in this way are never stressed immediately, for example when gluing after an Achilles tendon rupture . It is advantageous that fibrin is converted or broken down as protein, so that no foreign body remains in the body. Synthetic polycyanoacrylate ( super ) adhesives are currently only used externally due to unavoidably toxic monomers, for example on skin wounds for a cosmetically good result. Superficial adhesions are repelled during skin regeneration.
- Brackets ( English staples ) - In parentheses, "tacking" or "stacking" are set for the closure of skin wounds, metal clips, which hold the skin from the outside. The main advantage is a reduced operating time. Staples can also be used internally, but these are usually not set individually, but staple suturing devices are used.
- Stapling devices ( stackers ) - Hollow organs such as the esophagus, stomach, small, large or rectum can be connected with such special devices or cut through and stapled together again in one operation . Forklifts for vascular surgery have also been developed, but have not found significant acceptance.
literature
- RM Kirk: Surgical Techniques. 3rd ext. Ed., Thieme Verlag, Stuttgart 1997, ISBN 3-13-619403-9 .
- Paul Ferdinand Nockemann: Suture Techniques and Sutures in Visceral Surgery . Einhorn-Presse Verlag, Reinbek 2001, ISBN 3-88756-820-6 .
Web links
Individual evidence
- ↑ Volker Schumpelick : Surgical sewing - history, innovations, optimization approaches. In: nahdran. 2/08, Aesculap, Tuttlingen, online (PDF; 1.87 MB), at bbraun.de, accessed on March 25, 2017.
- ↑ Modern suture materials and suture techniques in surgery (PDF; 4.04 MB), on ueberweisungspraxis-bremen.de, accessed on March 24, 2017.
- ↑ Monika Franziska Maria Flury: Historical roots of the various suture material properties. Dissertation, Julius-Maximilians-Universität Würzburg, Würzburg 2002, DNB 969152930 , online (PDF; 6.51 MB), at opus.bibliothek.uni-wuerzburg.de, accessed on March 24, 2017.
- ^ J. R Siewert, M. Rothmund, V. Schumpelick (eds.): Gastroenterologische Chirurgie. 3rd edition, Springer, 2011, ISBN 978-3-642-14222-2 , pp. 164–176, limited preview in the Google book search.
- ↑ Severian Dumitriu: Polymeric Biomaterials. Second Edition, Marcel Dekker, 2002, ISBN 0-8247-0569-6 , pp. 492–506, limited preview in the Google book search.
- ↑ Barbara I. Tshisuaka: Sims, James Marion. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 1334.
- ^ J. Marion Sims: On the Treatment of Vesico-vaginal Fistula. In: American Journal of the Medical Sciences. 23, 1852, pp. 59-87.
- ^ Ulrich A. Dietz, Franz Kehl, Wulf Hamelmann, Christoph Weißer: On the 100th Anniversary of Sterile Catgut: Franz Kuhn (1866-1929) and the Epistemology of Catgut Sterilization. In: World J. Surg. Volume 31, 2007, pp. 2275-2283, doi : 10.1007 / s00268-007-9216-y .
- ^ Surgical suture material ( Memento from March 24, 2015 in the Internet Archive ).
- ↑ Gundolf Keil : The 'Cirurgia' Peters von Ulm. Investigations into a memorial of old German specialist prose with a critical edition of the text (= research on the history of the city of Ulm, Volume 2). Stadtarchiv, Ulm 1961 (also Philosophical Dissertation Heidelberg 1960).
- ↑ Ralf Vollmuth , Peter Proff: "Because the face is a special ornament and wellbeing of the people ..." Comments on the question of aesthetics in oral and maxillofacial surgery in the Middle Ages and early modern times. In: Dominik Groß , Monika Reininger (Hrsg.): Medicine in history, philology and ethnology. Festschrift for Gundolf Keil. Würzburg 2003, ISBN 3-8260-2176-2 , pp. 159-175; here: pp. 165–168.