外科打结

BASIC KNOTS ............................................................................................................................................. 2 KNOT SECURITY .......................................................................................................................................... 3 GENERAL PRINCIPLES OF KNOT TYING........................................................................................................ 5 SQUARE KNOT........................................................................................................................................... 7 SQUARE KNOT PICTURES............................................................................................................................. 7 TWO HAND TECHNIQUE............................................................................................................................... 8 Square Knot Two-Hand Technique Page 1 of 3 .................................................................................... 8 Square Knot Two-Hand Technique Page 2 of 3 .................................................................................. 10 Square Knot Two-Hand Technique Page 3 of 3 .................................................................................. 11 ONE-HANDED TECHNIQUE ........................................................................................................................ 12 Square Knot One-Hand Technique Page 1 of 2 .................................................................................. 12 SURGEON’S OR FRICTION KNOT....................................................................................................... 14 SURGEON'S OR FRICTION KNOT PAGE 1 OF 3 ............................................................................................ 14 SURGEON'S OR FRICTION KNOT PAGE 2 OF 3 ............................................................................................ 16 SURGEON'S OR FRICTION KNOT PAGE 3 OF 3 ............................................................................................ 17 DEEP TIE.................................................................................................................................................... 19 DEEP TIE PAGE 1 OF 2 ............................................................................................................................... 19 DEEP TIE PAGE 2 OF 2 ............................................................................................................................... 21 LIGATION AROUND HEMOSTATIC CLAMP.................................................................................... 22 LIGATION AROUND MEMOSTATIC CLAMP -MORE COMMON OF TWO METHODS....................................... 22 LIGATION AROUND HEMOSTATIC CLAMP -ALTERNATE TECHNIQUE......................................................... 24 INSTRUMENT TIE ................................................................................................................................... 26 INSTRUMENT TIE PAGE 1 OF 2 ................................................................................................................... 26 INSTRUMENT TIE PAGE 2 OF 2 ................................................................................................................... 28 GRANNY KNOT ........................................................................................................................................ 29 SUTURE MATERIALS ............................................................................................................................. 30 PRINCIPLES OF SUTURE SELECTION .............................................................................................. 32 PRINCIPLES OF SUTURE SELECTION .............................................................................................. 32 ABSORBABLE SUTURES........................................................................................................................ 34 ABSORBABLE SUTURES PAGE 1 ................................................................................................................. 34 ABSORBABLE SUTURES PAGE 2 ................................................................................................................. 36 NONABSORBABLE SUTURES............................................................................................................... 40 NONABSORBABLE SUTURES PAGE 1 .......................................................................................................... 40 NONABSORBABLE SUTURES PAGE 2 .......................................................................................................... 42 TRADEMARKS.......................................................................................................................................... 45 SURGICAL NEEDLES.............................................................................................................................. 46 PRACTICE BOARD .................................................................................................................................. 48 SELECTED TERMS.................................................................................................................................. 49 Basic Knots The knots demonstrated on the following pages are those most frequently used, and are applicable to all types of operative procedures. The camera was placed behind the demonstrator so that each step of the knot is shown as seen by the operator. For clarity, one-half of the strand is purple and the other white. The purple working strand is initially held in the right hand. The left-handed person may choose to study the photographs in a mirror. 1. Simple knot: incomplete basic unit 2. Square knot: completed knot 3. Surgeon's or Friction knot: completed tension knot Knot Security The knots demonstrated on the following pages are those most frequently used, and are applicable to all types of operative procedures. The camera was placed behind the demonstrator so that each step of the knot is shown as seen by the operator. For clarity, one-half of the strand is purple and the other white. The purple working strand is initially held in the right hand. The left-handed person may choose to study the photographs in a mirror. 1. Simple knot: incomplete basic unit 2. Square knot: completed knot 3. Surgeon's or Friction knot: completed tension knot Knot Security The construction of ETHICON* sutures has been carefully designed to produce the optimum combination of strength, uniformity, and hand for each material. The term hand is the most subtle of all suture quality aspects. It relates to the feel of the suture in the surgeon's hands, the smoothness with which it passes through tissue and ties down, the way in which knots can be set and snugged down, and most of all, to the firmness or body of the suture. Extensibility relates to the way in which the suture will stretch slightly during knot tying and then recover. The stretching characteristics provide the signal that alerts the surgeon to the precise moment when the suture knot is snug. Multifilament sutures are generally easier to handle and to tie than monofilament sutures, however, all the synthetic materials require a specific knotting technique. With multifilament sutures, the nature of the material and the braided or twisted construction provide a high coefficient of friction and the knots remain as they are laid down. In monofilament sutures, on the other hand, the coefficient of friction is relatively low, resulting in a greater tendency for the knot to loosen after it has been tied. In addition, monofilament synthetic polymeric materials possess the property of memory. Memory is the tendency not to lie flat, but to return to a given shape set by the material's extrusion process or the suture's packaging. The RELAY* suture delivery system delivers sutures with minimal package memory due to its unique package design. Suture knots must be properly placed to be secure. Speed in tying knots may result in less than perfect placement of the strands. In addition to variables inherent in the suture materials, considerable variation can be found between knots tied by different surgeons and even between knots tied by the same individual on different occasions. General Principles of Knot Tying Certain general principles govern the tying of all knots and apply to all suture materials. 1. The completed knot must be firm, and so tied that slipping is virtually impossible. The simplest knot for the material is the most desirable. 2. The knot must be as small as possible to prevent an excessive amount of tissue reaction when absorbable sutures are used, or to minimize foreign body reaction to nonabsorbable sutures. Ends should be cut as short as possible. 3. In tying any knot, friction between strands ("sawing") must be avoided as this can weaken the integrity of the suture. 4. Care should be taken to avoid damage to the suture material when handling. Avoid the crushing or crimping application of surgical instruments, such as needleholders and forceps, to the strand except when grasping the free end of the suture during an instrument tie. 5. Excessive tension applied by the surgeon will cause breaking of the suture and may cut tissue. Practice in avoiding excessive tension leads to successful use of finer gauge materials. 6. Sutures used for approximation should not be tied too tightly, because this may contribute to tissue strangulation. 7. After the first loop is tied, it is necessary to maintain traction on one end of the strand to avoid loosening of the throw if being tied under any tension. 8. Final tension on final throw should be as nearly horizontal as possible. 9. The surgeon should not hesitate to change stance or position in relation to the patient in order to place a knot securely and flat. 10. Extra ties do not add to the strength of a properly tied knot. They only contribute to its bulk. With some synthetic materials, knot security requires the standard surgical technique of flat and square ties with additional throws if indicated by surgical circumstance and the experience of the surgeon. An important part of good suturing technique is correct method in knot tying. A seesaw motion, or the sawing of one strand down over another until the knot is formed, may materially weaken sutures to the point that they may break when the second throw is made or, even worse, in the postoperative period when the suture is further weakened by increased tension or motion. If the two ends of the suture are pulled in opposite directions with uniform rate and tension, the knot may be tied more securely. This point is well-illustrated in the knot tying techniques shown in the next section of this manual. Square Knot Square Knot Pictures Two-Hand Technique One-Hand Technique Two Hand Technique Square Knot Two-Hand Technique Page 1 of 3 The two-hand square knot is the easiest and most reliable for tying most suture materials. It may be used to tie surgical gut, virgin silk, surgical cotton, and surgical stainless steel. Standard technique of flat and square ties with additional throws if indicated by the surgical circumstance and the experience of the operator should be used to tie PANACRYL* braided synthetic absorbable suture, MONOCRYL* (poliglecaprone 25) suture, Coated VICRYL* (polyglactin 910) suture, Coated VICRYL RAPIDE* (polyglactin 910) suture, PDS* II (polydioxanone) suture, ETHILON* nylon suture, ETHIBOND* EXCEL polyester suture, PERMA- HAND* silk suture, PRONOVA* poly (hexafluoropropylene- VDF) suture, and PROLENE* polypropylene suture. 1 White strand placed over extended index finger of left hand acting as bridge, and held in palm of left hand. Purple strand held in right hand. Purple strand held in right hand brought between left thumb and index finger. 2 3 Left hand turned inward by pronation, and thumb swung under white strand to form the first loop. Purple strand crossed over white and held between thumb and index finger of left hand. 4 Square Knot Two-Hand Technique Page 2 of 3 5 Right hand releases purple strand. Then left hand supinated, with thumb and index finger still grasping purple strand, to bring purple strand through the white loop. Regrasp purple strand with right hand. Purple strand released by left hand and grasped by right. Horizontal tension is applied with left hand toward and right hand away from operator. This completes first half hitch. 6 7 Left index finger released from white strand and left hand again supinated to loop white strand over left thumb. Purple strand held in right hand is angled slightly to the left. Purple strand brought toward the operator with the right hand and placed between left thumb and index finger. Purple strand crosses over white strand. 8 Square Knot Two-Hand Technique Page 3 of 3 9 By further supinating left hand, white strand slides onto left index finger to form a loop as purple strand is grasped between left index finger and thumb. Left hand rotated inward by pronation with thumb carrying purple strand through loop of white strand. Purple strand is grasped between right thumb and index finger. 10 11 Horizontal tension applied with left hand away from and right hand toward the operator. This completes the second half hitch. The final tension on the final throw should be as nearly horizontal as possible. 12 One-Handed Technique Square Knot One-Hand Technique Page 1 of 2 Wherever possible, the square knot is tied using the two-hand technique. On some occasions it will be necessary to use one hand, either the left or the right, to tie a square knot. These illustrations employ the left-handed technique. The sequence of throws illustrated is most commonly used for tying single suture strands. The sequence may be reversed should the surgeon be holding a reel of suture material in the right hand and placing a series of ligatures. In either case, it cannot be too strongly emphasized that the directions the hands travel must be reversed proceeding from one throw to the next to ensure that the knot formed lands flat and square. Half hitches result if this precaution is not taken. 1 White strand held between thumb and index finger of left hand with loop over extended index finger. Purple strand held between thumb and index finger of right hand. Purple strand brought over white strand on left index finger by moving right hand away from operator. 2 3 With purple strand supported in right hand, the distal phalanx of left index finger passes under the white strand to place it over tip of left index finger. Then the white strand is pulled through loop in preparation for applying tension. The first half hitch is completed by advancing tension in the horizontal plane with the left hand drawn toward and right hand away from the operator. Surgeon’s or Friction Knot Surgeon's or Friction Knot Page 1 of 3 The surgeon's or friction knot is recommended for tying PANACRYL* braided synthetic absorbable suture, Coated VICRYL* (polyglactin 910) suture, ETHIBOND* EXCEL polyester suture, ETHILON* nylon suture, MERSILENE* polyester fiber suture, NUROLON* nylon suture, PRONOVA* poly (hexafluoropropylene- VDF) suture, and PROLENE* polypropylene suture. The surgeon's knot also may be performed using a one-hand technique in a manner analogous to that illustrated for the square knot one-hand technique. 1 White strand placed over extended index finger of left hand and held in palm of left hand. Purple strand held between thumb and index finger of right hand. Purple strand crossed over white strand by moving right hand away from operator at an angle to the left. Thumb and index finger of left hand pinched to form loop in the white strand over index finger. 2 3 Left hand turned inward by pronation, and loop of white strand slipped onto left thumb. Purple strand grasped between thumb and index finger of left hand. Release right hand. Left hand rotated by supination extending left index finger to pass purple strand through loop. Regrasp purple strand with right hand. Surgeon's or Friction Knot Page 2 of 3 5 The loop is slid onto the thumb of the left hand by pronating the pinched thumb and index finger of left hand beneath the loop. Purple strand drawn left with right hand and again grasped between thumb and index finger of left hand. 6 7 Left hand rotated by supination extending left index finger to again pass purple strand through forming a double loop. Horizontal tension is applied with left hand toward and right hand away from the operator. This double loop must be placed in precise position for the final knot. 8 Surgeon's or Friction Knot Page 3 of 3 9 With thumb swung under white strand, purple strand is grasped between thumb and index finger of left hand and held over white strand with right hand. Purple strand released. Left hand supinates to regrasp purple strand with index finger beneath the loop of the white strand. 10 11 Purple strand rotated beneath the white strand by supinating pinched thumb and index finger of left hand to draw purple strand through the loop. Right hand regrasps purple strand to complete Hands continue to apply horizontal tension with left hand away from and right hand toward the operator. Final tension on final throw should be as nearly horizontal as possible. the second throw square. Deep Tie Deep Tie Page 1 of 2 Tying deep in a body cavity can be difficult. The square knot must be firmly snugged down as in all situations. However the operator must avoid upward tension which may tear or avulse the tissue. 1 Strand looped around hook in plastic cup on Practice Board with index finger of right hand which holds purple strand in palm of hand. White strand held in left hand. Purple strand held in right hand brought between left thumb and index finger. Left hand turned inward by pronation, and thumb swung under white strand to form the first loop. 2 3 By placing index finger of left hand on white strand, advance the loop into the cavity. Horizontal tension applied by pushing down on white strand with left index finger while maintaining counter-tension with index finger of right hand on purple strand. 4 Deep Tie Page 2 of 2 5 Purple strand looped over and under white strand with right hand. Purple strand looped around white strand to form second loop. This throw is advanced into the depths of the cavity. 6 7 Horizontal tension applied by pushing down on purple strand with right index finger while maintaining counter- tension on white strand with left index finger. Final tension should be as nearly horizontal as possible. Ligation Around Hemostatic Clamp Ligation Around Memostatic Clamp -More Common of Two Methods Frequently it is necessary to ligate a blood vessel or tissue grasped in a hemostatic clamp to achieve hemostasis in