end-to-end anastomosis

After the sharp instrument is cut or debrided, the arterial defect is smaller, and the end-to-end anastomosis can be directly performed. Treatment of diseases: vascular injury, hand vascular injury Indication After the sharp instrument is cut or debrided, the arterial defect is smaller, and the end-to-end anastomosis can be directly performed. Surgical procedure 1. Pre-anastomosis (1) Separation of the vascular end: The two ends of the artery should be properly separated and the adjacent joints should be kept in the semi-flexion to reduce the tension. Sometimes it is possible to cut off some unimportant side branches to increase the length of the main artery. The healthy artery of the young casualty can be stretched 2 to 3 cm to compensate for the defect gap and perform direct anastomosis. (2) Checking the blood flow condition: When the damaged part is cut off according to the predetermined resection range at the time of debridement, the proximal end of the artery should have active blood spurting. If the spurt is not prosperous, it should be considered that there is still obstruction in the proximal segment, and the plastic tube can be inserted into the artery to attract the flushing If it still does not work, it must be removed again. If the blood is strong, then use the blood vessel clamp to block the blood flow. Also open the distal vessel clamp temporarily and check if the arterial reflux is good. If there is a thrombus in the distal segment, it must be removed. (3) stripping the outer membrane of the blood vessel: the outer membrane of the vascular end of the blood vessel is clamped and pulled outward, and then cut off to prevent the thrombus from being formed when the outer membrane is brought into the lumen during suturing; or the blood vessel is carefully peeled off and cut off with a small scissors. The outer membrane of the broken end, be careful not to damage the vessel wall. Generally, the outer membrane of each side is peeled off by 0.5 to 1 cm each. (4) Rinse the end of the lumen: After trimming the ends of the two sides, use 0.1% heparin saline (also 0.5% procaine or 3.8% sodium citrate solution) to flush the lumens of the two ends, and punch out Clots to prevent thrombosis at the anastomosis. 2. Vascular anastomosis According to the size of the blood vessel, anastomosis is selected by intermittent or continuous suture. Generally, those with a diameter of 2 mm or less are preferably sutured intermittently; those with a diameter of 2 mm or more can be sutured continuously. Continuous hemostasis is better, but if the suture is too tight, it is possible to reduce the anastomosis. Sutures generally use 4-0 ~ 8-0 filament; small blood vessels with 8-0 ~ 11-0 Kaplan line, with both ends connected with non-invasive needles are more suitable; also available hair, but must Hit 3 knots. The commonly used two-point stitching method is relatively simple, but the three-point stitching method can prevent sewing to the opposite side wall. (1) Two-point intermittent suture method: the blood vessel clips at both ends of the blood vessel are pulled close, so that the opposite ends of the blood vessel are close together, and the upper and lower sides are sutured at a certain point, and each needle should be inserted out from the blood vessel to avoid the residual outer membrane. A blood clot forms a blood clot. The two needles are simultaneously ligated to the outside of the blood vessel. When ligating, strive to be gentle and stable, and be careful not to tear the wall. Then, another stitch is stitched between the two fixed point lines, and then the needle is appropriately added according to the size of the blood vessel. Generally, the stitch length and margin are 0.5 to 1 mm, and for small blood vessels, each is 0.3 to 0.5 mm. After each stitch is ligated, the assistant can gently lift the suture to make a needle]. After the anterior wall is sutured, the vessel clamps at both ends are turned upside down, and the posterior wall of the vessel is sutured according to the upper method During the suturing process, the needle is inserted into the lumen at any time and rinsed with heparin solution. When suturing the last needle, review the lumen again and rinse gently to prevent the clots from remaining inside. After the posterior wall is sutured, return to the vessel clamp to return the blood vessel to its normal position. If the blood vessel is thick, it can be used as a two-point valgus suture to make the endometrial eversion more satisfactory. (2) Three-point continuous stitching method: The operation technique is basically the same as the two-point method, and only the points are different. That is, the three-needle fixed line of the equidistant distance is first made on the circumference of the blood vessel, and the lines are pulled into an equilateral triangle. The posterior wall is ligated and the fixed suture of the anterior wall is ligated. Two fixed-point lines are lifted later, and the first 1/3 side of the blood vessel between the fixed-point lines is continuously stitched with the non-damaged needle thread. Each needle should be in contact with the intima of the vessels at both ends, and the wire should be properly tightened, but not too tight, so as not to shrink the lumen. At the end of the sewing, the suture is knotted with the fixed stitch. In the same way, the other side of the 1/3 side was sutured, and finally the two blood vessel clips were turned upside down to expose the 1/3 side of the posterior wall of the blood vessel, and the same was sutured continuously. 3. After anastomosis (1) Loosen the blood vessel clamp: After the anastomosis is completed, loose the distal blood vessel clamp. If there is a little blood leakage in the anastomosis, it can be stopped by gently pressing the gauze for a few minutes. If necessary, the suture can be filled with 1 or 2 needles, but such things should be avoided to prevent thrombosis. Stress should be perfected when matching. If there is no blood leakage, the proximal vessel clamp is opened. (2) Treatment of arterial spasm: Check the pulsation of the upper and lower arteries of the anastomosis and the color, temperature, and pulse of the distal end of the limb. If the artery is paralyzed, it can be applied with 2.5% poppy sputum gauze. If the blood supply of the injured limb is not good, procaine solution can be used for sympathetic ganglia or perivascular nerve block. (3) Treatment of parallel veins: Parallel veins (especially femoral veins and external iliac veins) should be repaired to reduce venous stasis if there is damage. If it is inconvenient, it can be cut after ligation. 4. suture the wound (1) Covering the anastomosis: the sutured arteries and veins should not be exposed, and must be well covered with surrounding tissues (preferably with muscles or skin or subcutaneous tissue) to protect and supply nutrients. When there is a fracture near the suture, the muscle is used to separate the blood vessel from the fracture end to prevent the formation of the epiphysis and to compress the blood vessel. (2) Avoid dead space: When suturing, avoid leaving dead space to prevent infection caused by plasma retention. (3) Drainage and suturing: If the wound is clean and fresh, it is feasible to suture one stage and place the drainage strip from another small incision, but not directly contact the vascular anastomosis. The drainage strips must be removed as soon as possible. If the wound is heavily contaminated, the skin must be open and sutured after 5-10 days.

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