Come metodo per la chiusura di ferite cutanee, la tecnica di sutura risale a migliaia di anni fa. Gli obiettivi nel tempo sono rimasti gli stessi: il rafforzamento delle ferite fino ad un recupero della resistenza alla trazione e la riduzione al minimo dei rischi di sanguinamento e infezione.

Punto di sutura visto al microscopio
Una ferita di cane, suturata, vista al microscopio.

Una corretta tecnica di sutura è necessaria per garantire buoni risultati in chirurgia dermatologica. L’aspetto postoperatorio di una chiusura o di un lembo può essere compromesso se ​​viene scelta una tecnica di sutura inadeguata o se l’esecuzione è scarsa. D’altra parte un trattamento delicato del tessuto è anche importante per ottimizzare la guarigione delle ferite.
La scelta della tecnica dipende da diversi fattori: il tipo e la localizzazione anatomica della ferita, lo spessore dei tessuti coinvolti, il grado di tensione e il risultato estetico desiderato.
Il corretto posizionamento dei punti migliora l’approssimazione precisa dei lembi della ferita e aiuta in questo modo a ridurre e ridistribuire la tensione cutanea. Nonostante i diversi tipi di suture e aghi, le tecniche di base di tenuta dell’ago, guida dello stesso e posizionamento del nodo, rimangono le stesse.

Ago da sutura e le sue componenti
Ago da sutura e le sue componenti

L’ago ha 3 sezioni:

  • La punta è la porzione più affiata e viene utilizzata per penetrare il tessuto.
  • Il corpo rappresenta la porzione intermedia dell’ago.
  • La base è la parte più spessa dell’ago e la parte a cui è collegato il materiale di sutura.

Nella chirurgia cutanea, vengono utilizzati 2 tipi principali di aghi: a taglio e a taglio inverso. Entrambi gli aghi hanno un corpo triangolare. Un ago a taglio ha il bordo affilato sulla curva interna dell’ago, rivolta verso il bordo della ferita. Un ago a taglio inverso ha il bordo affilato sulla curva esterna dell’ago, più lontana dal bordo della ferita, il che riduce il rischio di tirare la sutura attraverso il tessuto. Per questo motivo, l’ago a taglio inverso viene utilizzato più spesso dell’ago a taglio.
Gli aghi poi possono avere differenti forme: diritti, 1/4 di circonferenza, 1/8 di circonferenza, ecc…

Impugnatura di una porta-aghi
Impugnatura di una porta-aghi

Una porta-aghi viene utilizzata per afferrare l’ago in corrispondenza della porzione distale del corpo, a 1/2 o 3/4 di distanza dalla punta dell’ago, a seconda della preferenza del chirurgo. La porta-aghi viene serrata stringendola fino alla chiusura del primo cricchetto. Non si deve stringere eccessivamente in quanto può provocare danni sia all’ago che alla porta-aghi. L’ago viene tenuto con la base in posizione perpendicolare alla porta-aghi. Un posizionamento scorretto dell’ago nella porta-aghi può provocare la piegatura dell’ago stesso, una maggiore difficoltà di penetrazione della pelle e/o un’indesiderata angolazione di entrata dell’ago nel tessuto. Le porta-aghi – quelle a forbici – vengono tradizionalmente impugnate inserendo il pollice e l’anulare negli anelli e posizionando l’indice sul fulcro per fornire una maggiore stabilità e direzionare il movimento. In alternativa esistono le Mathieu, delle porta-aghi a pinza. Per sbloccare la porta-aghi, una volta serrata, si deve compiere un movimento ortogonale – rispetto all’asse del ferro – con pollice e anulare.

Mathieu, una porta-aghi a pinza
Mathieu, una porta-aghi a pinza

Il tessuto deve essere stabilizzato per consentire il posizionamento della sutura. Ecco allora che, a seconda delle preferenze del chirurgo, possono essere utilizzate delle pinze da presa anatomiche (Klemmer) o chirurgiche (Kocher) per afferrare il tessuto.

 

Due tipi di pinze emostatiche
Due tipi di pinze emostatiche

Le pinze si distinguono dalle porta-aghi per avere una punta più lunga; quelle chirurgiche, rispetto a quelle anatomiche presentano all’estremità della punta due dentini che assicurano una presa migliore, ma meno delicata e a volte lesiva, del tessuto.

Le pinze sono necessarie pure per cogliere l’ago appena esce dal tessuto dopo un passaggio o per afferrare e stabilizzare lo stesso all’interno della porta-aghi. Questa manovra riduce il rischio di perdere l’ago nel derma o nel grasso sottocutaneo.

L’ago deve sempre penetrare nella pelle con un angolo di 90°, che riduce al minimo la dimensione del foro di entrata. L’ago deve essere inserito 1-3 mm dal bordo della ferita, a seconda dello spessore della pelle. La profondità e l’angolo della sutura dipende dalla particolare tecnica di sutura. In generale, i due lati della sutura dovrebbero diventare immagini speculari e l’ago dovrebbe anche uscire perpendicolarmente alla superficie della pelle.

Una confezione tradizionale
Una confezione tradizionale

All’ago è connesso il filo da sutura. I fili vengono distinti in base alla:

  • Natura: animale, vegetale o sintetica.
  • Tecnica con cui vengono fabbricati: monofilamenti o multifilamenti, rivestiti o non rivestiti, intrecciati o ritorti.
  • Durata: non assorbibili se durano nel tempo o assorbibili se si consumano nell’arco di qualche settimana.

I fili devono essere resistenti alla trazione, dotati di scarsa memoria – la capacità di “ricordare” le angolazioni dovute alla piegatura del filo all’interno della confezione – e scarsa capillarità – intesa come impermeabilità alla penetrazione dei microrganismi e dei liquidi biologici.
Il loro calibro è variabile e in passato veniva indicato con la seguente numerazione:

  • per i fili assorbibili naturali: da 4, calibro massimo, a 7/0 – si legge “sette zeri” – calibro più piccolo.
  • per i fili non assorbibili e per quelli sintetici: da 6, calibro massimo, a 12/0, calibro minimo, usato nelle operazioni di microchirurgia.

Oggi viene adoperato il sistema europeo che identifica i fili, indipendentemente dalla loro natura e caratteristica, con un’unica numerazione corrispondente al loro calibro espresso in decimi di millimetro: da 0.1, calibro minimo, a 8, calibro massimo, per fili di ogni tipo.

Una volta posta in modo soddisfacente, la sutura va fissata con un nodo. Le suture possono essere suddivise in continue, quando lo stesso filo viene passato in tutti i punti senza essere interrotto e a punti staccati, o interrotte, in cui il filo viene tagliato dopo ogni punto.
Di queste ultime ricordiamo:

  • Sutura semplice
    Sutura semplice

    Semplice: si fa entrare l’ago da un lembo e uscire dall’altro; una volta ripreso l’ago con la porta-aghi si prende il filo – anche con le mani, che si suppone indossino dei guanti sterili – e lo si gira attorno alla punta della porta-aghi 3 volte in un senso, per poi afferrare con porta-aghi l’estremità libera – cioè non occupata dall’ago – del filo e infine tirare, ottenendo così il nodo, che verrà successivamente rinforzato ripetendo lo stesso procedimento altre 2 volte ma con sensi di rotazione del filo contrari.

  • Sutura da Materassaio
    Sutura da Materassaio

    Da materassaio: come nella semplice si fa passare l’ago da un lembo e uscire dall’altro, per poi spostarsi però di 0,5 cm lateralmente dal punto di uscita, rientrare dal secondo lembo e riemergere dal lembo iniziale e fare il nodo descritto nella sutura semplice

  • Del Donati: è come quella del materassaio, solo che l’ago rientra nel secondo lembo spostato di 0,5 sulla linea verticale e più internamente, così che i fori di entrata e uscita siano perfettamente simmetrici e che la quantità di stoffa afferrata nel punto sia uguale su entrambi i lati della ferita.
Sutura Intradermica
Sutura Intradermica

Delle continue ricordiamo la sutura intradermica, una sutura adoperata spesso nella chirurgia estetica e che utilizza fili e aghi sottilissimi passati direttamente nel derma, così da evitare decubito sulla cute.

Relativamente al tipo di affrontamento dei margini le suture possono invece risultare:

  • in opposizione: quando i bordi della ferita vengono affrontati perfettamente. È il caso delle suture cutanee.
  • introflettenti: quando i bordi vengono introflessi. È la tecnica usata nelle suture dello strato sieroso dell’intestino.
  • estroflettenti, quando i bordi vengono portati verso l’esterno. Come è richiesto dalle suture vascolari.

    Tipi di affrontamento dei lembi della ferita
    Tipi di affrontamento dei lembi della ferita

Ultimamente vengono sempre più spesso utilizzate suturatrici meccaniche e adesivi cutanei – come l’EPIGLU – che per la loro comodità hanno tempi di applicazione decisamente minori e permettono dunque di terminare prima l’operazione in sala.

 

 

 

Fonte | (1)Prof. Carlo de Werra, Università Federico II di Napoli; (1) medscape
Revisione a cura di: Carmine Petruzziello, Elena Beretta

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