Barbed unidirectional V-Loc 180 suture in laparoscopic Roux-en-Y gastric bypass: a study comparing unidirectional barbed monofilament and multifilament absorbable suture

Safety and Efficacy of Barbed Sutures Compared to Non-barbed Sutures in Bariatric Surgery: An Updated Systematic Review and Meta-analysis

PURPOSE

Mastering intracorporeal suturing is challenging in the evolution from conventional to laparoscopic bariatric surgery. Among various techniques competing for superiority in overcoming this hurdle, we focus on exploring the potential of barbed sutures through a meta-analysis that compares outcomes to those of conventional non-barbed sutures in bariatric surgery.

MATERIALS AND METHODS

We conducted a comprehensive search on PubMed, Scopus, and Embase to identify studies comparing barbed sutures with non-barbed sutures in bariatric surgeries, focusing on outcomes such as operative time, suturing time, postoperative complications, and hospital stay. The statistical analysis was carried out using RStudio version 4.3.2. Heterogeneity was assessed using the Cochrane Q test and I2 statistics.

RESULTS

Incorporating data from 11 studies involving a total of 27,442 patients, including 3,516 in the barbed suture group across various bariatric surgeries, our analysis demonstrates a significant reduction in suturing time (mean difference -4.87; 95% CI -8.43 to -1.30; p < 0.01; I2 = 99%) associated with the use of barbed sutures. Specifically, in Roux-en-Y gastric bypass, we observed a significant decrease in operative time (mean difference -12.11; 95% CI -19.27 to -4.95; p < 0.01; I2 = 93%). Subgroup analyses and leave-one-out analyses consistently supported these findings. Furthermore, we found that the mean body mass index did not significantly predict the mean difference in operative time outcome. No significant differences emerged in hospital stay or postoperative complications, including leak, bleeding, stenosis, and bowel obstruction (p > 0.05).

CONCLUSION

Our study findings address barbed sutures as a potential alternative for laparoscopic intracorporeal suturing in bariatric surgery.

A novel knotless hand-sewn end-to-end anastomosis using V-loc barbed suture vs. stapled anastomosis in laparoscopic left colonic surgery: A propensity scoring match analysis

Background

Laparoscopic colectomy is widely practiced for colon cancer, but many variations exist for anastomosis after laparoscopic colon cancer radical resection.

Method

We retrospectively analyzed 226 patients who underwent laparoscopic-assisted radical resection for left colon cancer with knotless hand-sewn end-to-end anastomosis (KHEA) technique with barbed V-loc™ suture material and compared perioperative outcomes, safety, and efficacy to those undergoing stapled anastomosis from 2010 to 2021.

Results

After the 1:2 propensity score matching, 123 participants with similar preoperative characteristics (age, body mass index, TNM stage, and tumor location) were enrolled in the study: 41 in the KHEA and 82 in the stapler group. Statistically significant differences were found in time to accomplish the anastomosis (mean 7.9 vs. 11.9 min, p < 0.001) and hospital costs (mean 46,569.71 vs. 50,915.35 CNY, p < 0.05) that differed between the KHEA and stapler group, respectively. No statistically significant difference was found in the mean delay to bowel function recovery (2.6 vs. 2.7 days, p = 0.466), duration of hospital stay (8.6 vs. 7.9 days, p = 0.407), or rate of postoperative complications (14.6% vs. 11.0%, p = 0.563). Anastomotic leakage occurred in 11 patients: 5 (12.2%) vs. 6 (7.3%) (p > 0.05) in the KHEA and stapler group, respectively.

Conclusion

KHEA is feasible and safe for anastomosis after laparoscopic left hemicolectomy. The KHEA technique could reduce operation time and hospital costs with complication rates comparable to stapling.

Barbed suture in gastro-intestinal surgery: A review with a meta-analysis

BACKGROUND

The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures.

MATERIALS AND METHODS

A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass.

RESULTS

We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used.

CONCLUSION

Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Barbed versus conventional thread used in laparoscopic gastric bypass: a systematic review and meta-analysis

INTRODUCTION

Hand-sewn gastrointestinal anastomosis during laparoscopic gastric bypass (GBP) could be performed using the conventional multifilament suture (CS) or a barbed suture (BS). This systematic review with meta-analysis aimed to assess the advantages and disadvantages of these two anastomosis alternatives.

METHODS

Bibliographic search for relevant studies was performed, according to the PRISMA guidelines, to perform the systematic review with meta-analysis. RevMan was applied to analyze the data using the random effects size.

RESULTS

Eight studies were eligible for analysis including 26,340 patients. These patients underwent a single gastric bypass or Roux-en-Y gastric bypass. According to the available data from this systematic review with meta-analysis, BS in GBP ensures similar morbidity rate (OR = 1.04, 95% CI: 0.82 to 1.31, p = 0.74) with shorter operative time (MD = - 7.90, 95% CI: - 12.95 to - 2.84, p = 0.002). BS is similar to CS in terms of anastomotic leak (OR: 1.25, 95% CI: 0.90 to 1.73, p = 0.19), stricture (OR: 0.89, 95% CI: 0.32 to 2.44, p = 0.82), bleeding (OR: 0.62, 95% CI: 0.20 to 1.86, p = 0.39), and hospital stay (MD: 0.04, 95% CI: - 0.28 to 1.86, p = 0.81). On the other way, BS is cheaper than CS.

CONCLUSION

The majority of studies were retrospectives. One study included the large majority of retained patients; thus then, this comparison should be interpreted with caution. BS and CS in gastrointestinal anastomosis during GBP are feasible and safe. BS is faster and cheaper with similar postoperative outcomes.

Esophageal Suspension Method for Hand-Sewn Esophagojejunostomy After Totally Laparoscopic Total Gastrectomy: A Simple, Safe, and Feasible Suturing Technique

Background: Totally laparoscopic total gastrectomy (TLTG) not only is difficult to operate but also has high technical requirements and a long learning curve. Therefore, it has not been widely carried out yet, and esophagojejunostomy is one of its difficulties. Relevant studies have shown that intracorporeal hand-sewn esophagojejunostomy is safe, feasible and low-cost, but it is complicated and time-consuming and requires a high-suture technique. This study introduces a simple, safe and feasible hand-sewn technique.

Methods: The clinical data of 32 patients with the esophageal suspension method for hand-sewn esophagojejunostomy (suspension group) after TLTG were collected from February 2018 to June 2019. During the same period, 32 patients with traditional hand-sewn esophagojejunostomy (traditional group) after TLTG were used as the control group.

Results: The operative time, anastomosis time, exhaust time and hospitalization time of the suspension group were shorter than those of the traditional group. The intraoperative blood loss in the suspension group was less than that in the traditional group. There were no postoperative complications associated with the suspension group.

Conclusion: For those who have some experience in laparoscopic suture technique, the esophageal suspension method for hand-sewn esophagojejunostomy after TLTG is a simple, safe, and feasible suture technique.

An easy and reliable method to close Petersen's defect using barbed suture to prevent internal hernia from developing after gastrectomy with Roux-en-Y reconstruction

INTRODUCTION

We propose a novel technique to close Petersen's defect using barbed sutures and evaluate the safety and usefulness of this technique by assessing postoperative complications and measuring the time required to close Petersen's defect.

MATERIALS AND SURGICAL TECHNIQUE

Petersen's defect was closed laparoscopically with running non-absorbable barbed sutures (V-loc®) after a nodal dissection and reconstruction procedure. First, the transverse colon was elevated cranially, making the dorsal side of the transverse mesocolon a flattened surface. The intersection of the transverse mesocolon and Roux limb mesentery was then identified, and closure was started from this point. We continued to sew the transverse mesocolon and Roux limb mesentery toward the transverse colon with a running suture. At the end of suturing, we placed one or two stitches in the fatty appendices of the transverse colon and cut the free tail of thread as short as possible.

DISCUSSION

We investigated postoperative complications and measured the time required to close Petersen's defect in 64 patients who underwent this technique. The results showed that this closure technique could be performed promptly and safely regardless of the patient, surgical procedure, and the experience of the operator.

Benefits of barbed suture utilisation in gastrointestinal anastomosis: a systematic review and meta-analysis

INTRODUCTION

Anastomosis formation constitutes a critical aspect of many gastrointestinal procedures. Barbed suture materials have been adopted by some surgeons to assist in this task. This systematic review and meta-analysis compares the safety and efficacy of barbed suture material for anastomosis formation compared with standard suture materials.

METHODS

An electronic search of Embase, Medline, Web of Science and Cochrane databases was performed. Weighted mean differences were calculated for effect size of barbed suture material compared with standard material on continuous variables and pooled odds ratios were calculated for discrete variables.

FINDINGS

There were nine studies included. Barbed suture material was associated with a significant reduction in overall operative time (WMD: -12.87 (95% CI = -20.16 to -5.58) (P = 0.0005)) and anastomosis time (WMD: -4.28 (95% CI = -6.80 to -1.75) (P = 0.0009)). There was no difference in rates of anastomotic leak (POR: 1.24 (95% CI = 0.89 to 1.71) (P = 0.19)), anastomotic bleeding (POR: 0.80 (95% CI = 0.29 to 2.16) (P = 0.41)), or anastomotic stricture (POR: 0.72 (95% CI = 0.21 to 2.41) (P = 0.59)).

CONCLUSIONS

Use of barbed sutures for gastrointestinal anastomosis appears to be associated with shorter overall operative times. There was no difference in rates of complications (including anastomotic leak, bleeding or stricture) compared with standard suture materials.

ROUTINE USE OF V-LOCK® SUTURE FOR BARIATRIC ANASTOMOSIS IS SAFE: COMPARATIVE RESULTS FROM CONSECUTIVE CASE SERIES

Background:

In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist.

Aim:

To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery.

Methods:

Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl^® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared.

Results:

All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05).

Conclusion:

The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

Small bowel obstructions following the use of barbed suture: a review of the literature and analysis of the MAUDE database

BACKGROUND

Barbed suture has been adopted across all surgical specialties. One of the infrequent complications seen with the use of barbed suture is small bowel obstructions (SBOs). In this study, we perform a review of the literature and the Manufacturer and User Facility Device Experience Database (MAUDE) to characterize SBOs after the use of barbed sutures in a variety of operative procedures.

METHODS

A review of the literature was performed by searching PubMed and Ovid. We used the search terms: "barbed," "suture," "bowel," and "obstructions." For each case report, we examined the initial surgical procedure, type of barbed suture used, the type of complication, the time to complication, the presentation, and the type of operative interventions required. We did the same with the MAUDE database.

RESULTS

Our review of the literature revealed 18 different cases of SBO secondary to the use of barbed suture. The four most common procedures, with a total of four cases each, were inguinal hernia procedures, myomectomy, hysterectomy, and pelvic floor reconstructive procedures. The average time of presentation to SBO was found to be 26.3 days post-op (1-196 days). A total of 16 patients (88.9%) presented with abdominal pain. Other common complaints included vomiting (33.3%), abdominal distension (27.8%), oral intolerance (22.2%), and constipation (16.7%). A total of 5 cases were also found to have a possible volvulus on computed tomography (CT), and 2 cases were reported to have strangulation. The MAUDE database had 14 cases reporting on obstruction.

CONCLUSIONS

Surgeons should have a high index of suspicion for SBO if a patient presents with obstructive symptoms after a surgery that used barbed suture. This will often present as a mesenteric volvulus on CT. These particular SBOs require operative exploration, with laparoscopy being successful in the majority of cases.

Absorbable barbed suture device for laparoscopic peritoneal closure after hernia repair via the transabdominal preperitoneal approach: A single-center experience with 257 cases

INTRODUCTION

The laparoscopic transabdominal preperitoneal approach requires peritoneal closure and technically skilled knotting. We have started to use a barbed running suturing device (V-Loc 180) without knotting for transabdominal preperitoneal repair of hernias. This study aimed to determine whether using V-Loc 180 was safe and shortened the time for laparoscopic peritoneal closure.

METHODS

Between December 2010 and February 2017, 3-0 V-Loc 180 and a multifilament absorbable running suture (3-0 Vicryl) were used for three-port transabdominal preperitoneal repair of inguinal hernia in 363 cases. Data including peritoneal closure time and the complications were retrospectively recorded.

RESULTS

Factors identified as significantly prolonging the peritoneal closure time were the hernia side (P = 0.0269), the type of hernia (P = 0.001), the suture device used (P < 0.0001), and the surgeon's experience (P < 0.0001). Use of the barbed suture was associated with a significantly shorter peritoneal closure time than the multifilament suture (mean closure time: 10.2 and 12.7 min, respectively). While there were no postoperative complications in the barbed suture group, there were two cases (1.9%) of postoperative complications in the multifilament suture group (P = 0.0272).

CONCLUSION

We demonstrated that the use of the barbed suturing device for laparoscopic peritoneal closure was safe and feasible.

Comparison of two different barbed suture materials for end-to-end jejuno-jejunal anastomosis in pigs

BACKGROUND

Hand-sewn intestinal anastomoses are a fundamental procedure in both open and laparoscopic intestinal surgery. Self-retaining barbed suture devices have been tested for a variety of surgical applications. With the exception of clinical reports and various experimental studies on enterotomy, little has been published so far on the use of barbed suture for end-to-end intestinal anastomoses. The aim of the study was to compare two different barbed suture materials for end-to-end jejuno-jejunal anastomosis in pigs. End-to-end jejuno-jejunal anastomosis were performed with unidirectional barbed (A group), bidirectional barbed (B group) or normal (C group) sutures in each animal. A comparison was then made between the groups based on adhesions scoring, suturing time, bursting pressure and histopathology.

RESULTS

Mean construction times in the A group (518 ± 40 s) and in the B group (487 ± 45 s) were significantly lower than in the C group (587 ± 63 s) but were not different between A and B group (P = 0.10). Mean bursting pressures were significantly higher in the intact intestine (197 ± 13 mmHg) than in any other group (group A 150 ± 16 mmHg, group B 145 ± 22 mmHg, group C 145 ± 24 mmHg). Among anastomotic techniques, the bursting pressures were not significantly different. Histologically no difference could be detected in the grade of inflammation, collagen deposition and neovascularization at the anastomotic sites.

CONCLUSIONS

Barbed sutures can be effectively used for handsewn end-to-end jejunojejunal anastomosis in pigs. They are comparable to normal suture but could provide a shorter surgical time.

Intramural Abscess Causing Obstruction at a Previous Jejunal Enterotomy Site in a Dog

This case report documents a novel late surgical complication in a 2 yr old dog following an enterotomy to remove a jejunal foreign body. Twenty-six days following the original surgery, the dog was re-presented with signs consistent with an intestinal obstruction. A mural intestinal abscess was found as the cause of the obstruction during exploratory surgery, and the site was successfully removed with a resection and anastomosis. Histopathology showed multifocal abscessation with cyst-like structures partially lined with mucosa. The dog recovered without complication and remains healthy 4 mo later. The exact cause of the lesion is not known; however, local contamination through a focal mucosal defect or complications related to the use of barbed suture in the original enterotomy repair may have contributed.

An option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: A single-layer suturing technique for the stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures

We report an option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We detail a single-layer suturing technique for the endoscopic linear stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures. From June 2013 to February 2017, we performed TLDG with delta-shaped gastroduodenostomy in 20 patients with gastric cancer. The linear stapler was closed and fired to attach the posterior walls of the remnant stomach and the duodenum together. After creating a good view of the greater curvature side of the entry hole for the stapler by retracting the knotted suture on the lesser curvature side toward the ventral side, we performed single-layer entire-thickness continuous suturing of this hole using a 15-cm-long barbed suture running from the greater curvature side to the lesser curvature side. We placed the second and third stitches between the seromuscular layer of the remnant stomach and the entire-thickness layer of the duodenum while suturing the duodenal mucosa as minutely as possible. In addition, we routinely added one or two entire-thickness knotted sutures at the site near the greater curvature side. We placed similar additional knotted sutures at the site with a broad pitch. TLDG with this reconstruction technique was successfully performed in all patients with no occurrences of anastomotic leakage or intraabdominal abscess around the anastomosis. It is suggested that this method can be one option for delta-shaped gastroduodenostomy in TLDG due to its cost-effectiveness and feasibility.

The Use of Unidirectional Knotless Barbed Suture for Enterotomy Closure in Roux-en-Y Gastric Bypass: a Randomized Comparative Study

PURPOSE

In this study, we assessed feasibility, safety, and time efficiency of laparoscopic running enterotomy closure for linear stapled Roux-en-Y Gastric Bypass (RYGB) using unidirectional barbed sutures (Stratafix™ 2/0- Ethicon).

MATERIALS AND METHODS

Two hundred patients undergoing laparoscopic RYGB were prospectively randomized regarding running enterotomy closure of the linear stapled gastrojejunal (GJA) and jejunojejunal anastomosis (JJA). Two groups were created: V-group (Vicryl® 2/0-Ethicon) and S-group (Stratafix™ 2/0-Ethicon). Time spent on closing the enterotomies was measured from first needle in until knot and cut (V-group) or last stitch and cut (S-group). If needed, a nonabsorbable "correction" ("c"; in order to close a small hiatus at the anastomosis) or hemostatic ("h") stitch was made (using a single Prolene® 2/0-Ethicon).

RESULTS

Average total procedure time was similar (S-group 1:01:22, V-group 1:00:44, P = 0.340). Closure of the enterotomy (GJA) was significantly shorter in the S-group (07:41 min versus 08:13 min in the V-group, P = 0.005). Extra stitches (GJA) were performed in 33 patients (16.5%): 3 (h) and 20 (c) in the V-group and 1 (h) and 9 (c) in the S-group. Four patients in the V-group suffered from postoperative intraluminal bleeding (3 self-limiting, 1 underwent endoscopic clipping). In the S-group, 1 patient suffered from leakage at the vertical transected staple line of the stomach.

CONCLUSIONS

The use of unidirectional barbed sutures for running enterotomy closure after linear stapled RYGB is feasible and safe. Significant time benefit was seen regarding the closure of the GJA. Fewer additional stitches were necessary and postoperative intraluminal bleeding was less encountered.

Shorter overall operative time when barbed suture is used in primary laparoscopic gastric bypass: A cohort study of 25,006 cases

BACKGROUND

Closing the remaining opening in a linear stapled anastomosis, for example in laparoscopic Roux-en-Y gastric bypass (LRYGB), can be challenging.

OBJECTIVES

To evaluate if the novel unidirectional barbed suture (BS) is of value in LRYGB compared with polyfilament (PS) suture. We have compared operative time, early complications, and length of stay, as well as anastomotic strictures and small bowel obstruction during the first year.

SETTING

Retrospective study from the Scandinavian Obesity Surgery Registry (SOReg).

METHODS

A nationwide cohort of 25,006 primary LRYGB (2211 BS and 22,795 PS) from SOReg were studied. No preoperative differences in age or gender were noted; however, BS patients had lower Body Mass Index (BMI) (41.3 versus 42.3 kg/m², P<.001) and less diabetes (13.7% versus 15.4%, P = .03).

RESULTS

Total operative time was 11 minutes (16%) shorter using BS compared with PS (58 versus 69 minutes, P<.001), although the mesenteric openings were more frequently closed among BS patients (94% versus 71%, P<.001). No differences were seen in early complications; anastomotic leaks or intra-abdominal abscesses were noted in 1.8% and 1.4%, respectively, P = .17. The incidence of anastomotic strictures was similar (.13% versus .17%, P = .73) as was the incidence of surgery for small bowel obstruction (1.8% versus 1.6%, P = .69).

CONCLUSIONS

The use of barbed suture for closing the remaining opening in the gastrojejunostomy shortened the operative time without increasing the risk of complications. BS is still uncommon in LRYGB, but its implementation could have significant impact on operative time.

Use of Barbed Sutures in Laparoscopic Gastrointestinal Single-Layer Sutures

Background and Objectives:

Laparoscopic anastomotic methods are not commonly used because of the cumbersome laparoscopic intracorporeal sutures and tying involved. The barbed suture is one of the various devices developed to simplify the placement of intracorporeal sutures. However, barbed sutures are not commonly used during reconstruction after radical gastrectomy in cancer patients or for single-layer entire-thickness running suturing for intestinal anastomoses. We describe the procedure for using barbed sutures and report on the short-term surgical outcomes.

Methods:

Between August 2012 and March 2014, 15-cm-long barbed sutures (V-Loc 180; Covidien, Mansfield, MA, USA) were used for laparoscopic intestinal anastomoses, including intestinal hole closure for esophagojejunal and gastrojejunal anastomoses after mechanical anastomoses and gastric wall closure after partial resection.

Results:

In total, 38 patients underwent 40 laparoscopic anastomoses (esophagojejunostomies, 26; gastrojejunostomies, 7; and simple closure of gastric defect, 7); no cases required conversion to open surgery. Two cases exhibited positive air leak test results during surgery (1 case of esophagojejunostomy and 1 case of simple closure of gastric defect). Two cases of intestinal obstruction were noted; of those, one patient with postoperative intestinal paresis (grade II) was managed conservatively, and the other underwent repeat laparoscopic surgery (grade IIIb) for internal herniation unrelated to V-Loc use. No postoperative complications at the anastomosis site and no surgery-related deaths were noted.

Conclusion:

Single-layer entire-thickness running suturing with the V-Loc 180 barbed suture after stapled side-to-side intestinal anastomosis was found to be safe and feasible in the reported cases.

Thoracoscopic esophageal repair with barbed suture material in a case of Boerhaave's syndrome

A 53-year-old man was referred to our hospital with Boerhaave's syndrome. Thirty hours after onset, a left thoracoscopic operation was performed, with carbon dioxide pneumothorax and the patient in right semi-prone position. The thoracic cavity was copiously irrigated with physiological saline and a 4-cm longitudinal rupture was identified on the left side of the lower esophagus. The esophageal injury was repaired in 2 layers by using barbed absorbable suture material. The patient was allowed oral feeds after contrast esophagography confirmed the absence of contrast leak at the sutured site on postoperative day 7, and discharged by day 28. Suturing of the ruptured esophagus under thoracoscopic guidance is considered to be difficult and requires expertise. This case report demonstrates that the use of a barbed suture material simplifies thoracoscopic esophageal repair and also highlights the importance of pneumothorax and patient position in improving access to the esophagus.

Five-Year Single Center Experience for Retroperitoneoscopic Ureterolithotomy

INTRODUCTION

Narrow working space is a major problem to overcome during retroperitoneoscopic ureterolithotomy. We evaluated initial 5 years experience of retroperitoneoscopic ureterolithotomy for large impacted upper ureteral calculi.

PATIENTS AND METHODS

Between January 2011 and December 2015, a total of 37 consecutive patients were evaluated. A 12-mm camera port at middle of midaxillary line and two 5-mm working ports in posterior axillary line were created. The stone was extracted through the site of camera trocar. A Double-J catheter (DJC) was placed antegradely by four steps (elevating of the proximal shaft, introducing the end of curl, advancing, and twisting) during retroperitoneoscopic ureterolithotomy. A knotless unidirectional barbed suture was applied to the incision site of the ureter in all cases. All patients were followed up at 2 weeks after discharge to remove a DJC and at 6 weeks after discharge to evaluate urinary drainage with intravenous urography.

RESULTS

The mean ± standard deviation for age (years), body mass index (kg/m²), stone size (mm), and postoperative hospital days were 57.9 ± 13.3, 24.6 ± 4.5, 15.5 ± 4.0, and 3.2 ± 1.2, respectively. Stones were successively removed without critical complications such as ureteral stricture in all cases. Total operation time, the time for placing a DJC, and ureteral suturing time at initial three trials were more than 150 minutes, more than 30 minutes, and about 15 minutes, respectively; however, they were about 60 minutes, less than 10 minutes, and about 5 minutes, respectively, in 25 case experiences.

CONCLUSIONS

Retroperitoneoscopic ureterolithotomy is a safe and excellent alternative for large impacted upper ureter stone. When performing retroperitoneoscopic ureterolithotomy in the narrow space, our step by step methods, including working port creation, DJC placement, and suturing, will be helpful for surgeons to learn the procedure easily.

Use of Barbed Sutures in Bariatric Surgery. Review of the Literature

Performing intracorporeal anastomoses and sutures is possibly the technique that requires the greater skill in laparoscopy. The emergence of new barbed sutures seems to facilitate the practice, with bariatric surgery (mainly in mixed and malabsorptive techniques) being one of the specialties that can most benefit from them. This review aims to evaluate barbed sutures' use and safety in bariatric surgery. Barbed sutures might facilitate the practice by improving some aspects of surgery such as reproducibility and operative time, although further research is needed.

Laparoscopic Treatment of Choledochal Cyst Using Barbed Sutures

PURPOSE

The usage of barbed sutures is increasingly being reported in the field of laparoscopic surgery. However, there have been reports of suture-related complications such as small bowel obstruction or anastomosis stricture. We present our experience of hepaticojejunostomy (HJ) using V-loc, during laparoscopic cyst excision for choledochal cyst.

METHODS

At our center, from August 2014 to January 2015, 4 patients were treated for choledochal cyst. Laparoscopic cyst excision with Roux-en-Y HJ was performed, and HJ was performed with intracorporeal suturing using unidirectional barbed sutures. After surgery, the patients were followed up in the outpatient clinic every 3 months to monitor for long-term complications such as biliary stricture.

RESULTS

There were no short-term complications. Among the 4 patients, 3 patients did not experience any long-term complications. As of this writing, the follow-up period for the 4 patients is 16 months for the first 2 patients and 11 months for the later 2 patients. Biliary stricture was diagnosed in 1 patient at 7 month follow-up. HJ revision was performed with an open right subcostal incision. The anastomosis showed dense fibrosis and stricture. The patient recovered uneventfully after the surgery.

CONCLUSIONS

HJ using barbed sutures was relatively easy to perform, but barbed sutures may have a tendency to cause stricture when used in biliary enteric anastomosis. Caution must be taken to prevent overtightening of the suture.

Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Absorbable Monofilament, Barbed Suture, Fibrin Glue, or Nothing? Results of a Prospective Randomized Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is associated with serious complications, such as staple line (SL) leaks and bleeding. In order to prevent the occurrence of these complications, surgeons have advocated the need to strengthen the staple line. The aim of this randomized controlled study was to compare the efficacy of three different ways of strengthening of the SL in LSG in preventing surgical post-operative complications.

METHODS

Between April 2012 and December 2014, 600 patients (pts) scheduled for LSG were prospectively randomized into groups without SL reinforcement (group A) or with SL reinforcement including fibrin glue coverage (group B), or oversewn SL with imbricating absorbable (Monocryl™; group C) or barbed (V lock®) running suture (group D). Primary endpoints were post-operative leaks, bleeding, and stenosis, while secondary outcomes consisted of the time to perform the staple line reinforcement (SLR) and total operative time.

RESULTS

Mean SLR operative time was lower for group B (3.4 ± 1.3 min) compared with that for groups C (26.8 ± 8.5 min) and D (21.1 ± 8.4 min) (p < 0.0001). Mean total operative time was 100.7 ± 16.4 min (group A), 104.4 ± 22.1 min (group B), 126.2 ± 18.9 min (group C), and 124.6 ± 22.8 (group D) (p < 0.0001). Post-operative leaks, bleeding, and stenosis were recorded in 14 pts (2.3 %), 5 pts (0.8 %), and 7 pts (1.1 %), respectively, without statistical difference between the groups.

CONCLUSION

Our study suggests that SLR during LSG, with an imbricating or non-imbricating running suture or with fibrin glue, is an unrewarding surgical act with the sole effect of prolonging the operative time.

Laparoscopic gastrointestinal anastomoses using knotless barbed absorbable sutures are safe and reproducible: a single-center experience with 242 patients

OBJECTIVE

Intracorporeal reconstruction of the digestive tract is technically challenging. The V-Loc 180 wound closure device (Covidien) is a self-anchoring unidirectional barbed suture that obviates the need for knot tying. The aim of this prospective cohort study was to investigate the use of the novel suture in gastrointestinal enterotomy closure.

METHODS

The subjects comprised patients with malignant disease who were scheduled to undergo laparoscopic gastrectomy with curative intent. The barbed suture was used to close the entry hole for the linear stapler during intracorporeal reconstruction following laparoscopic gastric resection. The primary endpoint was the proportion of patients who developed anastomotic leakage at the site where the barbed suture was applied.

RESULTS

Between July 2012 and March 2015, 242 patients were enrolled. Of 362 anastomoses, the enterotomy hole at 256 sites was closed using the barbed suture. These 256 sites consisted of 95 gastroduodenostomies, 25 gastrogastrostomies, 13 gastrojejunostomies, 90 jejunojejunostomies, 17 esophagojejunostomies and 16 primary closures of the stomach following local gastric resection. There were no anastomosis-related complications, conversion to usual sutures, mechanical closure of the entry hole and reoperation due to adhesive obstructions or mortality over a median follow-up period of 17.8 months.

CONCLUSIONS

The use of the unidirectional barbed absorbable suture for gastrointestinal closure is safe and effective in laparoscopic gastrectomy.

A novel continuous stitch fundoplication utilizing knotless barbed suture in children with gastroesophageal reflux disease: a pilot study

INTRODUCTION

The intracorporeal placement and tying of suture (IT) can be challenging leading to prolonged CO2 insufflation, anesthesia, and potential morbidity. The unidirectional barbed knotless suture (V-LOC) has emerged as an innovative technology that has been shown to reduce the time associated with IT. Therefore, we conducted a retrospective analysis comparing our initial experience utilizing V-LOC to perform a novel continuous stitch laparoscopic fundoplication (CF) to standard laparoscopic Nissen fundoplication (NF).

METHODS

Institutional review board approval was obtained to analyze data on patients who underwent V-LOC CF and NF. Data retrieval included age, gender, weight, diagnosis, procedure, operative time, major complications (reoperation for wrap failure/migration or recurrent symptoms), and follow up.

RESULTS

Twenty patients underwent the V-LOC CF and gastrostomy placement (GT) from January to October 2013. Seventeen patients underwent NF and GT from March 2012 to February 2013. There were no significant differences in age, weight, or incidence of major complications. V-LOC CF led to a significant 30% reduction in operative time compared to NF (79.1±24.2 min vs. 113.8±25.9 min, respectively, P<0.05).

CONCLUSIONS

This is the first report documenting the continuous stitch fundoplication utilizing the unidirectional barbed knotless suture in children. Although follow-up is short, the V-LOC CF appears to be a safe and effective technique that may reduce operative time in children with gastroesophageal reflux disease. This technology may be beneficial in other minimally invasive applications in pediatric surgery.

Use of self-retaining barbed suture for rectal wall closure in transanal endoscopic microsurgery

BACKGROUND

The aim of this study was to investigate the safety and efficacy of self-retaining barbed sutures in comparison with monofilament clip-fixated sutures for rectal wall closure in transanal endoscopic microsurgery.

METHODS

Horizontal full-thickness wall defects (3.5 cm) of cattle rectal specimens were closed via transanal endoscopic microsurgery using a monofilament suture with clips at the end (Surgipro(®) 2/0; Covidien, Mansfield, MA, USA, n = 25) or a self-retaining barbed suture (V-Loc™ 180 3/0; Covidien, Mansfield, MA, USA, n = 25). The primary endpoint was the pneumatic leakage pressure of the suture line. As a secondary endpoint, suture time was evaluated.

RESULTS

The median pneumatic leakage pressure for barbed sutures was 45.5 mbar (range 17-106 mbar) and 33.5 mbar (range 19-106 mbar) for monofilament sutures (p = 0.58). A pneumatic leak at a critical pressure below 25 mbar occurred in 3 cases with barbed sutures and in 7 cases with monofilament sutures (p = 0.29). Median suturing time [19:25 min:s (range 12:00-33:30) vs. 20:41 (17:00-28:33), p = 0.23] did not differ between the two groups.

CONCLUSIONS

Barbed sutures display the same bursting pressure as monofilament sutures and their use for rectal wall closure seems feasible.