The role of sutures and fibrin sealant in wound healing

Assessing the application of barbed sutures in comparison to conventional sutures for surgical applications: a global systematic review and meta-analysis of preclinical animal studies

BACKGROUND

Following an initiative published by Lancet in 2002 and an IDEAL-D framework, the value of preclinical animal studies has garnered increasing attention in recent research. Numerous preclinical animal experiments tried to generate evidence to guide the development of barbed sutures. However, discernible drawbacks and incongruities in outcomes have emerged between clinical and preclinical animal studies. Therefore, this meta-analysis aimed to review the preclinical animal experiments comparing barbed sutures with conventional sutures. The authors hope to facilitate clinical translation of barbed sutures by evaluating effectiveness, safety, and physical properties/reliability.

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov was conducted to identify controlled preclinical animal experiments comparing barbed sutures with conventional sutures. The risk of bias was assessed using SYRCLE. GRADE approach was used to evaluate evidence quality. Revman was applied to analyze all the data. Subgroup, sensitivity, and meta-regression analyses were also performed.

RESULTS

A total of 62 articles were eligible with low to moderate quality, including 2158 samples from 10 different animal species across 27 surgical procedures. Barbed suture exhibited a significant reduction in suture time, limited change in Cross-Sectional Area (CSA), and decreased instances of tissue disruption (all P <0.05). Subgroup analyses, considering both clinical and research significance, indicated that barbed sutures might cause more specific adverse events and demonstrate suboptimal performance of physical properties/reliability. Meta-regression suggested that heterogeneity resulted from variations in studies and animal models.

CONCLUSION

Although barbed suture demonstrated superiority in numerous surgeries for time efficiency, its safety and physical properties/reliability might be influenced by diverse preclinical models, sutures' brand, surgeries, and anatomical sites. Further evaluation, based on standardized and well-designed animal experiments, is essential for medical device development and applications in human beings.

Medical Adhesives and Their Role in Laparoscopic Surgery—A Review of Literature

Laparoscopic surgery is undergoing rapid development. Replacing the traditional method of joining cut tissues with sutures or staples could greatly simplify and speed up laparoscopic procedures. This alternative could undoubtedly be adhesives. For decades, scientists have been working on a material to bond tissues together to create the best possible conditions for tissue regeneration. The results of research on tissue adhesives achieved over the past years show comparable treatment effects to traditional methods. Tissue adhesives are a good alternative to surgical sutures in wound closure. This article is a review of the most important groups of tissue adhesives including their properties and possible applications. Recent reports on the development of biological adhesives are also discussed.

A new technique of suturing using adhesive skin closure for uncooperative patients

Open wounds are usually closed with suture. However, young patients often do not cooperate and prevent proper suture placement. Young patients are often terrified of mild pain and wholly uncooperative, which is why we introduce this timesaving, less painful, more aesthetic technique of placing and removing stitches. 104 patients with facial lacerations aged 5 to 15 years were treated at a single center from May 2019 to March 2021. Patients were randomly assigned equally to a simple interrupted suture group (the SI group) or a continuous locking with Steri‐Strip group (the CS group). Suture times, times for stitch removal, pain scores at stitch removal and mature scar scores were evaluated. Suture and stitch removal times were significantly shorter, and pain scores at stitch removal and observer scar assessment scale scores were lower in the CS group. Patient scar assessment scale score was non‐significantly lower in the SI group. This study shows that the novel continuous locking with the Steri‐Strip technique is easier and quicker to perform, causes less pain when removing stitches, provides better aesthetic results than the simple interrupted suture technique and suggests the continuous locking with Steri‐Strip technique would be very useful for uncooperative young patients.

Corneal dellen development after strabismus surgery

This study aimed to evaluate the frequency of corneal dellen development, the healing process, and associated factors that affecting the development and healing of corneal dellen formation after strabismus surgery. In this retrospective study, the records of 714 eyes of 1264 patients who underwent limbal approach strabismus surgery between January 2005 and January 2020 were examined and 47 eyes of 44 patients with corneal dellen were included in the study. Demographic features, ophthalmological examination findings, dellen occurrence and healing time, dellen localization, and the type of surgery were obtained from the medical records of the patients. Corneal dellen development rate was found to be 3.7%. A moderate positive correlation was determined between both mean dellen occurrence time (r = 0.387, p = .007), and mean dellen healing time (r = 0.376, p = .014) with age. In patients who underwent monocular two muscle surgery had significantly higher rates of dellen formation compared to patients who underwent single muscle surgery (p˂0.001). Corneal dellen was significantly higher in eyes undergoing single muscle rectus resection surgery than single muscle rectus recession surgery (p < .001). It was observed that corneal dellen developed more frequently after resection surgery, developed earlier in younger patients, and heals later in elderly patients. Therefore, patients can be followed up closely, keeping in mind the development of dellen, especially after resection surgery.

A comparative microbiological study of polyglycolic acid and silk sutures in oral surgical procedures

INTRODUCTION

Bacterial adherence to silk and polyglycolic acid suture is similar. Literature has shown bacterial adhesion is lower degree in polyglycolic acid suture compared to silk, but tissue reaction was more in the polyglycolic acid suture. The aim of the study was to compare the bacteria adhered on the silk and polyglycolic acid sutures.

METHODOLOGY

Sixty two patients who fulfilled the inclusion criteria were included in the study and were divided equally into group A and group B. After intraoral surgical procedures the operated site was sutured either with 3-0 black silk or 3-0 polyglycolic acid sutures in group A and B respectively. On seventh day after irrigation with normal saline sutures were removed and one suture strand was transported to the Department of Microbiology to inoculate and identify the bacteria.

RESULTS

- 3-0 black silk exhibited a high degree of aerobic bacteria. The bacteria identified on the suture were Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus viridians, Enterobacter, Escherichia coli, Citrobacter and Klebseilla. In 3-0 polyglycolic acid suture Pseudomonas aeruginosa, E. coli, Streptococcus Viridians bacteria were identified.

DISCUSSION

- PGA showed fewer bacterial adherences compared to black silk. Fewer bacterial adherence and resorbable PGA makes a better choice for intra oral surgical procedures.

Ultra-thin, high strength, antibiotic-eluting sutures for prevention of ophthalmic infection

Sutures are applied almost universally at the site of trauma or surgery, making them an ideal platform to modulate the local, postoperative biological response, and improve surgical outcomes. To date, the only globally marketed drug-eluting sutures are coated with triclosan for antibacterial application in general surgery. Loading drug directly into the suture rather than coating the surface offers the potential to provide drug delivery functionality to microsurgical sutures and achieve sustained drug delivery without increasing suture thickness. However, conventional methods for drug incorporation directly into the suture adversely affect breaking strength. Thus, there are no market offerings for drug-eluting sutures, drug-coated, or otherwise, in ophthalmology, where very thin sutures are required. Sutures themselves help facilitate bacterial infection, and antibiotic eye drops are commonly prescribed to prevent infection after ocular surgeries. An antibiotic-eluting suture may prevent bacterial colonization of sutures and preclude patient compliance issues with eye drops. We report twisting of hundreds of individual drug-loaded, electrospun nanofibers into a single, ultra-thin, multifilament suture capable of meeting both size and strength requirements for microsurgical ocular procedures. Nanofiber-based polycaprolactone sutures demonstrated no loss in strength with loading of 8% levofloxacin, unlike monofilament sutures which lost more than 50% strength. Moreover, nanofiber-based sutures retained strength with loading of a broad range of drugs, provided antibiotic delivery for 30 days in rat eyes, and prevented ocular infection in a rat model of bacterial keratitis.

Interposing layer of fibrin glue: A new horizon in vesico-vaginal fistula repair

AIM

In this study our idea is to compare the effectiveness of using interposing layer of fibrin glue to omental flap in reducing the failure of laparoscopic vesicovaginal fistula repair.

METHODS

Forty patients with fairly large vesicovaginal fistula were enrolled and divided in two groups of 20 each. We have used fibrin glue in one group and omental flap in the other group.

RESULT

Of 20 patients in fibrin glue group no failure was seen, while 5 patients out of 20 in omental flap group had failure.

CONCLUSION

This result is statistically significant and hence use of fibrin glue to be considered during laparoscopic repair of vesicovaginal fistulas.

A Prospective Randomized Control Study Comparing the Effects of Dermal Staples and Intradermal Sutures on Postoperative Scarring After Thyroidectomy

BACKGROUND

We compared cosmetic outcomes, pain intensity, and costs between dermal stapling and intradermal suturing in patients who underwent thyroidectomy through cervical incision.

PATIENTS AND METHODS

In total, 40 patients were randomly assigned to undergo thyroidectomy through a low cervical incision and dermal closure using either absorbable staples (n = 20, staple group) or interrupted intradermal sutures (n = 20, suture group). Wound complications, cosmetic outcomes (modified Stony Brook Scar Evaluation Scale [SBSES] and Manchester Scar Scale [MSS]), and pain intensity (visual analog scale) were assessed at 1, 4, 12, and 24 weeks postoperatively. The difference in total "wound-closure cost" between the two groups was also analyzed.

RESULTS

There were no wound-related complications and no significant differences in SBSES or MSS scores between the two groups (P = 0.609 and P = 0.141, respectively). However, the staple group had significantly higher SBSES scores, compared to the suture group, at 24 wk postoperatively (4.06 ± 0.94 versus 3.26 ± 1.24; P = 0.030, respectively); MSS scores were significantly lower in the staple group than in the suture group at 24 wk postoperatively (6.72 ± 1.27 versus 8.16 ± 2.17, respectively; P = 0.028). Visual analog scale scores were significantly lower in the suture group than in the staple group (P = 0.038). The total wound-closure cost was significantly higher in the staple group than in the suture group (137.10 ± 8.39 versus 81.79 ± 19.95 USD; P < 0.001).

CONCLUSIONS

When dermal staples were used, wound complications were absent and long-term cosmetic outcomes were superior; however, pain intensity was higher and the cost was greater, although healing was significantly more rapid, compared to intradermal sutures. Closure using absorbable dermal staples may be safe and effective for cervical incisions during thyroid surgery. Further studies with larger number of participants are needed to confirm our findings.

Recent Advances in Tissue Adhesives for Clinical Medicine

Tissue adhesives have attracted more attention to the applications of non-invasive wound closure. The purpose of this review article is to summarize the recent progress of developing tissue adhesives, which may inspire researchers to develop more outstanding tissue adhesives. It begins with a brief introduction to the emerging potential use of tissue adhesives in the clinic. Next, several critical mechanisms for adhesion are discussed, including van der Waals forces, capillary forces, hydrogen bonding, static electric forces, and chemical bonds. This article further details the measurement methods of adhesion and highlights the different types of adhesive, including natural or biological, synthetic and semisynthetic, and biomimetic adhesives. Finally, this review article concludes with remarks on the challenges and future directions for design, fabrication, and application of tissue adhesives in the clinic. This review article has promising potential to provide novel creative design principles for the generation of future tissue adhesives.

Wound healing effect of regenerated oxidized cellulose versus fibrin sealant patch: An in vivo study

Background

Topical hemostatic agents are used when ligation, electrocauterization, or other conventional hemostatic methods are impractical. Because a hemostatic agent is a foreign body, it can cause foreign body reactions, inflammation, and infections that can interfere with the wound healing process. Therefore, we should select hemostatic agents after considering their effects on wound healing. Here, we compared the effects of hemostatic agents on wound healing in a rectus abdominis muscle defect in rats.

Methods

Twelve Sprague Dawley rats were subjected to creation of a 6 × 6 mm defect in the rectus abdominis muscle and divided into four groups: control group; group A, Tachosil fibrin sealant patch; group B, Surgicel Fibrillar oxidized regenerated cellulose; and group C, Surgicel Snow oxidized regenerated cellulose. For the histologic analysis, biopsies were performed on the 3rd, 7th, and 27th days.

Results

The foreign body reaction was the weakest in group A and most significant in group C. The inflammatory cell infiltration was the weakest in group A and similar in groups B and C. Muscle regeneration differed among periods. The rats in group A were the most active initially, while those in group C showed prolonged activity.

Conclusion

Tachosil and Surgicel administration increased inflammation via foreign body reactions, but the overall wound healing process was not significantly affected. The increased inflammation in the Surgicel groups was due to a low pH. We recommend using Tachosil, because it results in less intense foreign body reactions than Surgicel and faster wound healing due to the fibrin action.

The safety and benefit of using oxidized regenerated cellulose to position free flap pedicle in head and neck reconstruction

BACKGROUND

Oxidized regenerated cellulose (ORC; Surgicel®; Ethicon, Neuchâtel, Switzerland) is an absorbable hemostatic agent used for hemostasis in operation, although some surgeons use it to position free flap pedicles. The increasing risk of vessel compromise is a huge concern. However, no scientific data to date demonstrate the safety and benefit of using ORC in microvascular surgery. In the present study, we compared the outcome of microvascular head and neck reconstruction with and without pedicle placement using ORC.

MATERIALS AND METHODS

From January 2015 to December 2017, we reviewed patients undergoing microvascular surgery with free fibular osteocutaneous flap in our hospital. The patients were divided into the ORC group and non-ORC group and their baseline characteristics and outcomes were compared.

RESULTS

In total, there were 27 patients in the ORC group and 67 in the non-ORC group. The non-ORC group had significantly higher cigarette consumption (70.4% vs. 89.6%; p = .022). The outcome of the ORC group was better regarding arterial thrombosis (0% vs. 3%), flap failure (0% vs. 4.5%), hematoma (7.4% vs. 10.4%), and wound complications (25.9% vs. 44.8%). The ORC group had a worse result than the non-ORC group for vein thrombosis (7.4% vs. 4.5%) and duration of hospitalization (24.111 days vs. 23.627 days). However, none of above results was significant.

CONCLUSIONS

Though this study was underpowered to detect the differences, the results showed a trend toward better outcomes of flaps and wounds in the ORC group. It seems that using ORC in this field is safe and beneficial.

Natural fiber reinforced biodegradable staples: Novel approach for efficient wound closure

Every year millions of lacerations and incisions taken place and require an effective methodology to manage the wound for a better life. The primary causes include mechanical trauma and surgical procedures. The rapid healing of the wound is critical to prevent further infection and reduction pain etc. Current options comprise of sutures, staplers, surgical strips and glues, again the intervention depends on the type of wound and the surgeon preference. The current wound closure techniques pose various potent limitations and confronting the problems to create a desired wound closure technique is necessary for faster and effective wound healing management. The surgical staplers are fast and easy to use wound closure devices, which approximates the edges of the wounds together by staples. The staples are mostly made up of metals like titanium and stainless steel. By modifying the existing stapling method using biodegradable staples that are expected to have good mechanical properties, not require removal procedure, minimized scarring and an overall acceleration in wound healing with minimal complications. Present, the paper focuses on the novel hypothesis on natural fiber reinforced biodegradable polymer staples as wound enclosures with high strength and degradability.

Low thrombin tissue sealant ARTISS (Baxter), in complex primary closure after Fournier's gangrene

The following case report describes the reconstruction of Fournier's gangrene (FG) which failed initial conventional primary closure due to issues with wound edge friability, large dead spaces, and significant tension and shearing forces created by excess adipose tissue in the patient's groin. In the first reported case that could be found in the literature ARTISS (Baxter), a low thrombin concentration fibrin sealant was used as a tissue adhesive to close the large post FG debridement wound flaps and ensure enough working time to allow for precise wound edge approximation. Employing Artiss in the closure of the large wound allowed for successful healing where simple primary closure had failed, aided an expedient recovery and reduced post reconstructive morbidity.

Effects of Botulinum Toxin A Observed During Early Scar Formation Following Rhytidectomy: Controlled, Double-Blinded Pilot Study

Several past studies have suggested there are benefits to using botulinum neurotoxin type A (BoNTA) for improving the aesthetic appearance of established scars. This article describes a study on the prophylactic use of BoNTA for controlling scar formations as they occur. It is based on a small, double-blinded, controlled group of patients having just undergone a facelift procedure. The results suggest that the use of BoNTA just after surgery yield both quantitative and qualitative aesthetic benefits, and the data provide some guidance on optimal doses.

The effect of mesenchymal stem cells combined with platelet-rich plasma on skin wound healing

INTRODUCTION

Mesenchymal stem cells (MSCs) are multipotent stem cells that have the potential of proliferation, high self-renewal, and the potential of multilineage differentiation. The differentiation potential of the MSCs in vivo and in vitro has caused these cells to be regarded as potentially appropriate tools for wound healing. After the burn, trauma or removal of the tumor of wide wounds is developed. Although standard treatment for skin wounds is primary healing or skin grafting, they are not always practical mainly because of limited autologous skin grafting.

EVIDENCE ACQUISITIONS

Directory of Open Access Journals (DOAJ), Google Scholar, PubMed (NLM), LISTA (EBSCO), and Web of Science have been searched.

EVIDENCE SYNTHESIS

For clinical use of the MSCs in wound healing, two key issues should be taken into account: First, engineering biocompatible scaffolds clinical use of which leads to the least amount of side effects without any immunologic response and secondly, use of stem cells secretions with the least amount of clinical complications despite their high capability of healing damage.

CONCLUSION

In light of the MSCs' high capability of proliferation and multilineage differentiation as well as their significant role in modulating immunity, these cells can be used in combination with tissue engineering techniques. Moreover, the MSCs' secretions can be used in cell therapy to heal many types of wounds. The combination of MSCs and PRP aids wound healing which could potentially be used to promote wound healing.

Does fibrin sealant applied to the kidney wound of a young rat affect the development of this organ? A comparative study

OBJECTIVE

The aim of the study was to compare the results of the application of fibrin sealant and absorbable interrupted sutures and to evaluate the impact of the kidney wound closure method on the further development of the organ in young rats.

MATERIALS AND METHODS

In 140 rats, a longitudinal bipolar incision of the renal parenchyma was made. In the study group the wound was closed using a fibrin sealant, whereas in the control group single absorbable sutures were applied to the renal parenchyma. Intravenous pyelography, postmortem and histopathological examinations were carried out 4 weeks and 6 months after the surgery.

RESULTS

The blood loss was smaller and the time of procedure shorter in the study group than in controls, and the differences were statistically significant. Both 4 weeks and 6 months after the surgery, the differences in the kidney dimensions and kidney weight between the two groups were statistically significant. The differences increased after a longer period of time following the surgery. The histopathological examination revealed that in the case of animals with surgical sutures applied to the wound, the rate of resorptive granulomas and abscess formation was higher, whereas kidneys with fibrin sealant applied to the wound featured a high number of lymphocytic infiltrations of minor severity.

CONCLUSIONS

The application of the fibrin sealant simplified the surgical procedure, shortened its duration, and provided hemostasis and permanent closure of the wound. The fibrin sealant facilitates the process of wound healing. The application of a fibrin sealant, compared to surgical sutures, improved the growth of rat kidneys without impairing their functions.

Applications of Fibrin Sealant in Surgery

Fibrin sealant has been used with increasing frequency in a variety of surgical field for its unique hemostatic and adhesive abilities. Fibrin sealant mimics the last step of the coagulation cascade and takes place independently of the patient's coagulation status. With rapid advances in minimally invasive surgery, the potential uses for this type of biologic and synthetic material are expanding exponentially. This article reviews the data associated with the application of fibrin sealant in various surgical procedures. From reinforcing gastrointestinal anastomosis to repair perforated duodenal ulcers to mesh fixation in laparoscopic inguinal hernia repair, fibrin sealant is gaining increasing acceptance among surgeons. The applications of fibrin sealant are expanding, and new preparations of fibrin sealant are currently being evaluated.

Effects of a Fibrin Sealant on Skin Graft Tissue Adhesion in a Rodent Model

OBJECTIVE

To establish a rodent model for skin grafting with fibrin glue and examine the effects of fibrin glue on the adhesive strength of skin grafts without bolsters.

STUDY DESIGN

Animal cohort.

SETTING

Academic hospital laboratory.

SUBJECTS AND METHODS

Three skin grafts were created using a pneumatic microtome on the dorsum of 12 rats. Rats were evenly divided into experimental (n = 6) and control (n = 6) groups. The experimental group received a thin layer of fibrin glue between the graft and wound bed, and the control group was secured with standard bolsters. Adherence strength of the skin graft was tested by measurement of force required to sheer the graft from the recipient wound. Adhesion strength measurements were taken on postoperative days (PODs) 1, 2, and 3.

RESULTS

The experimental group required an average force of 719 g on POD1, 895 g on POD2, and 676 g on POD3, while the average force in the control group was 161 g on POD1, 257 g on POD2, and 267 g on POD3. On each of the 3 PODs, there was a significant difference in adherence strength between the experimental and control groups (P = .036, P = .029, P = .024).

CONCLUSION

There is a significant difference in the adhesion strength of skin grafts to the wound bed in the early postoperative period of the 2 groups. In areas of high mobility, using the fibrin sealant can keep the graft immobile during the critical phases of early healing.

Massive Lumbosacral Subcutaneous Exudate After Surgical Treatment of a Large Lipomyelocele: Case Report and Literature Review

Lipomyelocele is an uncommon type of lipoma that occurs with spina bifida. We present the clinical course and therapeutic process of a female who underwent resection of a lipomyelocele and developed a massive lumbosacral subcutaneous exudate postoperatively. The therapeutic process is described in detail, and a review of the relevant literature on lipomyelocele is presented. A 23-year-old woman presented to our institution complaining of a large lumbosacral subcutaneous mass. She underwent surgical resection of the mass and untethering of the spinal cord under intraoperative neurophysiologic monitoring. A massive lumbosacral subcutaneous exudate developed postoperatively. After excluding cerebrospinal fluid (CSF) leakage, we placed a suction drain. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor of this journal. Because of this, there is no need to conduct special ethic review and the ethical approval is not necessary. Postoperative pathologic examination confirmed the diagnosis of lipomyelocele. Continuation of the negative-pressure drain for 1 week yielded >1000 mL of fluid. The patient recovered well and developed no further subcutaneous exudate. In a patient with massive lumbosacral subcutaneous exudate after surgical treatment of a large lipomyelocele, continuous negative-pressure drainage can be an effective treatment method after excluding CSF leakage.

Clinical applications of surgical adhesives and sealants

In the United States and Europe, the number of topical adhesives, surgical sealants, and hemostats approved for use in the surgical setting is ever expanding although no single device fills all medical and surgical needs to replace sutures. As more surgical procedures are performed through laparoscopic and robotic approaches, these devices are becoming more important, and current research is focused on solving the limitations of conventional wound treatments. This review article discusses clinical applications of various biologically derived and synthetic products that are currently available to surgeons and those that are in development.

Fibrin Sealant: A Review of Its Applications in Periodontal Surgery

Aim

Fibrin sealant is a biological tissue adhesive mimicking the final stage of coagulation. It has a wide variety of application in the field of periodontics. The aim of this article was to review current applications and identify potential use of fibrin sealant in periodontal surgical procedures on an evidence-based conclusion.

Materials and methods

An online search was performed in PubMed, Google Scholar and Cochrane Library databases using keywords fibrin sealant, fibrin glue, fibrin, regeneration, wound healing, tissue adhesive, gingival recession/therapy, surgical therapy, periodontal, and periodontitis in a mutually inclusive manner. The studies were evaluated by two independent reviewers for inclusion in this literature review.

Results

Out of 196 research papers identified, 59 articles were selected by the authors for this literature review, giving preference to clinical trials related to periodontal application.

Conclusion

Use of fibrin sealant is a simple, safe, costeffective, and rapid way to fix flaps and grafts avoiding any postoperative bleeding. Fibrin sealant has the property for regeneration when used in conjunction with a barrier membrane for formation of new connective tissue attachment. It is effective in microsurgical procedures and closing flaps around implant site. They initiate early wound healing through collagen synthesis and fibroblast proliferation. Fibrin sealant may be an alternate biomaterial for periodontal surgery which may stimulate periodontal wound healing and regeneration.

How to cite this article

Jacob S, Nath S. Fibrin Sealant: A Review of Its Applications in Periodontal Surgery. Int J Experiment Dent Sci 2015;4(1):40-46.

Surgical Materials: Current Challenges and Nano-enabled Solutions

Surgical adhesive biomaterials have emerged as substitutes to sutures and staples in many clinical applications. Nano-enabled materials containing nanoparticles or having a distinct nanotopography have been utilized for generation of a new class of surgical materials with enhanced functionality. In this review, the state of the art in the development of conventional surgical adhesive biomaterials is critically reviewed and their shortcomings are outlined. Recent advancements in generation of nano-enabled surgical materials with their potential future applications are discussed. This review will open new avenues for the innovative development of the next generation of tissue adhesives, hemostats, and sealants with enhanced functionality for various surgical applications.

One-piece modified gasket seal technique

Objectives Review the effectiveness of a modified gasket seal technique utilizing a porous high-density polyethylene plate/rectus sheath fascia construct without fat grafting for primary closure of anterior defects following endoscopic skull base surgery. Design Retrospective review (2011-2012). Setting Single academic medical center. Methods A retrospective review of five patients who underwent expanded endoscopic endonasal surgery for various pathologies (two craniopharyngiomas, two tuberculum meningiomas, and one planum meningioma) was performed. Skull base closure was performed using a one-piece modified gasket seal technique. Primary outcome measures included postoperative cerebrospinal fluid (CSF) leaks and donor site morbidity. Results There were no postoperative CSF leaks. Two patients experienced aseptic meningitis treated with a 14-day course of steroids. Two patients experienced new postoperative chronic/recurrent sinusitis treated with oral antibiotics and topical nasal therapy. There was no donor site morbidity such as infection, hematoma, or hernias. Conclusions The one-piece modified gasket-seal closure is a safe and effective method for reconstruction of endonasal defects of the anterior skull base. Rectus sheath fascia is an appropriate dural substitute for free tissue grafting with low donor site morbidity. The construction of the one-piece graft significantly decreases operative time and lowers the learning curve for multilayered closure.

Fibrinogen and thrombin concentrations are critical for fibrin glue adherence in rat high-risk colon anastomoses

OBJECTIVE

Fibrin glues have not been consistently successful in preventing the dehiscence of high-risk colonic anastomoses. Fibrinogen and thrombin concentrations in glues determine their ability to function as sealants, healers, and/or adhesives. The objective of the current study was to compare the effects of different concentrations of fibrinogen and thrombin on bursting pressure, leaks, dehiscence, and morphology of high-risk ischemic colonic anastomoses using fibrin glue in rats.

METHODS

Colonic anastomoses in adult female Sprague-Dawley rats (weight, 250-350 g) treated with fibrin glue containing different concentrations of fibrinogen and thrombin were evaluated at post-operative day 5. The interventions were low-risk (normal) or high-risk (ischemic) end-to-end colonic anastomoses using polypropylene sutures and topical application of fibrinogen at high (120 mg/mL) or low (40 mg/mL) concentrations and thrombin at high (1000 IU/mL) or low (500 IU/mL) concentrations.

RESULTS

Ischemia alone, anastomosis alone, or both together reduced the bursting pressure. Glues containing a low fibrinogen concentration improved this parameter in all cases. High thrombin in combination with low fibrinogen also improved adherence exclusively in low-risk anastomoses. No differences were detected with respect to macroscopic parameters, histopathology, or hydroxyproline content at 5 days post-anastomosis.

CONCLUSIONS

Fibrin glue with a low fibrinogen content normalizes the bursting pressure of high-risk ischemic left-colon anastomoses in rats at day 5 after surgery.

Evaluation of fibrin sealant for biologic mesh fixation at the hiatus in a porcine model

BACKGROUND

The ideal method to secure biologic mesh during laparoscopic hiatal hernia repair remains uncertain. Suture or tack fixation can be technically difficult, and serious cardiovascular complications have been reported. Fibrin sealant (FS) offers a potential solution to this problem. We hypothesized that FS provides comparable mesh fixation to suture repair during laparoscopic mesh hiatoplasty.

STUDY DESIGN

Using a porcine model, laparoscopic hiatal hernia repair was performed with suture reapproximation of the crura and reinforcement with an acellular porcine dermal matrix. Prior to repair, animals were randomized to mesh fixation with sutures (S) or FS. After 30-day survival, an esophagram was performed, the diaphragm harvested, and mesh position, fixation, and incorporation were evaluated histologically and biomechanically using a T-peel test.

RESULTS

Twenty (10 S and 10 FS) laparoscopic hiatal hernia repairs were performed. Total operative time was significantly less in the FS group (74.7 versus 127.0 min, p < 0.01). There were no instances of mesh migration in any animal. Mean peel force did not differ significantly between the S and FS groups (0.21 vs. 0.18 N/mm, respectively; p = 0.49). There was no significant difference in cellular repopularization or inflammatory changes around the mesh.

CONCLUSIONS

Fibrin sealant offers a reasonable alternative to suturing biologic mesh during laparoscopic hiatal hernia repair with equivalent mesh fixation. At 30 days it provides adhesive strength similar to suture fixation, while significantly reducing operative time.

[Influence of different types of surgical suture materials on mechanical damage of oral mucosa]

INTRODUCTION

Throughout history many kinds of different suture materials have been used for closing and suturing surgical wounds. Medical literature describes four basic characteristics of suture material: knot safety, tensile strength, tissue reaction and wound safety. The tissue reaction is reflected in an inflammatory response, which, though minimal, occurs during first two to seven days after implanting suture into the tissue. The aim of this research was to investigate whether different suture materials affect the development of decubital damage of oral mucosa, which to a great extent can compromise the process of wound healing. MATERIAL AND METHODS The investigation was designed as a prospective clinical study including 150 patients of both genders, aged between 25 and 60. The patients were distributed into three groups of 50 persons. The suture Black Silk was used in the first group, designated as a control group. Nylon and Vicril were used in the second and third group, i.e. experimental groups, respectively. Decubital damage of the surrounding soft tissues was the main parameter for monitoring the effects of selected suture materials on the oral mucosa.

CONCLUSION

The comparison of results obtained for the investigated suture materials after suturing oral mucosa revealed that certain advantage could be given to synthetic monofilament suture materials.

Systematic review of the use of fibrin sealant in abdominal-wall repair surgery

PURPOSE

Our objective was to analyze the advantages and inconveniences associated with the use of fibrin sealant compared with mechanical means for mesh fixation following abdominal-wall surgery.

METHODS

Literature search was conducted in MedLine, EMBASE, and Cochrane Library Plus databases. Articles were randomized clinical trials, nonrandomized comparative studies, and case series containing at least ten patients.

RESULTS

The fibrin sealant was shown to be biocompatible with the surrounding tissue. In patients treated with fibrin sealant, lower prevalence of acute and chronic postoperative pain was observed, and less hemorrhagic complications occurred. There are no data on the influence of fibrin sealant on seroma decrease. Efficiency in experimental models was similar to that observed for mechanical methods of fixation. Also, adhesions with fibrin sealant were less than that for mechanical methods.

CONCLUSIONS

Compared with mechanical methods, fibrin sealant is an efficacious alternative for mesh fixation postsurgery of the abdominal wall.

[Choice of surgical suture material used in oral cavity-clinical study]

INTRODUCTION

Historical data on closing and suturing of surgical wound describe a wide range of various suture materials. The choice of the surgical catgut, i.e. type and diameter, depends on the localization, characteristics and condition of the tissue to be treated. From the standpoint of oral-surgical practice the following clinical parameters are of the outstanding importance regarding the choice of suture material: accumulation of soft deposits on the sutures, decubitus of the adjacent soft tissues and dehiscence of the operative wound.

AIM

The aim of this research was to determine the correlation between different types of suture materials and accumulation of soft deposits on the sutures, decubitus of the adjacent soft tissues and dehiscence of the operative wound.

MATERIAL AND METHODS

Our prospective clinical study included 150 patients distributed into three groups of 50 subjects. The surgical procedure performed on each patient involved resection (aplicoectomy) of the tooth root end in the intercanine sector of the upper jaw. The following suture materials were applied: BLACK SILK 5-0, NYLON 5-0 and VICRYL 5-0. The effects of the selected sutures were evaluated by using several parameters: accumulation of soft deposits, wound dehiscence and decubitus of the adjacent soft tissues. The effects of the applied sutures were recorded on days 2, 5 and 7 after the surgery.

CONCLUSION

The comparison of cited parameters of the investigated materials of ter suture of oral cavity mucosa revealed that none of the used material was ideal; however a certain preference might be given to the synthetic monofilament suture materials.

Advances in bioadhesives, tissue sealants, and hemostatic agents

The use of bioadhesives, tissue sealants, and hemostatic agents has allowed for increased use of minimally invasive techniques for complex reconstructive urologic procedures. Hemostatic agents can facilitate clot formation through enzymatic reactions with host factors, mechanical compression, or a combination of the two. Tissue sealants and bioadhesives act through polymerization between themselves and adjacent tissues. This article reviews the unique features, mechanism of action, safety profile, and prototypical applications of the agents most commonly used in urologic surgery.

Role of fibrin glue in the prevention of cervical leakage and strictures after esophageal reconstruction of caustic injury

BACKGROUND

The colon is the organ most commonly used for esophageal reconstruction after severe caustic injury. Complications of cervical anastomosis are very common. Fibrin sealant may reduce the incidence of complications in this high-risk anastomosis. The purpose of the present study was to assess the role of fibrin glue in the prevention of leakage and stricture at cervical coloesophageal anastomoses in children treated with esophageal reconstruction after caustic injury.

METHODS

This was a case-control study of children with caustic esophageal injury treated surgically with esophageal reconstruction over a 10-year period. In the study group 3-4 ml of fibrin glue was placed over the anastomosis. The following variables were assessed: age, sex, weight, leakage or stricture at the cervical anastomosis, morbidity, and mortality.

RESULTS

The study group included 14 children, and the control group included 24 children. There were no differences in the distributions of sex, age, anthropometric variables, or preoperative laboratory test results. All children underwent esophageal replacement with colon substitution through the retrosternal space. Dehiscence and leakage at the cervical anastomosis were observed in 50% of children in the control group and 28.5% of children in the study group (P = 0.17). Strictures were observed in 7.15% of the study group and 20.8% of the control group, and 5 and 17 children, respectively, developed cervical complications (P = 0.03). There were no differences in major complications, and mortality was similar in the two groups (P = 0.60).

CONCLUSIONS

Fibrin glue, when used as a sealant for cervical coloesophageal anastomosis, can reduce the risk of leakage and stricture.

Parotid duct repair with suturing and anastomosis using tissue adhesive, evaluated by sialography: an experimental study in the dog

PURPOSE

The most common method of parotid duct anastomosis is suturing. In addition to the postoperative complications in suturing (ie, anastomosis leakage, fistula formation, and infection of maxillofacial spaces), the surgical duration and suturing difficulties arise as major problems. The efficacy of fibrin glue in parotid duct anastomosis was evaluated and compared with suturing in 15 dogs.

MATERIALS AND METHODS

Fifteen dogs (of the same breed and gender) were studied in this experimental trial. Intravenous cephalothin (1 g) and intramuscular dexamethasone (8 mg) were administered preoperatively for all cases, but no drug was administered postoperatively. Extraoral transverse incisions were made in buccal regions bilaterally to expose parotid ducts and transection was performed in similar areas (right and left). Next, the right transected duct was repaired with 7-0 nylon sutures, and then the left anastomosis was performed, using fibrin glue. At 10 days after the operation, clinical evaluations and sialography were used to evaluate the quality of the anastomosis repair, ductal leakage, and fistula.

RESULTS

The ductal fistula was found on the right in 2 cases (13.33%) and on the left (20%) in 3 cases. Aspiration was positive in the right parotid duct in 2 cases (13.33%) and in the left parotid duct (33.33%) in 5 cases. Also, right ductal leakage was seen in 4 cases (26.66%) and left ductal leakage in 7 cases (46.66%), using sialography.

CONCLUSIONS

The results of this study suggest that the efficacies of fibrin glue and suturing in parotid duct anastomosis are similar, but the use of fibrin glue had a number of advantages, including shortening of the operative time and the possibility of stent removal intraoperatively.

Anastomose colônica com adesivo de fibrina em ratos diabéticos

OBJETIVO: Estudar aspectos da cicatrização na anastomose colônica com adesivo de fibrina em ratos normais e diabéticos. MÉTODO: Foram utilizados 160 ratos Wistar (Rattus novergicus albinus), machos, com peso variando de 250 a 300g, sendo que oitenta destes animais eram não diabéticos e os outros oitenta animais apresentavam diabetes mellitus induzido pela aloxana, Os animais foram submetidos a procedimento operatório padronizado que consistiu em colectomia parcial esquerda e anastomose primária por sutura manual ou com adesivo de fibrina. Foram reavaliados no quarto ou sétimo dia de pós-operatório quando se observou a presença de coleção líquida ou purulenta na tela subcutânea; integridade da sutura; presença de aderências; presença de deiscência; resistência da anastomose (pressão máxima de insuflação) em mmHg, e a concentração tecidual de hidroxiprolina. RESULTADOS: Em relação à presença de deiscência de anastomose e mortalidade ocorreram piores resultados nos animais diabéticos no quarto e sétimo dias de observação em comparação ao controle. Nos grupos e subgrupos estudados os resultados com o uso do adesivo de fibrina não foram melhores que os da sutura manual. Em relação à concentração tecidual de hidroxiprolina não houve diferença significativa entre os grupos. CONCLUSÃO: O diabetes mellitus induzido pela aloxana impede a reparação normal da anastomose colônica em ratos e o uso adesivo de fibrina na anastomose colônica em ratos normais e diabéticos não trouxe benefícios na evolução pós-operatória.

An innovative method to evaluate the suture compliance in sealing the surgical wound lips

BACKGROUND AND AIM

The increasing number of surgical procedures performed with local anesthesia, followed by immediate patient discharge from the hospital, emphasizes the need for a tight waterproof suture that is capable of maintaining its tensile strength in the postoperative phase when the wound tumescence, edema due to the anesthetic drug, and surgical trauma disappear. Moreover, the issue of having an accurate surgical wound closure is very relevant in vivo in order to prevent hemorrhage and exogenous microbial infections. This study aimed at designing a new a lab technique that could be used for evaluating the best surgical material. Using such a technique, we compared the wound-lip-sealing properties of three commonly-used suture threads, namely polyurethane, polypropylene, and polyamide.

MATERIALS AND METHODS

The mechanical properties of same-size suture threads made from polyurethane, polypropylene, and polyamide, were compared in order to define the one that possess the best elastic properties by being able to counteract the tension-relaxation process in the first 12 hours following surgery. The tension holding capacity of the suture materials was measured in both in vivo and in vitro experiments. The surface area of the scar associated with the three different suture threads was measured and compared, and the permeability of the three different suture threads was assessed at 0 minute, 2 minute, 4 minute, 6 minute, and 8 minute- interval.

RESULTS

Results showed that polyurethane suture threads had significantly (P < 0.05) better tensile strength, elongation endurance before breakage, and better elasticity coefficient as compared to polypropylene and polyamide suture threads. Moreover, polyurethane suture threads were significantly (P < 0.05) more impermeable as compared to the other two suture thread types (polypropylene and polyamide). This impermeability was also associated with a tighter wound-lip-sealing ability, and with significantly (P < 0.05) less scar formation.

CONCLUSION

Among the main concerns that surgeons, physicians, and patients often have is the development infection, oozing, and scar at the incision site following suturing. This always raises the question about which suture to use to avoid the above problems. This study provides evidence that the new technique developed in our lab could be used to compare the wound-lip sealing properties of different surgical suture threads. Using such a technique, the results show that polyurethane is significantly better than other commonly-used suture threads, like polypropylene and polyamide, in relation to wound sealing and scar formation.

Influence of different types of surgical suture material on the intensity of tissue reaction in oral cavity

Throughout the history the most diverse suture material have been used for closing and suturing surgical wounds. The four basic features of suture material are described: knot safety, stretch capacity, tissue reactivity and wound safety. Tissue reaction, even the minimum one, which develops during the first to seven days after applying the suture in the tissue. The aim of this study was to investigate influence of a monofilament suture material (nylon) on the intensity of local tissue reaction in experimental conditions, and to compare it with the multifilament suture used in the routine practice of oral surgery (silk). This investigation is a prospective experimental study carried out on Wistar rats. The experiment included 30 animals, in which Black Silk (thickness 4-1) and Nylon (thickness 4-0) were applied in the upper and lower jaw, respectively. To monitor tissue reaction on different suture materials the following parameters were used: coagulum formation, presence of polymorphonuclear leukocytes, presence of macrophages and granuloma, formation of epithelial bridge and connective tissue, collagen synthesis, granulomatous tissue formation and presence of fibrous tissue. After comparing parameters for the intensity of tissue reaction to the investigate suture materials by suturing the oral mucosa, certain advantage could be given to the monofilament suture materials.

Comparison of fibrin sealant and staples for attaching split-thickness autologous sheet grafts in patients with deep partial- or full-thickness burn wounds: a phase 1/2 clinical study

We undertook a multicenter, randomized, controlled, phase 1/2 clinical study to investigate the safety and efficacy of a fibrin sealant containing 4 IU/ml thrombin (FS 4IU) for the attachment of autologous sheet grafts in patients with deep partial-thickness or full-thickness burn wounds. Fibrin sealant (FS 4IU) was compared with staples for adherence of sheet grafts in 40 patients. Patients had to have burn wounds measuring 40% TBSA or less with two comparable test sites measuring between 1% and 4% TBSA each. Wound beds were prepared before treatment assignment, which was randomized. Percent area of hematoma/seroma at Day 1 (P = .0138) and questionable viability at Day 5 (P = .0182) were significantly less for FS 4IU-treated sites. Median percent area of graft survival on Day 14 was 100% for both treatments (P = .3525). The percentage of completely closed sites generally was greater for FS 4IU-sites on Days 5 to 91; the maximum difference occurred at Day 28 (79.5% vs 59%; P = .0215). The safety profile of FS 4IU was excellent as indicated by the lack of any related serious adverse experiences. These findings indicate that FS 4IU is safe and effective for fixation of skin grafts, with outcomes similar to or better than staple fixation. The data suggest that FS 4IU is a promising candidate for further clinical studies focusing on skin graft adhesion and burn wound healing.

Current techniques for vesicovaginal fistula repair: Surgical pearls to optimize cure rate

Vesicovaginal fistulas (VVFs) are a devastating consequence of prolonged labor in developing countries and pelvic surgery in developed countries. Clinical history, physical examination, and pertinent radiographic studies are necessary for proper diagnosis. Endoscopic management can lead to successful closure of small fistulas; the advent of tissue bioglues has made this modality more promising. However, the majority of patients will require transvaginal or transabdominal repair of the fistula. This article reviews the basic principles of fistula closure and discusses adjuvant techniques with tissue interposition grafts; techniques for successful closure of fistulas; and newer modalities for repair using tissue bioglues, laparoscopy, and robotic surgery.

Comparing fibrin sealant with staples for mesh fixation in laparoscopic transabdominal hernia repair: a case control-study

BACKGROUND

Laparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative.

METHODS

We have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol(R)). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences.

RESULTS

From July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol(R)) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22-65 mins) compared to the group treated with staples (25 minutes, range 14-50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate.

CONCLUSIONS

Less post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

Percutaneous ipsilateral portal vein embolization using a modified four-lumen balloon catheter with fibrin glue: initial clinical experience

PURPOSE

The purpose of the present study was to show the feasibility and safety of ipsilateral portal vein embolization (PVE) using an improved four-lumen balloon catheter with fibrin glue.

MATERIALS AND METHODS

To improve the ipsilateral PVE with fibrin glue, we modified a commercially available four-lumen balloon catheter to create a catheter comprising one lumen with a catheter tip for a guidewire, one lumen for an occlusion balloon, and two lumens, each with a side-hole just proximal to the balloon. Eight patients had hepatobiliary disease (three with bile duct carcinoma, two with gallbladder carcinoma, one with hepatocellular carcinoma, one with Caroli disease, and one with metastatic carcinoma).

RESULTS

All embolization procedures were technically successful. After embolization, the volume of the future remnant liver increased a mean of 131%. There was no inadvertent embolization of portal vein branches and no major procedure-related complications.

CONCLUSION

Our method is potentially easier and safer than the traditional ipsilateral method with fibrin glue using a three-lumen balloon catheter because the fourth lumen makes possible the use of a guidewire to access the targeted portal vein and measurement of any portal vein pressure elevation following PVE via the fourth lumen.

Use of Fibrin Sealant in Hypospadias Surgical Repair Reduces the Frequency of Postoperative Complications

INTRODUCTION

Urethrocutaneous fistulas (UCF) and flap dehiscence (FD) are the most common postoperative complications after hypospadias (HS) surgical repair. The aim of this study was to evaluate whether the application of fibrin sealant over the site of surgery and suture lines reduces these complications.

MATERIALS AND METHODS

A prospective cohort of consecutive patients was treated over a 3-year period. 30 patients were submitted to HS surgical repair plus application of fibrin glue over the suture line and surgical site; for comparison, another 56 subjects made up the control group which was submitted to surgical repair only. Variables assessed included: age, type of HS, fibrin sealant used, complications and number of surgical procedures required to treat recurrences.

RESULTS

In general, the frequency of complications was 10 vs. 41% for UCF (p = 0.002), 13 vs. 50% for FD (p = 0.001), and for flap necrosis (FN) 6.7 vs. 28.6% (p = 0.01) for the treatment and control groups respectively. The number of surgical reinterventions to treat recurrences was higher in the control group than in the study group (p = 0.04).

CONCLUSION

The incidence of UCF after HS surgical repair can be reduced by applying fibrin sealant over the site of surgery and the suture lines.

Bioactive Sutures

With the first wave of bioactive sutures already in the marketplace, research is ongoing in the development of future products. Such sutures could potentially have not only antimicrobial activity but also anesthetic and antineoplastic functions. Some clinical trials have already been completed in Russia. This technology is likely to become commonplace. This article reviews the progress made to date in the development of this technology.