Suture augmentation of acromioclavicular and coracoclavicular ligament reconstruction for acute acromioclavicular dislocation.

ABSTRACT: The objective of this report was to introduce a new suture augmentation of coracoclavicular (CC) and acromioclavicular ligament reconstruction for acute Rockwood grade III to V acromioclavicular dislocations.From January 2015 to January 2019, 43 patients with Rockwood III to VI acute acromioclavicular dislocations were retrospectively reviewed. For comparison, another series of 28 patients treated with double Endobutton technique from January 2011 to December 2014 were reviewed. A P < .05 was considered statistical significance.The mean follow-up period of the 2 series were 39.69 ±â€Š7.42 months (range, 24-54 months) and 37.86 ±â€Š8.23 months (range, 26-48 months) (P > .05), respectively. There were significant differences regarding CC space (11.62 ±â€Š2.54 mm vs 16.78 ±â€Š5.53 mm; P < .05), CC reduction loss (5.56 ±â€Š4.73 mm vs 26.25 ±â€Š4.42 mm; P < .05), and acromioclavicular space (6.89 ±â€Š1.87 mm vs 7.95 ±â€Š2.37 mm; P < .05). There were significant differences regarding the disabilities of the arm, shoulder, and hand questionnaire (3.3 ±â€Š2.8 vs 5.32 ±â€Š4.37; P < .05) and University of California-Los Angeles shoulder rating scale (31.19 ±â€Š2.48 vs 29.24 ±â€Š2.48; P < .05). The excellent to good percentages were 100% (n = 32) and 85% (n = 23), respectively.In conclusion, the suture augmentation of acromioclavicular and CC ligament reconstruction is a reliable technique for acute acromioclavicular dislocation with minimal complications.Type of study/level of evidence: Therapeutic IIa.

[Early effectiveness of minimally invasive open reduction and internal fixation versus arthroscopic double-tunnel suture fixation for tibial avulsion fracture of posterior cruciate ligament].

OBJECTIVE: To compare the early effectiveness of minimally invasive open reduction and internal fixation via posterior median approach versus arthroscopic double-tunnel suture fixation in treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL). METHODS: A clinical data of 31 patients with the tibial avulsion fracture of the PCL and met the criteria between January 2015 and January 2019 was retrospectively analyzed. Nineteen patients (group A) were treated with open reduction and internal fixation with cannulated screw via posterior median approach. The other 12 patients (group B) were treated with arthroscopic double-tunnel suture fixation technique. There was no significant difference between the two groups ( P>0.05) in the gender, age, side of effected limb, the injury cause, the time from injury to operation, the combined meniscus injury, Meyers & McKeever classification and preoperative Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and the difference of tibial posterior displacement between bilateral knees. The operation time, postoperative complications, fracture healing, and the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score were recorded. RESULTS: Group B spent significantly longer operation time than group A ( t=7.347, P=0.000). No postoperative complication occurred in group B, and 1 patient in group A had a screw breakage. All patients were followed up 6-36 months (mean, 22 months). X-ray films showed that all fractures healed at 3 months after operation. At last follow-up, there was no significant difference in the patients with normal knee range of motion between the two groups ( P=0.510). At last follow-up, the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score in the two groups were superior to those before operation ( P<0.05); while there was no significant difference between the two groups ( P>0.05). CONCLUSION: For the tibial avulsion fracture of PCL, the minimally invasive open reduction and internal fixation and arthroscopic double-tunnel suture fixation can obtain similar early effectiveness. However, arthroscopic surgery has the advantages of being able to simultaneously deal with intra-articular combined injuries, avoiding internal fixator complications, and eliminating the need for secondary operation.

Evaluation of a new suture material (Duramesh™) by measuring suture tension in small and large bites techniques for laparotomy closure in a porcine model.

PURPOSE: After closure of laparotomies, sutures may pull through tissue due to too high intra-abdominal pressure or suture tension, resulting in burst abdomen and incisional hernia. The objective of this study was to measure the suture tension in small and large bites with a new suture material. METHODS: Closure of the linea alba was performed with small bites (i.e., 5 mm between two consecutive stitches and 5 mm distance from the incision) and large bites (i.e., 10 mm × 10 mm) with Duramesh™ size 0 (2 mm) and PDS II 2-0 in 24 experiments on six porcine abdominal walls. The abdominal wall was fixated on an artificial computer-controlled insufflatable abdomen, known as the 'AbdoMan'. A custom-made suture tension sensor was placed in the middle of the incision. RESULTS: The suture tension was significantly lower with the small bites technique and Duramesh™ when compared with large bites (small bites 0.12 N (IQR 0.07-0.19) vs. large bites 0.57 N (IQR 0.23-0.92), p < 0.025). This significant difference was also found in favour of the small bites with PDS II 2-0 (p < 0.038). No macroscopic tissue failure was seen during or after the experiments. CONCLUSION: Closure of the abdominal wall with the small bites technique and Duramesh™ was more efficient in dividing suture tension across the incision when compared to large bites. However, suture tension compared to a conventional suture material was not significantly different, contradicting an advantage of the new suture material in the prevention of burst abdomen and incisional hernia during the acute, postoperative phase.

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

An Efficient Single-session Spatial Skill Trainer for Robot-assisted Surgery: A Randomized Trial.

STUDY OBJECTIVE: To introduce and examine a single session of spatial skill training as an efficient means of improving surgical suturing performance in robot-assisted surgery. DESIGN: A randomized, controlled trial. SETTING: A tertiary university medical center in Israel. PARTICIPANTS: A purposive sample composed of 41 residents with no robotic suturing skills. INTERVENTIONS: A computer-based simulator training of spatial skills. MEASUREMENTS AND MAIN RESULTS: Participants were randomly assigned to training (n = 21: mean age of 34 years [standard deviation (SD) = 1.92]) and control (n = 20: mean age of 32 years [SD = 3.17]) conditions. The training group underwent a session of spatial skills training, whereas the control group engaged in a neutral activity. After 1 participant was lost to the follow-up of the posttraining performance test, data of 40 participants were analyzed. Robotic suturing task performance with the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) was evaluated using the da Vinci Skills Simulator built-in measure of "excess tissue piercing" and an expert rating of "tissue tearing." The mean number of excess tissue piercing after training (but not after the neutral activity) was significantly lower than before training (3.25 [SD = 1.996] vs 6.75 [SD = 3.68], respectively; p <.001), reflecting an improvement of 52% (decreasing the mean number of excess tissue piercing in a single suture by 3.5 excess piercing trials). After the interventions, the extent of tissue tearing was rated lower in the training group (p = .01), and there was no change in the control group (p = .14). CONCLUSION: We showed the efficiency of a training approach that focuses on spatial skills critical in robot-assisted surgery. We showed that surgeons who received a 1 session spatial skill training with a cognitive spatial skill trainer immediately improved the performance of a robotic suturing task compared with surgeons who did not receive such training.

Ex vivo comparison of the effect of storage temperature on canine intestinal leakage pressures.

OBJECTIVE: To determine the effect of storage temperature on cadaveric small intestinal leakage pressures after enterotomy. STUDY DESIGN: Experimental ex vivo study. ANIMALS: Grossly normal jejunal segments from four canine cadavers. METHODS: Thirty-six jejunal segments (n = 12 segments/group) were harvested immediately after euthanasia and assigned to a fresh group (tested within 4 hours), chilled group (stored for 24 hours at 4°C before testing), or freeze-thaw group (frozen at -20°C for 7 days and thawed at 21°C for 6 hours before testing). A 2-cm antimesenteric enterotomy was performed and repaired with 4-0 monofilament suture in a simple-continuous pattern. Initial leakage pressure (ILP), maximal intraluminal pressure (MIP), and leakage location were recorded, with testing performed at room temperature. RESULTS: Mean ± SD ILP for fresh, chilled, and frozen-thawed specimens was 52.9 ± 8.4, 51.8 ± 11.9 and 29.8 ± 4.4 mm Hg, respectively. There was a difference in ILP among groups (P < .003), with freeze-thaw samples demonstrating lower ILP compared with other groups. There was no difference in MIP between groups (P = .186) There was a difference in leakage location among groups (P = .004), with the majority of chilled and freeze-thaw samples leaking at the suture holes compared with the incisional line in fresh samples. CONCLUSION: Freezing and subsequent thawing prior to specimen testing reduced ILP compared with use of fresh and chilled specimens but did not affect MIP among experimental groups. CLINICAL SIGNIFICANCE: Cadaveric canine intestinal specimens tested immediately after collection or after chilling for 24 hours should be recommended for ex vivo burst pressure assessment in dogs. Additional studies to evaluate loss in testing viability of chilled intestinal specimens are warranted to help govern experimental methodologies.

Ex vivo comparison of barbed sutures for pelvic flexure enterotomy in horses.

OBJECTIVE: To evaluate two different barbed sutures for closure of pelvic flexure enterotomies and compare results achieved with two previously described closure techniques. STUDY DESIGN: Ex vivo. SAMPLE POPULATION: Twenty-four fresh cadaver adult equine large colons. METHODS: Cadavers were randomly assigned to four closure groups (n = 6 each group): single-layer absorbable suture, double-layer absorbable suture, single-layer unidirectional barbed suture, or single-layer bidirectional barbed suture. Construction time, luminal reduction (percentage), bursting pressure, and method of failure were measured. Cost, leakage, exposed suture, and general appearance were recorded. Comparisons were performed with one-way analysis of variance and post hoc Bonferroni test (P < .05). RESULTS: Double-layer absorbable closure had the highest bursting pressure (mean = 178.5 mm Hg, SD = 9.79, P < .001) but took more time (P = .001) compared with all other groups. The construction time of both barbed suture closures did not differ from the single-layer closure (P > .06). Bursting strengths of both unidirectional (mean = 91.6 mm Hg, SD = 5.57) and bidirectional (mean = 87.5 mm Hg, SD = 8.69) barbed sutures were lower (P > .006 for both) than those of both single- (mean = 117.6 mm Hg, SD = 11.69) and double-layer (mean = 178.5 mm Hg, SD = 9.79) closures. Unidirectional barbed suture closure had a reduction in lumen diameter (P = .004) compared with bidirectional and single-layer closures. CONCLUSION: Enterotomy closures with the two different barbed suture patterns were comparable in bursting strength and construction time. However, the barbed suture patterns had lower bursting strength compared with traditional single- and double-layer closures. Unidirectional barbed suture closure also reduced lumen diameter. CLINICAL SIGNIFICANCE: Closure of a large colon enterotomy with barbed suture patterns may be less secure than single- and double-layer suture closure.

Polydioxanone Threads for Facial Rejuvenation: Analysis of Quality Variation in the Market.

BACKGROUND: Beside botulinum-toxin injections and hyaluronic acid fillers, thread lifts have established themselves as the third column of minimally invasive facial rejuvenation. Most commonly, barbed threads for this approach are made out of polydioxanone, a material known for decades from application in resorbable sutures. The clinical efficacy and the putative material safety of polydioxanone have fueled the popularity of thread lifts. METHODS: The present study highlights significant variation among six commercially available threads in microstructure, tensile strength, elasticity, anchoring capacity in human tissue, and biocompatibility. RESULTS: Despite their license to be marketed and sold in the European Union, some products performed significantly worse than others on material testing, and even displayed cytotoxic characteristics. CONCLUSION: The results of this study are highly relevant for clinicians and may be linked to various typical side effects of polydioxanone threads for facial rejuvenation.

Mesh versus suture repair of primary inguinal hernia in Ghana.

Background: Most patients in Ghana undergo suture repair for primary inguinal hernia. Although there is strong evidence from high-income country settings to indicate superiority of mesh repair for inguinal hernia, the evidence to support the safety and effectiveness of mesh repair in the Ghanaian setting is limited. This study aimed to compare hernia recurrence rates following suture versus mesh repair in Ghana. Methods: Men aged 18 years or over presenting with symptomatic, reducible inguinal hernias were included. Over the first 6 months all consecutive patients were enrolled prospectively and underwent a standardized suture repair; an equal number of patients were subsequently enrolled to undergo mesh repair. The primary outcome was hernia recurrence within 3 years of the index operation. Multivariable analysis was adjusted for age and right or left side. Adjusted odds ratios (ORs) with 95 per cent confidence intervals are reported. Results: A total of 116 sutured and 116 mesh inguinal hernia repairs were performed. Three years after surgery, follow-up data were available for 206 of the 232 patients (88·8 per cent). Recurrence occurred significantly more frequently in the suture repair group (23 of 103, 22·3 per cent) than in the mesh group (7 of 103, 6·8 per cent) (P = 0·002). In multivariable analysis, suture repair was independently associated with an increased risk of recurrence (OR 4·51, 95 per cent c.i. 1·76 to 11·52; P = 0·002). Conclusion: In Ghana, mesh inguinal hernia repair was associated with reduced 3-year recurrence compared with sutured repair. Controlled dissemination across Ghana should now be assessed.

[Comparative study on effectiveness of intermittent suture versus cosmetic suture in total knee arthroplasty].

OBJECTIVE: To compare the effectiveness of the intermittent suture and the cosmetic suture in total knee arthroplasty (TKA). METHODS: A clinical data of 48 patients with knee osteoarthritis, who underwent initial TKA between January 2017 and April 2018, was retrospectively analyzed. Among them, 23 patients underwent intermittent suture (group A) and 25 patients underwent cosmetic suture (group B). There was no significant difference in gender, age, body mass index, disease duration, degrees of varus and valgus deformities, knee society score (KSS), visual analogue scale (VAS) score, and levels of interleukin-6 (IL-6), procalcitonin (PCT), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) in serum before operation between the two groups ( P>0.05). KSS scores at 1 and 6 months after operation were used to assess the knee function. VAS scores at 1, 3, and 5 days after operation were used to assess the pain degree of knee. Levels of IL-6, PCT, CRP, and ESR in serum at 1 day and 1 month after operation were recorded to evaluate the risk of periprosthetic infection. Likert score at 6 months after operation was used to evaluate the satisfaction of incision. The hospitalization time after operation was also recorded. RESULTS: All patients were followed up 7- 17 months (mean, 11.3 months). There was no significant difference in hospitalization time after operation between two groups ( t=-1.907, P=0.063). The Likert score in group A was significantly lower than that in group B ( t=-2.196, P=0.033). The VAS score, KSS clinical score and KSS functional score at different time points after operation were significantly better than those before operation in two groups ( P<0.05). The VAS score at 5 days after operation was better than that at 1 day after operation in two groups, and the KSS clinical score and KSS functional score at 6 months after operation were better than those at 1 month after operation in two groups, all showing significant differences ( P<0.05). The VAS scores at 3 and 5 days after operation were significantly lower in group B than in group A ( P<0.05), and there was no significant difference in VAS score and KSS scores between two groups at other time points after operation ( P>0.05). There was no significant difference in the levels of IL-6, PCT, CRP, and ESR between the two groups at different time points after operation ( P>0.05). CONCLUSION: Cosmetic suture is superior to intermittent suture in incision appearance and pain management, but there is no significant difference in short-term joint function and risk of periprosthetic infection after TKA.

Fio de sutura elástico / Elastic suture thread

Introdução: O tratamento de grandes e médias feridas é um desafio para os cirurgiões quando precisam fechálas e, normalmente, são utilizadas técnicas cirúrgicas de enxertias ou retalhos, que podem deixar sequelas e até mesmo mutilações. Ao longo do tempo desenvolveu-se a técnica de "sutura elástica" que promove a cicatrização em curto espaço de tempo com sequelas menores, entretanto o procedimento tem sido realizado com material improvisado. Objetivo: Desenvolver um fio de sutura elástico cirúrgico que possa ser esterilizado e confeccionado nos moldes dos produtos médicos cirúrgicos. Métodos: Revisão das patentes existentes por meio da busca de anterioridade e comparação com o dispositivo do estudo. Pesquisa de materiais com as características necessárias como elasticidade e tensão. Teste destas características em laboratórios especializados. Resultados: O produto desenvolvido é um fio elástico com duplo agulhamento para suturas, com matéria prima de silicone que apresenta elasticidade e resistência a tensão. Conclusão: O fio de sutura elástico, com duplo agulhamento, para feridas de médio e grande porte foi desenvolvido.

Introduction: Closing large and medium wounds is challenging for surgeons and often leads to the use of graft or flap surgical techniques. These procedures can leave sequelae and even mutilations. An "elastic suture" technique was developed to promote wound healing in a short time span with minor sequelae; however, improvised materials have been used in this procedure. Objective: To develop a surgical elastic suture thread that can be manufactured and sterilized following the standards of surgical medical products. Methods: We conducted a patent search, compared the findings with the study device, and researched materials with necessary characteristics such as elasticity and tension. Testing these characteristics in specialized laboratories. Results: The developed device is a double-needled elastic suture made of silicone that presents tensile strength. Conclusion: Here, we developed a double-needled elastic suture for medium and large wounds.

Drainage tube hole suture improvement: Removal-free stitches.

Surgical method improvements aim to optimize the patient experience. The problem of healing of the drainage tube hole has not received attention and is of concern because it can plague patient recovery. In this article we report on how we have improved the method of suturing the drainage tube hole and explore the safety and effectiveness of this method. Between December 2017 to August 2018, 102 patients underwent thoracoscopic lung resection (single port or single utility port) using different methods of suturing drainage tube holes. The intervention group received improved methods with subcuticular and intradermal suture and removal-free stitches, whilst the control group received a conventional mattress suture and fixed chest tube. A preset line was left to tie knots and close the hole after the removal of the chest tube. The stitches were removed 7-12 days after surgery. The baseline clinical features of the patients were subsequently analyzed. The objective and subjective conditions of scars were evaluated using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) at one month after surgery. The intervention group (n = 71) and control group (n = 31) had balanced baseline clinical characteristics. There were no significant differences between the two groups in terms of three-day postoperative pain and postoperative hospital stay. In the intervention group, three patients (4.23%) had wound splitting that required re-suturing, which was better than five patients (16.13%) in the control group (P < 0.05). The incidence of pleural fluid outflow, wound infection, post-removal pneumothorax, chest tube prolapse and incisional hernia were not different between the two groups. We conclude that the objective and subjective evaluation results of scars were significantly different between the two groups (P < 0.05), and the experimental group was superior to the control group. A balanced result between aesthetic appearance and safety as regards video-assisted thoracic surgery can be achieved through the chest tube hole improved suture method. This method also improves the patient's recovery experience.

The application of barbed suture during the partial nephrectomy may modify perioperative results: a systematic review and meta-analysis.

BACKGROUND: Barbed sutures can avoid knot tying and speed the suture placement in the PN(partial nephrectomy). On account of the impact on clinical outcomes are ambiguous, this study is determined to identify the application of barbed suture during PN. METHODS: ClinicalTrials.gov, Cochrane Register of Clinical Studies, PubMed and EMBASE were searched for RCTs(randomized controlled trials) and cohort studies focusing on the comparison of barbed and traditional sutures in PN(last updated on Feb in 2015). According to Cochrane Library's suggestion, quality assessment was performed. Review Manager was applied to analyze all the data and sensitivity analyses were performed through omitting each study sequentially. RESULTS: Eight cohort studies and none of RCTs proved eligible (risk of bias: moderate to low,431 patients). Warm ischemia time(MD = - 6.55,95% CI -8.86 to - 4.24, P < 0.05) decreased statistically in the barbed suture group, as well as operative time(MD = - 11.29,95% CI -17.87 to-4.71, P < 0.05). Postoperative complications also reduced significantly(OR = 0.44, 95% CI 0.24 to0.80, P < 0.05). Unidirectional barbed suture resulted in fewer postoperative complications based on the subgroup analysis(OR = 0.48,95% CI 0.24 to 0.94, P < 0.05). CONCLUSIONS: The barbed suture may be a useful surgical innovation which can modify perioperative results for surgeons and patients. Randomly-designed studies with longer follow up and larger sample sizes are in the need of to explore the applicability.

Expert Consensus on Achieving Optimal Outcomes With Absorbable Suspension Suture Technology for Tissue Repositioning and Facial Recontouring.

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Since that time, the clinical experience of the authors has further shaped their treatment practices, highlighting the need for additional guidelines to support an optimal treatment approach. This update will expand upon the 2017 consensus paper on the safety and efficacy of absorbable suspension sutures and provide guidance for obtaining consistently high patient satisfaction with the procedure. Recommendations are based on the extensive clinical experience of expert physicians with absorbable suspension sutures over the past 2.5 years. Here, the authors provide guidance on full face assessment and treatment to support maximum benefit and provide patient selection and procedural recommendations. In addition, the authors stress the benefits of the dual mechanisms of action within the absorbable suspension suture: the immediate lift and volumizing over time that together lead to the outcome of recontouring. J Drugs Dermatol. 2018;17(6):647-655.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial.

BACKGROUND: Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. METHODS: We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. FINDINGS: Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths. INTERPRETATION: This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size. FUNDING: Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Comparative Evaluation of N-Butyl Cyanoacrylate and Silk Sutures on Healing of Periodontal Flaps: A Clinico Histological Evaluation.

Background The periodontal flap is one of the most frequently employed procedures. Closure of reflected flap is important step in flap surgery. Black silk sutures are most often used material in routine surgical procedures. These suture materials demand more time and effort and expertise from the surgeon. Tissue adhesives have been developed as alternatives to overcome these problems such as cyanoacrylates. Objective The present study is an attempt to compare effectiveness of the black silk suture with cyanoacrylate adhesives in closing reflected periodontal flap. Method Thirty systemically healthy patients who underwent bilateral flap surgery were given 3-0 black silk sutures on one side and N-butyl cyanoacrylate adhesive on the other side to close a surgical incision. All the participants in the study were recalled on the seventh, 21st, 42nd day. Participants were evaluated for healing and plaque accumulation by assessing the gingival index, plaque index, wound healing index. Biopsy specimens were obtained on seventh and 42nd postoperative day. Result The amount of inflammation was less during the first week of healing when cyanoacrylate was compared with silk. However, over a period of 21 days to 42 days, the sites treated with both the materials showed similar healing patterns without any significant difference in the evaluated parameter. Conclusion The result of the study showed that the use of cyanoacrylate for the closure of periodontal flaps results in better initial post-operative healing as compared to closure with silk suture and that this method of closure can be advocated in a routine surgical periodontal practice.

The Requirement of Sutures to Close Intercostal Drains Site Wounds in Thoracic Surgery.

BACKGROUND: Chest drains are used routinely in thoracic surgery. Often a pursestring or mattress suture is used to facilitate closure of the defect on removal of the drain. This stitch can cause an unsightly scar, increase drain removal pain, and necessitate that the patient attend a community health care center to have this removed. The objective of this study was to assess whether this stitch is necessary in modern thoracic surgical practice. METHODS: Data from a single surgeon's practice were collected over an 18-month period. During this time, all patients who underwent both emergency and elective thoracic surgery who had at least one postoperative chest drain of 28F or above inserted were included in the study. The surgeon did not routinely use a suture to close the drain site. RESULTS: In all, 312 patients underwent thoracic surgery during the 18-month period. Each patient had a range of 1 to 3 drains inserted of a size between 28F and 32F. No patients had drain sutures for closure of the drain site. Four patients had pneumothoraces after drain removal requiring further chest drain insertion. Five patients had superficial drain site infections. A single patient had to have a suture inserted at a local hospital owing to leakage from the drain site. CONCLUSIONS: The use of pursestring sutures in thoracic surgery is an outdated practice that causes not only unsightly scars but is also associated with increased pain. Furthermore, these unnecessary pursestring sutures place a burden on the patient and health care system to have them removed.

Evolution and Standardisation of Techniques in Single-Incision Laparoscopic Bariatric Surgery.

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical "tips" and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Holding Strength of a Hem-o-lok/Lapra-Ty Clip Combination on Sutures Used During Partial Nephrectomy.

OBJECTIVE: To investigate the anti-slip strength of closing systems employing sutures terminated with a Hem-o-lok/Lapra-Ty clip combination to determine which sutures perform best for this application. Partial nephrectomy is the reference standard for treatment of small renal masses. The main disadvantage of partial nephrectomy is the risk of technical complications, including renorrhaphy site bleeding and urine leak. MATERIALS AND METHODS: A materials testing system produced a constant velocity pull on the free end of an anchored suture. A Lapra-Ty clip was attached 1 cm from the end of each suture as a backstop for the Hem-o-lok. A digital force gauge measured the tension that was applied until the suture slipped in the closing system. Vicryl, Monocryl, Chromic, Stratafix, and V-Loc sutures of diameters 1 to 4-0 were tested (n = 7 for each suture type, 161 total experiments). RESULTS: The holding strength of a Lapra-Ty/Hem-o-lok clip combination is lowest for Vicryl 4-0 (4.3 ± 1.4N) and highest for Monocryl 0 (16.5 ± 1.6N) sutures. Larger sutures (1 and 0) hold at higher tensions than sutures with smaller dimensions (4-0 and 3-0). For 2-0 sutures, the holding strength was 5.7N with Vicryl, 13.8N with Stratafix, and 15.9N with V-Loc sutures. CONCLUSION: The mean values of holding tension of this anchoring system for all sutures tested was greater than the amount found to be sufficient for tissue closure in previous studies (3.2N). Barbed sutures (Stratafix, V-Loc) appeared to have superior holding strength when compared with most standard sutures; barb orientation does not influence holding tension.

Comparing the tensile strength of square and reversing half-hitch alternating post knots.

BACKGROUND: Square knots are the gold standard in hand-tie wound closure, but are difficult to reproduce in deep cavities, inadvertently resulting in slipknots. The reversing half-hitch alternating post (RHAP) knot has been suggested as an alternative owing to its nonslip nature and reproducibility in limited spaces. We explored whether the RHAP knot is noninferior to the square knot by assessing tensile strength. METHODS: We conducted 10 trials for each baseline and knot configuration, using 3-0 silk and 3-0 polyglactin 910 sutures. We compared tensile strength between knot configurations at the point of knot failure between slippage and breakage. RESULTS: Maximal failure strength (mean ± SD) in square knots was reached with 4-throw in both silk (30 ± 1.5 N) and polyglactin 910 (39 ± 12 N). For RHAP knots, maximal failure strength was reached at 5-throw for both silk (31 ± 1.5 N) and polyglactin 910 (41 ± 13 N). In both sutures, there were no strength differences between 3-throw square and 4-throw RHAP, between 4-throw square and 5-throw RHAP, or between 5-throw square and 6-throw RHAP knots. Polyglactin 910 sutures, in all knot configurations, were more prone to slippage than silk sutures (p < 0.001). CONCLUSION: The difference in mean tensile strength could be attributed to the proportion of knot slippage versus breakage, which is material-dependent. Future studies can re-evaluate findings in monofilament sutures and objectively assess the reproducibility of square and RHAP knots in deep cavities. Our results indicate that RHAP knots composed of 1 extra throw provide equivalent strength to square knots and may be an alternative when performing hand-ties in limited cavities with either silk or polyglactin 910 sutures.

CONTEXTE: Les nœuds plats sont la norme en matière de points de suture manuels, mais ils sont difficiles à reproduire dans des cavités profondes et deviennent par inadvertance des nœuds coulants. Le nœud de type demi-clé inversée alternée a été proposé comme solution de rechange en raison de sa nature non glissante et de sa reproductibilité dans des espaces restreints. Nous avons voulu vérifier la non-infériorité de la demi-clé inversée alternée par rapport au nœud plat en évaluant sa résistance à la traction. MÉTHODES: Nous avons réalisé 10 essais de référence et autant d'essais pour chaque type de nœud, en utilisant des fils de soie de taille 3-0 et de polyglactine 910 de taille 3-0. Nous avons comparé la résistance à la traction des différentes configurations de nœuds, c'est-à-dire le point de défaillance entre le glissement du nœud et la rupture de celui-ci. RÉSULTATS: La résistance maximale à la traction (moyenne ± É.-T.) des nœuds plats a été atteinte avec 4 boucles, tant pour le fil de soie (30 ± 1,5 N) que le fil de polyglactine 910 (39 ± 12 N). Pour les demi-clés inversées alternées, la résistance maximale à la traction a été atteinte avec 5 boucles pour le fil de soie (31 ± 1,5 N) et de polyglactine 910 (41 ± 13 N). Dans les 2 types de sutures, on n'a noté aucune différence de résistance entre le nœud plat à 3 boucles et la demi-clé inversée alternée à 4 boucles, entre le nœud plat à 4 boucles et la demi-clé inversée alternée à 5 boucles, ni entre le nœud plat à 5 boucles et la demi-clé inversée alternée à 6 boucles. Dans tous les types de nœuds, les sutures de polyglactine 910 ont été plus sujettes au glissement que les sutures de soie (p < 0,001). CONCLUSION: La différence de résistance moyenne à la traction a pu être attribuée à la proportion de glissement c. la rupture des nœuds, qui dépend du matériau. D'autres études pourraient réévaluer les résultats obtenus avec des sutures monofilaments et mesurer objectivement la reproductibilité des nœuds plats et des demi-clés inversées alternées dans des cavités profondes. Selon nos résultats, les demi-clés inversées alternées comportant une boucle supplémentaire offrent une résistance équivalente à celle des nœuds plats et seraient une solution de rechange lors de sutures manuelles dans des cavités restreintes, avec la soie ou la polyglactine 910.