Treinamento de anastomoses vasculares com modelo de baixo custo / Training of vascular anastomoses with a low-cost model

Introdução: Habilidades cirúrgicas são geralmente ensinadas desde os estágios iniciais da Faculdade de Medicina. A sutura é considerada um dos pilares da formação médica, e uma competência essencial de qualquer especialidade cirúrgica, sendo uma das habilidades mais comumente ensinadas. Objetivo: Validar um modelo para treinamento de anastomoses vasculares de baixo custo, desenvolvido no Serviço de Cirurgia Vascular do Hospital do Servidor Público Municipal de São Paulo ­ SP (HSPM). Método: Foram incluídos no estudo 14 residentes de cirurgia, que foram avaliados com base no modelo estatístico Objective Structured Assessment of Technical Skill (OSATS). Os participantes foram treinados utilizando um modelo sintético desenvolvido no Serviço de Cirurgia Vascular do HSPM, sendo avaliado especialmente o tempo necessário para sutura dos vasos. Resultados: Foram realizados, em média, 5 sessões de treinamento por residente (com amplitude de 4 a 7), refletindo um ganho de 103% no score de pontuação observado entre as avaliações. Esse resultado é corroborado com as análises descritivas e inferenciais, onde foram observadas reduções no tempo de sutura, ocorridas em todas as análises de medidas de tendência e dispersão. Houve uma redução de 53% do tempo médio de sutura entre os treinamentos. Conclusão: O treinamento resultou em considerável redução do tempo necessário para realização das suturas. A despeito de algumas limitações, o modelo é de produção rápida e descomplicada, utiliza materiais facilmente disponíveis, apresenta baixo custo, é reprodutível, e permite treinamento de anastomoses de forma a melhorar as habilidades manuais dos residentes em cirurgia. Sugere-se a realização de uma nova avaliação com uma amostra maior, com o intuito de verificar se os resultados aqui observados se repetirão quando avaliados em maior escala. Palavras-chave: Cirurgia Vascular. Anastomoses. Modelos Sintéticos. Tempo de sutura.

Dermatological surgery: an update on suture materials and techniques. Part 2.

This is the second part of a two-part series summarizing the latest evidence related to suture materials and wound closure techniques in dermatological surgery. We critically appraised evidence focusing on the following consequences of suture choice: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases MEDLINE, PubMed and Embase using the keywords 'skin surgery', 'dermatological surgery', 'sutures', 'braided sutures', 'monofilament sutures' and 'antibacterial sutures' to identify relevant English-language articles. This part of the review assesses the evidence for different types of buried sutures, including braided vs. monofilament sutures, longer-absorbing sutures and antibacterial sutures. The majority of trials were noted to be of poor quality, single-centre (thus lacking external validity) and underpowered, which presents challenges in comparing suture techniques in skin surgery. Future large-scale, multicentre, randomized trials are needed, with both surgeon and patient-assessed validated outcomes.

Dermatological surgery: an update on suture materials and techniques. Part 1.

Significant variation exists in the surgical suture materials and techniques used for dermatological surgery. Many wound-closure techniques are now practised, including use of sutures, staples and topical adhesives. The focus of our review article is to summarize the latest evidence relating to suture materials and wound-closure techniques, considering the following areas: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases Medline, PubMed and Embase using the keywords 'skin surgery', 'dermatologic surgery', 'sutures', 'suture techniques', 'suturing techniques' and 'surgical techniques' to identify relevant English-language articles. Absorbable superficial sutures may be a preferred alternative to nonabsorbable sutures by both patients and surgeons. Subcuticular sutures may be preferable to simple interrupted sutures for superficial wound closure, and there may also be a role for skin staples in dermatological surgery, particularly on the scalp. However, there remains limited evidence specific to dermatological surgery supporting the use of particular suture materials and suturing techniques. Further high-quality research is required, including multicentre randomized trials with larger cohorts.

Reducing the cost of robotic hysterectomy: assessing the safety and efficacy of using prograsp forceps in lieu of needle holder for vaginal cuff closure.

Robotic-assisted surgery is criticized for its high cost. As surgeons get more experienced in robotic surgery, modifications to existing techniques are tried to reduce surgical costs. Vaginal cuff closure using prograsp forceps in lieu of needle holder can be safe and cost-effective in patients undergoing robotic-assisted hysterectomy. The objective of this study is to compare the safety, efficacy, and cost effectiveness of using prograsp forceps in lieu of needle holder for suturing the vaginal cuff after robotic-assisted hysterectomy. This was a single-institution retrospective review of patients who underwent robotic-assisted hysterectomy for benign and malignant conditions from October 2015 to August 2018. Patients were stratified based on whether prograsp forceps or needle holder was used for suturing vaginal cuff. Data obtained included demographic, surgical data, and postoperative outcomes. Mann-Whitney U test and Chi-square test were used to compare qualitative and quantitative data, respectively. 367 patients underwent robotic-assisted hysterectomies during this period. 75 patients belonged to the needle holder cohort; 292 patients had vaginal cuff closure using prograsp forceps. Vault closure time was comparable between the groups (6.4 vs. 6.6 p = 0.33). There were no significant differences in the postoperative vault-related complications between groups. There was no instrument damage in either group. Using prograsp saved 220 USD in instrument-related charges. This study shows that using prograsp in lieu of needle holder for suturing is safe, there is no increase in operative time or complications, and there is a cost advantage.

Systematic review of hemostatic agents used in vascular surgery.

BACKGROUND: Hemostatic agents are routinely used in vascular surgery to complement proper suture techniques and decrease the risk of perioperative bleeding. A relative lack of comparative research studies have left surgeons with the option of choosing hemostatic agents based on their personal experience. The present review has highlighted the efficacy and safety of hemostatic agents and categorized them according to their primary mechanism of action and cost. METHODS: A systematic search strategy encompassing hemostatic agent products was deployed in the PubMed database. Single-center and multicenter, randomized, controlled trials with >10 patients were included in the present study. RESULTS: We reviewed 12 studies on the efficacy and safety of hemostatic agents compared with manual compression or other hemostatic agents. Using the time to hemostasis as the primary end point, all studies had found hemostatic agents to be significantly more efficient than manual compression. Likewise, adhesives (high pressure sealants) and dual agents (containing biologically active and absorbable components) were found to be more efficient, but costlier, than agents with either biologically active or absorbable components only. Agents with porcine or bovine constituents were found to trigger anaphylactic reactions in rare cases. Additionally, the absence of fibrin stabilizing factor XIII in a brand of fibrin sealant was speculated to reduce the affinity of the fibrin sealant for the expanded polytetrafluoroethylene graft. The cost of agents varied greatly depending on their active ingredient. CONCLUSIONS: Hemostatic agents appear to be highly effective at decreasing the risk of bleeding during surgical procedures. Although some hemostatic agents were demonstrated to achieve hemostasis faster than others, most are able to control bleeding within <10 minutes. Based on the limited data, the least expensive agents might suffice for limited suture lines used in routine procedures.

Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation.

OBJECTIVE: Techniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution. METHODS: All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018. RESULTS: During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups. CONCLUSIONS: Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

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.

Barbed and conventional sutures in spinal surgery patients: an economic and clinical outcomes comparison.

OBJECTIVE: To compare economic and clinical outcomes of barbed sutures versus conventional sutures alone in wound closure for patients undergoing spinal surgery. METHOD: A retrospective study using the Premier Healthcare Database. The database was searched for patients who underwent elective inpatient spinal surgery (fusion or laminectomy) for a spinal disorder between 1 January 2014 and 30 June 2018 (first=index admission). Using billing records for medical supplies used during the index admission, patients were classified into mutually-exclusive groups: patients with any use of STRATAFIX (Ethicon, US) knotless tissue control devices (barbed sutures group); or patients with use of conventional sutures alone (conventional sutures group). Outcomes included the index admission's length of stay, total and subcategories of hospital costs, non-home discharge, operating room time (ORT, minutes), wound complications and readmissions within ≤90 days. Propensity score matching and generalised estimating equations were used to compare outcomes between the study groups. RESULTS: After matching, 3705 patients were allocated to each group (mean age=61.5 years [standard deviation, SD±12.9]; 54% were females). Compared with the conventional suture group, the barbed suture group had significantly lower mean ORT (239±117 minutes, versus 263±79 minutes conventional sutures, p=0.015). Operating room costs were also siginificantly lower in the barbed suture group ($6673±$3976 versus $7100±$2700 conventional sutures, p=0.020). Differences were statistically insignificant for other outcomes (all p>0.05). Subanalysis of patients undergoing fusions of ≥2 vertebral joints yielded consistent results. CONCLUSION: In this study, wound closure incorporating barbed sutures was associated with lower ORT and operating room costs, with no significant difference in wound complications or readmissions, when compared with conventional sutures alone.

Subcuticular sutures for skin closure in non-obstetric surgery.

BACKGROUND: Following surgery, surgical wounds can be closed using a variety of devices including sutures (subcuticular or transdermal), staples and tissue adhesives. Subcuticular sutures are intradermal stitches (placed immediately below the epidermal layer). The increased availability of synthetic absorbable filaments (stitches which are absorbed by the body and do not have to be removed) has led to an increased use of subcuticular sutures. However, in non-obstetric surgery, there is still controversy about whether subcuticular sutures increase the incidence of wound complications. OBJECTIVES: To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery. SEARCH METHODS: In March 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: All randomised controlled trials which compared subcuticular sutures with any other methods for skin closure in non-obstetric surgery were included in the review. DATA COLLECTION AND ANALYSIS: Two review authors independently identified the trials, extracted data and carried out risk of bias and GRADE assessment of the certainty of the evidence. MAIN RESULTS: We included 66 studies (7487 participants); 11 included trials had more than two arms. Most trials had poorly-reported methodology, meaning that it is unclear whether they were at high risk of bias. Most trials compared subcuticular sutures with transdermal sutures, skin staples or tissue adhesives. Most outcomes prespecified in the review protocol were reported. The certainty of evidence varied from high to very low in the comparisons of subcuticular sutures with transdermal sutures or staples and tissue adhesives; the certainty of the evidence for the comparison with surgical tapes and zippers was low to very low. Most evidence was downgraded for imprecision or risk of bias. Although the majority of studies enrolled people who underwent CDC class 1 (clean) surgeries, two-thirds of participants were enrolled in studies which included CDC class 2 to 4 surgeries, such as appendectomies and gastrointestinal surgeries. Most participants were adults in a hospital setting. Subcuticular sutures versus transdermal sutures There may be little difference in the incidence of SSI (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.80 to 1.52; 3107 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce wound complications (RR 0.83; 95% CI 0.40 to 1.71; 1489 participants; very low-certainty evidence). Subcuticular sutures probably improve patient satisfaction (score from 1 to 10) (at 30 days; MD 1.60, 95% CI 1.32 to 1.88; 290 participants; moderate-certainty evidence). Wound closure time is probably longer when subcuticular sutures are used (MD 5.81 minutes; 95% CI 5.13 to 6.49 minutes; 585 participants; moderate-certainty evidence). Subcuticular sutures versus skin staples There is moderate-certainty evidence that, when compared with skin staples, subcuticular sutures probably have little effect on SSI (RR 0.81, 95% CI 0.64 to 1.01; 4163 participants); but probably decrease the incidence of wound complications (RR 0.79, 95% CI 0.64 to 0.98; 2973 participants). Subcuticular sutures are associated with slightly higher patient satisfaction (score from 1 to 5) (MD 0.20, 95% CI 0.10 to 0.30; 1232 participants; high-certainty evidence). Wound closure time may also be longer compared with staples (MD 0.30 to 5.50 minutes; 1384 participants; low-certainty evidence). Subcuticular sutures versus tissue adhesives, surgical tapes and zippers There is moderate-certainty evidence showing no clear difference in the incidence of SSI between participants treated with subcuticular sutures and those treated with tissue adhesives (RR 0.77, 95% CI 0.41 to 1.45; 869 participants). There is also no clear difference in the incidence of wound complications (RR 0.62, 95% CI 0.35 to 1.11; 1058 participants; low-certainty evidence). Subcuticular sutures may also achieve lower patient satisfaction ratings (score from 1 to 10) (MD -2.05, 95% CI -3.05 to -1.05; 131 participants) (low-certainty evidence). In terms of SSI incidence, the evidence is uncertain when subcuticular sutures are compared with surgical tapes (RR 1.31, 95% CI 0.40 to 4.27; 354 participants; very low-certainty evidence) or surgical zippers (RR 0.80, 95% CI 0.08 to 8.48; 424 participants; very low-certainty evidence). There may be little difference in the incidence of wound complications between participants treated with subcuticular sutures and those treated with surgical tapes (RR 0.90, 95% CI 0.61 to 1.34; 492 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce the risk of wound complications compared with surgical zippers (RR 0.55, 95% CI 0.15 to 2.04; 424 participants; very low-certainty evidence). It is also uncertain whether it takes longer to close a wound with subcuticular sutures compared with tissue adhesives (MD -0.34 to 10.39 minutes; 895 participants), surgical tapes (MD 0.74 to 6.36 minutes; 169 participants) or zippers (MD 4.38 to 8.25 minutes; 424 participants) (very low-certainty evidence). No study reported results for patient satisfaction compared with surgical tapes or zippers. AUTHORS' CONCLUSIONS: There is no clear difference in the incidence of SSI for subcuticular sutures in comparison with any other skin closure methods. Subcuticular sutures probably reduce wound complications compared with staples, and probably improve patient satisfaction compared with transdermal sutures or staples. However, tissue adhesives may improve patient satisfaction compared with subcuticular sutures, and transdermal sutures and skin staples may be quicker to apply than subcuticular sutures. The quality of the evidence ranged from high to very low; evidence for almost all comparisons was subject to some limitations. There seems to be no need for additional new trials to explore the comparison with staples because there are high-quality studies with large sample sizes and some ongoing studies. However, there is a need for studies exploring the comparisons with transdermal sutures, tissue adhesives, tapes and zippers, with high-quality studies and large sample sizes, including long-term assessments.

Valuing innovative endoscopic techniques: endoscopic suturing to prevent stent migration for benign esophageal disease.

BACKGROUND AND AIMS: Reimbursement often presents a significant barrier to widespread adoption of innovative endoscopic devices. We aimed to determine the value (defined as cost savings to a payer) of endoscopic suturing devices in preventing the migration of esophageal stents placed for benign esophageal diseases. METHODS: A decision-analytic model was constructed from a payer perspective evaluating fully covered metal stent placement for benign esophageal diseases (fistula, leak, perforation, or stricture) in a hospital outpatient setting. The model compared 2 strategies: endoscopic suturing to anchor the stent or no suture. Health care outcomes and costs were derived from published systematic reviews and national databases (U.S. Food and Drug Administration Manufacturer and User Facility Device Experience [MAUDE] for safety data; 2018 Medicare Physician Fee Schedule and Provider Utilization and Payment Data databases for reimbursement data). RESULTS: From a payer perspective, reimbursement for care increased by US$1487.98 without endoscopic suturing per patient, compared with US$621.06 with endoscopic suturing, to cover the risk of stent migration in addition to usual professional and facility reimbursement for stent placement. Thus, an average cost saving of US$866.92 per patient was achieved with endoscopic suturing to reduce stent migration risks. Cost savings associated with suturing ranged from US$147.48 to US$1586.36 per patient, based on the indication for the procedure in sensitivity analysis. Cost savings increased with higher rates of technical success in suture placement. CONCLUSIONS: Creating a defined reimbursement pathway for endoscopic suture fixation of a stent for the treatment of benign esophageal diseases appears to be justified from a payer perspective.

Simple Technique for Transscleral Fixation of a Foldable Posterior Chamber Intraocular Lens Using a Single Suture.

Objective: To explore the simplified technique for transscleral fixation of a foldable posterior chamber intraocular lens (IOLs) in patients with aphakia or inadequate posterior capsule support. Methods: A review was conducted of 18 eyes of eighteen patients with the absence of-or inadequate-capsule support, after the simplified technique of using a foldable posterior chamber intraocular lens (PC IOLs) with stable four-point transscleral fixation, as performed by a skilled surgeon. This technique uses only a single suture and a knot to fix a PC IOL firmly without creating a scleral flap. The mean follow-up time was 18 ± 5.8 months (ranging from 12 to 24 months). Results: All patients exhibited improved visual acuity. No IOL tilt or dislocation or iris capture was observed, and all patients exhibited stable and centered IOL after surgery. No complex complications, such as suture shedding and exposure, corneal endothelial decompensation, persistent uveitis, or retinal detachment and endophthalmitis were observed. Conclusion: The simplified technique proposed here is a reliable, economical, and reproducible method of treating patients with aphakia or inadequate posterior capsule support. It provides excellent IOL stability, reduces surgical duration and complexity, and prevents certain complications.

Cost-effectiveness analysis in a randomized trial of late in-the-bag intraocular lens dislocation surgery: repositioning versus exchange.

PURPOSE: To compare the cost-effectiveness of two operation methods for late in-the-bag intraocular lens (IOL) dislocation. METHODS: In this randomized clinical trial, 104 patients were randomly assigned to IOL repositioning by scleral suturing (n = 54) or IOL exchange with a retropupillary iris-claw lens (n = 50). A cost-effectiveness analysis (CEA) was performed in conjunction with previously published 6-month efficacy and safety results. An incremental cost-effectiveness ratio was calculated as the cost difference between the operation groups relative to their difference in postoperative corrected distance visual acuity (CDVA) (mean and 95% confidence interval: minimum and maximum), reported as the cost difference in United States Dollars ($) per logMAR difference. RESULTS: Exchange surgery was $281.20 ± 17.66 more expensive than repositioning, mainly explained by the new IOL and the frequent use of anterior vitrectomy. A previous trial publication revealed no significant difference in the 6-month postoperative CDVA between the groups. In the CEA, the mean group difference yielded an incremental cost-effectiveness ratio of -$281.20 per -0.11 logMAR (-$1108/QALY) in favour of repositioning, ranging from -$281.20 per -0.29 logMAR (-$406/QALY) in favour of repositioning to +$281.20 per -0.08 logMAR (+$1522/QALY) in favour of exchange. The CEA did not include the mean 9.5 min shorter operation time for exchange. CONCLUSION: Repositioning tended to be more cost-effective than exchange; however, this is modified if also considering the operation time. Overall, it seems the cost-effectiveness is not alone sufficiently different to recommend one of the operation methods over the other for late in-the-bag IOL dislocation.

Staplers vs. loop-ligature: a cost analysis from the hospital payer perspective.

BACKGROUND: Presently, there is equipoise regarding the surgical technique used to manage the appendiceal stump during laparoscopic appendectomy. The purpose of this research was to determine whether the routine use of loop ligature, compared to stapling, is cost effective from a hospital payer perspective. METHODS: A retrospective cohort study was conducted amongst patients undergoing emergency laparoscopic surgery for acute appendicitis at two major academic hospitals. In order to eliminate possible systematic bias arising from one technique being preferentially employed with more complex presentations, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and open appendectomies were excluded. Costs were determined using a previously published model derived from publicly available data from the Ontario Case Costing Initiative, in conjunction with local cost data for disposable procurement. Secondary outcomes included operating room time, length of stay, and complication rates. RESULTS: Between Jan 1, 2014 and Dec 31, 2015, 567 adult patients had an emergency laparoscopic appendectomy for acute appendicitis. In comparing surgeons who routinely employed LLA to LSA, there was a significant decrease in total mean hospital cost with LLA ($1988 ± $143 vs. $2253 ± $99, p = 0.002). In addition, mean disposable cost was reduced for surgeons using LLA ($310 ± $27 vs. $668 ± $26, p < 0.001). This reduction in cost was not associated with a difference in length of stay (1.5 vs. 1.4 days, p = 0.28) or complication rates (8% vs. 10%, p = 0.43). CONCLUSIONS: These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost-effective care compared to stapler users, saving their institution more than $200 per case with no clear disadvantages. A shift from routine use of staplers to loop ligature should result in significant overall cost savings to the hospital.

A Systematic Review of Suture Technologies in Total Knee Arthroplasty.

Over time, various materials and techniques have been developed for superficial and deep wound closure. However, potential complications, such as infections and dehiscences, can still occur, driving the development of new closure modalities. As wound closure technology continues to advance and change, the need to continuously evaluate the current techniques and materials persists. Therefore, the purpose of this systematic review was to evaluate the current literature on the various closure materials and techniques utilized for total knee arthroplasty. Specifically, we evaluated: 1) closure times; 2) infections and complication rates; as well as 3) costs related to superficial and deep wound closures. Based on the findings from the current literature, barbed suture was associated with significantly shorter closing times in all five studies when compared to interrupted sutures (p<0.05). Additionally, the use of barbed sutures may result in similar postoperative complication rates. Although the cost of an individual barbed suture is potentially higher than the cost of an individual conventional suture, a knotless technique can require a shorter suture length, which might also help decrease costs.

Dissection of Incomplete Fissure Using Electrocautery Is a Safe and Acceptable Method for Thoracoscopic Right Upper Lobectomy.

OBJECTIVE: The incidence of prolonged air leak may be highest after right upper lobectomy due to incomplete minor fissure. The objective of this study was to compare the efficacy of direct electrocautery division and suture with that of a fissureless technique during thoracoscopic right upper lobectomy with incomplete fissure. METHODS: One hundred and two patients underwent right upper lobectomy between January 2016 and December 2016. Of these, 60 patients underwent a right upper lobectomy conducted using the fissureless technique (group A), and 42 consecutive patients underwent a right upper lobectomy via electrocautery division of the fissure and suture (group B). The preoperative, operative, and postoperative parameters were compared between the two groups. RESULTS: The electrocautery and suture group had a higher incidence of prolonged air leak (> 5 days) (30% [12/40] vs 11% [7/62], p = 0.00), a higher incidence of air leakage (20 [32%] vs 38 [95%], p = 0.00), a longer air leak duration (days) (4.93 ± 0.86 vs 3.00 ± 1.60 days, p = 0.00), a longer duration of chest tube (mean 5.30 ± 1.20 vs 3.13 ± 1.88 days, p = 0.00), and a lower hospitalization cost (6463.28 ± 958.30 vs 7459.07 ± 1185.00 €, p = 0.00) than did the fissureless technique group. No differences were observed with respect to patient characteristics, operative characteristics, perioperative mortality, or duration of hospital stay after surgery. CONCLUSIONS: The number of patients with prolonged air leak was higher in the electrocautery group. However, electrocautery does not prolong overall length of stay and decreases hospitalization costs. Dissection of incomplete fissure using electrocautery is a safe and acceptable method for thoracoscopic right upper lobectomy.

A simple and novel technique for training in microvascular suturing in a rat model.

BACKGROUND: Though microvascular clamps are widely used for anastomosis training, there still have several shortcomings, including the bulging, expensiveness and unavailability due to sterilization. The aim of this study is to introduce a simple and novel microvascular training model without use of microvascular clamps. METHODS: Femoral vessels of Sprague Dawley rats training model were used to evaluate the usefulness of 4-0 silk as a slipknot for performing arterio-arterial and veno-venous microvascular anastomoses. A total of 12 Sprague Dawley rats were randomly assigned to either slipknot group or vascular clamp group. We also assess other endpoints, including ischemic time, patency rate, and clinical features. An additional histological study was performed to compare their immediate traumatic effects on vessel wall. RESULTS: There was no ischemic change or congestive sign in the lower limb after microvascular anastomosis. The total warm ischemic time for the vascular anastomosis was not significantly different. We performed the patency test immediately after microvascular anastomosis and one week after surgery. No intraoperative vascular bleeding was found during these procedures and no thrombosis occurred postoperatively. The histologic damages to occluded area were not significantly different in both groups. CONCLUSION: We demonstrate a microsurgical suture technique performed without any vascular clamp on a rat model. This rat model was designed for training in the technique of microvascular anastomosis. Compared with microvascular clamps, silk slipknot is a cheap, easily available, less space-occupying technique while performing microvascular anastomoses training. This preliminary study provides a simple and effective alternative method for microvascular anastomosis training.

A Modified Strategy Using Barbed Sutures for Wound Closure in Total Joint Arthroplasty: A Prospective, Randomized, Double-Blind, Self-Controlled Clinical Trial.

BACKGROUND Barbed suture has reported time-saving and safety benefits for wound closure in total joint arthroplasty (TJA). However, this technique requires further investigation. The aim of this study was to use a prospective, randomized, self-controlled study to further determine the efficiency and safety of this technology and to introduce our modified suturing method through a randomized, self-controlled trial. MATERIAL AND METHODS From August 2015 to December 2016, 84 patients (hip 46, knee 38) who had undergone primary simultaneous bilateral total knee or hip arthroplasties were enrolled in this study. Barbed sutures were randomized and used on one side, and traditional sutures (Vicryl) were used on the other side. RESULTS Closure time was shorter with the barbed sutures: 6.25 min (12.00 min vs. 18.25 min, p=0.000) for hip and 5.54 min (13.18 min vs. 18.71 min, p=0.000) for knee. There was no difference in the complication rate for the 2 groups. The total cost of our suturing strategy (Quill) was 872.3 RMB, which is 375.1 RMB higher than the total cost of the standard suture method (Vicryl). However, the traditional barbed suturing method (Quill) cost 2195.6 RMB. CONCLUSIONS Barbed suturing was a fast and safe method for wound closure in TJA. We also recommend our modified suturing strategy, especially in countries where operation cost was not associated with operation time.