Laparoscopic single-layer running "trapezoid-shaped" suture versus mechanical stapling for esophagojejunostomy after total gastrectomy for gastric cancer: cost-effect analysis of propensity score-matched study cohorts.

OBJECTIVES: Totally laparoscopic total gastrectomy has been developed with difficulty in intracorporeal esophagojejunostomy. Although mechanical stapling has been widely used for intracorporeal esophagojejunostomy, manual suture holds great promise with the emergence of high-resolution 3D vision and robotic surgery. After exploration of how to improve the safety and efficiency of intracorporeal suture for esophagojejunostomy, we recommended the technique of single-layer running "trapezoid-shaped" suture. The cost-effectiveness was analyzed by comparing with conventional mechanical stapling. METHODS: The study retrospectively reviewed the patients undergoing laparoscopic gastrectomy for gastric cancer from January 2010 to December 2021. The patients were divided into two cohorts based on the methods of intracorporeal esophagojejunostomy: manual suture versus stapling suture. Propensity score matching was performed to match patients from the two cohorts at a ratio of 1:1. Then group comparison was made to determine whether manual suture was non-inferior to stapling suture in terms of operation time, anastomotic complications, postoperative hospital stay, and surgical cost. RESULTS: The study included 582 patients with laparoscopic total gastrectomy. The manual and stapling suture for esophagojejunostomy were performed in 50 and 532 patients, respectively. In manual suture cohort, the median time for the whole operation and digestive tract reconstruction were 300 min and 110 min. There was no anastomotic bleeding and stenosis but two cases of anastomotic leak which occurred at 3 days after surgery. The median length of postoperative hospital stay was 11 days. After propensity score matching, group comparison yielded two variables with statistical significance: time for digestive tract reconstruction and surgery cost. The manual suture cohort spent less money but more time for esophagojejunostomy. Intriguingly, the learning curve of manual suture revealed that the time for digestive tract reconstruction was declined with accumulated number of operations. CONCLUSIONS: Laparoscopic single-layer running "trapezoid-shaped" suture appears safe and cost-effective for intracorporeal esophagojejunostomy after total gastrectomy. Although the concern remains about prolonged operation time for beginners of performing the suture method, adequate practice is expected to shorten the operation time based on our learning curve analysis.

Incidence of Postoperative Adhesions after Laparoscopic Myomectomy with Barbed Suture.

AIM: The aim of the study was to assess the incidence of postoperative adhesion by baseball running suture using barbed suture (BS) in laparoscopic myomectomy in comparison with sutures using an absorbable thread. METHODS: Two hundred fifteen patients who underwent second-look laparoscopy (SLL) 6 months after laparoscopic myomectomy at our hospital between 2010 and 2014 were retrospectively reviewed. The incidence, numbers, types, and extent of adhesions were evaluated according to the more comprehensive adhesion scoring method. Propensity score matching (PS) (1:1) between the groups was performed by using the diameter of the largest myoma, the number of enucleated myomas, and the type of adhesion barrier. RESULTS: Running baseball sutures and running sutures were applied to 28 and 187 patients with unidirectional BS and absorbable thread, respectively, to close the incised serosal wounds enucleating largest myomas during laparoscopic myomectomy. After PS matching for the patients, surgical findings and the incidence of postoperative wound adhesions were compared between the groups, including 22 patients each. The surgical findings were similar between the groups, except for the total surgical duration and blood loss (medians), which were significantly shorter and lower in the BS group than in the absorbable thread group (70 vs. 100 min; p = 0.01, 50 vs. 100 mL; p = 0.02). Regarding findings of SLL, no significant differences in the incidence of postoperative wound adhesions were found between the groups (BS, 4/22 [18.2%] versus absorbable thread, 8/22 [36.4%]; p = 0.31). CONCLUSION: Our data indicated that the incidence of postoperative adhesion following the use of BS for wound closure in laparoscopic myomectomy was similar to that following the use of conventional suture.

Bleeding control using intrauterine continuous running suture during cesarean section in pregnant women with placenta previa.

PURPOSE: The purpose of this study was to evaluate the effectiveness of intrauterine continuous running suture during cesarean section in pregnant women with placenta previa. METHODS: We enrolled 277 women and medical records were retrospectively reviewed. Pregnant women were grouped according to uterine bleeding control methods as follows: Group A, using intrauterine continuous running suture and Group B (control group) using figure-of-eight suture. RESULTS: Intrauterine continuous running sutures were used in 104 pregnant women. Mean total blood loss in Group A was significantly less than that in Group B (1332.70 ± 152.92 mL vs 1861.56 ± 157.74 mL, P = 0.029). Mean total transfusion unit of Group A was significantly less than that in Group B (1.74 ± 0.41 vs 3.52 ± 0.75, P = 0.037). CONCLUSIONS: Intrauterine continuous running sutures can significantly reduce postpartum blood loss and transfusion units during cesarean section in pregnant women with placenta previa.

[Clinical application of enterostomy using running suture of dermis and seromuscular layer in laparoscopic-assisted radical resection for rectal carcinoma].

Objective: To explore the clinical safety and feasibility of enterostomy using running suture of dermis and seromuscular layer in laparoscopic-assisted radical resection for rectal carcinoma. Methods: From May 1, 2017 to May 1, 2018, 46 patients who underwent laparoscopic-assisted radical resection for rectal carcinoma with enterostomy using running suture of dermis and seromuscular layer in Cancer Hospital, Chinese Academy of Medical Sciences were retrospectively enrolled in this study. Data regarding clinicopathologic characteristics, operation and postoperative outcomes, stoma-related complications and functions of stoma were collected and analyzed. Results: All of the 46 patients successfully underwent this operation. Among them, 30 patients underwent laparoscopic-assisted abdominoperineal resection for rectal cancer with sigmoidostomy and 16 patients underwent laparoscopic-assisted low anterior resection for rectal cancer with loop ileostomy. The mean operation time was 115.3 minutes and intraoperative blood loss was 86.1 ml. The mean time for enterostomy was 14.1 minutes. The average time to flatus, time to fluid diet intake and length of hospital stay were 1.8 days, 2.9 days and 6.5 days, respectively. During the follow-up period, three patients suffered from stomal edema, two patients suffered from parastomal hernia, and two patients suffered from skin inflammation surrounding stoma. None of re-operation related stoma and severe mobility such as stomal stenosis, stomal necrosis, stomal prolapse, stomal retraction and stomal mucocutaneous separation occurred. Thirty-five patients recovered with satisfactory stomal function, two with middle function and one with poor function. Conclusion: Enterostomy using running suture of dermis and seromuscular layer in laparoscopic-assisted radical resection for rectal carcinoma is a safe and feasible procedure with a satisfactory short-term effect.

Laparoscopic sacral colpopexy and a new approach to mesh fixation: a randomized clinical trial.

PURPOSE: Laparoscopic sacral colpopexy (LSC) plus supracervical hysterectomy (LSH) for pelvic organ prolapse (POP) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to vaginal-mesh fixation during LSC with continuous locked suture. METHODS: This is a prospective randomized double-blinded clinical trial enrolling 90 patients with severe POP from January 2016 to April 2017. Patients underwent LSH plus a "two-meshes" LSC and were randomized, regarding mesh fixation, in Group 1 (extracorporeal interrupted 3-0 delayed absorbable sutures) and Group 2 (running locked 3-0 delayed absorbable suture). Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications. RESULTS: A total of 42 patients for group completed the study. Baseline characteristics were similar between the groups. Overall mesh fixation time (24 vs. 39 min; p < 0.01), and operative time (121 vs. 138 min; p < 0.05) resulted significantly lower in Group 2. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. CONCLUSIONS: Laparoscopic continuous locked 3-0 absorbable suture for anterior and posterior mesh fixation during LSC guaranteed a faster and effective alternative to multiple interrupted sutures. The significant operative time reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LSC.

Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy (PD). Both patient-derived and technical factors contribute to pancreatic anastomotic failure. The continuous suture duct-to-mucosa pancreaticojejunostomy (PJ) described previously is associated with a low rate of POPF. The aim of the present study was to observe whether the new technique would effectively reduce the POPF rate in comparison with conventional interrupted suture duct-to-mucosa PJ. METHODS: Data on 255 consecutive patients, who underwent the two methods of PJ after standard PD by one group of surgeons between 2006 and 2013, were collected retrospectively from a prospective database. The primary end point was the POPF rate. The risk factors of POPF were investigated by using univariate and multivariate analyses. RESULTS: A total of 120 patients received continuous suture PJ and 135 underwent interrupted suture PJ. Rate of POPF for the entire cohort was 12.5%. There were 9 fistulas (7.5%) in the continuous anastomosis group and 23 fistulas (17%) in the interrupted anastomosis group (P = 0.022). The rates of major complications (Clavien grades 3-5) were less in the continuous anastomosis group (5%) compared with the interrupted anastomosis group (13.3%) (P = 0.023). The greatest risk factor for a POPF was pancreatic duct diameter: POPF developed in only 3 patients (3.6%) with large pancreatic ducts (≥ 3 mm) and in 29 patients (16.9%) with small pancreatic ducts (<3 mm). There were four postoperative (in-hospital) deaths (both in the interrupted anastomosis group); two of which had POPF as the proximate cause of death, followed by bleeding and sepsis. CONCLUSIONS: The continuous suture duct-to-mucosa PJ effectively reduces the POPF rate after PD in comparison with interrupted anastomosis. The results confirm increased POPF rates in patients with pancreatic duct diameter <3 mm compared with pancreatic duct diameter ≥ 3 mm.

Running suture versus interrupted suture for vesicourethral anastomosis in retropubic radical prostatectomy: a randomized study.

OBJECTIVES: To determine the feasibility of vesicourethral anastomosis using running suture during retropubic radical prostatectomy and to compare the surgical outcomes of vesicourethral anastomosis using running suture with those of the standard interrupted suture technique. METHODS: A total of 60 patients undergoing radical prostatectomy from 2010 to 2012 at the Yamaguchi University Hospital, Japan were included in the present study, and were randomly assigned to vesicourethral anastomosis using running suture (n = 30 patients) or a standard interrupted suture technique group (n = 30 patients). Vesicourethral anastomosis using running suture was carried out with 12-bite sutures using 3-0 poliglecaprone. The primary end-point was the time to catheter removal. Patients' health-related quality of life was assessed using the Expanded Prostate Cancer Index Composite in 56 patients (28 patients in each group). RESULTS: No significant difference was found in the median suturing time between the two study groups (both 19 min, P = 0.449). The time to catheter removal was significantly better in the vesicourethral anastomosis using running suture group (hazard ratio 5.23, 95% confidence interval 1.73-17.65, P = 0.003). The pad-free rate was significantly higher in the vesicourethral anastomosis using running suture group at 1 month after surgery (20.7% vs 3.3%, P = 0.0463); however, there was no significant difference at 3 months and beyond. The Expanded Prostate Cancer Index Composite urinary and bowel summary scores at 1 month were significantly better in the vesicourethral anastomosis using running suture patients (both P < 0.01), though no significant difference was observed thereafter. A vesicourethral anastomosis stricture was noted in three patients (10%) in the standard interrupted suture technique group, and none in the vesicourethral anastomosis using running suture group. CONCLUSION: Running suture for vesicourethral anastomosis is feasible during retropubic radical prostatectomy. Furthermore, it offers better outcomes than the conventional standard interrupted suture technique, with a higher likelihood of improvement in patients' health-related quality of life.

Novel prototype sewing device, EndoSew®, for minimally invasive surgery: an extracorporeal ileal conduit construction pilot study in 10 patients.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The EndoSew(®) prototype was first tested in a porcine model several years ago. The investigators found it both simple to master and reliable, its greatest advantage being a 2.4-fold time saving compared with straight laparoscopic suturing. In addition to that publication, there is a single case report describing the performance of an open EndoSew(®) suture to close parts (16 cm) of an ileal neobladder. The time for suturing the 16 cm ileum was 25 min, which is in line with our experience. The knowledge on this subject is limited to these two publications. We report on the first consecutive series of ileal conduits performed in humans using the novel prototype sewing device EndoSew(®). The study shows that the beginning and the end of the suture process represent the critical procedural steps. It also shows that, overall, the prototype sewing machine has the potential to facilitate the intracorporeal suturing required in reconstructive urology for construction of urinary diversions. OBJECTIVE: To evaluate the feasibility and safety of the novel prototype sewing device EndoSew(®) in placing an extracorporeal resorbable running suture for ileal conduits. PATIENTS AND METHODS: We conducted a prospective single-centre pilot study of 10 consecutive patients undergoing ileal conduit, in whom the proximal end of the ileal conduit was closed extracorporeally using an EndoSew(®) running suture. The primary endpoint was the safety of the device and the feasibility of the sewing procedure which was defined as a complete watertight running suture line accomplished by EndoSew(®) only. Watertightness was assessed using methylene blue intraoperatively and by loopography on postoperative days 7 and 14. Secondary endpoints were the time requirements and complications ≤30 days after surgery. RESULTS: A complete EndoSew(®) running suture was feasible in nine patients; the suture had to be abandoned in one patient because of mechanical failure. In three patients, two additional single freehand stitches were needed to anchor the thread and to seal tiny leaks. Consequently, all suture lines in 6/10 patients were watertight with EndoSew(®) suturing alone and in 10/10 patients after additional freehand stitches. The median (range) sewing time was 5.5 (3-10) min and the median (range) suture length was 4.5 (2-5.5) cm. There were no suture-related complications. CONCLUSIONS: The EndoSew(®) procedure is both feasible and safe. After additional freehand stitches in four patients all sutures were watertight. With further technical refinements, EndoSew(®) has the potential to facilitate the intracorporeal construction of urinary diversions.

Rectovaginal fistula surgery with horizontal mattress and running suture after unsuccessful first repair: a report of two cases.

Rectovaginal fistula (RVF) repair after failed primary repair is uncommon. Patients with RVF experience physiological and sexual dysfunction with a significantly high risk of intravaginal infection and sepsis. There are many surgical procedures available for RVF repair. We performed an improvised transvaginal repair technique. Methods: We report two cases of recurring RVF after failed primary repair. Patient 1 developed RVF because of a failed vaginoplasty due to cosmetic reasons, while patient 2 developed RVF because of a fourth-degree perineal rupture repair post-delivery. We used a combination of horizontal mattress and running suture with the addition of diverting colostomy. Both surgeries went successfully and there were no complications. Outcomes: RVF repair using a combination of horizontal mattress and running suture went successfully and there were no complications. Both patients were able to be discharged after a short stay. Long-term evaluation was done by physical and supporting examinations for 2-3 months. Both patients showed excellent wound healing and physiological function. Conclusions: The combination of a transvaginal horizontal mattress and running suture in the posterior to anterior fashion with diverting colostomy is a safe and effective procedure for recurring RVF repair.

Advantages of Double Running Sutures in Astigmatism After Penetrating Keratoplasty.

Background: The purpose of this prospective study is to evaluate the effects of different suturing techniques in perforating keratoplasty surgery, in order to identify the most effective in reducing post-operative astigmatism. Methods: We analysed data from patients who underwent penetrating keratoplasty for different indications. All interventions were performed by the same surgeon. Patients were subjected to a follow-up of at least 12 months after surgery, during which astigmatism (assessed by keratometry, topography and refraction) best-corrected visual acuity (BCVA) and complications were evaluated. A total of 100 eyes from 100 patients were included and were randomly assigned to five different groups, each one featuring a different suturing technique: interrupted (INT), single running (SRS), double running with two 10-0 sutures (DRS), double running antitorque with two 10-0 sutures (DRSa), double running with both 10-0 and 11-0 sutures (DRS with 11-0). Results: There is a statistically significant difference in astigmatism after surgery between the double running sutures groups and the others with different techniques. However, there is no statistically significant difference between the INT and the SRS group; moreover, there is no statistically significant difference between the different groups with double running sutures (DRS, DRSa, DRS with 11-0). There is no statistically significant difference in BCVA values among the five groups. The wound leak rate was 10% in the INT group, 5.3% in the SRS group and 0% in all groups with double running sutures. Conclusion: In penetrating keratoplasty surgery, the double running suture technique reduces postoperative astigmatism, provides faster visual rehabilitation and features lower complication rates when compared to techniques featuring single running and interrupted sutures. No significant difference in terms of postoperative astigmatism or complication rates was observed among patients receiving double running suture techniques.

Update on Suture Techniques in Corneal Transplantation: A Systematic Review.

Effective suturing remains key to achieving successful outcomes in corneal surgery, especially anterior lamellar keratoplasty and full thickness transplantation. Limitations in the technique may result in complications such as wound leak, infection, or high astigmatism post corneal graft. By using a systematic approach, this study reviews articles and conducts content analysis based on update 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria). The aim of this paper is to summarize the state of the art of corneal suturing techniques for every type of corneal transplant and patient age and also their outcomes regarding astigmatism and complications. Future developments for corneal transplantation will be also discussed. This is important because especially the young surgeon must have knowledge of the implications of every suture performed in order to achieve consistent and predictable post-operative outcomes and also be aware of all the possible complications.

Novel adaptation of a running suture technique in a mouse model of corneal transplantation.

Several murine models of corneal transplantation have been developed over the years to study the immunopathological processes that lead to the failure of grafted corneas. In all of them, the classic eight interrupted sutures technique is utilized for transplanting the donor cornea on the host bed. However, in clinical practice, a single continuous suture with a single knot is generally performed for corneal transplantation. Here, we describe the adaptation of the single continuous suture technique in a mouse model of corneal transplantation.

Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage. METHODS: After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked by performing the Valsalva maneuver at the end of the surgery. RESULTS: No CSF leakages were observed after surgery. CONCLUSIONS: Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might be effective in cases with untraumatized arachnoid membrane.

Single loop interrupted suture technique for cerebrovascular anastomosis: Technical note.

The ideal suturing technique for cerebrovascular anastomosis remains a point of debate. Although simple interrupted sutures are considered to achieve higher patency, they require longer anastomosis time compared with running sutures. The authors describe a novel techniques named single loop interrupted suture to place interrupted sutures for cerebrovascular anastomosis. The single loop interrupted suture technique consists of repeatedly placing, tying and cutting a single loop between anchor stitches. A single loose loop was placed next to the anchor stitch, tied and cut, and then another loop was placed next to the knot. The loops resulted in efficiently placed interrupted sutures. This technique is employed for a range of end-to-side cerebrovascular anastomosis procedures, and is feasible in placing interrupted suture.

Correction of inverted nipples with the double-track sun-cross running suture technique.

Various techniques have been reported for correcting inverted nipples; however, problems such as incomplete correction, recurrence, scarring and nerve or duct injury persist. To minimise the recurrence rate and reliably attain a well-projected nipple, we developed a technique involving a single suture that runs through both the periphery and the core of the nipple. After the dissection and release of fibrotic connective tissue, an absorbable monofilament suture was passed through the periphery and core to leave double tracks of the suture at all locations, creating the final shape of a cross inside a circle (resembling the sun-cross symbol). Finally, the suture was tied in a purse-string manner to push the nipple outward. We performed this surgery on 34 congenital cases, comprising 29 patients with bilateral inverted nipples, 5 patients with a unilateral inverted nipple and 12 patients with an acquired deformity. During a mean follow-up period of 22.4 months, all of the corrected nipples remained everted without reinvagination. We successfully corrected inverted nipples with the double-track sun-cross running suture technique, which provided long-lasting eversion and created an aesthetically pleasing nipple contour.

Video-assisted thoracoscopic diaphragm plication using a running suture technique is durable and effective.

OBJECTIVE: Surgeons have hesitated to adopt minimally invasive diaphragm plication techniques because of technical limitations rendering the procedure cumbersome or leading to early failure or reduced efficacy. We sought to demonstrate efficacy and durability of our thoracoscopic plication technique using a single running suture. METHODS: We retrospectively reviewed patients who underwent our technique for diaphragm plication since 2008. We used a single, buttressed, double-layered, to-and-fro running suture with additional plicating horizontal mattress sutures as needed. RESULTS: Eighteen patients underwent thoracoscopic plication from 2008 to 2015. There were no operative mortalities and 2 unrelated late deaths. Median hospital stay was 3 days (range, 1-12). Atrial fibrillation occurred in 1 patient (5.5%), pneumonia occurred in 2 patients (11%), reintubation occurred in 1 patient (5.5%), and ileus occurred in 1 patient (5.5%). Of 14 patients with complete follow-up, median follow-up was 29.4 months (range, 3.4-84.7). Significant increases between preoperative and postoperative pulmonary function tests (% predicted values) were found for mean forced expiratory volume in 1 second (73.5% ± 3.5% to 88.8% ± 4.5%, P = .002) and mean forced vital capacity (70.6% ± 3.5% to 82.3% ± 3.5%, P = .002). Preoperative mean Baseline Dyspnea Index was 8.1 ± 0.7. Mean Transitional Dyspnea Index 6 months postoperatively was 7.1 ± 0.6 (moderate to major improvement). Transitional Dyspnea Index at last contact (median 29.4 months postoperatively) was 7.2 ± 0.6 (P = .38). Compared with previously published results, this is at least equivalent. CONCLUSIONS: Thoracoscopic diaphragm plication with a running suture is safe and achieves excellent early and long-term improvements. This addresses technical challenges of tying multiple interrupted sutures by video-assisted thoracoscopic surgery without any apparent compromise to efficacy or durability.

Modified laparoscopic biliary enteric anastomosis procedure using handmade double-armed needles.

INTRODUCTION: Laparoscopic biliary enteric anastomosis (BEA) offers several advantages, including good visualization, which helps to overcome the compromised visual field resulting from the biliary tract being located on the right anterior side of the body at some distance from the surgical opening. Laparoscopic BEA, however, requires skillful manipulation of the forceps over a limited range to achieve optimal outcomes. Here we describe a modified and reorganized BEA technique that increases the simplicity and feasibility of the procedure. MATERIALS AND SURGICAL TECHNIQUES: After biliary tract surgery for benign diseases such as laparoscopic choledocholithotomy, handmade double-sided needles were used for BEA in 20 patients. First, one of the needles was placed at the right edge of the bile duct wall from the outside to the inside, while the other arm of the needle entered the right edge of the intestine from the outside to the inside. Next, continuous sutures were placed on the posterior wall with the needle that was placed on the intestine. Then, continuous sutures were placed on the anterior wall with a second needle. Finally, both threads were laparoscopically tied. DISCUSSION: This relatively simple and feasible method has demonstrated excellent results and will be beneficial in the clinical setting.