Absorbable Running Suture Research Articles

High rate of incisional hernia observed after mass closure of burst abdomen.

This study investigated the long-term development of incisional hernia after implementation of a standardized surgical treatment strategy for burst abdomen in abdominal midline incisions with a continuous mass closure technique. The study was a single-center, observational study evaluating all patients treated for burst abdomen between June 2014 and April 2019 with a long-term follow-up in October 2020. In June 2014, a standardized surgical treatment for burst abdomen involving a monofilament, slowly absorbable suture in a continuous mass-closure stitch with large bites of 3cm and small steps of 5mm was introduced. The occurrence of incisional hernia was investigated and defined as a radiological-, clinical-, or intraoperative finding of a hernia in the abdominal midline incision at follow-up. Ninety-four patients suffered from burst abdomen during the study period. Eighty patients were eligible for follow-up. The index surgery prior to burst abdomen was an emergency laparotomy in 78% (62/80) of the patients. Nineteen patients died within the first 30 postoperative days and 61 patients were available for further analysis. The long-term incisional hernia rate was 33% (20/61) with a median follow-up of 17months (min 4, max 67months). Standardized surgery for burst abdomen with a mass-closure technique using slow absorbable running suture results in high rates of long-term incisional hernias, comparable to the hernia rates reported in the literature among this group of patients.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined. This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations. From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P < 0.001). One patient in the mesh group required mesh removal because of deep infection. Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

Standardized Surgical Primary Repair for Burst Abdomen Reduces the Risk of Fascial Redehiscence.

To determine whether a standardized surgical primary repair for burst abdomen could lower the rate of fascial redehiscence. Burst abdomen after midline laparotomy is associated with increased morbidity and mortality. The surgical treatment is poorly investigated but known for a poor outcome with high rates of re-evisceration (redehiscence). This study was a single-center, interventional study comparing rates of fascial redehiscence after surgery for burst abdomen in a study cohort (July 2014-April 2019) to a historical cohort (January 2009-December 2013). A standardized surgical strategy was introduced for burst abdomen: The abdominal wall was closed using a slowly absorbable running suture in a mass closure technique with "large bites" of 3 cm in "small steps" of 5 mm, in an approximate wound-suture ratio of 1:10. Demographics, comorbidities, preceding type of surgery, and surgical technique were registered. The primary outcome was fascial redehiscence. The secondary outcome was 30- and 90-day mortality. The study included 186 patients with burst abdomen (92 patients in the historical cohort vs 94 patients in the study cohort). No difference in sex, performance status, comorbidity, or body mass index was found. In 77% of the historical cohort and 80% of the study cohort, burst abdomen occurred after emergency laparotomy (P = 0.664). The rate of redehiscence was reduced from 13% (12/92 patients) in the historical cohort to 4% (4/94 patients) in the study cohort (P = 0.033). There was no difference in 30- or 90-day mortality. Standardized surgical primary repair for burst abdomen reduced the rate of fascial redehiscence.

Prevention of Fascial Dehiscence with Onlay Prophylactic Mesh in Emergency Laparotomy: A Randomized Clinical Trial

Fascial dehiscence (FD) occurs in up to 14.9% of high-risk patients undergoing emergency laparotomy. Although prophylactic mesh can prevent FD, its use in emergency operations remains controversial. A prospective randomized clinical trial was conducted at the Hospital das Clínicas from Faculdade de Medicina da Universidade de São Paulo in Brazil. It was performed among high-risk patients, defined according to Rotterdam risk model, undergoing midline emergency laparotomy. The patients were randomized into the suture group (SG), with slowly absorbable running sutures placed with a 36-mm-long needle at a suture-to-wound length ratio of 4:1, and the prophylactic mesh group (PMG), with fascial closure as in the SG but reinforced with onlay polypropylene mesh. The primary end point was incidence of FD at 30 days post operation. We analyzed 115 patients; 52 and 63 were allocated to the SG and PMG, respectively. In all, 77.4% of the cases were for colorectal resection. FD occurred in 7 (13.5%) patients in the SG and none in the PMG (p= 0.003). There was no difference between the groups in number of patients with surgical site occurrence (SSO) or SSO requiring procedural intervention. However, some specific SSOs had higher incidences in the mesh group: surgical site infection (20.6% versus 7.7%; p= 0.05), seroma (19.0% versus 5.8%; p= 0.03), and nonhealing incisional wound (23.8% versus 5.8%; p= 0.008). Of SSOs in the PMG and SG, 92.3% and 73.3%, respectively, resolved spontaneously or with bedside interventions. Prophylactic onlay mesh reinforcement in emergency laparotomy is safe and prevents FD. Surgical site infection, seroma, and nonhealing incisional wound were more common in the mesh group, but associated with low morbidity within 30 days post operation.

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

The laparoscopic transabdominal preperitoneal approach requires peritoneal closure and technically skilled knotting. We have started to use a barbed running suturing device (V-Loc 180) without knotting for transabdominal preperitoneal repair of hernias. This study aimed to determine whether using V-Loc 180 was safe and shortened the time for laparoscopic peritoneal closure. Between December 2010 and February 2017, 3-0 V-Loc 180 and a multifilament absorbable running suture (3-0 Vicryl) were used for three-port transabdominal preperitoneal repair of inguinal hernia in 363 cases. Data including peritoneal closure time and the complications were retrospectively recorded. Factors identified as significantly prolonging the peritoneal closure time were the hernia side (P = 0.0269), the type of hernia (P = 0.001), the suture device used (P < 0.0001), and the surgeon's experience (P < 0.0001). Use of the barbed suture was associated with a significantly shorter peritoneal closure time than the multifilament suture (mean closure time: 10.2 and 12.7 min, respectively). While there were no postoperative complications in the barbed suture group, there were two cases (1.9%) of postoperative complications in the multifilament suture group (P = 0.0272). We demonstrated that the use of the barbed suturing device for laparoscopic peritoneal closure was safe and feasible.

Modified end-to-side double-layer open pancreaticogastrostomy after Whipple procedure: surgical tips for a safe anastomosis.

Pancreatic fistula (PF) remains the Achilles' heel of pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) appears to be associated with a lower risk of postoperative leak according to recent evidence. We started to fashion PG, especially in soft pancreas, modifying the original technique described by Bassi. At our institution, 105 PD procedures were carried out from January 2011 to December 2016; pancreatic-enteric continuity was restored by PG in 35 cases. Superior mesenteric/portal vein resection/reconstruction was necessary in three patients. A total of 34/35 patients underwent PG with an open anterior gastrostomy approach. Briefly, our double-layer PG anastomosis (illustrated by a video) starts with a posterior row of interrupted absorbable 4/0 monofilament sutures including the gastric serosa and the pancreatic capsule. It is essential to mobilize the left pancreas for 4-5cm and to shape the posterior gastrostomy shorter than the pancreatic stump. After a wide anterior auxiliary gastrostomy the pancreas is invaginated into the stomach and an interrupted row of sutures between the posterior gastric wall (full-thickness) and the body of the pancreatic stump is fashioned. The anterior gastrostomy is closed with an absorbable running suture. Finally, a further layer of sutures is applied over the posterior suture line between the gastric serosa and the pancreatic capsule. The 90-day postoperative mortality was nihil. No biliary leakage was detected and the overall PF rate was 11.4% (4/35) according to the ISGPF study group. Only one patient suffered a grade B PF (in this case, PG was carried out only through a posterior gastrostomy), whereas three patients had a minor (grade A) PF. Our modified PG proved to be safe and easy to perform, while it carried excellent outcomes even in the setting of soft pancreas. Despite the limited number of cases, such modified PG appears promising, particularly for pancreatic remnants at higher risk of PF.

V12-07 RECONSTRUCTION OF A SIXTEEN-CENTIMETER ANTERIOR URETHRAL STRICTURE: DOUBLE DORSAL BUCCAL MUCOSA GRAFT WITH THE ASOPA TECHNIQUE

You have accessJournal of UrologyReconstruction1 Apr 2016V12-07 RECONSTRUCTION OF A SIXTEEN-CENTIMETER ANTERIOR URETHRAL STRICTURE: DOUBLE DORSAL BUCCAL MUCOSA GRAFT WITH THE ASOPA TECHNIQUE Alvaro Saavedra, Alejandro Rojas, Jose Arenas, Laura Velarde, and Reynaldo Gomez Alvaro SaavedraAlvaro Saavedra More articles by this author , Alejandro RojasAlejandro Rojas More articles by this author , Jose ArenasJose Arenas More articles by this author , Laura VelardeLaura Velarde More articles by this author , and Reynaldo GomezReynaldo Gomez More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2133AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiple surgical techniques have been described for long segment anterior urethral strictures (LSAUS), including staged urethroplasty, dorsal buccal mucosa graft (DBMG), fasciocutaneous flap, perineal urethrostomy and flap plus graft. In 2001 Asopa et al. described a new technique for dorsal graft by exposing the stricture through a ventral urethrotomy and a wide midline incision of the urethral plate to acommodate the dorsal graft. Compared to DBMG a randomized study showed significantly less blood loss and less operative time for Asopa technique with a similar 2-year success rate over 85%. Theoretically, in this approach blood supply is better preserved. In addition, it has been claimed that it is easier to learn and may provide a better visualization of the diseased urethra. The aim of this video is to provide a detailed demonstration of the Asopa technique to solve a LSAUS which required a double sequential BMG graft METHODS A 60 year-old patient with long-standing lower urinary tract symptoms presented with acute urinary retention; urethral catheterization was impossible and a suprapubic cystostomy was placed. Urethrocystoscopy and retrograde urethrogram confirmed a LSAUS, with severe spongiofibrosis. Surgical Technique: A vertical perineal incision and midline splitting of the bulbospongiosum muscle allow for wide exposure of the corpus spongiosum. Urethroscopy was used to determine the distal end of spongiofibrosis. Then, a ventral urethrotomy along penile and bulbar urethra is performed until healthy urethra is found. A deep midline dorsal urethrotomy is done dissecting urethral plate with an ophthalmic scalpel in order to accommodate a double tandem BMG affixed to the underlying corpus cavernosum with absorbable running sutures. Interrupted stitches are placed in the midline to facilitate graft take. A 16F urethral catheter is placed and standard closure by layers is performed using running sutures RESULTS Operative time was 173 minutes and blood loss was 200cc. Total stricture length was 16 cm. Patient was discharged on the 4th postoperative day with a suprapubic tube and a silicone urethral catheter. There were no postoperative complications. Pericatheter retrograde urethrogram at 3 weeks showed minimal extravasation so urethral catheter was removed. Cystostomy was left one more week and then removed. Six months after surgery his AUA-IPSS questionnaire was 5 and Qmax was 17 ml/sec CONCLUSIONS For LSAUS, the Asopa technique appears to be a reproducible, safe and effective choice to be considered in these complex cases © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1068 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alvaro Saavedra More articles by this author Alejandro Rojas More articles by this author Jose Arenas More articles by this author Laura Velarde More articles by this author Reynaldo Gomez More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Single Running Suture versus Single-Knot Running Suture for Vesicourethral Anastomosis in Laparoscopic Radical Prostatectomy: A Prospective Randomised Comparative Study

Aim: To investigate the safety, surgical efficiency and patients' ability to recover from urinary continence as a result of a single absorbable running suture versus single-knot running suture for vesicourethral anastomosis (VUA) during laparoscopic radical prostatectomy (LRP). Material and Methods: In a prospective randomised study, we evaluated 162 consecutive patients who underwent LRP with VUA using the single running suture technique or the single-knot running suture technique. Perioperative patients' characteristics, morbidity and urinary continence were analysed. Results: The baseline characteristics were similar between the 2 groups. The single running suture technique was related to decreased anastomotic and total operative times compared with the Van Velthoven technique (13.17 ± 5.74 min vs. 28.49 ± 6.45 min, p = 0.0001, and 174.41 ± 62.97 min and 184.94 ± 46.16 min, p = 0.04, respectively). Overall, urinary continence rates at 3, 6 and 12 months in groups 1 and 2 were 49.4 and 69.1%, 81.5 and 86.4%, and 91.4 and 93.8%, respectively (all with p > 0.05 except the follow-up assessment at 3 months following surgery, p = 0.011). Conclusions: Both methods ensure satisfactory rates of urinary leakage and bladder neck stricture, as well as continence after LRP. However, since the single running suture VUA technique is easier to perform, and the mean anastomosis time of the single running suture VUA technique is shorter than that of the Van Velthoven technique, it appears, therefore, preferable.

Outcome of Living Related Renal Grafts With Multiple Arteries -A Single Center Experience From a Developing Country.

Purpose: This study report the outcome of renal allograft with multiple arteries and the complication encountered in a developing country setting. Material & Method: Between 1995 and 2012, 3442 live related transplant were performed at our center. Of these 256 had multiple arteries. Implantation was by double barrel with side to side anastomosis using 7/0 non absorbable running sutures. In some cases end to side anastomosis was performed. Most of the graft renal arteries were anastomised with external iliac artery in end to side fashion using 6/0 non-absorbable running sutures. Ureter was anastomised with urinary bladder in extravesical Lich-Gregoir Technique. DJ stents were placed in some cases. All patients received a cyclosporine based triple during regimen. The outcome of recipients with multiple arteries grafts were compared with age, gender and transplant period matched controls with single vessels transplanted in the same period. Results: of the 3442 live related transplants 256 (7.5%) graft had multiple arteries. The mean age of the recipient was 29.6 + 9.7 with a M:F ratio of 3.4:1. Of the 256 grafts 241 (94%) had double, 14 (5.4%) triple and 1 (0.4%) five vessels. Delayed graft function was observed in 35 (13.6%). Complications were encountered in 6 (2.3%). Re-exploration in 2, re-implantation of ureter in 2, re-implantation in 1 and primary non function in 1. Acute rejection rates were 13% in multiple artery cased vs 11% in controls. One and five year graft survival in multiple artery cases was 96% and 85% vs 96% and 83% respectively in controls. Conclusion: The outcome of graft with multiple arteries was similar to the control group with single artery. The presence of multiple renal arteries in kidney grafts should not be considered a risk factor for graft outcomes.

Quill Barbed Sutures in Body Contouring Surgery: A 6-Year Comparison With Running Absorbable Braided Sutures

Body contouring operations are concluded with suture closure of long incisions under tension. While an expeditious and secure repair without complications is the objective, wound closure typically consumes a substantial percentage of the operative time and too often leads to delayed wound healing and other problems. The authors evaluate suture-line wound healing for body contouring operations with barbed suture wound closure compared with absorbable running suture closure. In this retrospective study, wound-healing complications for a 228 consecutive-patient cohort with barbed sutures over a period of 4 years were compared with those for a prior 132 consecutive-patient cohort with absorbable running sutures over a period of 2 years. Complications were classified according to severity: grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The preferred suture techniques for the closure of either thick or thin subcutaneous tissue under tension are described. The authors' clinical impressions are also presented. Patients whose wounds were closed with absorbable running sutures had a significantly greater incidence of complications at all severity grades of severity than did those with barbed suture closures, with the exception of grade 3 (severe) complications in thighplasty. Logistical regression was <1, and the confidence interval was also <1, in support of these results. Proper barbed suture selection and 2-layer technique led to a statistically significant lower rate of wound-healing complications as compared with prior experience with traditional running braided absorbable sutures. Other benefits were more rapid speed of closure, adequate security of the wound closure, and increased surgeon satisfaction. 3.

SMALL BOWEL LAPAROSCOPIC RESECTION FOR STRANGULATED UMBILICAL HERNIA

BMI of 51.3 kg/m 2 . A laparoscopic approach was performed; the exploration confirmed the strangulated umbilical hernia containing small bowel. Kelotomy was necessary to reduce the small bowel. Given the ischemic injuries of the herniated small bowel segment, the resection with side-to-side stapled anastomosis was then performed. The hernia sac was also resected. The parietal defect was then closed by conventional non absorbable running suture. The postoperative course was uneventful and the patient was discharged in the 4 th postoperative day. CONCLUSION: Even the laparoscopic small bowel resection for strangulated hernia is controversial the technique is feasible and safe in obese patients and could avoid operative site infection.

Gastrointestinal stromal tumor: Our experience

Gastrointestinal stromal tumor: Our experience

1394 TECHNICAL RAY OF HOPE IN THE CONTEXT OF MINIMALLY INVASIVE URINARY DIVERSION: SEWING WITH THE PROTOTYPE DEVICE ENDOSEW® - RESULTS OF AN INTRAOPERATIVE HUMAN PILOT SERIES

You have accessJournal of UrologyTechnology & Instruments: Robotics - Malignant Disease & Benign Disease II1 Apr 20121394 TECHNICAL RAY OF HOPE IN THE CONTEXT OF MINIMALLY INVASIVE URINARY DIVERSION: SEWING WITH THE PROTOTYPE DEVICE ENDOSEW® - RESULTS OF AN INTRAOPERATIVE HUMAN PILOT SERIES Beat Roth, Frederic D. Birkhaeuser, George N. Thalmann, and Pascal Zehnder Beat RothBeat Roth Bern, Switzerland More articles by this author , Frederic D. BirkhaeuserFrederic D. Birkhaeuser Bern, Switzerland More articles by this author , George N. ThalmannGeorge N. Thalmann Bern, Switzerland More articles by this author , and Pascal ZehnderPascal Zehnder Bern, Switzerland More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1843AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Minimally invasive cystectomy is rapidly developing. However, complete intracorporeal confection of the urinary diversion remains challenging. Therefore, stapler devices are widely used to facilitate the reconstructive part of the procedure despite the known risk of infections and stone formation. Our goal was to evaluate feasibility and safety of an absorbable running suture for ileal conduits using the prototype sewing device EndoSew®. METHODS Consecutive series of 10 patients scheduled for urinary diversion with an ileal conduit. In order to close the proximal end of the resected bowel segment an extracorporeal running suture (Vicryl 3-0) was performed with the use of the prototype device EndoSew®. Feasibility and time requirements of the procedure were analyzed as were the number of stitches and length of suture line. Water tightness of the suture line was assessed with methylene blue intraoperatively and with loopographies on postoperative day 7 and 14. Technical requirements and complications were recorded as were overall and intervention specific complications occurring within 30d following surgery. RESULTS A complete running suture with EndoSew® was feasible in all but 1 patient (90%). Median suturing time was 5.5min (range:3-10), median suture length was 4.5cm (range:2-5.5). In three patients, an additional single freehand stitch was needed at the beginning and/or the end of the suture line in order to anchor the running machine thread. In one patient, suturing with the device had to be abandoned due to a mechanical problem after 50% of the suturing distance. Finally, all conduits were watertight at any time. No suture related complications were observed. CONCLUSIONS We present the first consecutive series of patients undergoing urinary diversion with an ileal conduit using the sewing device prototype EndoSew®. The procedure per se is feasible and safe. All sutures were watertight. Therefore, EndoSew® has the potential to facilitate the intracorporeal confection of the urinary diversion. However, technical refinements are necessary. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e566 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Beat Roth Bern, Switzerland More articles by this author Frederic D. Birkhaeuser Bern, Switzerland More articles by this author George N. Thalmann Bern, Switzerland More articles by this author Pascal Zehnder Bern, Switzerland More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Single-Incision Transumbilical Laparo-Endoscopic Gastric Benign Tumor Resection

The authors report resection of a gastric benign tumor through single-incision laparoscopy, guided by peroperative gastroscopy. VIDEO: A 25-year-old man consulted after diagnosis of a 40 × 20 cm(2) endoluminal lesion of the gastric cardia. Preoperative work-up showed a stromal tumor with invasion of the muscular layer. The umbilical scar was incised and, after placement of a purse-string suture, an 11-mm nondisposable trocar was inserted for a 10-mm 30° angled scope. Curved and reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) and straight ultrasonic shears (Ethicon Endosurgery, Cincinnati, OH, US) were inserted transumbilically. Peroperative gastroscopy located the lesion on the smaller gastric curvature, 1 cm from the gastroesophageal junction. A stitch was placed in the center of the lesion, and gastroscopic grasper helped in maintaining the limits of resection. Gastrostomy was closed using two converting absorbable running sutures. Because of the curves of the instruments there was no conflict between the instruments' tips inside the abdomen (Fig. 1a), or between the surgeon's hands outside the abdomen (Fig. 1b). Leak test with the gastroscope checked the integrity of the suture. The specimen was retrieved transumbilically in a plastic bag. Operative time was 150 min, and the umbilical incision was less than 15 mm. The patient was discharged after 5 days, and he is doing well 3 months postoperatively. Laparoscopic gastric resection can be safely performed through a single-access. Peroperative gastroscopy permits the limits of resection to be precisely determine, and use of curved and reusable instruments allows surgeon to achieve ergonomic conditions as in classic laparoscopy, without increasing the laparoscopic cost.

Labia Majora Hypertrophy

A case involving hypertrophy of the labia majora is described. A married 34-year-old mother of a 5-year-old daughter reported that from adolescence, her large labia majora and its protuberance have resembled male genitalia even when she is wearing a slip. For that reason, in the summer, she is ashamed of her appearance and thus has avoided swimming pools and beach areas.With the patient in supine position, the crural creases were marked. The marks were drawn 1 cm apart medially in to the medial part of the labia majora parallel to the natural vulvar crease. The estimated amount of skin and fat to be removed was marked. In this case, more skin and fat needed to be removed from the left side than from the right side. The surgery was performed using sedation and local anesthesia as with outpatient surgery. To avoid excessive bleeding of this area, profuse infiltration was performed using 200 ml of anesthetic solution. Resection of the skin and fat in the area was performed with two hooks holding the area up to avoid introducing the scalpel too deeply.Only the superficial fat was removed. After meticulous hemostasia, two layers of 3/0 absorbable running sutures were placed, one in the deep fat and another in the subdermis,until the wound edges were approached. A 5/0 mononylon running suture closed the skin. These sutures provided strong support to all this very mobile area,avoiding dead spaces and bleeding because postoperative compressive bandages are difficult to hold in this region.The patient was instructed to wash the area four times a day. The surgery was ambulatory, with the patient returning to her province the day after surgery, then coming back for a control visit on postoperative day 10. On postoperative day 1, a moderate edema was observed but no hematoma. The stitches were removed on day 10 after surgery. The postoperative evolution of the case was uneventful. The sensitivity of the labia majora's interior aspect was preserved. With legs open, the labia majora closed the entrance to the vagina without showing the labia minora. A moderate edema was observed 4 weeks after surgery, and 6 months after surgery, the patient's external genitalia had reached a normal appearance. At 4 months after surgery, the scars were barely noticeable.

Airway complications after lung transplantation: risk factors, prevention and outcome☆

Anastomotic complications following lung transplantation (LuTx) have been described in up to 15% of patients. Challenging to treat, they are associated with high morbidity and a mortality rate of 2-5%. The aim of this study was to analyze the incidence of complications in a consecutive series of bronchial anastomosis after LuTx at our center and to delineate the potential risk factors. Between 1992 and 2007, 441 bronchial anastomoses were performed in 235 patients. Indications for transplantation were cystic fibrosis (35.7%) emphysema (28.1%) pulmonary fibrosis (12.8%) and pulmonary hypertension (7.7%). There were 206 sequential bilateral and 28 single transplants including lobar engraftments in 20 cases. The donor bronchus was shortened to the plane of the lobar carina including the medial wall of the intermediate bronchus. Peribronchial tissue was left untouched. Anastomosis was carried out using a continuous absorbable running suture (PDS 4/0) at the membranous and interrupted sutures at the cartilaginous part. Six elective surveillance bronchoscopies were done monthly during the first half-year post-LuTx, with detailed assessment of the pre- and post-anastomotic airways. One-year survival since 2000 was 90.5%. In all 441 anastomoses performed, no significant dehiscence was observed. In one patient, a small fistula was detected and closed surgically on postoperative day five. Fungal membranes were found in 50% of the anastomoses at 1 month and in 14% at 6 months. Discrete narrowing of the anastomotic lumen without need for intervention was found in 4.9% of patients at 1 month and in 2.4% at 6 months. Age, cytomegalovirus status, induction therapy, immunosuppressive regimen, ischemic time, and ventilation time had no influence on bronchial healing. Clinically relevant bronchial anastomotic complications after LuTx can be avoided by use of a simple standardized surgical technique. Aggressive antibiotic and antifungal therapy might play an important supportive role.

Evaluation of Renal Defect Healing, Hemostasis, and Urinary Fistula after Laparoscopic Partial Nephrectomy with Oxidized Cellulose

Laparoscopic partial nephrectomy (LPN) has been performed at several institutions using oxidized cellulose (OC) as a means of bleeding and urinary fistula (UF) prevention. However, a foreign-body reaction mimicking either abscess or tumor recurrence has been associated with the use of OC. We evaluated renal-defect healing after LPN with and without OC. Sixteen female Landrace pigs underwent lower-pole excision; all the collecting systems were entered and then closed with absorbable running suture. In group 1, hemostatic U-shaped stitches were the only method of hemostasis. In group 2, a bolster of OC was added to the renal defect. The pigs were sacrificed at 1, 4, 7, or 21 days, and gross findings such as perirenal collection were observed. A catheter was advanced up to the kidney, and methylene blue was injected with collecting system pressure observation; burst pressure was defined as the appearance of extravasation. High risk for UF was defined as burst pressure <10 mm Hg. Neither hemorrhage nor urinoma was observed during sacrifice. One pig from group 2 had a burst pressure of 4 mm Hg At 7 days (high risk for UF). At 21 days in group 2, the tissue was grossly solid, apparently a granuloma. Suppuration tended to be greater in group 2. The foreign-body reaction was more intense in group 2 and was strongly present at 4, 7, and 21 days. The use of OC is associated with higher scores of suppuration and foreign-body reaction. After LPN with OC, postoperative day 7 might be a critical time for the development of urinary leakage.

Total laparoscopic gastrocystoplasty: experimental technique in a porcine model

Describe a unique simplified experimental technique for total laparoscopic gastrocystoplasty in a porcine model. We performed laparoscopic gastrocystoplasty on 10 animals. The gastroepiploic arch was identified and carefully mobilized from its origin at the pylorus to the beginning of the previously demarcated gastric wedge. The gastric segment was resected with sharp dissection. Both gastric suturing and gastrovesical anastomosis were performed with absorbable running sutures. The complete procedure and stages of gastric dissection, gastric closure, and gastrovesical anastomosis were separately timed for each laparoscopic gastrocystoplasty. The end-result of the gastric suturing and the bladder augmentation were evaluated by fluoroscopy or endoscopy. Mean total operative time was 5.2 (range 3.5 - 8) hours: 84.5 (range 62 - 110) minutes for the gastric dissection, 56 (range 28 - 80) minutes for the gastric suturing, and 170.6 (range 70 to 200) minutes for the gastrovesical anastomosis. A cystogram showed a small leakage from the vesical anastomosis in the first two cases. No extravasation from gastric closure was observed in the postoperative gastrogram. Total laparoscopic gastrocystoplasty is a feasible but complex procedure that currently has limited clinical application. With the increasing use of laparoscopy in reconstructive surgery of the lower urinary tract, gastrocystoplasty may become an attractive option because of its potential advantages over techniques using small and large bowel segments.

Laparoscopic-assisted radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable titanium staples

Introduction Recently, nonabsorbable staples have been safely used in a variety of urologic open and laparoscopic extirpative and reconstructive procedures. We report the surgical steps of our technique of U-shaped orthotopic ileal neobladder created with titanium staples. Technical Considerations Using stay stitches, a 45 to 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and an afferent limb of 5 or 10 cm. An opening is made at the lowest point of the U-ileal segment on its antimesenteric border. The jaws of the 80 × 3.5-mm nonabsorbable mechanical stapler are accommodated within the bowel loop and fired twice, bringing together and detubularizing approximately 15 cm of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom of the chimney on its medial border. After this, a third nonabsorbable mechanical stapler had its jaws introduced through this opening and through the open end of the bowel segment on the right side and the stapler is fired, completing the U pouch. Subsequently, the open ends of the U segment and the opening made at the base of the afferent limb are closed with absorbable running sutures. Conclusions Our technique is feasible and may represent an alternative to expand the spectrum of continent urinary reservoirs that could be expeditiously created with nonabsorbable staples. Continued surveillance is mandatory to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.

Bidirectional glenn shunt without cardiopulmonary bypsss

Objective: The aim of this study is to review the experience of using bidirectional Glenn shunt without cardiopulmonary bypass(CPB). Methods: Fifty-eight patients underwent bidirectional Glenn shunt without CPB between May, 2000 and September, 2001. The age was (3.65±1.59) years and the weight was (13.6±4.0) kg. The procedure consists of establishing temporary bypass with cannulae placed in the SVC and right auricular appendage for venous drainage and transection of right SVC. The cardiac end of the SVC is overseen. The cranial end is anastomosed to a longitudinal incision in the superior margin of the right pulmonary artery with absorbable running suture. The anterior wall of the anastomosis is widened with pericardium patch. Results: There was no operative mortality. Five cases had postoperative complications including coma in 1 and chylothorax in 4. The mean SVC crossclamp time was (48±15) mins. The preoperative oxygen saturation and CVP were 0.75±0.09 and (12.8±2.3) mmHg, respectively. While the postoperative oxygen saturation and CVP were 0.93±0.05 and (16.5±2.9) mmHg, respectively. The drainage was (145±103)ml. The average mechanical ventilation time was (13±7) hrs. The mean postoperative hospital stay was (10±5) days. Conclusion: Bidirectional Glenn shunt without CPB is a safe and reliable method, for complicated congenital heart diseases children with inadequate pulmonary blood flow when anatomic and primary physiological correction are not suitable.