Additional Stitches Research Articles

Technical feasibility of endoscopic gastric reduction: a pilot study in a porcine model

Gastric restrictive procedures are widely used for the surgical treatment of morbid obesity. Our purpose was to determine the technical feasibility of endoscopic gastric reduction in a live porcine model. Acute experiments on 50-kg pigs under general anesthesia. After per-oral intubation, the endoscope was inserted into the stomach. A fishing line was sutured to the gastric wall along the fundus approximately 5 cm below the gastroesophageal junction with a prototype endoscopic suturing device (Olympus, Eagle Claw). Then the fishing line was tied to create a small proximal pouch. A flexible sheath was placed on one side of fishing line and additional knots were tied, forming a ring at the outlet of the gastric pouch. The ring was anchored to gastric wall with additional stitches, completing the gastric reduction. Then the animals were killed for postmortem examination. The feasibility of endoscopic gastric reduction. We performed 4 acute experiments. It required 12 to 14 stitches in each animal to create gastric reduction. There were no technical problems during the procedures. Postmortem examination demonstrated an approximately 30-mL gastric pouch separated from the rest of the stomach by the line of stitches. There were no complications during the procedure. We have not performed survival experiments to determine how long our gastric reduction will last. Endoscopic gastric reduction is technically feasible on a live porcine model.

Efficacy of Acrylate Tissue Adhesive as Vascular Repair and Hemostatic Material

The objective of the study was to determine the efficacy of utilizing n-butyl cyanoacrylate (NBCA) tissue adhesive glue as a vascular repair and hemostatic material in the closure of vascular wounds using a prospective, animal-based design. The study was performed on the carotid arteries of 22 goats. The experiment was performed on bilateral carotid arteries (44 procedures). In each animal, both carotid arteries were opened by a procedure simulating carotid endarterectomy. On one side, the repair material was conventional sutures; on the other side, NBCA tissue glue was utilized. The main outcome measures were duration of total flow arrest (clamping time), duration of time from start of arterial repair to complete hemostasis after clip removal (repair time), any additional stitches required after repairing either by stitch or by NBCA, and hematoxylin and eosin histopathology preparations. Forty-four simulated carotid endarterectomy and repair procedures were performed in 22 adult goats. The average repair time on the stitch side was 437 sec and on the NBCA side, 169 sec (P < 0.001). The average clamping time on the stitch side was 716 sec and on the NBCA side, 477 sec (P < 0.001). Macroscopic pathological study did not reveal any significant luminal stenosis. Foreign body microscopic changes were similarly present in both the NBCA and stitch groups, with no significant difference. This is a prospective animal-based controlled study looking into the efficacy of NBCA tissue glue as a material for arterial repair in comparison to classical suture repair. NBCA tissue adhesive glue may be of value especially when fast control of bleeding is required.

Use of Lowsley Tractor during Laparoscopic Prostatectomy to Reduce Urethrovesical Anastomotic Tension*

We describe a technique to reduce the tension on the urethra while performing the urethrovesical anastomosis during a laparoscopic radical prostatectomy. A Lowsley tractor is passed through the urethral stump, and a single traction stitch is placed in the posterior bladder neck. The first anastomotic stitch is placed through the urethra and bladder neck at the 6 o'clock position but not tied. The traction stitch is then grasped with the wings of the Lowsley and retracted into the urethra, bringing the bladder neck and urethral stump into close proximity. While maintaining traction on the bladder neck, the previously placed 6 o'clock suture is tied. Before releasing the traction stitch from the Lowsley tractor and bladder neck, two additional stitches are placed at the 4 and 8 o'clock positions, completing the posterior anastomosis. Grasping the traction stitch with the Lowsley tractor relieves tension on the posterior urethra and places it on the bladder neck. This prevents urethral tears and gaps in the posterior wall. The anterior portion of the urethra and bladder neck remains open, maintaining vision. Creating a secure posterior anastomosis allows the remaining sutures to be placed under minimal tension. This technique uses an instrument readily available in the urology operating room and facilitates completion of the difficult anastomosis under minimal tension, resulting in a high-quality anastomosis with fewer gaps.

A new approach for proximal anastomosis in type “a” acute aortic dissection: prosthesis eversion

One of the crucial aspects of surgical repair of type A aortic dissection is to achieve hemostasis of the anastomosis. Furthermore, the possibility of improving the suture with additional stitches is often technically demanding. We, therefore, describe a new surgical technique for the proximal anastomosis, positioning the prosthesis within the left ventricle. We present our series of 6 patients treated with this new technique. The immediate results confirmed the efficacy, speed, and simplicity of the technique. During long-term follow-up no patient showed significant residual aortic valve incompetence.

Assessment of an aortosaphenous vein graft anastomotic device in coronary surgery: Clinical experience and early angiographic results

Background Until now technologic evolution in coronary bypass surgery has focused on extracorporeal circulation, on operation without extracorporeal circulation, and on the exposure of the operative site. Recently a one-shot anastomotic device for the proximal anastomosis in coronary surgery was developed. We investigated whether the use of the aortic connector system (ACS) could facilitate the creation of aortosaphenous vein graft anastomoses in myocardial revascularization. Methods From November 2000, 40 ACS devices were used in 36 consecutive patients (mean age 70.7 ± 8.9 years); 12 patients (33.3%) underwent surgery on pump and 24 patients (66.6%) off pump; 50 distal anastomoses were performed. In all cases the connection with the ascending aorta was created before the distal anastomoses because of the necessity to slide the saphenous vein graft (SVG) over the vein transfer sheath. Intraoperative graft function was tested measuring blood flow by Doppler analysis. Postoperative evaluation of the anastomotic patency was carried out by early angiography in 34 patients (94.7%) but was excluded in 5 patients (5.3%) with extensive extracardiac vascular occlusive disease. Results Of 38 AC (95%) evaluated, 36 (94.7%) functioned properly. The end-to-side proximal anastomosis without aortic clamping is instantaneous, the quality of anastomoses was highly rated, no additional stitches were required, and all coronary arteries could be reached. Intraoperative quantity flow was measured by Doppler analysis and all but one showed good flow. Early postoperative angiography demonstrated good patency of the grafts in all cases but 2 (5.3%). At 1-year follow-up, 1 patient died of stroke; all other patients remained free of symptoms and no reoperation was required. Conclusions The use of ACS makes end-to-side anastomosis rapid, effective, and reproducible while eliminating aortic cross clamping; it opens a new era in beating or nonbeating coronary surgery. Long-term results are mandatory to confirm our favorable preliminary results.

The heartflo device for distal coronary anastomoses: clinical experiences in 60 patients

Background. The Heartflo anastomotic device automates the suturing process with simultaneous delivery of 10 standard polypropylene sutures through the graft and the coronary vessel wall to construct the anastomosis. We performed clinical testing in 60 patients undergoing coronary artery bypass grafting. Methods. One automated distal coronary anastomosis was initially placed in each patient, the other anastomoses were created with standard running sutures. After a “flat foot”-shaped prototype was deployed in 30 patients (group I), the design of the foot was modified and deployment of the new device performed in the next 30 patients (group II). Results. In group I, automated anastomoses were completed in 16 patients (53%) using 1.7 ± 1 additional stitches. In 26 group II patients (86%), a hemostatic anastomosis using 1.2 ± 1 additional stitches was achieved. Anastomoses were completed in 19.0 ± 3 minutes in group I and in 15.6 ± 2 minutes in group II. Conclusions. We have shown the feasability of coronary anastomoses using the Heartflo device. The modified version improved tissue capture, resulting in a higher rate of completed anastomoses. Because anastomotic time is still prolonged, an easier suture management is mandatory in the next developmental step.

Sutured coronary artery grafting utilizing the Heartflo anastomosis device--first clinical experiences.

The Heartflo device was developed to facilitate consistency in distal coronary anastomosis quality. The device automates the suturing process during the anastomosis procedure via simultaneous delivery of ten standard 7-0 polypropylene sutures through the graft and the coronary vessel wall. In 30 elective coronary artery bypass patients, one distal anastomosis was intentionally performed with the anastomosis device. Device success was stated if a patent anastomosis with a minimal flow of 50 ml/min resulted, additional stitches were counted if bleeding occurred. 4 cases of device failure occurred in the first 5 patients. The subsequent patients were operated without any mechanical problems. In 16 patients (53 %), a patent anastomosis with a mean flow of 75 +/- 6 ml/min using 1.7 +/- 0.3 additional stitches was achieved. Anastomoses were completed in 19.0 +/- 0.7 min; postoperative course was uneventful in all patients. We have shown that coronary anastomoses are feasible using the Heartflo device, representing a promising step on the way to automated coronary anastomoses. Its application is still limited by the size and tissue quality of the target vessel and difficult suture management during the anastomosis procedure.

Studies on the Influence of Through-the-Thickness Reinforcement on Low-Velocity and High Strain Rate Response of Woven S2-Glass/Vinyl Ester Composite

Due to their inherent weakness in the thickness direction, laminated fiber reinforced composites are susceptible to undergo large delamination damage as well as splitting when subjected to transverse loading and microbuckling under in-plane compressive loading. In the current work, an effort is made to improve the transverse strength by providing discrete 3D reinforcement in the form of pins and stitching the laminate in the thickness direction. The effectiveness of the 3D reinforcement is compared with 2D-Plain laminates. The laminates were made of 15 layers of 2 × 2 twill weave S2-glass fabric and vinyl ester C-50 resin system. Specimens of size 75 × 100mmwere subjected to low-velocity impact loading at energy levels of 20, 30 and 40 joules. The effectiveness of 3D-reinforcement to in-plane dynamic loading was studied using a Compression Split Hopkinson’s Pressure Bar at three different strain rates of 327/s, 436/s and 544/s using cubic samples of size 6.0mm. The stitched samples were subjected to high strain rate loading in two configurations. In the first, the sample (referred to as 3D-Stitch1) had stitching along the loading direction at the center while in the second; the sample (referred to as 3D-Stitch2) had an additional stitch line along the width at the center. The results of the study indicate that, reinforcement using stitching confines the delamination growth under low-velocity impact loading. Reinforcement in the form of pins did not show considerable improvement in the damage containment. However, under high strain rate compressive loading, 3D-Stitch1 and 3D-Pin reinforced laminates demonstrated higher compressive strengths at the strain rates of 327/s and 436/s. Stitch2 and 2D-Plain samples, in comparison, exhibited lower strength. Both 2D-Plain and 3D-Pin reinforced laminates exhibited increasing strength with the increase in the strain rate. Whereas, stitched laminates exhibited increase in strength from the strain rate of 327/s to 436/s before dropping in magnitude at 544/s. Thiswas attributed to the localized damage in the fabric due to piercing of the needle during stitching resulting in resin pooling.

An automated interrupted suturing device for coronary artery bypass grafting: automated coronary anastomosis

Background. The purpose of this study was to have a preliminary assessment of the safety and efficacy of an automated vascular suturing device. Methods. The device (Heartflo, Perclose/Abbott Labs, Redwood City, CA), which delivers 10 interrupted 7-0 polypropylene sutures between side-to-side arteriotomies, was evaluated in animals (8 Yorkshire pigs). Results. Tissue edge capture and quality of anastomosis were highly rated. Time of anastomoses averaged 22 minutes. This time was prolonged primarily due to suture management, tying of interrupted sutures, and learning curve effects. Six of the anastomoses were hemostatic and two required an additional stitch each. Angiography and histology of the anastomosis confirmed patency and quality of the anastomosis. Conclusions. Our preliminary results indicate that the Heartflo automated anastomotic device is safe and effective. Preclinical and clinical studies to validate its acute and long-term effectiveness will commence shortly.

Our experience in the treatment of the vesico-ureteral reflux with Lich-Gregoir antireflux surgical procedure.

In the period between January 1980 and December 1990 we had applied the operative Lich-Gregoir antireflux method on 166 patients, all of whom were children and adolescents, and performed 275 antireflux surgical procedures. The application of the above mentioned method on our patients yielded a success of 97.8%. There have been no intraoperative complications which would affect the ultimate successful result of this antireflux operative method. However, early postoperative complications occurred in two of our patients, causing infection of the wound, which resulted in further ureter stenoses. Recurrent reflux occurred in 4 (2.2%) and the stenoses also in other 4 (2.2%) operated ureters. The follow-up lasted from 4 up to 14 years. We added our personal detail to the original Lich-Gregoir antireflux method considering it to be a further improvement in achieving better results. We fixed the ureter to the detrusor with additional stitches in the newly formed hiatus, i.e. at the exit of the ureter out of the new submucous canal. The possibility of arousing postoperative paraostial diverticula is thus avoided, enabling us, at the same time, to enhance the newly formed ureteral hiatus in the detrusor. In this way the possibility of postoperative ureter stenoses is reduced. According to our experience the above mentioned antireflux method does not give good postoperative results in patients with greatly dilated and aperistaltic ureter (megacystis-megaureter type), while all other examples show a high percentage of postoperative success.

Tenonchirurgie bei Schieloperationen

There is a good chance to reduce the scaring between conjunctiva, Tenon's capsule, muscle and sclera after surgical treatment of rectus and oblique muscles if a careful reconstruction of Tenon's capsule is made. In the rare cases that you have to reoperate, you will experience the benefit of these additional stitches (7-0 vicryl) that restore the integrity of Tenon.

A new instrument for pulmonary resection: the bipolar Nd-YAG laser dissector.

A bipolar Nd-YAG laser dissector was developed to quickly dissect or resect organs, and the possibility of laser pulmonary dissection without scissors and ligation threads was studied experimentally. Pulmonary tissue was completely and easily divided using a bipolar laser handpiece, and the dissected edge was perfectly sealed. Leakage of air and blood from the edge was not induced and no additional stitching was required. Histological examination of the dissected edge revealed tissue remodeling after laser irradiation. The formation of amorphous layers, including vacuoles, was peculiar to the fusion-coagulation area, and alveolar atelectasis and capillary obstructions were characteristic of the degenerative area. When tissue dissection was performed by laser vaporazation, tissue remodeling seemed to be the most important factor in the prevention of leakage. In conclusion, we can effectively and quickly resect pulmonary tissue using the bipolar Nd-YAG laser dissector without scissors and without ligation threads.

Clinical evaluation on Le Duc-Camey antireflux ureteroileal implantation

Le Duc-Camey antireflux ureteroileal implantation was evaluated clinically; by applying to various types of urinary reconstruction utilizing the ileum. Nineteen ureters in 10 cases including five Kock continent ileal urinary reservoirs (Kock pouches); five ileal conduit urinary diversions and one Goodwin ileocystoplasty were performed from March 1987 to August 1988. Male and female ratio was 8 to 2 and the average age was 61.7 years old. The post operative observation period was 13.9 months on the average. The outline of the operative procedure was as follows: a 3 cm sulcus was created in the mucosa along the long axis of the ileum; the ureter was passed from the serosal surface to the luminal surface and the adventitia of the ureter and the mucosa were sutured at three points in each side using 3-0 absorbable ligature to implant the ureter in the mucosal sulcus. The ureteral end was spatulated 3 mm in the upper wall and it was fixed to the mucosa by three stitches. A ureteral stent catheter, 7-8 Fr. in diameter, was indwelled in the ureter. Additional stitches were placed to strengthen the fixation on the outside surface of Kock pouches or a Goodwin ileocystoplasty. The afferent limb was not fabricated in Kock pouches because ileoureteral reflux could be prevented by the implantation technique on the pouch. Radiological evaluation was done taking IVP, loopography, pouchgraphy and cytography periodically after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

手の外科治療における２，３の工夫

A little device sometimes brings good results in hand surgery. Some of our new devices are presented.1. Old unreduced dislocations of distal radioulnar joint. Bunnell and Liebolt stabilized the joint by free tendon, however good results were not obtained.Using sublimis tendon as a dynamic stabilizer, we obtained a good result.2. Nonunions of the scaphoid.Bone graft by Russe's method is commonly accepted. However in two cases because of small proximal fragment or radiocarpal osteoarthritis, we performed transposition of free tendon in defect of resected proximal scaphold and obtained good results.3. End to end suture of tendons.Tendon suture techniques were developed recently on the basis of intratendinous circulation.However in practice, incongruity or rotational malposition was often observed at anastomosis.So, we apply stay-sutures of 7/0 nylon bilaterally, then performed Tsuge's tendon suture.This simple device needs no additional stitches and makes the suture much easier.

The use of a quilting stitch for the repair of indirect inguinal hernia

The new repair is essentially a modification of the Halsted technic . A quilting type stitch (Fig. i) is placed in the medial edge of the internal ring and three additional stitches in the rest of the inguinal canal . This type of suturing approximates all the layers of the wall of the inguinal canal, including the peritoneum, thus providing a strong resistance against a recurrent indirect hernia, It is suitable in cases in which debility, senility, long-standing use of a truss or an extremely large hernia present a weak conjoined tendon and thinned out abdominal muscles in the wall of the inguinal canal . For such cases this repair has been used for a number of years in the Nankin Clinic with excellent results . Where the muscles of the abdominal wall are normal, however, the Halsted repair is used . The inguinal canals of ten cadavers, nine males and one female, ranging from forty to seventy years of age, were used in the experiment. The apparatus (Fig . 2) consisted of a single pulley and a strong malleable copper wire, one end of which was threaded through the inguinal canal and internal ring . A transverse incision was then made through the abdominal wall just inferior to the umbilicus . This permitted visualization of the internal ring and the end of the copper wire to which a stainless steel, bullet-shaped cone was attached . (Fig . 2.) At the other end of the copper wire weights were attached until the cone was puffed through the inguinal canal and the external inguinal ring . In this way an artificial indirect hernia resulted. Surprisingly enough, avulsion E VvER since the time of Halsted [3] and Bassini [r], numerous modifications of hernial repair have been devised. A new modification of the original Halsted repair has been devised which seals off the inguinal canal in those direct hernias where there is marked atrophy of the tissues ; it appears to he stronger than either the Bassini or Halsted repair . The method will be described and the technic applied for testing its strength . The recurrence rate is one of the clinical criteria used in evaluating repairs . According to Clear [a] a ten-year period of follow-up is required . This type of study is feasible when dealing with a select group of patients, such as veterans, since they usually return to a government institution more readily than do patients from the general population . As a result it becomes difficult to evaluate recurrence rates of follow-ups in non-government hospitals. Because of this difficulty it was decided to test the new type of repair in the laboratory using cadaver material . Although long clinical experience must be the ultimate test for any procedure, laboratory testing has the advantages that one can use as controls successive repairs on the same or opposite sides of the same cadaver . Furthermore, a cadaver is not subject to the extremely variable factors of activity, diet, emotional stress, disease, etc . Of course, such experiments arc designed to test only the strength of the repair and cannot be compared to the living individual in regards to intra-abdominal pressure, elasticity, or strength of tissues .