Broken Sutures Research Articles

Predictability of the Phenylephrine Test in Congenital Ptosis: Ten Years of Experience.

To assess the predictability of phenylephrine testing for congenital ptosis and review outcomes of Müller's Muscle-conjunctival resection (MMCR) for congenital ptosis across ten years of follow-up. In this retrospective case series, all patients who underwent MMCR for congenital ptosis at a single institution between 2010 and 2020 were identified. Exclusion criteria included patients who had not undergone preoperative testing with 2.5% phenylephrine in the superior fornix; patients who underwent revision surgery; and patients who had a broken suture in the early postoperative period. Demographics, margin-reflex distance 1 (MRD1) values pre- and postphenylephrine, millimeters of tissue resected intraoperatively, and final postoperative MRD1 were recorded. A total of 28 patients were included; 19 patients received MMCR and 9 patients received a combined MMCR plus tarsectomy. The amount of tissue resected ranged from 5 to 11 mm. There was no significant difference between median postphenylephrine MRD1 and median final postoperative MRD1 in either surgical group. Neither patient age nor levator function was significantly associated with a change in MRD1 in either group. The addition of a tarsectomy had no bearing on the final MRD1 value. MMCR is a viable option for patients with congenital ptosis and moderate levator function with a response to phenylephrine. In these patients, MRD1 after 2.5% phenylephrine testing correlates to the final postoperative MRD1 outcome within 0.5 mm.

Barbed Sutures for Total Hip and Knee Arthroplasty Have Shorter Wound Closure Time and are Cost-Effective in Comparison to Traditional Sutures: A Systematic Review and Meta-analysis of 16 Randomized Controlled Trials.

Surgical wound closure is of paramount importance, especially in total joint replacement surgeries wherein correct closure technique not only aids in rapid healing, but with lesser complications, we would be looking at a quicker rehabilitation of the patients. Bidirectional barbed sutures appear to reduce the wound closure time in all the planes and are cost-effective in comparison with traditional sutures. This study is aimed at evaluating the efficacy and superiority of bidirectional barbed sutures in comparison to traditional suturing techniques. Electronic databases like Embase, PubMed, Cochrane Library, Lilacs were searched up to February 2021. 16 high-quality randomized-controlled trials (RCT) were selected in this study. The search method identified 2168 total knee replacements (TKR) and 229 total hip replacements (THR) among 2397 patients. All the studies compared barbed sutures with traditional wound closure techniques. Data of wound closure time, overall cost, length of hospital stay, overall wound complications, suture-related complications, range of motion data, and knee society scores were collected and further analyzed. The baseline patient characteristics were identical among all the included studies. Compared to traditional sutures a significantly decreased wound closure time in both THR and TKRs (p < 0.00001) and cost (p < 0.00001) was noted, although no statistically significant difference was found in overall complications in THRs (p = 0.95) and TKRs (p = 0.69). ROM (p = 0.54-6weeks after surgery and p = 0.68-3months after surgery) and Knee society scores (p = 0.92) in both the groups of patients undergoing TKR. However, the length of hospital stay was prolonged in the barbed suture group (p = 0.01), pinpricks (p = 0.02), and broken sutures (p = 0.02). Novel methods of wound closure such as barbed sutures achieve satisfactory surgical implementation being more efficient in the form of decreasing the overall wound closure time, with comparable wound complication rates and being cost-effective. But the drawbacks like the incidence of broken sutures and pinpricks are more. Overall using barbed sutures in place of traditional sutures may be considered safe and a viable alternative choice for suturing in total joint replacements. Level I, Systematic review and Meta-analysis of RCT.

Outcomes of big-bubble deep anterior lamellar keratoplasty for pediatric keratoconus.

To evaluate the outcomes and complications of deep anterior lamellar keratoplasty (DALK) performed for pediatric keratoconus. This retrospective study enrolled 44 consecutive eyes of 39 keratoconus-affected children (≤ 18years of age). All patients underwent big-bubble DALK from March 2004 to June 2016. The outcome measures included postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction, keratometry readings, and complications. The mean participant age was 16.8 ± 1.4years, and the mean follow-up period was 68.5 ± 39.9months. Successful big bubble was achieved in 33 eyes (75.0%), while the surgical technique was predescemetic DALK in 11 (25.0%). The mean BSCVA changed from 1.34 ± 0.49 LogMAR preoperatively to 0.24 ± 0.10 LogMAR postoperatively (P < 0.001). The mean keratometry decreased from 59.54 ± 5.17D preoperatively to 46.23 ± 2.17D postoperatively (P < 0.001). The complications encountered during the study period were intraoperative Descemet's membrane perforation (n = 5, 11.4%), the Urrets Zavalia syndrome (n = 1, 2.3%), graft epithelial problems (n = 3, 6.8%), subepithelial graft rejection (n = 5, 11.4%), high intraocular pressure (n = 8, 18.2%), and traumatic wound dehiscence (n = 2, 4.6%). Suture-related complications included premature loosening (n = 13, 29.6%), broken sutures (n = 12, 27.3%), suture-tract vascularization (n = 6, 13.6%), suture-associated abscesses (n = 5, 11.4%), and suture cheese wiring (n = 2, 4.6%). A clear graft was found in 40 eyes (90.9%) at the last follow-up examination. This study showed promising results with big-bubble DALK in keratoconus-affected children. A frequent and close follow-up with dedicated parental involvement is essential for the early recognition and management of postoperative complications.

Efficacy and safety of barbed sutures in total hip arthroplasty and total knee arthroplasty: a meta-analysis

Objective: To appraise the clinical outcomes of barbed suture in closure of total hip and total knee arthroplasty. Methods: Databases (Web of Science, Embase, PubMed, Cochrane Controlled Trials Register,Cochrane Library,Highwire,China Biology Medicine disc (CBM), China National Knowledge Infrastructure (CNKI),VIP and Wanfang database) were searched for randomized controlled trials comparing barbed sutures and conventional sutures in total hip and total knee arthroplasty published before January, 2019. Finally, 11 articles (12 randomized controlled trials) involving 1 629 hips or knees were included in this study. The meta-analysis was performed using the Review Manager software. Results: Compared with conventional sutures,barbed sutures resulted in shorter total wound closure time (P<0.001), less ecchymosis and needle prick (both P<0.05).There was no significant differences in terms of wound related complications, superficial infection, stitch abscess, blister, exudation, broken sutures, range of motionand KSS between barbed sutures and conventional sutures(all P>0.05). Conclusions: Based on available level Ⅰ evidence, it indicated that knotless barbed suture maybe a better approach for wound closure in total hip and total knee arthroplasty.

Rescuing the host Descemet’s membrane in full-thickness traumatic wound dehiscence in deep anterior lamellar keratoplasty: intraoperative optical coherence tomography (iOCT)-guided technique

Optimal visual recovery following full-thickness traumatic wound dehiscence in a case of operated deep anterior lamellar keratoplasty (DALK) is rarely seen. Here we report a case of 22-year-old male patient...

Exophiala phaeomuriformis Fungal Keratitis: Case Report and In Vivo Confocal Microscopy Findings

Corneal infections, particularly fungal keratitis due to rare fungal species, pose a diagnostic and therapeutic challenge because of difficulty in identification and varying susceptibility profiles. In this study, we report the first case of fungal keratitis because of Exophiala phaeomuriformis. We report the clinical findings and microbial identification techniques of a case of fungal keratitis due to E. phaeomuriformis. An 84-year-old woman presented with redness, pain, and itching in the left eye for 2 weeks. Slit-lamp biomicroscopy revealed one broken suture from previous penetrating keratoplasty (PKP), black infiltrates at the 4-o'clock position, without an overlying epithelial defect and hypopyon. Microbial identification was based cultures on Sabouraud dextrose agar and DNA sequencing and correlations to laser in vivo confocal microscopy (IVCM; Heidelberg Retinal Tomograph 3/Rostock Cornea Module, Heidelberg Engineering) and multiphoton microscopy (Ultima Microscope; Prairie Technologies) images. Slit-lamp biomicroscopy revealed one broken suture from previous PKP, black infiltrates at the 4-o'clock position, without an overlying epithelial defect and hypopyon. Based on a clinical suspicion of fungal keratitis, antifungals and fortified antibiotics were started. However, the patient did not respond to therapy and required urgent PKP. After surgery, the patient was maintained on topical and systemic voriconazole and also topical 2% cyclosporine for 5 months because of possibility of scleral involvement noticed during surgery. At the end of the treatment period, her vision improved from hand motion to 20/40, with no recurrence observed in a follow-up period of 1 year. Results of diagnostic tests were supported by fungal elements in stroma on IVCM. Culture from the infiltrate grew black yeast. DNA sequencing led to the diagnosis of E. phaeomuriformis keratitis. Antifungal susceptibility testing revealed sensitivity to voriconazole. This is, to our knowledge, the first reported case of E. phaeomuriformis fungal keratitis. Diagnostic testing included slit-lamp biomicroscopy, which revealed pigmented infiltrates, culture plates grew black yeast, microscopy showed branched fungal hyphae with budding conidia, and physiological features showed tolerance to high temperatures, nitrate assimilation, and ribosomal DNA sequencing. Collectively, these tests demonstrate unique features seen for this microorganism. High suspicion should be kept with pigmented infiltrates and with dark yeast on culture plates. Prompt and aggressive medical management with voriconazole or therapeutic PKP in nonresponsive cases is essential to prevent irreversible loss of vision.

Recurrence mechanisms after inguinal hernia repair by the Onstep technique: a case series

Inguinal hernia repairs should have few complications and a short learning curve. A new operation called Onstep has promising results, but still some recurrences. The aim of the study was to find reasons for recurrence, by studying the re-operations. The study is a case series, where 565 patients operated with Onstep at six hospitals between December 2011 and April 2015 were identified. If a recurrence had occurred, the description of the re-operation was studied and compared to the primary Onstep operation. We found 26 inguinal hernia recurrences, giving a recurrence rate of 4.6%. The reasons for recurrence were a cranial displacement of the mesh in five patients, a caudal displacement in three patients, a folded mesh in one patient, and broken sutures in the mesh laterally in six patients. We found indications of a learning curve, since 70% of the recurrences had their primary operation among the first half of the total Onstep procedures. Another finding was that 30 patients had complaints from the ring in the mesh, and most of these patients were slender. Fifteen patients have had the ring removed, and for six patients with a follow-up, the complaints have been reduced or disappeared. The main reasons for recurrence may be broken sutures in the mesh laterally or a suboptimal size of the opening in fascia transversalis medially, enabling the mesh to displace. Furthermore, the results suggest a learning curve. These findings may guide further improvement in the Onstep method for inguinal hernia repair.

A case of suture-related bacterial keratitis and its treatment with topical imipenem

Risk factors for the development of corneal infection include loose or broken sutures, corticosteroid use, persistent epithelial defects, contact lens use, keratoconjunctivitis sicca, and a history of herpes simplex virus keratitis. Most of the data regarding suture-related keratitis come from literature on penetrating keratoplasty [1]. However, suture-related keratitis following cataract surgery appears to be a rare event [2]. The treatment of bacterial keratitis in patients with or without sutures is similar. In the treatment of serious suture-related corneal infections, topical fortified antibiotic combinations like vancomycin (50 mg/mL) and gentamicin (14 mg/mL) [3] or ceftazidime (50 mg/mL) and vancomycin (50 mg/mL) [3] have been used successfully. However, despite intensive topical, subconjunctival, and systemic antibiotics, corneal perforation can develop [2]. Therefore, selection of the appropriate agent and treatment planning are important for treatment of corneal infections. A beta-lactam antibiotic, imipenem, has often been used systemically and as an intravitreal therapy. However, no study has reported the topical use of imipenem as a monotherapy in the treatment of bacterial keratitis in patients with or without corneal sutures. This report presents the treatment of corneal infection with topical imipenem (50 mg/mL) as monotherapy in a patient who developed an infectious corneal complication due to a broken corneal suture after extracapsular cataract extraction with posterior chamber intraocular lens implantation.

Performance assessment of surgical residents in a vascular anastomosis laboratory

Introduction We designed a low cost workshop to teach surgical residents basic skills of vascular anastomosis. We studied our ability to differentiate between novice, proficient individuals and experts using objective measures of performance. Methods Ten PGY-2 residents without prior vascular surgery experience (novice) and four attending surgeons (expert) performed end-to-side anastomosis using synthetic graft. Residents were taught basic skills of vascular anastomosis during three didactic workshops. Objective metrics included volume leaked after saline perfusion (leak) and time to complete the anastomosis. Penalty points were assigned for broken sutures, air knots, locking sutures and failure to maintain an outside-in to inside-out technique. Leak, time and penalties before and after training were compared. Results Mean leak for the novice group was 70.4mL ±13.7 and mean completion time was 18.7 ±3 minutes versus 45.3mL ±10.6 (p Conclusions We report a low cost workshop for teaching surgical residents the basic skills of performing vascular anastomosis. A simple, objective scoring system is described that can differentiate between a novice, a person who is proficient and an expert at performing vascular anastomosis.

Orbitomalar Suspension During High SMAS Facelift

Traditional facelift techniques have some limitations: superficial musculo-aponeurotic system (SMAS) dissection may be incomplete in the superior medial orbitomalar region, and the centrofacial approach does not incorporate SMAS elevation. Orbitomalar suspension (OMS) during high SMAS facelift combines the best of other techniques and may enhance aesthetic results and improve blending of the eyelid-cheek junction while minimizing the risk of lower eyelid ectropion. The authors examine the efficacy and complication rates of the OMS procedure. Sixty patients underwent OMS as a primary component of high SMAS facelift and lower blepharoplasty. The technique is designed to accomplish superior-medial repositioning of the cheek while stabilizing lower eyelid position, reducing the risk of postoperative ectropion. Minor complications related to the OMS procedure occurred in three patients, all of whom had palpable and slightly visible Vicryl knots on one or both lateral upper eyelids. In one patient, the right side was reopened with a limited incision and the knot was removed. One case of lower eyelid malposition occurred and required revision. This patient presented on day three with unilateral left ectropion (2 mm), but the broken suture was easily replaced under local anesthesia, and the patient had no further ectropion. Two patients had transient lower eyelid malposition, which resolved within four weeks of surgery after gentle massage and lateral eyelid support with steri-strips. Two patients with prominent eyes and inferior orbital rim recession (negative vector) were not fully corrected; however, their lid position was no worse than the preoperative position and curvature. OMS during high SMAS facelift complements the deeper plane by adding a medial and superior vector of elevation to the cheek. Blending of the lower eyelid-cheek junction is accomplished with little risk of lower eyelid malposition.

Corneal oedema after cataract surgery: predisposing factors and corneal graft outcome

Pseudophakic bullous keratopathy (PBK) is one of the main indications for corneal transplantation. Graft survival and visual outcome in this group are often poorer than for other indications. The aim of this study was to find risk factors for developing corneal oedema after cataract surgery and factors that influence the subsequent survival of the graft and the visual outcome. We carried out an observational, retrospective cohort study using data from the Swedish Cornea Transplant Register and patient medical records. A total of 273 patients whose indication for corneal transplantation was corneal oedema after cataract surgery were included in the study. Multiple logistic regression analysis and, where appropriate, univariate analyses were applied. A total of 43% of the patients developed persistent corneal oedema immediately after cataract surgery, the main risk factors for which were phacoemulsification and pre-existing endothelial disease. Almost a third (32%) of the transplants for PBK failed within 2 years, for which rejection and other postoperative complications increased the risk. Half (50%) the patients had visual acuity < or = 0.1 at 2 years after keratoplasty. Comorbidity, increasing duration of the bullous keratopathy and increasing age affected the visual outcome negatively. Phacoemulsification was a risk factor for immediate persistent corneal oedema after cataract surgery, although it did not increase the overall risk of developing PBK. However, transplants for immediate PBK had a better survival rate than those for later onset PBK. Shorter duration of PBK and intraocular lens exchange at the time of penetrating keratoplasty increased the likelihood of good visual acuity.

Resuturing following penetrating keratoplasty: a retrospective analysis

Aim:To examine the clinical profile of cases requiring resuturing following penetrating keratoplasty (PKP) at a tertiary care eye hospital.Methods:The medical records of 947 consecutive patients who had undergone PKP between...

Prior Video Game Exposure Does Not Enhance Robotic Surgical Performance

Prior research has demonstrated that counterintuitive laparoscopic surgical skills are enhanced by experience with video games. A similar relation with robotic surgical skills has not been tested. The purpose of this study was to determine whether prior video-game experience enhances the acquisition of robotic surgical skills. A series of 242 preclinical medical students completed a self-reported video-game questionnaire detailing the frequency, duration, and peak playing time. The 10 students with the highest and lowest video-game exposure completed a follow-up questionnaire further quantifying video game, sports, musical instrument, and craft and hobby exposure. Each subject viewed a training video demonstrating the use of the da Vinci surgical robot in tying knots, followed by 3 minutes of proctored practice time. Subjects then tied knots for 5 minutes while an independent blinded observer recorded the number of knots tied, missed knots, frayed sutures, broken sutures, and mechanical errors. The mean playing time for the 10 game players was 15,136 total hours (range 5,840-30,000 hours). Video-game players tied fewer knots than nonplayers (5.8 v 9.0; P = 0.04). Subjects who had played sports for at least 4 years had fewer mechanical errors (P = 0.04), broke fewer sutures (P = 0.01), and committed fewer total errors (P = 0.01). Similarly, those playing musical instruments longer than 5 years missed fewer knots (P = 0.05). In the extremes of video-game experience tested in this study, game playing was inversely correlated with the ability to learn robotic suturing. This study suggests that advanced surgical skills such as robotic suturing may be learned more quickly by athletes and musicians. Prior extensive video-game exposure had a negative impact on robotic performance.

Corneal Wound Dehiscence After Penetrating Keratoplasty

To describe the clinical features of corneal wound dehiscence after penetrating keratoplasty (PK) after trauma and suture removal. A retrospective review of all eyes needing resuturing in the 5-year period of July 2000 to June 2005 was performed. In total, 76 eyes of 76 patients needed wound resuturing. The indications were early wound leak, wound dehiscence, broken suture, or loose suture. In 29 of the 76 cases, the indication for resuturing after PK was wound dehiscence. Of these, 19 were caused by trauma, and in 10 eyes, dehiscence shortly followed suture removal. The interval between original PK and traumatic wound dehiscence caused by trauma ranged from 15 days to 33 years. In 5 eyes, it was >15 years. Nine eyes (47%) with traumatic dehiscence had final visual acuity better than 6/60, whereas 8 eyes (80%) with suture removal dehiscence had final visual acuity better than 6/18. Most of the dehiscence in the traumatic group was located in the inferior 2 quadrants, in contrast to temporally in the postsuture removal group. The time interval between PK and suture removal in the postsuture removal group was 16 +/- 4 months, and 7 (70%) patients had a continuous suture. Post-suture removal dehiscence was more common when corneal edema was the indication for grafting. Eyes with traumatic wound dehiscence have worse visual outcome than those with dehiscence after suture removal. Patients should be cautioned about the risks and consequences of wound dehiscence. The suture may be left in place longer in older patients or when corneal edema is the indication for grafting.

Microbial Keratitis Following Corneal Transplantation

To study clinical and microbiologic characteristics of corneal infections following penetrating keratoplasty (PK). Retrospective case series. Medical records of patients who presented to Duke University Eye Center from January 1, 1999 to July 1, 2005 with microbial keratitis after PK were reviewed. Forty-four corneal graft infections were reviewed. Mean interval between PK and infection was 26.3 months. Associated conditions included broken or loose sutures (10, 22.7%) and topical corticosteroids (34, 77.3%). Staphylococcal (12, 20.7%) and Pseudomonal (7, 12.1%) species were common pathogens, and fungal species accounted for eight (18.2%) infections. Twelve patients (27.3%) had polymicrobial infections. Thirteen patients (29.5%) underwent repeat PK. Mean postinfection visual acuity at last follow-up was 20/400. Microbial infections within corneal grafts can occur anytime in the postoperative course and are associated with broken sutures and the use of topical corticosteroids. The diversity of pathogenic organisms, antibiotic resistance, and the potential for poor outcomes supports aggressive management of these infections.

Long-term Graft Survival in Patients with Down Syndrome after Penetrating Keratoplasty

To determine graft survival and long-term visual outcome after penetrating keratoplasty (PK) for keratoconus in patients with Down syndrome. The records of all patients with Down syndrome who received PK by the same provider were reviewed. A retrospective analysis was performed to determine long-term graft survival, incidence of graft failure, and complication rate. Twenty-one PKs were performed on 18 eyes of 13 patients with Down syndrome with keratoconus. Three repeat PKs were performed for secondary graft failure. All 18 eyes had clear grafts at the most recent examination. Follow-up ranged from 4 to 88 months, with a mean of 34.9 months. The average age of patients was 42 years, with a range of 20 to 63 years. Preoperative visual acuity ranged from 20/160 to count fingers. Postoperatively, visual acuity was objectively measurable in 12 eyes of 8 patients and ranged from 20/30 to 20/200, with a mean of 20/60. Broken sutures and difficulties with unsedated suture removal complicated postoperative care in some patients. Clear grafts and improvements in visual acuity can be obtained after PK in patients with Down syndrome, but consideration must be given to careful postoperative care by health care providers and home support personnel.

Risk Factors for the First Episode of Corneal Graft Rejection in Keratoconus

To evaluate the relationship between topical corticosteroids and other variables and the risk for rejection after penetrating keratoplasty for keratoconus. The records of all keratoconus patients who, after their first penetrating keratoplasty in that eye, experienced a first episode of corneal graft rejection during a specific 3-year period were retrospectively reviewed in a case-control fashion. Twenty-three cases were identified, and they were matched with 3 controls each, for a total of 69 controls and 92 total patients. Multiple variables including steroid potency, recent steroid tapering, and length of time on the current level of steroids were analyzed to see whether there were any significant relationships between postoperative changes in steroid management and rejection. In addition, other variables such as graft size, suture technique, recent suture removal, suture status at the time of the rejection episode, and prior grafting in the fellow eye were examined to determine if any of these factors were associated with a higher risk of graft rejection. Most of the proposed risk factors, including steroid dose and tapering, differing suturing techniques, loose and/or broken sutures at the time of rejection, percentage of sutures remaining at the time of rejection, and prior grafting in the fellow eye, did not correlate with the risk of rejection. Only graft size had a correlation, with host trephination size > or = 8.25 mm having a nearly sixfold increased risk of rejection (P = 0.015). Most patients (70%) were diagnosed with rejection at a scheduled office visit rather than at an emergency visit, and correspondingly, nearly one half (43%) had no symptoms when rejection was identified. There was no significant difference in final best-corrected visual acuities between the cases and controls, and 91% of the corneas that underwent rejection did not progress to graft failure, remaining centrally clear at most recent follow-up. In this study, the most important risk factor for rejection after corneal transplantation for keratoconus was the size of the graft. Physician detection of rejection is paramount, because a graft rejection episode is more often diagnosed at a scheduled office visit than at an emergency visit. Fortunately, progression to graft failure can usually be prevented if treatment is started promptly and intensively.

Comparison of Complication Rates and Postoperative Astigmatism Between Nylon and Mersilene Sutures for Corneal Transplants in Patients with Fuchs Endothelial Dystrophy

The purpose of this study is to evaluate corneal astigmatism and suture-related complications for transplants sutured with nylon and transplants sutured with Mersilene in primary corneal transplants for Fuchs endothelial dystrophy. A retrospective, observational, and comparative study between transplants sutured with either nylon 10-0 or 11-0 (n = 108) or Mersilene 11-0 (n = 58) was done. One hundred sixty-six eyes of 140 patients who received a primary penetrating keratoplasty for Fuchs endothelial dystrophy between 1995 and 2001 at the Rotterdam Eye Hospital in Netherlands were included. Overall, transplant survival did not differ between groups (log-rank test; P = 0.24). During the first 2 years after transplantation, significantly lower astigmatism was seen in transplants sutured with nylon (P = 0.03). Transplants sutured with Mersilene had a significantly higher risk of surgical intervention to correct astigmatism or wound dehiscence after transplantation (hazard ratio, 2.83; 95% confidence interval, 1.34-6.01). Time to first infiltrate, metaplasia (marked scarring along the sutures), or cheesewiring was significantly less in the Mersilene group (P < 0.01). There was a tendency toward a higher risk of complications associated with loose or broken sutures in the nylon group (hazard ratio, 2.00; 95% confidence interval, 0.57-6.98), which was more pronounced after 2 years. During the first years after corneal transplant surgery, Mersilene sutures are associated with a higher risk of complications and more interventions to correct suture-related problems. However, after 2 years, the grafts seem to be able to retain Mersilene sutures with less risk of suture-related complications as compared with grafts with retained nylon sutures. These favorable long-term effects of Mersilene sutures may outweigh its short-term disadvantage in patients with Fuchs endothelial dystrophy.

Comparison of Two-Dimensional and Three-Dimensional Suturing: Is There a Difference in a Robotic Surgery Setting?

Robotic surgery allows three-dimensional (3D) viewing of tissues. We compared two-dimensional (2D) and 3D suturing drills using the daVinci surgical system to determine if the latter is advantageous. Twenty-eight anastomotic drills were completed by seven surgeons using the daVinci robot. Three surgeons had considerable (>6 months) robotic experience, and four had none. Drills were performed randomly in both dimensional modes in a blinded fashion. Drill 1 was an interrupted four stitch and drill 2 a running closure. All tasks were kept uniform. We recorded time to completion, difficulty, and accuracy. The drills were evaluated by two independent reviewers for accuracy and major errors (i.e., broken suture, torn graft). The average operative time per drill in two dimensions was 13.1 minutes (range 6.9-21.9 minutes) and in three dimensions was 8.5 minutes (range 4.7-12.8 minutes) (P<0.001). Drill 1 was 6.1 minutes faster in three dimensions (mean 9.2 minutes; P<0.01), and drill 2 was 2.9 minutes faster (mean 7.8 minutes; P=0.03). Both advanced and novice groups were faster in 3D (P<0.01). There were two major errors in the 3D performances and 5 in the 2D exercises (P<0.05). The participants correctly identified the dimensional mode 92.9% of the time (P<0.01). The anastomosis was completed 65% faster using 3D with equal, if not greater, accuracy. Drill 1 was improved to a greater degree than drill 2, suggesting most benefit of 3D views during knot tying. Use of three dimensions outperformed two dimensions in both groups. Surgeons can immediately benefit from 3D viewing during robotic surgery.

Initial Evaluation of Robotic Technology for Microsurgical Vasovasostomy

Conventional microscope assisted vasovasostomy (MAVV) is a technically difficult procedure that is most successful in the hands of well-trained microsurgeons. Robotics may help surgeons overcome the microsurgical challenges of tremor, limited dexterity, miniaturized instrumentation and use of fine suture. We determine the feasibility of a robotic assisted vasovasostomy (RAVV) and compare performance measures with those of conventional MAVV. One surgeon performed 10 vasovasostomies with a modified 1-layer technique and 9-zero suture on fresh human vas specimens using the robot in 5 RAVV cases and standard microsurgical instrumentation in 5 MAVV cases. Pre-specified performance measures and adverse haptic events (broken sutures, bent needles or loose stitches) were recorded. Patency was evaluated by instilling saline through the anastomoses. Mean operating time and number of adverse haptic events were higher for RAVV than for MAVV (84 vs 38 minutes, p = 0.01; 2.4 vs 0.0 events, p = 0.03). The number of needle passes required for the 6 full-thickness stitches was similar in both groups (16.8 vs 15.2 passes, p = 0.55). Although no tremor occurred during RAVV, minimal to moderate amounts occurred during MAVV. Minimal fatigue was noted for both groups. Patency was confirmed in all 10 operations. Use of RAVV in this human ex vivo vas model was feasible. While RAVV took longer to perform and was associated with adverse haptic events, elimination of tremor and comparable patency rates suggest that it may be a viable surgical alternative for microsurgical vasovasostomy.