Suture Choice Research Articles

Safety and Efficacy of Smooth Surface Tissue Expander Breast Reconstruction.

Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation. The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction. The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated. A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction. STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.

Suture constructs for rehabilitation using early active motion after tendon transfer surgery.

The purpose of this study was to better define an ideal tendon transfer suture construct to allow for early active range of motion. A side-to-side tendon construct was used to test suture technique (cross stich vs. Krackow stitch), number of suture throws, and calibre of suture. A minimum load to failure of 100 N was used to comfortably allow early motion while minimizing rupture risk. All constructs tested, except the 4-0 Krackow construct, were strong enough to withstand 100 N of load. The choice of suture should be based on surgeon preference, patient compliance, and specific surgery, and 3-0 non-absorbable suture may be more suitable for tendon transfers from a yield force standpoint.

Absorbable versus non-absorbable sutures for skin closure after carpal tunnel decompression surgery.

Carpal tunnel syndrome is a common problem and surgical decompression of the carpal tunnel is the most effective treatment. After surgical decompression, the palmar skin may be closed using either absorbable or non-absorbable sutures. To date, there is conflicting evidence regarding the ideal suture material and this formed the rationale for our review. To assess the effects of absorbable versus non-absorbable sutures for skin closure after elective carpal tunnel decompression surgery in adults on postoperative pain, hand function, scar satisfaction, wound inflammation and adverse events. We searched the following databases on 30 October 2017: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two clinical trials registries on 30 October 2017. We considered all randomised or quasi-randomised controlled trials comparing absorbable and non-absorbable sutures for skin closure after any form of carpal tunnel decompression surgery in adults. The unit of analysis was the hand rather than the patient. We performed meta-analysis of direct comparisons to generate standardised mean differences (SMDs) with 95% confidence intervals (CIs) in pain scores and risk ratios (RRs) with 95% CIs for dichotomous outcomes, such as wound inflammation. The primary outcome was postoperative pain. Secondary outcomes included hand function, scar satisfaction, scar inflammation and adverse events (complications). We assessed the quality of evidence for key outcomes using GRADE. We included five randomised trials (255 participants). The trials were all European (UK, Republic of Ireland, Denmark and the Netherlands). Where quoted, the mean age of participants was between 48 and 53 years. The trials measured outcomes between one and 12 weeks postoperatively.Meta-analysis of postoperative pain scores for absorbable versus non-absorbable sutures at 10 days following open carpal tunnel decompression (OCTD) produced a SMD of 0.03 (95% CI -0.43 to 0.48; 3 studies, number of participants (N) = 137; I2 = 43%); the SMD suggests little or no difference, but with a high degree of uncertainty because of very low-quality evidence. At 10 days following endoscopic carpal tunnel decompression (ECTD), the SMD for postoperative pain with use of absorbable versus non-absorbable sutures was -0.81 (95% CI -1.36 to -0.25; 1 study; N = 54); although the SMD is consistent with a large effect, the very low-quality evidence means the results are very uncertain. Only the OCTD studies provided pain data at 6 weeks, when the SMD was 0.06 (95% CI -0.72 to 0.84; 4 studies; N = 175; I2 = 84%), which indicates little or no evidence of difference, but with a high degree of uncertainty (very low-quality evidence). The RR for wound inflammation using absorbable versus non-absorbable sutures after OCTD was 2.28 (95% CI 0.24 to 21.91; N = 95; I2 = 90%) and after ECTD 0.93 (95% CI 0.06 to 14.09; 1 study, N = 54). Any difference in effect on wound inflammation is uncertain because the quality of evidence is very low. One study reported postoperative hand function but found no evidence of a difference between suture types at two weeks (mean difference (MD) -0.10, 95% CI -0.53 to 0.33, N = 36), with similar findings at six and 12 weeks. Only the ECTD trial reported scar satisfaction, with 25 out of 28 people reporting a 'nice' result in the absorbable-suture group, versus 18 out of 26 in the group who received non-absorbable sutures (RR 1.29, 95% CI 0.97 to 1.72, N = 54). These findings are also very uncertain as we judged the quality of the evidence to be very low. All studies were at high risk of bias for most domains. No trials reported adverse events. It is uncertain whether absorbable sutures confer better, worse or equivalent outcomes compared to non-absorbable sutures following carpal tunnel decompression, because the quality of evidence is very low. Use of absorbable suture eliminates the need for suture removal, which could confer considerable savings to patients and healthcare providers alike. We need rigorously-performed, non-inferiority randomised trials with economic analyses to inform choice of suture.

A survey of current practices and influences on the choice of suture material, pattern and size used in commonly performed procedures in UK small animal veterinary practice

ObjectivesA survey of UK veterinarians was conducted to determine factors influencing suture choice and current suture practice for common surgical procedures.MethodsAn online survey was designed and the survey was sent...

Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model.

Open-label laboratory investigational study; non-animal surgical simulation. The authors perform a comparison of dural closure strength in a durotomy simulator across 2 different suture materials. Incidental durotomy leading to persistent cerebrospinal fluid leak adds considerable morbidity to spinal procedures, often complicating routine elective lumbar spinal procedures. Using an experimental durotomy simulation, the authors compare the strength of closure using Gore-Tex with other suture types and sizes, using various closure techniques. A comparison of dural closures was performed through an analysis of the peak pressure at which leakage occurred from a standardized durotomy closure in an established cerebrospinal fluid repair model with a premade L3 laminectomy. Nurolon was compared with Gore-Tex sutures sizes (for Gore-Tex, CV-6/5-0 and CV-5/4-0 was compared with Nurolon 4-0, 5-0, and 6-0). Thirty-six trials were performed with Nurolon 4-0, 5-0, and 6-0, whereas 21 trials were performed for 4-0 and 5-0 Gore-Tex. The mean peak pressure at which fluid leakage was observed was 21 cm H2O for Nurolon and 34 cm H2O for Gore-Tex. Irrespective of suture choice, all trials were grouped by closure technique: running suture, locked continuous, and interrupted suture. No significant difference was noted between the groups. For each of the 3 trials groups by closure technique, running, locked continuous, and interrupted, Gore-Tex closures had a significantly higher peak pressure to failure. Interrupted Gore-Tex was significantly higher than Interrupted Nurolon (P=0.007), running Gore-Tex was significantly higher than running Nurolon (P=0.034), and locked Gore-Tex was significantly higher than locked Nurolon (P=0.014). Durotomy closure in the lumbar spine with Gore-Tex suture may be a reasonable option for providing a watertight closure. In this laboratory study, Gore-Tex suture provided watertight dural closures that withstood higher peak pressures.

Spotlight on … gynaecological surgery

Obstetrics and gynaecology has always been a popular career choice. The fact that one can develop a significant surgical interest is cited as one of the many reasons for its popularity. The editor (a very persuasive man!) asked me to write a review of past TOG publications dealing with gynaecological surgery. Readers who practice pure obstetrics will also find something of interest and education in some of the following highlighted papers. The days of ‘see one, do one, teach one’ have gone. Training has to be more focused and structured. Bisson et al. (TOG 2006;8:107−12) drew attention to the then newly introduced tools for trainee assessment (objective structured assessment of technical skills [OSATS]) and the research that underpins their usefulness. Simulation training shortens the learning curve and Ramsey-Marcelle et al. (TOG 2011;13:253−7) explained how to do it and the importance of the choice of facilitators. If we understand the basis of acquiring psychomotor skills we would be better equipped to teach them. White et al. (TOG 2016;18:53−63) explained the theory and practicalities of teaching laparoscopic surgical skills. Open surgery (including caesarean section) will always be required, though is difficult to simulate. An article on how best to teach open surgery would be interesting. Raghavan et al. (TOG 2014;16:13−18) reviewed abdominal incisions and suture choice, an area previously covered by Hogston (TOG 2001;3:127−31), who also described the factors that affect tissue healing. Aslam and Moran (TOG 2014;16:161−8) reviewed the indications for catheter use in gynaecology and Foon et al. (TOG 2006;8:78−85) discussed the technique and indications for cystoscopy. Laparoscopic surgery is a quantum leap, though is associated with surgeon fatigue and physical strain. Quinn and Moohan (TOG 2015;17:77−82) provided useful tips regarding ergonomics in the laparoscopic operating theatre. Torbé et al. (TOG 2013;15:263−8) described how enhanced recovery is good for the patient and the hospital. All these areas are poorly covered in our teaching and these papers should be compulsory reading for all trainees. Heavy menstrual bleeding is a common presenting symptom. Justin et al (TOG 2007;9:223−232) reviewed minimal access techniques for its treatment, whilst Oláh (TOG 2005;7:233−240) argued the case for vaginal hysterectomy in the absence of prolapse. Perhaps the time has come to argue for laparoscopic hysterectomy? I also enjoyed Jefferis et al.'s challenge of vaginal hysterectomy in the treatment of prolapse (TOG 2016;18:17−23). Practice for long enough, and you will see a patient with vaginal agenesis. Minto and Creighton's article on vaginoplasty (TOG 2003;5:84−9) described the surgical approach and will be of interest as background information for many of us. However, referral to a centre of expertise with a multidisciplinary team must be the current standard of care. Gibb and Saridogan (TOG 2015;18:117−25) described the indications for transabdominal cervical cerclage, which will benefit a few well selected patients and Cooper and Clark (TOG 2013;15:159−66) reviewed ambulatory hysteroscopy, which benefits many patients. All operations carry risk, some more so than others. Biswas and Hogston (TOG 2011;13:87−91) taught us about the risks of obesity and Frappell (TOG 2012;14:207−209) discussed laparoscopic entry after previous surgery. Both issues are increasing in frequency. Relph et al. (TOG 2016;18:65−8) told us how to reduce the risk of failed hysteroscopy and management options if failure does occur. Uterine perforation is well recognised; Shakir and Diab (TOG 2013;15:256−61) described when it is more likely to occur and what to do if it does. Large specimens and laparoscopic surgery pose a conundrum. Stavroulis et al. (TOG 2013;15:26−30) provided useful tips for specimen extraction. The urinary tract is at risk of damage in our practice. Jha et al. (TOG 2004;6:203−8) reviewed ureteric injury in obstetric and gynaecological surgery. Minas et al. (TOG 2014;16:19−28) updated this by looking at urinary tract injuries in laparoscopic surgery. Reading both articles should reduce the fear of the urinary tract. I was also unaware of the importance of nerve injuries associated with gynaecological surgery until I read Kuponiyi et al.'s paper (TOG 2014;16:29−36). Read and James covered a broad range of immediate postoperative complications (TOG 2002;4:29−35) – another compulsory read. The TOG reviews have been informative, educational and challenging. Just what I want from my CPD journal! An online collection of all TOG gynaecological surgery articles is available at http://onlinetog.org.

An alternative model for teaching tendon repair and surgical skills in plastic surgery

In the article we will describe the use of a simple, reproducible and practical urinary catheter model for tendon repair simulation. The structure of the model gives a satisfactory imitation of a tendon's texture, contour and flexibility. This model is easily stored and disposed of. It is free of any ethical committee restrictions. In addition, it can be reused and is easy to handle. There are no disease transmission risks and one catheter can be divided into multiple segments such that several trainees can use one catheter at any one time, therefore saving on costs. In addition, different techniques can be performed on the same model.Tendon repair is an important surgical skill to be attained by all core surgical trainees; especially in Plastic and Orthopedic Surgery. However, tendon repair simulation materials can be relatively expensive. In the Basic Surgical Skills Course®, trainees learn tendon repair techniques using a pig's trotter. The caveat to this is the difficulty in obtaining animal models, and ethical dilemmas that this presents.A simple, effective and cheap method to practice tendon repair techniques is by dividing a Urinary Catheter into multiple pieces, which can be secured to cardboard or perspex using clips, staples, or pins. The Catheter thus simulates a divided tendon, providing a pragmatic medium for practice. The two ends can be opposed and repaired with various suture techniques.Trainees will be able to practice different repair techniques, surgical skills as well as basic surgical principles. The surgical skills include the handling of tissues and instruments effectively and safely, disposal of sharps, suture choice and use, suturing technique and knot tying and surgical dexterity. Principles that can be demonstrated during the simulation session include planning operative approach and choosing appropriate instruments.

The end for the ‘Roman Sandal’: an observational study of methods of securing chest drains in a deployed military setting

There is ongoing debate regarding the optimal method of securing chest drains in trauma patients. Various courses describe methods for chest drain insertion, but little has been published to identify the best method to secure the drain. This article aims to examine differences in approach to securing chest drains and the security of the methods used. Whilst in a deployed medical treatment facility, 26 clinicians from various specialties and nationalities were asked to secure a pre-placed drain. A 32F drain was placed in a manikin and the clinicians were given a chance to prepare their equipment. They were given a choice of suture and their attempts were observed by one of the researchers. The attempts were timed and photographed. A second researcher, who had not observed the technique, then assessed the security of the drain. 15/26 clinicians used a 'Roman Sandal' technique with 5/26 proving to be insecure. Other techniques used showed no failure. The rate of consultant-secured failure was 12.5% compared to 40% for registrars and 33% for General Duties Medical Officers. The type of suture used made no difference, but the traditional 'Roman Sandal' method was insecure. Knots tied close to the skin and those that bit into the drain were shown to be most effective.

Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse

We sought to describe perioperative and postoperative adverse events associated with uterosacral colpopexy, to describe the rate of recurrent pelvic organ prolapse (POP) associated with uterosacral colpopexy, and to determine whether surgeon technique and suture choice are associated with these rates. This was a retrospective chart review of women who underwent uterosacral colpopexy for POP from January 2006 through December 2011 at a single tertiary care center. The electronic medical record was queried for demographic, intraoperative, and postoperative data. Strict definitions were used for all clinically relevant adverse events. Recurrent POP was defined as the following: symptomatic vaginal bulge, prolapse to or beyond the hymen, or any retreatment forPOP. In all, 983 subjects met study inclusion criteria. The overall adverse event rate was 31.2% (95% confidence interval [CI], 29.2-38.6), which included 20.3% (95% CI, 17.9-23.6) of subjects with postoperative urinary tract infections. Of all adverse events, 3.4% were attributed to a preexisting medical condition, while all other events were ascribed to the surgical intervention. Vaginal hysterectomy, age, and operative time were not significantly associated with any adverse event. The intraoperative bladder injury rate was 1% (95% CI, 0.6-1.9) and there were no intraoperative ureteral injuries; 4.5% (95% CI, 3.4-6.0) of cases were complicated by ureteral kinking requiring suture removal. The rates of pulmonary and cardiac complications were 2.3% (95% CI, 1.6-3.5) and 0.8% (95% CI, 0.4-1.6); and the rates of postoperative ileus and small bowel obstruction were 0.1% (95% CI, 0.02-0.6) and 0.8% (95% CI, 0.4-1.6). The composite recurrent POP rate was 14.4% (95% CI, 12.4-16.8): 10.6% (95% CI, 8.8-12.7) of patients experienced vaginal bulge symptoms, 11% (95% CI, 9.2-13.1) presented with prolapse to or beyond the hymen, and 3.4% (95% CI, 2.4-4.7) required retreatment. Number and type of suture used were not associated with a higher rate of recurrence. Of the subjects who required unilateral removal of sutures to resolve ureteral kinking, 63.6% did not undergo suture replacement; this was not associated with a higher rate of POP recurrence. Perioperative and postoperative complication rates associated with severe morbidity after uterosacral colpopexy appear to be low. Uterosacral colpopexy remains a safe option for the treatment of vaginal vault prolapse.

Suture Related Iatrogenic Bladder Stone

OZET Iatrogenic suture materials within bladder cavity related to previous bladder surgeries or others with proximity to bladder may cause stone formation around themselves. This phenomenon has been well characterized with experimental animal studies. Though care related to choice of suture and technique of suturing is taken for, still such cases are reported after both urological and non-urological surgeries. In this report, such a case that had been operated for incontinence previously is presented for stone formation around the suture material within bladder cavity together with radiological examinations and endoscopical visualizations.

Severe Perineal Lacerations in Obstetric Practice: The Effect of Institutional Practice Guidelines on Repair Failures in a Single Centre.

Background. There is a high incidence of failure after repair of severe perineal lacerations (SPLs). A tertiary referral hospital in the Caribbean introduced guidelines in an attempt to improve outcomes. We performed an audit of SPL repairs at this centre in an attempt to determine the effect on repair failure. Methods. All patients with SPL repairs between November 1, 2007, and December 30, 2012, were identified. The primary aim was to determine the incidence of failed repairs (wound dehiscence, anal sphincter disruption, rectovaginal fistula, and/or faecal incontinence). The Cleveland Clinic Incontinence Score (CCIS) was used to assess continence at discharge and 24 weeks after repair. Data were analyzed with SPSS version 12. Results. There were 8108 vaginal deliveries, 23 third-degree injuries, and 3 fourth-degree injuries. Three patients experienced a repair failure. Notably, 69% of surgeons chose an inappropriate suture for sphincter repair. Conclusions. Experienced operators are performing repairs, but there is a high prevalence of inappropriate suture choice for repairs. A targeted educational campaign may be necessary to remind clinicians of the best practice in repair techniques.

Sutures, needles, and tissue adhesives: a review for dermatologic surgery.

Dermatologic surgery generally requires the removal of offending or excessive tissue followed by repair of the resultant defect. The functional and cosmetic outcome is increasingly important as patients' expectations grow and physicians become increasingly aware of surgical materials and techniques that enable them to repair defects in a functionally and cosmetically appealing manner. To perform an updated and thorough review of the literature regarding sutures, surgical tape, tissue adhesives and stitching techniques. A comprehensive literature review was conducted on-line via multiple search engines and sites using the keywords suture, suture techniques, suturing techniques, surgical techniques, surgical tapes, surgical adhesives, and tissue adhesives. There are numerous articles on sutures, surgical tape, and tissue adhesives, but there are no current articles that review them together in a comprehensive manner and combine the review with a discussion of stitching techniques. Suture choice and surgical and stitching techniques may be guided by the TAFT concept of wound closure that recognizes the main function of suture and closure devices: Tension relief; Apposition enhancement; and surface Finishing Touches. The dermatologist's goal is to create functionally and aesthetically pleasing scars for optimal patient satisfaction, which is of ultimate importance considering that the scars patients receive leave a lasting impression of their dermatology experience.

Sutures in abdominal surgery: biomechanical study and clinical application

Abstract The aim of this study is to improve treatment results and SSI prevention by differential usage of the contemporary suture materials and choice of proper suturing technique. To simulate suturing process and compared two suturing techniques, two FE models were developed. Finite-element analysis (FEA) was based on experimental data of contemporary commercial sutures and soft tissue properties. We applied obtained results for abdominal wall closure in rats and compared non-absorbable suture (capron) with absorbable suture (PDS Plus) for chosen technique. Cross-sections were examined by lighting electron microscope. Afterwards, the results of patients’ treatment are also presented. It was shown that running sew was more appropriate for aponeurosis suturing compared to interrupted sew. The optimal parameters of suturing techniques were computed. Single-row running sew by PDS Plus was proved to hold wound edges for 90 days with less inflammatory response compared to other suture in the result of histological analysis. Application of contemporary synthetic absorbable suture materials with antibacterial coating for laparotomic wounds closure and anastomosis decreases local inflammatory reaction and provides the successful tissue regeneration. Application of advanced SSI prophylactics algorithm was shown to decrease risk of post-operative suppurative complications from 14.2 to 1.6 %.

Introduction to the Barbed Sutures Supplement: The Expanding Applications of Barbed Sutures

In 1881, Alexander Graham Bell invented what arguably could be called the first metal detector. President James Garfield had been shot. His doctors needed to locate the bullet that was lodged in his chest, but the president already had lost a significant amount of blood. Doctors therefore were reluctant to perform manual exploration. Bell's invention seemed the best hope. What no one realized at the time was that the metal springs in the mattress upon which the president lay would render Bell's metal detector ineffective. Garfield ultimately died from his wounds. The metal detector endured. Through the work of later inventors, it evolved into a device serving a variety of important functions, most notably helping to ensure our safety in public places.1 Many useful inventions originally intended for one purpose end up better serving another. In plastic surgery, such has been the evolution of barbed sutures. In the 1990s, lifting of the brows, midface, and neck using barbed sutures, usually applied subcutaneously with a threading technique, was widely promoted as a safer, quicker, and less invasive alternative to traditional surgical procedures. However, for many surgeons and their patients, both the short- and longer-term results were disappointing. Complications and other adverse events were common. Some problems were undoubtedly technique related, as practitioners with various backgrounds and little hands-on training with barbed sutures aggressively promoted themselves as experts and performed procedures without the requisite experience. Nevertheless, interest in these threading techniques for suspension of facial tissues waned considerably in the plastic surgery community. Subsequently, however, expanded applications for barbed suture technology have evolved. Sutures are essential in almost every procedure that we perform. The choice of suture depends on several variables, including the anatomic site, desired suture characteristics, and surgeon preference. In my practice, barbed sutures have come to play an …

Effects of Suture Choice on Biomechanics and Physeal Status After Bioenhanced Anterior Cruciate Ligament Repair in Skeletally Immature Patients: A Large-Animal Study

The objective of this study was to assess the effect of absorbable or nonabsorbable sutures in bioenhanced anterior cruciate ligament (ACL) repair in a skeletally immature pig model on suture tunnel and growth plate healing and biomechanical outcomes. Sixteen female skeletally immature Yorkshire pigs were randomly allocated to receive unilateral, bioenhanced ACL repair with an absorbable (Vicryl) or nonabsorbable (Ethibond) suture augmented by an extracellular matrix-based scaffold (MIACH). After 15 weeks of healing, micro-computed tomography was used to measure residual tunnel diameters and growth plate status, and biomechanical outcomes were assessed. At 15 weeks postoperatively, there was a significant difference in tunnel diameter with significantly larger diameters in the nonabsorbable suture group (4.4 ± 0.3 mm; mean ± SD) than in the absorbable group (1.8 ± 0.5 mm; P < .001). The growth plate showed a significantly greater affected area in the nonabsorbable group (15.2 ± 3.4 mm(2)) than in the absorbable group (2.7 ± 0.8 mm(2), P < .001). There was no significant difference in the linear stiffness of the repairs (29.0 ± 14.8 N/mm for absorbable v 43.3 ± 28.3 N/mm for nonabsorbable sutures, P = .531), but load to failure was higher in the nonabsorbable suture group (211 ± 121.5 N) than in the absorbable suture group (173 ± 101.4 N, P = .002). There was no difference between the 2 groups in anteroposterior laxity at 30° (P = .5117), 60° (P = .3150), and 90° (P = .4297) of knee flexion. The use of absorbable sutures for ACL repair resulted in decreased physeal plate damage after 15 weeks of healing; however, use of nonabsorbable sutures resulted in 20% stronger repairs. Choice of suture type for ACL repair or repair of tibial avulsion fractures may depend on patient skeletal age and size, with absorbable sutures preferred in very young, small patients at higher risk with physeal damage and nonabsorbable sutures preferred in larger, prepubescent patients who may place higher loads on the repair.

Complete anal sphincter complex disruption from intercourse: A case report and literature review

INTRODUCTIONAnal sphincter injuries are uncommon injuries outside of obstetric practice – but they may cause disastrous complications. PRESENTATION OF CASEWe present a case of complete anal sphincter disruption from anal intercourse in a 25 year old woman. Clinical management is presented and technical details of the repair are discussed. She had an uneventful post-operative course and good continence after 154 days of follow up. DISCUSSIONThis is one of a handful of reported cases of anal sphincter disruption secondary to anal intercourse. The established risk factors in this case included receptive anal intercourse coupled with alcohol use. We review the pertinent surgical principles that should be observed when repairing these injuries, including anatomically correct repair and appropriate suture choice. There is little evidence to support simultaneous faecal diversion for primary repair of acute perineal lacerations. CONCLUSIONAcute post-coital sphincter injuries should be treated operatively on an emergent basis, without diversion because they are low energy injuries with minimal tissue loss and excellent blood supply. Although repair of each injury should be individualized, the majority of these injuries do not require concomitant protective colostomy creation.

Editorial Comment

Randomized controlled trials (RCTs) demonstrating strong evidence for surgical interventions are rare within urology. The authors of this report are to be congratulated on seeking to provide the best level of evidence for a new technology very early in its introduction. 1 Centre for Evidence Based MedicineCEBM > EBM Tools > Finding the Evidence > Levels of Evidence. http://www.cebm.net/index.aspx?o=1025 Google Scholar Recent urologic interest for the use of barbed sutures has been intense, predominantly for urethrovesical anastomosis (UVA) during robotic radical prostatectomy and during rennorhaphy within robotic partial nephrectomy. This is illustrated by the large number of abstracts on the subject at this year's major urologic meetings. Anastomosis During Robot-assisted Radical Prostatectomy: Randomized Controlled Trial Comparing Barbed and Standard Monofilament SutureUrologyVol. 78Issue 3PreviewTo compare perioperative and functional outcomes after urethrovesical anastomosis (UVA) with barbed polyglyconate and monofilament poliglecaprone in robot-assisted radical prostatectomy (RARP). Barbed polyglyconate suture was first used for the UVA during RARP beginning in January 2010; safety and feasibility were previously demonstrated in 51 patients. Full-Text PDF ReplyUrologyVol. 78Issue 3PreviewWe are thankful for the editorial comments and support many of the cautions raised in their critique. Ultimately, suture choice should be made according to surgeon preference and comfort; it is, after all, simply a tool. Although it is possible that barbed suture may be best used by “those who have already reached competence at UVA,” it would seem counterproductive for academic institutions to train robotic surgeons to use monofilament suture, which, in our opinion, is an inferior tool for the job of UVA. Full-Text PDF

Reply

We are thankful for the editorial comments and support many of the cautions raised in their critique. Ultimately, suture choice should be made according to surgeon preference and comfort; it is, after all, simply a tool. Although it is possible that barbed suture may be best used by “those who have already reached competence at UVA,” it would seem counterproductive for academic institutions to train robotic surgeons to use monofilament suture, which, in our opinion, is an inferior tool for the job of UVA.

Innovations in Managing Cleft Lip/Palate: A Multicenter Perspective

Program Description: Cleft and craniofacial teams with both pediatric otolaryngology and facial plastic surgery backgrounds continue to develop. Novel approaches in the management of children with cleft lip and palate have contributed to a variety of treatment paradigms. Each institution and individual surgeon brings a unique perspective of treatment preferences that are worthy of discussion. Beginning in the prenatal period, advances in ultrasound technology now allow parents and surgeons to begin early preparation and education. Presurgical orthopedic devices introduced in the 1960s by the late 1990s have developed into nasoalveolar molding. The appliance is created in conjunction with an orthodontist with adjustments leading to approximation of the alveolar segments, as well as to mold the nasal deformity (columellar lengthening). Recently published modifications of the microform, unilateral, and bilateral cleft lip repair will be presented. Other innovations seeking to improve the aesthetic outcomes such as the subunit approach, suture choice, tissue glue, and scar prevention with silicone gel will be justified. Cleft surgeons from five institutions will present their approach to the cleft lip nasal deformity at the time of cleft lip repair. This can range from delaying repair (no rhinoplasty) to bolstering placement, or even direct lower lateral cartilage repositioning with rhinoplasty. This miniseminar will provide the participant a perspective on how different institutions approach common problems in management of the cleft lip, palate, and nasal deformity. This forum supports the goals of the Specialty Surgery Committee of the AAFPRS in fostering collaboration between those cleft surgeons within pediatric otolaryngology and the facial plastic surgery subspecialties. Secondary speech surgery evaluation and treatment will be presented with fluoroscopic and endoscopic examples and panelist discussion. Lastly, difficult cases will also be presented. Audience touchpad interaction will facilitate discussion. The format will include presentations including intraoperative video and subsequent discussion of the following topics: Presurgical nasoalveolar molding, unilateral cleft lip and nasal deformity repair, bilateral cleft lip and nasal deformity repair, primary cleft rhinoplasty options, and management of the extremely wide cleft lip and nasal deformity. Educational Objectives: 1) Understand the timing and techniques for cleft lip/palate repair based on evidence-based guidelines. 2) Learn the panelists’ preferred basic and advanced cleft lip repair designs. 3) Be able to interpret and choose treatment for velopharyngeal dysfunction audibly, on fluoroscopy, and nasopharyngoscopy.

Bacterial Adherence to Suture Materials

Wound infections may be problematic for physicians. Whether a practitioner is managing complex penetrating trauma or a skin biopsy, there may be a need for suture closure. Suture material is an operator dependent variable and while little objective data exist to guide the choice of suture, it may play a role in wound infection. This study evaluates bacterial adherence to commonly used suture materials with a bioluminescent in vitro model. In all, 11 strands of size 2-0 poliglecaprone suture (Monocryl; Ethicon, Inc, Somerville, New Jersey), polypropylene suture (Prolene; Ethicon, Inc), silk suture (Ethicon, Inc), polyglycolic acid suture (Vicryl; Ethicon, Inc), and antimicrobial polyglycolic acid suture treated with triclosan (VicrylPlus; Ethicon, Inc) were immersed in a broth of Staphylococcus aureus engineered to emit photons. After biofilm formation, the suture strands were irrigated and imaged with a photon-capturing camera system yielding a total photon count that correlates with residual bacteria. The Vicryl suture had the highest counts and was statistically significant in bacterial adherence versus all other sutures. No other suture material was significantly different from any other. This study gives data to guide the selection of suture materials. Absorbable braided suture should not be used in closure of contaminated wounds or wounds at risk for developing infection. The antibiotic impregnated absorbable braided suture was similar to the other suture types; however, it is at risk for reverting to the properties of its untreated counterpart over time. The bacterial adherence of suture materials should be taken into account by all practitioners when closing wounds or debriding infected wounds.