Horizontal Mattress Research Articles

Double-Row Suture Anchor Repair of Posterolateral Corner Avulsion Fractures

Posterolateral corner avulsion fractures are a rare variant of ligamentous knee injury primarily described in the skeletally immature population. Injury is often related to a direct varus moment placed on the knee during sporting activities. Various treatment strategies have been discussed ranging from nonoperative management, to excision of the bony fragment, to primary repair with screws or suture. The described technique is a means for achieving fixation of the bony avulsion using principles familiar to double-row transosseous equivalent rotator cuff repair. Proximal anchors are placed in the epiphysis, and sutures are passed in horizontal mattress fashion. Once tied, the limbs of these same sutures are then passed to more distal anchors. Remaining eyelet sutures can be used to manage peripheral tissue. The final repair provides anatomic reduction and compression of the fragment to its bony bed with minimal extracortical hardware prominence and no violation of the physis. Risks include potential for physeal injury or chondral damage to the lateral femoral condyle through aberrant anchor placement. Postoperative care includes toe-touch weight-bearing restrictions and range of motion restrictions of 0°-90° in a hinged brace for 6 weeks followed by gradual return to activity.

ASSESSMENT OF UTERINE SCAR AFTER MODIFIED DOUBLE LAYER VERSUS DOUBLE LAYER CLOSURE OF THE UTERUS DURING CESAREAN SECTION

Background: Modified two layers closure consists of full thickness closure of uterus by interrupted horizontal mattress sutures in first layer followed by a continuous running suture in the second layer. To assess the healing of scar and the risk of uterine rupture in a subsequent pregnancy, ultrasonography is used in the evaluation of uterine scar in the postpartum period. Objective: To compare the effect of different suturing techniques in cesarean section in terms of blood loss and operative time during the operation and scar thickness three months after the operation. Patients and methods: The study included a total 60 women, they were divided into two equal groups: ● Group A underwent double layers closure of the uterus after lower segment cesarean section. ● Group B underwent modified double layers closure of the uterus after lower segment cesarean section. Ultrasound evaluation of the scar thickness was performed at three months post partum. Results: Results of the study showed that there was a statistically significant higher scar thickness in group B compared to group A. Conclusion: Change in suturing technique affected the thickness of uterine scar as detected by ultrasonography in post partum period. Scar thickness significantly increased with modified two layers closure when compared with traditional two layers closure of lower transverse uterine incision.

Arthroscopic Repair of Posterior Bony Bankart Lesion and Subscapularis Remplissage

Posterior shoulder instability with glenoid bone loss has only a fraction of the prevalence of anterior instability. Unlike the latter, there is a paucity of literature regarding the treatment of posterior bony Bankart lesions and even less with concomitant reverse Hill-Sachs lesions. This combination of pathology leads to a difficult situation regarding treatment options. We present our technique for arthroscopic repair of a posterior bony Bankart lesion and reverse Hill-Sachs lesion. The importance of proper portal placement cannot be overstated. By use of the lateral position and strategically placed portals, the posterior bony Bankart lesion and attached labral complex were appropriately mobilized. We reduced the glenoid bone, with the attached capsulolabral complex, to the glenoid rim and performed fixation using a knotless suture anchor. We then placed 2 double-loaded suture anchors into the reverse Hill-Sachs lesion. The sutures were passed creating horizontal mattress configurations that were tied at the end of the procedure, effectively externalizing the humeral head defect. Our technique results in satisfactory fragment reduction, as well as appropriate capsular tension, and effectively prevents the reverse Hill-Sachs lesion from engaging.

A new pancreatojejunostomy of duct-to-mucosa combining back-to-back cross horizontal mattress anastomosisin pancreaticoduodenectomy.

e18216 Background: Postoperative pancreatic fistula(POPF) is always related to the morbidity and mortality. The objective of our study was to evaluate the safety and efficiency of the novel anastomotic method that termed duct-to-mucosa combining with “back-to-back” cross horizontal mattress inserting pancreatojejunostomy. In this technique, we used 4-0 Coated VICRYL to stitch the posterior of the stump of pancreas into the side of jejunum in the method of horizontal mattress suture. Then, we used 5-0 polypropylene to stitch the posterior of the pancreatic duct into the jejunum interruptedly. After that, a pancreatic duct stent was inputted. The anterior side of the pancreatic duct and the pancreas was stitched the same as the anastomosis of the posterior side. Methods: We investigated the postoperative recovery and complications of 49 patients who underwent pancreaticoduodenectomy from October 2015 to October 2016 retrospectively. The new technique was used in 24 patients, and was compared with the regular interrupted suturing anastomosis technique that was used in 25 patients as controls. We defined, diagnosed and graded POPF accroding to the International Study Group in Pancreatic Surgery criteria. Results: The anastomosis time in the conventional group was less than that in new technique group (21.52±2.26 min vs28.10±6.20 min, P=0.000), but we could find the POPF rate decreased significantly in the new technique group from the following data. There were 2 grade B POPF patients in the new technique group. Meanwhile, there were 8 grade B POPF and 1 grade C POPF patients in the control group (8.3% vs 36.0%, P=0.020). Conclusions: Duct-to-mucosa combining with “back-to-back” cross horizontal mattress inserting pancreatojejunostomy reduced the incidence of POPF effectively in our study. [Table: see text]

Developing Cognitive Task Analysis–based Educational Videos for Basic Surgical Skills in Plastic Surgery

To describe the development of cognitive task analysis (CTA)-based multimedia educational videos for surgical trainees in plastic surgery. A needs assessment survey was used to identify 5 plastic surgery skills on which to focus the educational videos. Three plastic surgeons were video-recorded performing each skill while describing the procedure, and were interviewed with probing questions. Three medical student reviewers coded transcripts and categorized each step into "action," "decision," or "assessment," and created a cognitive demands table (CDT) for each skill. The CDTs were combined into 1 table that was reviewed by the surgeons performing each skill to ensure accuracy. The final CDTs were compared against each surgeon's original transcripts. The total number of steps identified, percentage of steps shared, and the average percentage of steps omitted were calculated. Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, an urban tertiary care teaching center. Canadian junior plastic surgery residents (n = 78) were sent a needs assessment survey. Four plastic surgeons and 1 orthopedic surgeon performed the skills. Twenty-eight residents responded to the survey (36%). Subcuticular suturing, horizontal and vertical mattress suturing, hand splinting, digital nerve block, and excisional biopsy had the most number of residents (>80%) rank the skills as being skills that students should be able to perform before entering residency. The number of steps identified through CTA ranged from 12 to 29. Percentage of steps shared by all 3 surgeons for each skill ranged from 30% to 48%, while the average percentage of steps that were omitted by each surgeon ranged from 27% to 40%. Instructional videos for basic surgical skills may be generated using CTA to help experts provide comprehensive descriptions of a procedure. A CTA-based educational tool may give trainees access to a broader, objective body of knowledge, allowing them to learn decision-making processes before entering the operating room.

In Vitro Tensile Strength Study on Suturing Technique and Material.

Suture technique and materials are important in preventing complications such as wound dehiscences. The purpose of this study was to determine the tensile strength of different suturing techniques, comparing several materials with different diameters. One hundred sixty sutures were performed using silk, e-PTFE, and 2 types of polyamide (monofilament and Supramid). Ten simple, 10 horizontal mattress, and 10 combinations of the two stitches were performed with 4-0 gauge of each material. Additionally, 10 simple sutures were performed with the 5-0 gauge of each material. The maximum tensile force resisted by each suture was recorded. When 5 mm of traction was applied, the polyamide monofilament resisted significantly better without untying or breaking compared with Supramid or silk, while the e-PTFE was superior to all the others. However, the force when e-PTFE 4-0 sutures untied or broke was lower than for either type of polyamide. The combined technique withstood a significantly higher tensile force before unknotting or breaking than did the simple and mattress stitches. The 5-0 gauges of silk and both types of polyamide showed lower tensile strengths than the 4-0 materials. Among the 5-0 sutures, Supramid showed a higher tensile strength than silk. The combined suture technique possessed greater tensile strength than did a simple or a horizontal mattress suture, and e-PTFE 4-0 withstood more traction without untying or breaking than did all the other materials, although at a lower tensile force. With the exception of e-PTFE, 4-0 sutures had greater tensile strength than did 5-0 sutures.

Interlocking horizontal mattress suture versus Kakiuchi technique in repair of Achilles tendon rupture: a biomechanical study

BackgroundIn recent years, the type of surgical treatment for Achilles tendon rupture has been the subject of controversial debate. This biomechanical study evaluates for the first time in literature the ultimate failure load (UFL) of interlocking horizontal mattress (IHM) suture as compared with Kakiuchi suture in Achilles tendon rupture. The hypothesis is that IHM suture can be performed also for Achilles tendon rupture and ensures higher resistance compared with the traditional Kakiuchi suture.Materials and methodsTwenty fresh bovine Achilles tendons were obtained. Ten preparations were randomly assigned to each of two different groups: group A (10 specimens) sutured by IHM technique, and group B (10 specimens) sutured by Kakiuchi technique. Each construct was mounted and fixed on a tensile testing machine. Static preconditioning of 50 N was applied for 5 min as initial tensioning to stabilize the mechanical properties of the graft, then a load to failure test was performed at crosshead speed of 500 mm/min.ResultsTen specimens were tested for each group. The mean UFL was 228.6 ± 98.6 N in the IHM suture group and 96.57 ± 80.1 N in the Kakiuchi suture group. Statistical analysis showed a significant difference (p < 0.05) with better UFL in the IHM group. In both groups, the failure mode registered in each specimen was suture breakage (rupture of suture thread).ConclusionsIHM suture achieved better UFL compared with Kakiuchi suture in an animal model of Achilles tendon repair. These results seem to support IHM as a valid option in Achilles tendon rupture.

Open surgical approach and technique in left pneumonectomy

The classic posterolateral thoracotomy remains an important incision to any surgeon for lung resections. It allows inspection, complete mobilization of the lung and hilum and access to mediastinal structures. For pneumonectomy, the key-step is the circumferential hilar dissection, exposing the hilar structures, resect lymph nodes and assess resectability in cancer operations. The dissection starts at the level of the left pulmonary artery (PA) and proceeds posteriorly and inferiorly. Suspension of the posterior mediastinum provides excellent exposure of the left main bronchus and the inferior pulmonary vein, while at the same time protects the recurrent nerve and the esophagus. The dissection circumvents the ligament and continues anteriorly, until the superior pulmonary vein is identified and the hilar loop is completed. Isolation of each structure by blunt or even finger dissection commences, and a vascular tape is applied for gentle retraction. The PA is divided first, followed by the inferior and superior pulmonary veins. Either non-absorbable monofilament sutures or staplers may be equally used for the transection of each structure. We suggest initial clamping and then proximal and distal transfixion of the vessels rather than simple ligation if sutures are to be used. Special attention should be paid to the transection of the bronchus, as this step is usually responsible for late complications. The bronchus should be dissected free, up to the level of the carina, retracted, clamped and divided, leaving the shortest possible stump. Either double horizontal mattress sutures or stapler provide equally safe result. The procedure is completed with extended lymph node dissection and air leak assessment.

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

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

Peri-Implant Mucositis and Peri-Implantitis: A Current Understanding of Their Diagnosis, Clinical Implications, and a Report of Treatment Using a Combined Therapy Approach.

Abstract The clinical condition involving dental implants, characterized by soft tissue inflammation, bleeding, suppuration and rapid bone loss is widely known as peri implantitis. The main objective in the treatment of peri-implantis is to arrest the progression of the disease and at the same time to keep the dental implant in the mouth solving the inflammations signs of bleeding and pain. The aim of this paper is to highlight the effectiveness of the use of titanium brush and antimicrobial photodynamic therapy (aPDT) to decontaminate the implant surface, in association with regenerative procedures by means of autologous bone and demineralized bovine bone mineral (DBBM) in the treatment of peri-implantitis defects.

Technique and outcomes of bladder neck intussusception during robot-assisted laparoscopic prostatectomy: A parallel comparative trial

IntroductionPostprostatectomy incontinence significantly impairs quality of life. Although bladder neck intussusception has been reported to accelerate urinary recovery after open radical retropubic prostatectomy, its adaption to robotic surgery has not been assessed. Accordingly, we describe our technique and compare outcomes between men treated with and without bladder neck intussusception during robot-assisted laparoscopic prostatectomy. Materials and methodsWe performed a comparative trial of 48 men undergoing robot-assisted laparoscopic prostatectomy alternating between bladder neck intussusception (n = 24) and nonintussusception (n = 24). Intussusception was completed using 3-0 polyglycolic acid horizontal mattress sutures anterior and posterior to the bladder neck. We assessed baseline characteristics and clinicopathologic outcomes. Adjusting for age, body mass index, race, and D׳Amico risk classification, we prospectively compared urinary function at 2 days, 2 weeks, 2 months, and last follow-up using the urinary domain of the Expanded Prostate Cancer Index—Short Form. ResultsBaseline patient characteristics and clinicopathologic outcomes were similar between treatment groups (P>0.05). Median catheter duration (8 vs. 8d, P = 0.125) and rates of major postoperative complications (4.2% vs. 4.2%, P = 1.000) did not differ. In adjusted analyses, Expanded Prostate Cancer Index—Short Form urinary scores were significantly higher for the intussusception arm at 2 weeks (65.4 vs. 46.6, P = 0.019) before converging at 2 months (69.1 vs. 68.3, P = 0.929) after catheter removal and at last follow-up (median = 7mo, 80.5 vs. 77.0; P = 0.665). ConclusionsBladder neck intussusception during robot-assisted laparoscopic prostatectomy is feasible and safe. Although the long-term effects appear limited, intussusception may improve urinary function during the early recovery period.

Effects of different sutures on fibrosis and wound healing in a rabbit model of corneal wounds.

The aim of the study was to investigate wound healing and scar formation in rabbit corneal lamellar wounds repaired with simple interrupted sutures (SIS) or horizontal mattress sutures (HMS). Two parallel ‘I’-shaped lamellar cornea wounds were created in one eye of 40 white New Zealand rabbits, while 5 uninjured rabbits were sacrificed to serve as normal controls. One side of the wounds, in the test rabbits, was closed with SIS, while the other side was treated with HMS. Ten days later, the stitches were removed under anesthesia. The animals were sacrificed on days 14 and 21, and months 3 and 6 after the suturing surgery, and corneal samples were subjected to histological and immunofluorescent studies: α-smooth muscle actin (α-SMA) and vimentin were used to detect myofibroblasts and fibroblasts, respectively, and collagen type I and III was used to detect extracellular matrix (ECM) deposition. Relevant mRNA levels were assessed by quantitative polymerase chain reaction (qPCR) to elucidate the differences in wound healing and formation of fibrosis. Macroscopic and hematoxylin and eosin staining observations showed that the two sides of the wounds developed the most prominent fibrotic tissue on day 21. The immunofluorescence and qPCR results showed that HMS wounds produced increased α-SMA, vimentin and collagen type III compared to the SIS wounds on day 14 or 21. The collagen type I expression showed no distinctive difference in SIS and HMS wounds. In conclusion, corneal lamellar wounds treated with SIS developed less fibrotic-related proteins and related mRNA in the early stages of wound healing than wounds treated with HMS. Although differences were not distinct after 3 months, the results of the present study suggest a benefit in choosing SIS over HMS, as at least the initial fibrotic process seems more benign with SIS. Corneal wounds should be carefully sutured, ensuring the tissue is well aligned.

Augmented repair of radial meniscus tear with biomimetic electrospun scaffold: an in vitro mechanical analysis.

BackgroundLarge radial tears that disrupt the circumferential fibers of the meniscus are associated with reduced meniscal function and increased risk of joint degeneration. Electrospun fibrous scaffolds can mimic the topography and mechanics of fibrocartilaginous tissues and simultaneously serve as carriers of cells and growth factors, yet their incorporation into clinically relevant suture repair techniques for radial meniscus tears is unexplored. The purposes of this study were to (1) evaluate the effect of fiber orientation on the tensile properties and suture-retention strength of multilayered electrospun scaffolds and (2) determine the mechanical effects of scaffold inclusion within a surgical repair of a simulated radial meniscal tear. The experimental hypothesis was that augmentation with a multilayered scaffold would not compromise the strength of the repair.MethodsThree multilayered electrospun scaffolds with different fiber orientations were fabricated–aligned, random, and biomimetic. The biomimetic scaffold was comprised of four layers in the following order (deep to superficial)–aligned longitudinal, aligned transverse, aligned longitudinal, and random–respectively corresponding to circumferential, radial, circumferential, and superficial collagen fibers of the native meniscus. Material properties (i.e., ultimate stress, modulus, etc.) of the scaffolds were determined in the parallel and perpendicular directions, as was suture retention strength. Complete radial tears of lateral bovine meniscus explants were repaired with a double horizontal mattress suture technique, with or without inclusion of the biomimetic scaffold sheath. Both repair groups, as well as native controls, were cyclically loaded between 5 and 20 N for 500 cycles and then loaded to failure. Clamp-to-clamp distance (i.e., residual elongation) was measured following various cycles. Ultimate load, ultimate elongation, and stiffness, were also determined. Group differences were evaluated by one-way ANOVA or Student’s t-test where appropriate.ResultsAligned scaffolds possessed the most anisotropic mechanical properties, whereas random scaffolds showed uniform properties in the parallel and perpendicular directions. In comparison, the biomimetic scaffold possessed moduli in the parallel (68.7 ± 14.7 MPa) and perpendicular (39.4 ± 11.6 MPa) directions that respectively approximate the reported circumferential and radial tensile properties of native menisci. The ultimate suture retention load of the biomimetic scaffold in the parallel direction (7.2 ± 1.6 N) was significantly higher than all other conditions (p < 0.001). Biomimetic scaffold augmentation did not compromise mechanical properties when compared against suture repair in terms of residual elongation after 500 cycles (scaffold: 5.05 ± 0.89 mm vs. repair: 4.78 ± 1.24 mm), ultimate failure load (137.1 ± 31.0 N vs. 124.4 ± 21.4 N), ultimate elongation (12.09 ± 5.89 mm vs. 10.14 ± 4.61 mm), and stiffness (20.8 ± 3.6 vs. 18.4 ± 4.7 N/mm).ConclusionsWhile multilayered scaffold sheets were successfully fabricated to mimic the ultrastructure and anisotropic tensile properties of native menisci, improvements in suture retention strength or adoption of superior surgical techniques will be needed to further enhance the mechanical strength of repairs of radial meniscal tears.

V Advancement Flap for Fingertip Injury Preventing Necrosis and Hook Nail Deformity

Objectives: V-Y advancement flap has been a reliable method to reconstruct fingertip defect, since described by Tranquilli-Leali originally in 1935 and popularized by Atasoy later in 1970. But flap necrosis and hook nail deformity due to suture line tension have been pointed out as relatively common complications in V-Y advancement flap for fingertip reconstruction. Concern about this problems, several authors have been described a modification of this technique. The aim of this study was to describe our modification of V advancement flap based on V-Y concept and to review the outcome of this procedure for fingertip amputation in 28 patients. Materials and Methods: This study was conducted from January 2006 to February 2014 and involved 28 consecutive patients (20 men and 8 women; 30 fingertip amputations) with fingertip injury that were treated operatively with the same procedure. All patients with a fingertip defect of more than 1.0 cm2 in area from the tip to lunula were included in this study. The causes of injuries were crushing with or without avulsion in 21, amputation with sharp laceration in 8, and human bite in 1. Twenty-seven injuries were transverse or dorsal oblique type and 3 were mild volar oblique type. According to Allen’s classification, 18 cases were type 2, 11 were type 3, and 1 was type 1. To allow for a tension-free closure, the proximal incision was left unclosed to heal by secondary intension. In addition, the distal nail bed was supported and maintained eversion against base of the flap with a minimal number of horizontal mattress sutures, and there was no suture crossing over the top to prevent hook nail deformity. Postoperatively, dressing changes were performed once daily for 3 or 4 weeks until reepithelialization was observed. Results: The mean age of the patients was 43.6 years (range, 24-65 years). The average follow-up periods was 15 months (range, 12-37 months). All patients underwent objective and subjective assessment at 6 and 12 months routinely and at final follow-up. At final follow-up, all flap healed uneventfully. In objective evaluation with Semmes-Weinstein monofilaments test, 24 cases recognized the 2.83 monofilament (0.07 g), 6 cases recognized the 3.61 monofilament (0.4 g). In static 2-point discrimination test, the mean values were 4.61 mm in injured finger and 4.00 mm in contralateral finger. None of the patients developed a noticeable hook nail deformity. None of the patients complained of hypersensitive digit. However, 3 patients had some residual short nails and 2 patients had mild nail ridges. Patients’ subject rating of the outcome was recorded: “excellent,” “good,” “fair,” and “poor.” Excellent or good results were achieved in 28 cases. Two cases had fair results and none of the patients had a poor result. Conclusions: This modified V advancement flap technique, when properly designed and executed, can minimize morbidity and successfully results in good wound healing without necrosis and hook nail deformity for fingertip injury.

The Medial Stitch in Transosseous-Equivalent Rotator Cuff Repair

Background: Despite advances in surgical technique, rotator cuff repair retears continue to occur at rates of 10%, 22%, and 57% for small, medium, and large tears, respectively. A common mode of failure in transosseous-equivalent rotator cuff repairs is tissue pullout of the medial mattress stitch. While the medial mattress stitch has been studied extensively, no studies have evaluated a vertical mattress pattern placed near the musculotendinous junction in comparison with a horizontal mattress pattern. Hypothesis: Vertical mattress stitches will have higher load to failure and lower gapping compared with horizontal mattress stitches in a transosseous-equivalent rotator cuff repair. Study Design: Controlled laboratory study. Methods: Double-row transosseous-equivalent rotator cuff repairs were performed in 9 pairs of human male cadaveric shoulders (mean age ± SD, 58 ± 10 years). One shoulder in each pair received a medial-row suture pattern using a vertical mattress stitch, and the contralateral shoulder received a horizontal mattress. Specimens were mounted in a materials testing machine and tested in uniaxial tensile deformation for cyclic loading (500 cycles at 1 Hz to 1.0 MPa of effective stress), followed by failure testing carried out at a rate of 1 mm/s. Construct gapping and applied loads were monitored continuously throughout the testing. Results: Vertical mattress sutures were placed in 5 right and 4 left shoulders. Peak cyclic gapping did not differ between vertical (mean ± SD, 2.8 ± 1.1 mm) and horizontal mattress specimens (3.0 ± 1.2 mm) (P = .684). Vertical mattress sutures failed at higher loads compared with horizontal mattress sutures (568.9 ± 140.3 vs 451.1 ± 174.3 N; P = .025); however, there was no significant difference in failure displacement (8.0 ± 1.6 vs 6.0 ± 2.1 mm; P = .092). Failure stiffness did not differ between the suture patterns (P = .204). Conclusion: In transosseous-equivalent rotator cuff repairs near the musculotendinous junction, a vertical mattress suture used as the medial stitch has a higher load to failure but no difference in gapping compared with a horizontal mattress pattern. Clinical Relevance: A vertical mattress suture may offer enhanced strength of repair for transosseous-equivalent repairs.

How we do it: the Running-X suture technique

There are a myriad of suture techniques available to close incisions of the brow and forehead, each with their own advantages and disadvantages. The ideal suture technique would provide excellent cosmetic results, offer expedient wound closure, optimize skin eversion and wound edge apposition, and provide excellent cosmetic results. The authors describe a new suture technique, the Running-X suture, a running horizontal mattress suture that has successfully been used by the senior author for many years to re-approximate surgical wounds of the brow and forehead in an expeditious and aesthetic manner.

V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS

You have accessJournal of UrologyRobotics - Renal1 Apr 2016V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS Matthew J. Maurice, Daniel Ramirez, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, and Jihad H. Kaouk Matthew J. MauriceMatthew J. Maurice More articles by this author , Daniel RamirezDaniel Ramirez More articles by this author , Peter A. CaputoPeter A. Caputo More articles by this author , Ryan J. NelsonRyan J. Nelson More articles by this author , Onder KaraOnder Kara More articles by this author , Ercan MalkocErcan Malkoc More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1194AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Hilar tumors are challenging due to their centrality and proximity to the renal hilum, increasing the complexity of tumor excision and renal reconstruction. We sought to highlight these challenges and demonstrate techniques for successful execution and excellent outcomes. METHODS Using our retrospective robotic partial nephrectomy database, we abstracted data on patients who were treated between 2006 and 2015. Videos demonstrating robotic partial nephrectomy for two particularly challenging hilar tumors were selected for presentation. For all cases, patients were positioned in full 45-degree flank, and surgery was performed with four working ports. Intraoperative ultrasound was used to identify tumor margins and guide excision. The renorrhaphy was performed in a minimum of two layers, including a deep layer closed with 2-0 polyglactin 910 in a running fashion and a capsular layer closed with 0 polyglactin 910 suture in a horizontal mattress fashion. RESULTS Of 1123 total operations, 97 (8.9%) were performed for hilar tumors. Median tumor size was 3.7 cm (IQR, 3.0-4.6), and median RENAL score was 9 (IQR, 8-10). Median estimated blood loss was 200 cc (IQR, 100-300). Median operative and warm ischemia times were 3.3 hours (IQR, 2.7-4.3) and 26 minutes (IQR, 21-33), respectively. The overall complication rate for all tumors was 22.2% (249/1,123), including 183 (16.3%) minor and 66 (5.9%) major complications. For hilar tumors, the complication rate was 30.9% (30/97), including 21 (21.6%) minor and 9 (9.3%) major complications. CONCLUSIONS Robotic partial nephrectomy is technically feasible for highly complex hilar tumors. Operative times and warm ischemia may be prolonged. For select cases, clinical, oncological, and functional outcomes are excellent. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e860 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Matthew J. Maurice More articles by this author Daniel Ramirez More articles by this author Peter A. Caputo More articles by this author Ryan J. Nelson More articles by this author Onder Kara More articles by this author Ercan Malkoc More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Biomechanical Performance of Hip Labral Repair Techniques

To determine the strength of various suture techniques and the impact of suture passer size on cyclically loaded hip labra. We assigned 63 bovine hip labra to 9 simple knotless suture technique groups using OrthoCord suture: (1) penetrating grasper (2.6 mm)-placed horizontal mattress, (2) penetrating grasper-placed vertical mattress, (3) SutureLasso (1.8 mm)-placed vertical mattress, (4) penetrating grasper-placed oblique repair, (5) penetrating grasper-placed vertical mattress plus radiofrequency, (6) SutureLasso-placed horizontal mattress, (7) SutureLasso-placed oblique mattress, (8) SutureLasso-placed horizontal mattress plus radiofrequency, and (9) SutureLasso-placed oblique mattress plus radiofrequency. After 20 cycles of uniaxial tensile loading (5 to 80 N), destructive testing was performed. Penetrating grasper-placed horizontal mattress sutures showed lower ultimate failure loads than vertical and oblique mattress sutures (P < .05). Penetrating grasper-placed vertical mattress sutures had higher peak-to-peak displacement than SutureLasso-placed vertical mattress sutures (P= .04). SutureLasso-placed oblique mattress sutures had a higher ultimate load (P < .01) and stiffness (P= .04) than SutureLasso-placed horizontal mattress sutures. SutureLasso-placed horizontal mattress sutures had lower cyclic elongation than penetrating grasper-placed horizontal mattress sutures (P= .01) and lower ultimate load (P < .01) and stiffness than SutureLasso-placed vertical mattress sutures (P < .01). Horizontal mattress sutures with radiofrequency had a higher ultimate load (P= .02), stiffness, and cyclic elongation (P < .01) than without radiofrequency. A horizontal mattress hip labrum stitch shows a lower ultimate failure load than vertical or oblique mattress stitches. Smaller-diameter suture-passing devices show less cyclic displacement and elongation than larger-diameter devices. Radiofrequency labral treatment does not alter vertical stitch strength but does alter horizontal mattress stitch strength. Vertical and oblique stitches are stronger than horizontal stitches. A 1.8-mm passing device shows a better cyclic loading performance than a 2.6-mm device.

Curative Surgical Excision of a Squamous Cell Carcinoma Associated with the Digit of an American Bullfrog (Lithobates catesbeianus)

Abstract An adult female American bullfrog (Lithobates catesbeianus) presented with an exophytic multilobular soft tissue mass involving the majority of the second left front digit. An excisional biopsy was performed under general anesthesia using a buffered tricaine methanesulfonate bath. The entire digit, including the distal, middle, and proximal phalanges, and associated mass were surgically removed by dislocation at the metacarpophalangeal joint. The incision was closed with 4-0 polydioxanone using two horizontal mattress sutures and the frog was recovered in a freshwater bath. Histological examination revealed a well-differentiated squamous cell carcinoma with a mitotic rate of less than one per high power field. Six months following surgery the frog was fully recovered and returned to use in an educational program. The frog survived four years postsurgery with no gross or histological evidence of neoplasm recurrence.

Neonatal closure of bladder exstrophy

The ureteric orifices are identified and stented. Large mucosal polyps are excised and mucosa is repaired. A midline incision is made, starting above the umbilical cord, encircling it and extending on each side on the mucosal edge of the bladder up to the level of the verumontanum. The edge of bladder is partially mobilised and bladder closure is started from the dome with interrupted inverting sutures. A stent is placed across the bladder neck and secured before the closure of the bladder. The abdominal muscles are mobilised off the skin and apposed with interrupted horizontal mattress sutures starting from the upper part of the wound. In the lower part of the wound, the sutures are applied and put on crossover traction to stretch the pelvic ligaments, and tied in turn while maintaining traction to approximate the pelvis. The skin and subcutaneous tissue are approximated. Epidural analgesia and enteral nutrition are key to postoperative pain management and healing.