Knotless Barbed Suture Research Articles

1078: Barbed versus conventional suture for uterine closure during cesarean section: An integrated retrospective study

Although a variety of options exist for uterine incision repair during cesarean section (CS) in regards to suture type and repair technique, there is limited evidence on the best approach. The objective of this study was to compare knotless barbed and conventional synthetic suture use for uterine closure in different settings of CS. A retrospective cohort study was conducted using 217 CS cases at a community teaching hospital between January 2016 and May 2019, in which the hysterotomy incision was closed with knotless barbed (n=99, 45.6%) or conventional synthetic suture (n=118, 54.4%). Aggregate cases were further categorized into one or two-layer hysterotomy closure and primary or repeat CS. Parameters of operating room (OR) time, estimated blood loss (EBL), and complication rate were designated for comparison. Patient body mass index (BMI) and assistant post-graduate year (PGY) were correlated with OR time. Statistical analysis was performed to assess whether differences between groups were significant using a p-value of ≤0.05. Mean OR times, mean EBL, and complication rates were lower for knotless barbed compared to conventional synthetic suture across all uterine closure scenarios (Figure 1 and 2). Statistically significant differences were observed for EBL in aggregate (752.9 vs. 820.9 mL; p=0.03), two-layer closure (643.6 vs. 850.4 mL; p=0.002), and repeat CS (712.2 vs. 824 mL; p=0.03) groups. BMI positively correlated with OR time (r=0.205; p=0.002). There was no significant correlation between assistant PGY and OR time (r=-0.067; p=0.325). Using knotless barbed suture compared with conventional synthetic suture for uterine closure during CS is associated with significantly lower EBL, particularly for two-layer closure and repeat CS groups. Consideration of other factors is imperative during such comparison. When selecting suture material for uterine closure, knotless barbed suture may be a favorable option to conventional synthetic suture from a patient care and healthcare cost perspective.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

975: Glove perforation after handling of knotless barbed and smooth sutures during cesarean section

975: Glove perforation after handling of knotless barbed and smooth sutures during cesarean section

Endoscopic Transoral Hybrid Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy.

The hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP, that is, open partial horizontal laryngectomies OPHL Type IIa) has been described using a flexible next generation robotic surgical platform for manipulation. We sought to evaluate the feasibility of performing this procedure using endoscopic transoral (EndoT) surgical techniques without robotics. Preclinical cadaveric study using two human cadavers. Hybrid SCPL-CHEP was performed with a flexible endoscope for visualization and hand-held instruments for manipulation (SILS Hook monopolar and Dissect, HAVAS LaryngoFIT malleable straight jaw instruments, and Stratafix 4-0 spiral knotless barbed suture). EndoT hybrid SCPL-CHEP was successfully performed. The hand-manipulated rigid instruments allowed for transoral incisions and mucosal suturing. We provide the procedural steps of EndoT hybrid techniques. EndoT hybrid SCPL-CHEP was technically feasible in the preclinical cadaveric laboratory setting and appeared comparable to the hybrid SCPL-CHEP via transoral robotic surgery (TORS). Selected handheld instruments and flexible endoscopy appear to facilitate minimally invasive surgery of the larynx. This novel procedure and technique warrant further clinical study for consideration of feasibility, applicability, and patient benefit.

Simple dural closure using a knotless barbed suture in endoscopic transsphenoidal surgery: preliminary experience

Background: Several literatures reported that suturing dura was reliable in preventing cerebrospinal fluid (CSF) leak in transsphenoidal surgery. However, suturing and knotting is technically challenging and time consuming in the transsphenoidal approach.Objectives: To simplify the dural suturing procedure, a preliminary study of barbed suturing in endoscopic transsphenoidal surgery was introduced.Material and methods: We retrospectively reviewed the patients underwent dural closure using knotless suturing after endoscopic transsphenoidal surgery from August 2015 to September 2018. In the cases of no or low-flow CSF leak (Kelly’s classification grade 0–2), the dura was sutured to restore anatomic structure and prevent postoperative CSF leak. In the cases of high-flow CSF leak (Kelly’s classification grade 3), multilayered reconstruction including dural suturing was performed. The suturing time, intra- and postoperative CSF leak were recorded.Results: Thirty-three patients underwent dural barbed suturing. The mean suturing time was about 10 min. Intraoperative CSF leak was encountered in 16 patients, including 7 patients with grade 1 CSF leak, 5 patients with grade 2 CSF leak and 4 patients with grade 3 CSF leak. No one developed into postoperative CSF leak.Conclusion: Dural closure using a barbed suture is a simply and reliable technique.

EP27.41: The efficacy and safety of knotless barbed sutures in Caesarean section

EP27.41: The efficacy and safety of knotless barbed sutures in Caesarean section

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.

Successful outcomes in laparoscopic pyeloplasty using knotless self-anchoring barbed suture in children

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in children has gained increasing importance over the last decade. Intracorporeal knot tying still remains a technical challenge for the surgeon. Self-anchoring suture incorporates a new concept for tissue approximation and reduces intracorporeal knot tying problems. There are very few reports on self-anchoring knotless suture and its application for laparoscopic pyeloplasty in children. We present our results of a series of consecutive children undergoing laparoscopic pyeloplasty with knotless barbed sutures. We prospectively evaluate 15 consecutive patients who underwent laparoscopic pyeloplasty with knotless barbed sutures (V-LocTM, Covidien) for ureteropelvic anastomosis. The decision of the operation was given by pediatric nephrology-urology-radiologic imaging diagnostic team, and all patients were operated by a single surgeon. Pyeloplasty was performed without pelvic reduction, and the anastomosis was made by barbed sutures using running fashion. The mean age of the patients were 5.39 (3 months-17 years). Two cases had undergone a right-sided pyeloplasty, and thirteen had undergone a left-sided pyeloplasty. The duration of the operative procedure was 60-110min. Neither intraoperative nor postoperative complication was encountered in any of the cases. Patients were followed by ultrasonographic evaluation. The anteroposterior diameter (AP) diameter of renal pelvis and hydronephrosis grade Society for Fetal Urology (SFU) are significantly different when compared with pre-operative and postoperative period (p=0.001 and p=0.001, respectively). Owing to the renal parenchymal thickness change by age pre-operative and postoperative thickness comparison is adjusted by age, because age is considered as a covariate (confounder variable). We observed statistically significant (p=0.003) difference in parenchymal thickness in all cases. Follow-up periods of the 15 consecutive pediatric pyeloplasty cases were 6-54 months. In the present study, successful outcome of the laparoscopic pyeloplasty using barbed suture was shown for the first time in children in literature. We believe that successful outcome of laparoscopic pyeloplasty could be achieved by eliminating knots and less manipulation on the wound edge also minimizes tissue injury during the procedure.

A Biomechanical Comparison of Tendon Repair with a Knotless Barbed Suture and a Conventional Monofilament Suture Material: An Ex-Vivo Animal Experiment

A Biomechanical Comparison of Tendon Repair with a Knotless Barbed Suture and a Conventional Monofilament Suture Material: An Ex-Vivo Animal Experiment

Barbed Versus Conventional Suture for Uterine Repair During Caesarean Section: A Randomized Controlled Study

This study sought to compare the short-term outcome of uterine incision repair during a Caesarean section (CS) using a bidirectional knotless barbed suture versus polyglactin suture. A randomized controlled trial was conducted at a university hospital. Participants undergoing a CS were randomly assigned to uterine incision closure by bidirectional knotless barbed suture (group A) or polyglactin (group B). The primary outcome was the time needed to repair the uterine incision. The analysis was by intent to treat. A sample size of 35 per group (n = 70) was planned to detect a 30% reduction in uterine repair time (Canadian Task Force Classification I). From July 2016 through October 2017, 150 women were screened, and 70 were statistically analyzed: group A (n = 35) and group B (n = 35). Time to complete uterine incision repair was 308±57 seconds for group A and 411±74 seconds for group B (P<0.001). Total surgery time (33.4±8.8 minutes vs. 33.2±7.5 minutes; P=0.64) was not significantly different between groups A and B, respectively. Repair of the CS uterine incision with barbed suture compared with polyglactin suture reduces suturing time.

The Effectiveness and Safety of Barbed Sutures in the Bariatric Surgery: a Systematic Review and Meta-analysis.

Knotless barbed sutures can eliminate knot tying during the bariatric surgery (BS). Since effects reported on patients and surgeons are ambiguous, this study is determined to identify the effectiveness and safety of knotless barbed suture in BS. PubMed, EMBASE, Cochrane Register of Clinical Studies, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) and cohort studies comparing barbed sutures with conventional sutures in BS (until July 2, 2018). Quality assessment was conducted due to Cochrane's recommendations. Review Manager was applied to analyze the data, and we performed subgroup analyses based on study design type and surgery type. A total of four cohort studies (25,505 patients, low to moderate risk of bias) and four RCTs (1480 patients, low to moderate risk of bias) proved eligible. BS includes laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy. Comparing to conventional suture, pooling data showed that suture time (MD = - 4.87, 95%CI - 8.82 to - 0.92, P = 0.02) and operative time (MD = - 7.88, 95%CI - 14.10 to - 1.67, P = 0.01) declined significantly in the barbed group. Although no significant change was in the overall postoperative complications and hospital stay, subgroup analysis of RCTs suggested that significantly, fewer bleeding conditions happened in barbed groups. Although quality of all the studies was relatively moderate and the number of the included studies was limited, the barbed suture may have the potentiality to be an effective and reliable technique and extend the application in other bariatric surgeries. More evidence with randomized design, larger sample sizes, and longer follow-up need to compel validations of this state-of-the-art in the future.

Retrospective comparison of outcomes of laparoscopic pyeloplasty using barbed suture versus nonbarbed suture: A single-center experience.

Introduction:laparoscopic pyeloplasty is an important tool in urology armamentarium. The most important & also the difficult part of this surgery is intracorporial suturing and knotting. There are only a few reports of knotless Barbed sutures for upper tract reconstruction. We report the comparative outcomes of Laparoscopic Pyeloplasty with barbed suture vs non barbed sutures used for uretero-pelvic anastomosis.Materials and Methods:We retrospectively reviewed patients' records that underwent Laparoscopic pyeloplasty at our Institution from January 2013 to May 2014. Total 37 patients were underwent LP in this period. Whole of the procedure was same as conventional LP except suture material. 3-0 barbed suture was used in 21 patients and 3-0 vicryl used in 16 patients for uretero-pelvic anastomosis and continuous suturing technique was employed. Patients' demographics, total operative time, intracorporial suturing time, post operative complications, symptoms & renal isotope scan were recorded.Results:Average total operative time was significantly less in barbed suture group vs vicryl group (162 vs 208 minutes) (p=0.0811). Average time taken for intracorporial suturing was 31.2 minutes vs 70 minutes (p=0.0576). 1 patient developed post operative urine leak which persisted for 5 days in barbed group (4.76 %) vs no leak in vicryl group. Most common complication was UTI presented in 2 patients (9.5 %) vs 2 in vicryl (12.5%). JJ stent was removed at 4 weeks. Median follow up was 3 months with 7 patients lost to follow up. None of the patients found to have obstructive drainage or deterioration of split function on follow up isotope renogram at 3 months.Conclusions:In this study, Laparoscopic pyeloplasty with barbed suture has acceptable outcome when compared to conventional non barbed suture on short term basis. Laparoscopic Pyeloplasty with barbed suture can potentially become the standard approach in near future.

Failure of a Unidirectional Barbed-Suture Device at the Arthrotomy Repair Site Following Total and Unicondylar Knee Arthroplasty

We report the failure of a routine arthrotomy repair following knee arthroplasty. Five additional cases of arthrotomy failure occurred within a 14-month period during which a specific unidirectional knotless barbed suture device had been used for arthrotomy closure. Additional study on larger cohorts may be useful to understand the effectiveness of barbed suture for arthrotomy closure in knee arthroplasty.

The effects of barbed suture on watertightness after knee arthrotomy closure: a cadaveric study

BackgroundWound closure is one of the crucial aspects of total knee arthroplasty (TKA) for patients who perform high-flexion activities of daily living, because the joint capsule is highly stretched and integrity of the arthrotomy closure must be maintained. Watertightness of the knee joint is a different aspect of the repair integrity of arthrotomy closure and is being noticed with increasing usage of the drain clamp method for blood management after TKA. Recently, the barbed knotless suture has been growing in popularity as a strong, secure closure appropriate for high-tension areas, such as the fascia and joint capsule. The purpose of this study was to compare the barbed knotless suture with simple interrupted suture in cadaveric knees.MethodsNine fresh-frozen cadaveric lower extremities were used. After placing a parapatellar incision and setting a closed suction drain, arthrotomies were closed randomly using three suture materials: simple interrupted absorbable suture (No. 0 PDS, group C); or a single running knotless barbed suture Stratafix with 8N (group BS-8N) or 15N (group BS-15N) of tension. After arthrotomy closure, saline was injected in a retrograde manner into the joint through a drain until saline started to leak from the joint. Peak values for intra-articular pressure and infusion volume in each group were recorded and compared.ResultsMean infusion volumes were 13.0 ± 7.2 ml, 38.6 ± 10.7 ml, and 5.1 ± 2.5 ml in groups BS-8N, BS-15N, and C, respectively. Mean intra-articular pressures were 0.67 ± 0.47 kPa, 9.44 ± 4.55 kPa, and 0.56 ± 0.44 kPa in groups BS-8N, BS-15N, and C, respectively. Infusion volume and joint internal pressure were significantly higher in group BS-15N than in groups BS-8N (p = 0.008) or C (p = 0.04).ConclusionsBarbed suture with 15N appears appropriate for maintaining maximal watertightness after knee joint capsule closure, offering successful drain clamping, higher resistance to early mobilization protocols, and subsequent achievement of early deep knee flexion after TKA.

Influence of barbed suture on leak pressures after double-layer inverting closure of cystotomy sites in sheep.

To determine the influence of barbed suture on double-layer inverting closure of cystotomy sites in sheep. Ex vivo study. Urinary bladders harvested from ovine (n = 26) cadaveric specimens. After collection and specimen preparation, a 3-cm-long incision was created on the ventral aspect of the urinary bladder. The cystotomy was repaired with barbed (n = 13) or nonbarbed analogous monofilament absorbable suture (n = 13) in a double-layer inverting suture pattern. Time required for closure in seconds was recorded for each test. Each bladder was connected to a pressure transducer to monitor intraluminal pressure during infusion with dyed Hartmann's solution until leakage occurred. Intraluminal pressure at time of initial leakage and leakage site were also recorded. Two-sample t tests were used to compare initial leakage pressure and closure time between the 2 types of suture (P = .05). The mean ( ± SD) leakage pressure of ovine urinary bladder incisions did not differ between closures with barbed sutures (42.3 ± 21.7 mmHg) and nonbarbed closures (32.5 ± 14.4 mmHg, P = .187). Cystorrhaphies were performed faster with barbed suture (307 ± 50 seconds) than with nonbarbed suture (390 ± 62 seconds, P = .001). The use of barbed suture did not affect mean leakage pressure of ovine urinary bladder incisions but decreased the time required to complete cystorrhaphies in this model. This study provides evidence to support the use of knotless barbed suture for open ovine cystorrhaphies. Use of such suture for laparoscopic and laparoscopic-assisted procedures in sheep warrants caution until cyclic and in vivo testing is performed with appropriate laparoscopic instrumentation.

The efficacy and safety of knotless barbed sutures in total joint arthroplasty: a meta-analysis of randomized-controlled trials

BackgroundThe knotless barbed sutures (KBS) are an innovative type of suture that can accelerate the placement of sutures and eliminate knot tying. Whether the KBS are safe and efficient in total joint arthroplasty (TJA) remains controversial. Therefore, we conducted a meta-analysis to evaluate its efficacy and safety.MethodsRandomized-controlled trials (RCTs) were identified from the PubMed, Embase, and Cochrane Library databases up to October 2017. The Cochrane risk of bias tool was used to assess methodological quality. The statistical analysis was performed with RevMan 5.3.5 software.ResultsA total of five RCTs (600 participants) were included in our meta-analysis. The results showed that KBS reduced wound suture time (MD − 4.51, 95% CI − 5.37 to − 3.66, P < 0.00001) and the wound suture cost (MD − 282.63, 95% CI − 445.32 to − 119.95, P < 0.00001), and did not significantly increase the rate of complications (OR 0.77, 95% CI 0.42–1.39, P = 0.13) or intraoperative events (OR 0.86, 95% CI 0.04–17.28, P = 0.92). There were no significant differences in ROM at postoperative 6 weeks and 3 months (MD − 0.74, 95% CI − 4.19 to 2.71, P = 0.67; MD − 0.30, 95% CI − 2.62 to 2.02, P = 0.80; respectively).ConclusionOur findings suggest that KBS are a safe and effective method for TJA. Given the possible biases, adequately powered and better designed studies with longer follow-up are required to reach a firmer conclusion.

A Novel Knotless Barbed Suture Technique for Traumatic Thoracolumbar Fracture in Posterior Surgery.

Surgical wound closure directly influences spinal surgical efficiency and several postoperative complications. The traditional suture technique is time-consuming and associated with greater rates of complications. Bidirectional absorbable barbed sutures seem to compensate for some of the limitations of traditional suture; however, they rarely are reported in spinal surgery. We designed a novel suture technique for use in thoracolumbar spinal surgery. The data of 189 patients with traumatic thoracolumbar fractures were analyzed between bidirectional barbed suture closure and traditional interrupted suture closure. Data of operative time, wound closure time, length of incision, intraoperative blood loss, complications of wound dehiscence and postoperative hematoma, cost, and neurologic status were collected. No significant differences were observed in the baseline demographics of included patients. Compared with the traditional suturing group, the barbed sutures decreased the mean operative time (P= 0.037), suture time (P < 0.01), and mean suturing time (P < 0.01) significantly, although no statistically significant differences were found in blood loss (P= 0.724) and neurologic functional scores (preoperative: P= 0.901; 3 months after surgery: P= 0.208; final follow-up assessments: P= 0.163), and no statistically significant differences were found in rates of postoperative infection, hematoma, and wound dehiscence. Our findings suggest that the novel knotless barbed suture has comparable strength to traditional sutures, with the advantage of less suturing time. It is an efficient, safe technique, and alternative choice for patients with thoracolumbar fracture after posterior surgery.

A randomized clinical trial of knotless barbed suture vs conventional suture for closure of the uterine incision at cesarean delivery

Knotless barbed sutures are monofilament sutures with barbs cut into them. These sutures self-anchor, maintaining tissue approximation without the need for surgical knots. The hypothesis of this study was that knotless barbed suture could be used on the myometrium to close the hysterotomy at cesarean delivery. The objective was to compare uterine closure time, need for additional sutures, and blood loss between this and a conventional suture. This was a prospective, unblinded, randomized controlled trial conducted at the Ziv Medical Center, Zefat, Israel. The primary outcome was the length of time needed to close the uterine incision, which was measured from the start of the first suture on the uterus until obtaining uterine hemostasis. To minimize provider bias, women were randomized by sealed envelopes that were opened in the operating room just prior to uterine closure with either a bidirectional knotless barbed suture or conventional suture. Secondary outcomes included the number of additional hemostatic sutures needed and blood loss during incision closure. Patients were enrolled from August 2016 until March 2017. One hundred two women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesarean deliveries. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 minute 43 seconds (P < .001, 95% confidence interval, 67.69-138.47 seconds). Knotless barbed sutures were associated with a lower need for hemostatic sutures (median 0 vs 1, P < .001), and blood loss measured during incision closure was significantly lower (mean 221 mL vs 268 mL, P<.005). The use of a knotless barbed suture is a reasonable alternative to conventional sutures because it reduced the closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

The Role of Barbed Sutures in Wound Closure Following Knee and Hip Arthroplasty: A Review.

Lower extremity joint arthroplasty procedures often require a large incision to have an adequate exposure, which subsequently leads to lengthy wounds that may contribute to long closure, anesthesia, and overall operative times. The recently introduced knotless barbed suture may provide better outcomes, faster closure time, and decreased material utilization. Therefore, the aim of this study was to review the impact of barbed sutures on: (1) wound-related complications; (2) closure and operative time; (3) patient outcomes (range of motion and Knee Society Scores [KSS]); and (4) effects on cosmesis and patients' satisfaction. A literature search was performed using up to February 2017. Barbed sutures were associated with shorter closure times, shorter operative times, and larger cost savings per procedure as well as comparable wound complication rates after total joint arthroplasty. Although the current review is limited by the number of studies included, it demonstrates that overall, barbed sutures contribute to surgical efficiency when compared with conventional skin closure modalities.

32: Knotless barbed suture closure of the uterine incision at cesarean - a randomized controlled trial

Knotless barbed sutures are becoming increasingly available for surgical procedures in obstetrics and gynecology. Our purpose was to determine if the use of the knotless barbed suture reduces closure time of the uterine incision at cesarean delivery. This was a prospective randomized controlled trial. The primary outcome was closure time of the uterine incision. In order to show a decrease of 25% from 6 min to 4.5 min using the knotless barbed suture with a power of 0.9 and type 1 error of 5%, at least 34 women would be needed in each group. Women were randomized by sealed envelope to uterine closure with either a bidirectional knotless barbed suture or polyglactin 910 braided (conventional) suture. Secondary outcomes included blood loss during incision closure and the number of additional hemostatic sutures needed. Patients were enrolled from August 2016 until March 2017. 102 women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesareans. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 min 43 sec (P<0.000, 95% CI 67.69 - 138.47 sec). Blood loss estimated during incision closure was significantly lower (mean 221 ml versus 268 ml, P<0.005) and the use of hemostatic sutures was significantly less (median 0 versus 1, P<0.0001). The use of a knotless barbed suture significantly reduced closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

Laparoscopic proximal gastrectomy with hinged double flap method using knotless barbed absorbable sutures: A case series

BackgroundIntracorporeal reconstruction following laparoscopic proximal gastrectomy is technically challenging. The aim of this study was to investigate the use of knotless barbed absorbable sutures in esophagogastrostomy closure using the hinged double flap method. Design & methodThe subjects comprised patients with gastric cancer who were scheduled to undergo laparoscopic proximal gastrectomy. The V-Loc™ 180 wound closure device (V-Loc; Covidien, Mansfield, MA, USA) was used for all laparoscopic esophagogastrostomy closures. Between January 2015 and November 2016, 13 patients were enrolled. ResultsThe mean suturing time was 109.6 min. Median hospital stay was 14 days. One anastomotic minor leakage occurred in an esophagogastrostomy and it was managed conservatively. Twelve of 13 patients did not exhibit any symptoms of reflux esophagitis. ConclusionThese results suggest the use of the unidirectional barbed absorbable suture is safe and produce reproducible results for esophagogastrostomy closure using the hinged double flap method.