Layer Of Sutures Research Articles

Hybrid surgical approach for a large schwannoma from the cervical esophagus to the upper thoracic esophagus: a case report

BackgroundEsophageal schwannoma is an extremely rare esophageal submucosal tumor. We report a case of a hybrid surgery for a large esophageal schwannoma that had extended from the cervical to the upper thoracic esophagus by using thoracoscopic and cervical approaches.Case presentationA 58-year-old male was referred to our hospital for further examination and treatment of dysphagia and weight loss over the past 6 months. Upper gastrointestinal endoscopy revealed a 5.7-cm submucosal tumor from the cervical esophagus to the upper thoracic esophagus. The submucosal tumor was diagnosed as esophageal schwannoma by endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA). Contrast-enhanced CT showed that the tumor had not invaded surrounding organs. Since the tumor extended from the cervical esophagus to the upper thoracic esophagus, we decided that it should be resected by not only the cervical but also the thoracoscopic approach. In operation, the patient was first placed in the prone position, and a thoracoscopic dissection of the upper thoracic esophagus containing the tumor was performed from the surrounding area. After changing the patient’s position from prone to supine, a cervical skin incision was performed, and we underwent the tumor enucleation. After enucleation, the esophageal wall was thinned, so the right sternocleidomastoid muscle was used to reinforce the esophageal wall. The tumor size of the specimen was 60 × 52 × 42 mm. The postoperative course was uneventful, and the patient was discharged on the 22nd day after surgery.ConclusionsEnucleation of a large esophageal schwannoma from the cervical to the upper thoracic esophagus could be safely performed using both thoracoscopic and cervical approaches. The sternocleidomastoid muscle flap is useful in the occasion considering stenosis by muscular layer suture.

New linear stapled semimechanical esophagogastric anastomosis with invagination

Objective. Development and implementation esophagogastric linear stapled semimechanical anastomosis with invagination. Material and methods. Seromuscular stitches are applied over 4 cm on both sides to the lateral surfaces of the esophagus posterior wall and gastric graft posterior wall, towards their edges. The posterior wall of the anastomosis is sutured and cutted with a linear stapler on 30–40 mm deep. The anterior wall sutured with a linear stapler. The next layer of sutures on the anastomosis anterior wall invaginates the anastomos and the esophageal stump into the gastric graft. Results. There was no early postoperative mortality. Average I. Lewis minimally invasive esophagectomy time was 353 minutes (245–470 minutes). The average volume of blood loss was 114 mL (50–200 mL). No patient faced an anastomotic leak. Anastomotic stricture occurred in 5 patients (19.2%) during 21 days to 6 months of follow-up. There were no anastomosis-related complications above Clavien-Dindo grade II. Conclusions. Linear stapled semimechanical anastomosis with invagination has proven both clinical and technical advantages of its use.

A Comparison of the Efficacy Between Mass Closure and Layer by Layer Closure of Midline Laparotomy and Its Influence on Wound Healing: A Prospective Study

Introduction: The midline laparotomy is the most common approach in surgery which gives access to viscera of the abdomen. Following surgery, the laparotomy wound is sutured by two techniques: mass closure and layer by layer closure. The primary objective of wound closure is to restore the function of the abdominal wall. However the method adopted for incision closure has an influence on the outcomes of wound healing. Our study wants to compare the two suture techniques in terms of efficacy and wound healing. Aims: To compare conventional layer by layer suture technique versus mass closure in terms of efficacy and wound healing in patients with midline laparotomy approach. Methods: A Prospective study with a population size of 94 was performed at the surgery department of Nepalgunj medical college teaching hospital, Nepalgunj, starting from September 2023 to May 2024. A pre-tested questionnaire containing structural, semi-structural, and open-ended questions in printed form was made as a data collection tool. All the people in this study were interviewed after receiving their consent. Patients were followed up for 3 months to rule out any post operative complications. Results: Total 94 patients were studied among which majority of patients were in 30-39 age group. Male outnumbered the females. Incidence of early complications like seroma, wound infection and wound dehiscence was more in layered closure group as compared to mass closure. Average time taken in layered vs. mass closure group is 15 vs 25 mins respectively. Overall wound healing was found more efficacious in mass closure group which is also cost effective than layered closure group. Conclusion: Mass closure technique is less time consuming, along fewer instances of surgical site infection and dehiscence with better overall compliance.

Double-Needle Bidirectional Barbed Wire Continuous Layered Suture Technique for Laparoscopic Stage I Common Bile Duct Surgery.

Background: Laparoscopic common bile duct exploration (LCBDE) proves a safe and effective treatment for choledochal stones. After LCBDE, preferred choledochal closure is favored for short- and long-term outcomes compared with t-tube drainage. However, there are no relevant studies on the technique of layered closure of the common bile duct with double-needle bidirectional barbed suture at home and abroad. Materials and Methods: A retrospective study of 37 patients who underwent laparoscopic choledochotomy from January 2021 to October 2023 in our hospital was performed. A continuous layered one-stage suture using two-needle bidirectional barb wire. The primary outcomes were stone clearance, operative time, blood loss, and complications. Secondary outcomes were complications, length of hospitalization, and time to drain removal. Results: During the study period, laparoscopic surgery was successful in all cases, and the initial stones were removed without complications. Conclusion: The treatment of choledocholithiasis with continuous layered one-stage suture with double-needle bidirectional barbed wire after LCBDE is a new convenient and effective treatment in selected patients.

Artificial selection of mutations in two nearby genes gave rise to shattering resistance in soybean

Resistance to pod shattering is a key domestication-related trait selected for seed production in many crops. Here, we show that the transition from shattering in wild soybeans to shattering resistance in cultivated soybeans resulted from selection of mutations within the coding sequences of two nearby genes - Sh1 and Pdh1. Sh1 encodes a C2H2-like zinc finger transcription factor that promotes shattering by repressing SHAT1-5 expression, thereby reducing the secondary wall thickness of fiber cap cells in the abscission layers of pod sutures, while Pdh1 encodes a dirigent protein that orchestrates asymmetric lignin distribution in inner sclerenchyma, creating torsion in pod walls that facilitates shattering. Integration analyses of quantitative trait locus mapping, genome-wide association studies, and allele distribution in representative soybean germplasm suggest that these two genes are primary modulators underlying this domestication trait. Our study thus provides comprehensive understanding regarding the genetic, molecular, and cellular bases of shattering resistance in soybeans.

Comparison of surgical outcomes of robot-assisted laparoscopic partial nephrectomy performed by a single experienced surgeon according to two reconstruction methods, including single-layer and double-layer renorrhaphy.

This study aimed to assess the surgical outcomes of single-layer versus double-layer renorrhaphy in robot-assisted laparoscopic partial nephrectomy (RAPN) performed by an experienced surgeon.We enrolled 655 patients who underwent RAPN between January 2019 and June 2023. After excluding those with multiple tumors or incomplete medical records, 554 patients were included in the final analysis. We compared surgical outcomes between single-layer renorrhaphy (outer cortical closure) and double-layer renorrhaphy (inner layer suture and outer cortical closure), adjusting for preoperative factors such as sex, age, body mass index, American Society of Anesthesiologists score, preoperative estimated glomerular filtration rate (eGFR), preoperative complications (diabetes or hypertension), surgical approach (transperitoneal or retroperitoneal), tumor size, and tumor complexity, using propensity score matching. Of the 554 patients analyzed, 59 were classified into the single-layer group and 495 into the double-layer group. Before matching, the double-layer group had more complex and larger tumors. After matching, 58 patients were included in each group. The single-layer group showed significantly shorter operative times (91min vs. 100min, p = 0.0361), lower estimated blood loss (EBL) (7.9ml vs. 27ml, p = 0.021), and better preservation of eGFR (-1.2% vs. -5.1%, p = 0.0313). Other outcomes, such as perioperative complications and postoperative hospital stay, were not significantly different between the groups. Single-layer renorrhaphy demonstrated better surgical outcomes, including shorter operative time, lower EBL, and better preservation of kidney function, compared to double-layer renorrhaphy. These findings suggest that single-layer reconstruction may optimize RAPN outcomes in selected patients.

Effect of Single layer versus Double Layer Suturing on Healing of cesarean Uterine Scar: A Randomized controlled trial

Effect of Single layer versus Double Layer Suturing on Healing of cesarean Uterine Scar: A Randomized controlled trial

Single-layer versus double-layer renorrhaphy technique during robot-assisted partial nephrectomy: impact on perioperative outcomes, complications, and functional outcomes.

The debate between single-layer and double-layer renorrhaphy techniques during robot-assisted partial nephrectomy (RPN) represents a subject of ongoing discourse. The present analysis aims to compare the perioperative and functional outcomes of single- versus double-layer renorrhaphy during RPN. Study data were retrieved from prospectively maintained institutional database (Jan2018-May2023). Study population was divided into two groups according to the number of layers (single vs. double) used for renorrhaphy. Baseline and perioperative data were compared. Postoperative surgical outcomes included type and grade of complications as classified according to Clavien-Dindo. Serum creatinine and estimated glomerular filtration rate were used to measure renal function. Three hundred seventeen patients were included in the analysis: 209 received single-layer closure, while 108 underwent double-layer renorrhaphy. Baseline characteristics were not statistically different between the groups. Comparable low incidence of intraoperative complications was observed between the cohorts (P=0.5). No difference was found in terms of mean (95% CI) Hb level drop postoperation (single-layer: 1.6 g/dL [1.5-1.7] vs. double-layer: 1.4 g/dL [1.2-1.5], P=0.3). Overall and "major" rate of complications were 16% and 3%, respectively, with no difference observed in terms of any grade (P=0.2) and major complications (P=0.7). Postoperative renal function was not statistically different between the treatment modalities. At logistic regression analyses, no difference in terms of probability of overall (OR 0.82 [0.63-1.88]) and major (OR 0.94 [0.77-6.44]) complications for the number of suture layers was observed. Single-layer and double-layer renorrhaphy demonstrated comparable perioperative and functional outcomes within the setting of the present study.

Suturing with or without surgical glue is superior to surgical glue alone for sealing ex vivo swine gallbladders.

To assess the effectiveness of various sealing techniques in cholecystotomies under maximum intraluminal pressure stress using an ex vivo swine model. 30 gallbladders from different animals were used. The experiment was conducted ex vivo, with the formation of 3 groups, each comprising 10 samples. Group 1 utilized a traditional single-layer Cushing suture made from polydioxanone material. Group 2 employed a single layer of Cushing suture, also made from polydioxanone material, but in conjunction with surgical glue (n-butyl cyanoacrylate). Group 3 relied solely on the use of surgical glue (n-butyl cyanoacrylate) for sealing the edges of the surgical wound. The intraluminal pressure was gauged with a pressure transducer. The maximum intraluminal pressures (mean ± SD) sustained in G1, G2, and G3 were, respectively, 48.70 ± 21.32 mm Hg, 110.90 ± 37.52 mm Hg, and 10.9 ± 4.07 mm Hg. Comparisons between groups showed that G2 supported significantly higher pressures (56.1% higher) than G1 (P < .001) and G3 (90.2% higher; P < .001). When G1 was compared with G3, a significantly higher pressure (77.6%) was also observed (P < .01). The study's conclusions demonstrated the safest suture techniques for the gallbladder and provided advice regarding the use of surgical glue.

Reducing patient’s perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT)

Study ObjectiveDetermine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients’ perception of postoperative bleeding after laparoscopic hysterectomy. DesignRandomized controlled trial. SettingUniversity-based medical center. PatientsFemales ages 18–60 undergoing laparoscopic hysterectomy. InterventionsPatients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90–114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days. Resultsn = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0–5.0) v 2.0 (0–4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30–75) vs 50 mL (20–75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar. ConclusionIndependently suturing the vaginal cuff angles reduces patients’ perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar.

Pilonidal sinus hastalığında Rhomboid eksizyon ve Modifiye Limberg flep uygulanan hastalarda tek merkez klinik deneyiminin değerlendirilmesi

Aims: Pilonidal sinus disease (PSD) is a chronic inflammatory disease that is seen especially in young men, is often located in the sacrococcygeal region and negatively affects the quality of life and daily life of the person. In this study, we aimed to share our experience with the literature by examining our clinical approach and results in the patient group who underwent Modified Limberg flap technique electively in PSD.&#x0D; Methods: Patients who underwent elective modified Limberg flap application due to PSD in the general surgery clinic were included in the study. Demographic and clinical parameters of the patients were investigated retrospectively.&#x0D; Results: The mean age of 76 patients included in the study was 27.5±8.5 years (18-51 years). The median duration of hospitalisation was 2 days. The most commonly preferred prophylactic antibiotic at surgery was cefuroxime + metranidazole combination (60.5%) or cefuroxime alone (32.9%). Drain use was present in approximately 40% of the cases. Subcutaneous tissues were closed with a single layer of polyglactin suture in most cases (94.7%). During the median follow-up period of 12 months, postoperative recurrence was observed in only 6 cases (7.9%).&#x0D; Conclusions: Modified Limberg flap technique is a well-defined, safe and feasible surgical method. Since it is an effective off-midline technique, its application by experienced surgeons in complicated and recurrent cases in elective PSD surgery and its transfer to junior and resident surgeons will be effective in terms of moving away from midline techniques.

Reconstruction Techniques After Partial Nephrectomy: Classic vs. Sutureless Approach-A Narrative Review.

The purpose of this review is to update the information about the different types of reconstruction after partial nephrectomy, with special emphasis on the new methods of suture-free hemostasis currently available. The aim of renal reconstruction is to avoid bleeding and leakage of the collecting system, but now the renorrhaphy technique used is considered one of the modifiable determinants of renal function after surgery. In an attempt to avoid the loss of renal function implicit in classic reconstruction, new techniques have been described to control hemostasis and urinary leakage, which employ fewer suture layers, different suture materials and designs, and a wide range of commercially available hemostatic materials. Multiple suture characteristics have been studied as a potential factor influencing the renal function observed after partial nephrectomy. Single-plane suture techniques, the use of bearded sutures, and running sutures seem to be associated with less deterioration in postoperative renal function, and deep medullary sutures should be avoided to avoid affecting the arcuate arteries. Sutureless hemostasis systems could prevent the deterioration of renal function and complications derived from suturing, also reducing ischemia time and surgical time without increasing the risk of complications.

Esophageal anastomosis: experience of open surgery and modern possibilities of video endoscopic technologies. A review

The weakest link in laparoscopic gastrectomy is the esophageal anastomosis, the reliability of which, despite the large number of proposed techniques, remains insufficient. The article presents modern methods of intracorporeal esophageal anastomosis, assesses their advantages and disadvantages. Almost all techniques use a single-layered, mostly mechanical, suture. The probability of maintaining the tightness of a single-layered esophageal anastomosis in case of its healing by secondary tension is extremely small. The experience of open surgery has shown that the placement of the terminal esophagus and the first layer of sutures of anastomosis in a serous-muscular sheath, which is formed from the wall of the intestine or stomach using invagination or wrapping methods, provides a greater likelihood of maintaining the tightness of the anastomosis in any type of healing. Expanding indications for the use of these methods in open surgery and developing a technique for intracorporeal esophageal anastomosis with covering the first layer of sutures of anastomosis with the wall of the anastomosed organ seems to be a promising direction that can significantly reduce the incidence of anastomotic leak both in open and laparoscopic surgery.

489. COLON DIVERTICULUM IN THE CERVICAL REGION FOLLOWING COLON INTERPOSITION FOR CORROSIVE INJURY: A CASE REPORT

Abstract Background Colon interposition is one of the traditional procedures for esophageal reconstruction following corrosive injury. While the colonic conduit has the potential to restore swallowing function in patients, yet the long term complications are not well documented. we, herby, present a case of colon diverticulum in the neck 17 years after bypass surgery. Methods a 22 years old female patient presented with a one year history of gradually progressive grade I dysphagia following a colon bypass surgery performed for esophageal reconstruction for corrosive stricture at the age of 5 years old. Clinical assessment revealed the presence of a swelling on the left side of her neck which increased in size upon swallowing. The patient reported that applying pressure on the swelling was associated with sensation of passage of the food bolus. Endoscopic and Radiological assessment confirmed the presence of a neck diverticulum at the site of the anastomosis. Results Neck exploration was performed. The diverticulum was dissected from the surrounding tissues with particular care to preserve the colon mesentery. The esophago-colic anastomosis was identified. It was found that this anastomosis was performed in an end to side fashion. The diverticulum appeared to be the enlarged side of the colon which was enlarged causing compression on the esophagus (1). This part was resected using a stapler after intraoperative endoscopic assessment (2,3). A second layer of interrupted sutures was performed over the stapled part (4). The postoperative course was uneventful and was associated with improved dysphagia. Conclusion Symptomatic colon diverticulum in the neck is a rare long term complication following colon bypass and esophago-colic anastomosis. Particular care should be made when performing it in an end to side fashion. End to end esophago-colic anastomosis could potentially prevent such complication.

Influence of design parameters on the flexural properties of a bio-inspired suture structure

ABSTRACT Among various bio-inspired structures, sutures are a prominent structure which has evolved independently to optimize their functionalities. The diabolical ironclad beetle suture-inspired structure was fabricated using multi-material additive manufacturing (3D printing) system with TangoBlackPlus (TBP) as the soft suture layer and VeroWhitePlus (VWP) as the hard material. The print quality of the specimen was assessed through the optical microscope images, and a nanoindentation test was performed to investigate the interfacial hardness between TBP and VWP. Flexural properties of the suture structure when changing the thickness of the soft layers were then studied. Experiments were continued to identify the effect of combining different sizes of suture modules to develop the suture structure. A numerical simulation model was then generated and validated using the experimental results to proceed with the parametric study. A design of experiment (DoE) was developed to analyse the effect of changing the suture geometry to optimize performance. The research concluded that gradually decreasing the size of the suture allowed the structure to withstand higher loads. It was also evident that the deformability of the structure could be increased by incorporating smaller interlocking angles and larger a:b ratios, while larger interlocking angles and smaller a:b ratios generate stiff structures.

Comparing the closure of hepatocaval ligament using stapler or suturing in liver surgery

Objectives: Hepatocaval ligament is localized on the posterior and lateral side of the retrohepatic Inferior Vena Cava (IVC) , above the right adrenal vein. Bleeding due to retro-hepatic cava injury could sometimes occur during the dissection and closure of hepatocaval ligament (HCL). We aim to determine closing meth- ods of HCL in terms of cost, ease of application and safety. Methods: The study population included 90 recipient hepatectomy patients who had cadaveric and live-donor liver transplantation at Organ Transplant Center of Acıbadem Hospital between 2017 and 2019. The patients were divided into two groups. The first group contained 40 patients who were closed with 25 mm EndoTA 30 stapler. The second group contained 50 patients who were closed by continuous double- layer suturing with 5/0 propylene. Results: In the group closed by endovascular stapler, reinforcement suturing was performed in eight patients (20%) using 5/0 propylene suture due to mild blood leakage in the closing line. In two patients (5%), on the other hand, the staple device could not be used due to the fact that HCL was very close to the right hepatic vein and the distance between the liver and the vena cava was short. There were no perioperative and postoperative HCL-associated liver and vena cava bleeding complications in both groups. However, the cost was significantly higher in the stapler group than in the suturing group. Conclusions: The present study is the first to compare the stapler or suturing techniques for closing HCL in the receiver hepatectomy of liver transplantation. The results indicated that the closure with suturing was at least as useful and convenient in terms of cost, ease of application and safety.

Application of endoscopic suturing instrument in laparoscopic gastrojejunostomy

Objective: To investigate the safety and feasibility of using an endoscopic suturing instrument in laparoscopic gastrojejunostomy. Methods: A descriptive case series study was conducted to retrospectively analyze the clinical data of 5 patients with gastric cancer who underwent laparoscopic distal gastrectomy (Billroth II + Braun anastomosis) at Tangdu Hospital, Air Force Medical University from October 2022 to January 2023. The common opening was closed using an endoscopic suturing instrument. The indications were as follows: (1) patients aged between 18 and 80 years; (2) patients with gastric adenocarcinoma; (3) cTNM between I-III; (4) lower-third gastric cancer and radical gastrectomy is recommended; (5) no history of upper abdominal surgery (except for laparoscopic cholecystectomy). The surgery was performed as follows: A side-to-side gastrojejunostomy was performed with endoscopic linear cutter stapler. Then the common opening was closed with endoscopic suturing instrument. During suturing and closing the common opening, a vertical mattress suture was used to completely invert and close the mucosa-to-mucosa and serosa-to-serosa of the gastric and jejunum walls. After the first layer of suture was completed, the seromuscular layer was sutured from top to bottom to embed the common opening of stomach and jejunum. Results: Laparoscopic closure of the common gastrojejunal opening with endoscopic suturing instrument was successfully completed in all 5 patients. The operative time was (308.6±22.6) minutes, while the time of gastrojejunostomy was (15.4±3.1) minutes. The operative blood loss was (34.0±10.8) ml. No intraoperative or postoperative complications occurred in any of the patients. The first passage of gas occurred at (2.6±0.9) days, and the postoperative hospital stay was (7.0±1.9) days. Conclusion: The application of endoscopic suturing instrument in laparoscopic gastrojejunostomy is safe and feasible.

Effectiveness of fascial tissue flaps and skin flaps with layered sutures for repair of wounds after excision of sacrococcygeal pilonidal sinus

To investigate the feasibility and effectiveness of fascial tissue flaps and skin flaps with layered sutures for repairing wounds after excision of sacrococcygeal pilonidal sinus. Between March 2019 and August 2022, 9 patients with sacrococcygeal pilonidal sinus were admitted, including 7 males and 2 females with an average age of 29.4 years (range, 17-53 years). The disease duration ranged from 1 to 36 months, with a median of 6 months. There were 7 cases with obesity and dense hair, 3 cases with infection, and 2 cases with positive bacterial culture of sinus secretion. The wound area after excision ranged from 3 cm×3 cm to 8 cm×4 cm, with a depth of 3-5 cm, reaching the perianal or caudal bone; there were 2 cases with perianal abscess formation and 1 case with caudal bone inflammatory edema. Enlarged resection was performed during operation, and the fascial tissue flap and skin flap were designed and excised at both left and right sides of the buttock, ranging from 3.0 cm×1.5 cm to 8.0 cm×2.0 cm. A cross drainage tube was placed at the bottom of the wound, and the fascial tissue flap and skin flap were advanced and sutured in three layers, namely, 8-string sutures in the fascial layer, barbed wire reduction sutures in the dermis, and interrupted skin sutures. All 9 patients were followed up 3-36 months, with an average of 12 months. All incisions healed by first intention, and no complication such as incisional dehiscence or infection in the operative area occurred. There was no recurrence of sinus tracts, the shape of gluteal sulcus was satisfactory, both sides of buttocks were symmetrical, local incision scar was concealed, and the shape disruption was minimal. Fascial tissue flaps and skin flaps with layered sutures for repairing wounds after excision of sacrococcygeal pilonidal sinus can effectively fill the cavity and reduce the incidence of poor incision healing, with the advantages of small trauma and simple operation.

V08-12 PERINEAL APPROACH IN THE MANAGEMENT OF URORECTAL FISTULA

You have accessJournal of UrologyCME1 Apr 2023V08-12 PERINEAL APPROACH IN THE MANAGEMENT OF URORECTAL FISTULA Agusti Marfany, Anastasia Frost, Nicola Jeffery, Mariya Dragova, Angelica Lomiteng, Daniela Andrich, and Anthony Mundy Agusti MarfanyAgusti Marfany More articles by this author , Anastasia FrostAnastasia Frost More articles by this author , Nicola JefferyNicola Jeffery More articles by this author , Mariya DragovaMariya Dragova More articles by this author , Angelica LomitengAngelica Lomiteng More articles by this author , Daniela AndrichDaniela Andrich More articles by this author , and Anthony MundyAnthony Mundy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003306.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The current increase in radical prostatectomies has raised the incidence of urorectal fistulas. When the conservative management fails, a surgical solution should be considered. Urorectal fistulas are one of the most difficult problems a urologist can face. There is no standard surgical approach to treat such fistulas as few surgeons have enough large experience to deal with them. Several approaches have been described: transabdominal, posterior-sagittal (Kraske), posterior trans-sphincteric (York-Mason), transanal and perineal. The perineal approach grants a greater exposure of the rectum and the inferior urinary tract and allows the interposition of flaps if needed. But it is a surgical challenge since it is a narrow space surrounded by relevant structures. The objective of this video is to present the perineal approach of urorectal fistula repair. METHODS: A 72-year-old patient is derived to a quaternary care urology center for a reconstructive solution. He had a radical assisted laparoscopic prostatectomy (RALP) performed one year ago due to a high-risk prostate cancer, complicated with a urorectal fistula. He was initially treated with a urethral catheter and a defunctioning loop colostomy. Patient was fit and well in our first assessment. A cystoscopy is performed to assess the location and size of the fistula, its relation to the ureter orifices and bladder neck, as well as the presence of visible health tissue near the fistula. An MRI gives information about the fistula tract and its relation to surrounding organs. The patient was put in for surgery. RESULTS: An inversed U-shaped perianal incision is performed. A deepen dissection through the perineal body, levators ani and the anterior rectal wall leads to the fistula tract. Precaution is taken to follow the right directions of the dissection until the rectovesical pouch is reached. Bladder and rectal defects are closed separately with two layers of sutures. Levators ani are interposed, and dead space is obliterated with sutures. Urethral catheter is removed 4 weeks after the operation with confirmed leak tightness on the peri-catheter urethrogram. CONCLUSIONS: Urorectal fistulas are manageable through a perineal approach, which is part of the armamentarium of the urology reconstructive surgeon. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e752 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Agusti Marfany More articles by this author Anastasia Frost More articles by this author Nicola Jeffery More articles by this author Mariya Dragova More articles by this author Angelica Lomiteng More articles by this author Daniela Andrich More articles by this author Anthony Mundy More articles by this author Expand All Advertisement PDF downloadLoading ...

V11-11 A 3-D PRINTED SYNTHETIC VAS DEFERENS FOR MICROSURGERY PRACTICE AND TRAINING

You have accessJournal of UrologyCME1 Apr 2023V11-11 A 3-D PRINTED SYNTHETIC VAS DEFERENS FOR MICROSURGERY PRACTICE AND TRAINING Parth Joshi, Brian Gillette, and Richard Schoor Parth JoshiParth Joshi More articles by this author , Brian GilletteBrian Gillette More articles by this author , and Richard SchoorRichard Schoor More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Microsurgery is difficult to perform and to teach. While other models for microsurgical practice exist, such as rubber tubing, dog neuter specimens, bull reproductive tracts, and human cadaver specimens, these are either not realistic enough to be useful as practice tools or are expensive or are not readily available. We believe that practicing microsurgery improves performance in real world conditions. As such, in order to become better microsurgeons ourselves and for our patients and to improve the quality of microsurgical training for our residents, we developed a synthetic vas deferens that has the physical characteristics of native human vas deferens. This video demonstrates the results of that endeavor. METHODS: We determined the physical characteristics of native human vas deferens in terms of inner lumen diameter, outer diameter, flexibility, axial rigidity, and tactile similarity using previously published anatomic studies, ultrastructural and imaging research and professional knowledge. We then used to a 3-D printer to create a cylindrical tube that had similar characteristics to native vas deferens and then tested it by performing anastomoses on the model using 7-0, 8-0, and 9-0 suture. After a process of trial and error, we eventually developed a working prototype that met our specifications. RESULTS: The synthetic 3-D printed vas deferens models had similar inner luminal diameter and outer diameter to native human vas deferens. The synthetic vas deferens had a similar tactile feel and physical characteristics as native vas. Surgical placement of 7-0, 8-0, and 9-0 nylon suture into the wall of the synthetic vas deferens and its lumen mimicked closely the experience of operating on native vas deferens. While tying good quality square knots was straightforward using 7-0 and 8-0 nylon suture, the synthetic vas deferens was too springy for the 9-0 suture and often resulted in either air-knots or suture breakage. However, by using excellent microsurgical techniques, it was possible to perform a quality modified one layer anastomosis using our 3-D printed synthetic vas deferens. The experience of practice with our model system simulated the experience of doing an actual anastomosis on a human. Aside for research and development costs, the cost for each synthetic vas specimen is less than $1.00 and the specimens have an unlimited shelf-life. CONCLUSIONS: The time to learn microsurgery or to practice it is not when the patient is on the operating table. We have developed a excellent, inexpensive, and readily available simulation vas deferens that is useful for both the experienced microsurgeon and the trainee or novice. Our research team is continually refining the synthetic vas deferens so that it becomes more lifelike and better accommodates 9-0 sutures and even everted 10-0 inner layer suture placement. Our goal is to share this technology with other training programs and standardize microsurgical education nationally and internationally. Source of Funding: Internal funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1002 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parth Joshi More articles by this author Brian Gillette More articles by this author Richard Schoor More articles by this author Expand All Advertisement PDF downloadLoading ...