Precise Suture Placement Research Articles

Optimizing cutaneous excisions on extremities: a comparative review of elliptical closure and S-plasty techniques

This review elucidates the comparative applications of elliptical closures and S-plasty or “lazy s” in the excision of cutaneous neoplasms on the extremities. The article completes an analysis of closure techniques by discussing their merits, limitations, and optimal applications based on their orientation and tension dynamics. It also provides a detailed guide on suture placement and specific intraoperative maneuvers associated with the S-plasty to enhance surgical outcomes. The S-plasty, preferred for its diminished suture line tension and adaptability to convex areas, is analyzed against traditional relaxed skin tension lines and the emerging biodynamic excisional skin tension (BEST) lines. The review underscores the BEST lines’ role in minimizing perpendicular traction and their impact on improved surgical outcomes on the extremities. It also addresses the challenges of excessive traction along wound margins and the consequential suboptimal healing outcomes, emphasizing the importance of appropriate tension management. This review also compares the stability, efficiency, and esthetic outcomes of the S-plasty with elliptical excisions, highlighting the S-plasty’s superior ability to distribute tensile forces evenly, thus reducing the risk of scar-related complications. It also discusses the benefits of using BEST lines for tension vector dispersion coupled with the design of an S-plasty, even when relaxed skin tension line favors a horizontal orientation. Furthermore, the review elaborates on the procedural execution of the S-plasty, emphasizing the importance of precise suture placement and selecting suitable suture materials and techniques to ensure optimal wound edge perfusion. The overarching theme is the prioritization of technique based on specific anatomic considerations and the surgeon’s expertise to ensure the most effective and beneficial cutaneous excisions on the extremities.

In Vivo Efficacy of a Novel, Sutureless Coaptation Device for Repairing Peripheral Nerve Defects.

Although microsuture neurorrhaphy is the accepted clinical standard treatment for severed peripheral nerves, this technique requires microsurgical proficiency and still often fails to provide adequate nerve approximation for effective regeneration. Entubulation utilizing commercially available conduits may enhance the technical quality of the nerve coaptation and potentially provide a proregenerative microenvironment, but still requires precise suture placement. We developed a sutureless nerve coaptation device, Nerve Tape®, that utilizes Nitinol microhooks embedded within a porcine small intestinal submucosa backing. These tiny microhooks engage the outer epineurium of the nerve, while the backing wraps the coaptation to provide a stable, entubulated repair. In this study, we examine the impact of Nerve Tape on nerve tissue and axonal regeneration, compared with repairs performed with commercially available conduit-assisted or microsuture-only repairs. Eighteen male New Zealand white rabbits underwent a tibial nerve transection, immediately repaired with (1) Nerve Tape, (2) conduit plus anchoring sutures, or (3) four 9-0 nylon epineurial microsutures. At 16 weeks postinjury, the nerves were re-exposed to test sensory and motor nerve conduction, measure target muscle weight and girth, and perform nerve tissue histology. Nerve conduction velocities in the Nerve Tape group were significantly better than both the microsuture and conduit groups, while nerve compound action potential amplitudes in the Nerve Tape group were significantly better than the conduit group only. Gross morphology, muscle characteristics, and axon histomorphometry were not statistically different between the three repair groups. In the rabbit tibial nerve repair model, Nerve Tape offers similar regeneration efficacy compared with conduit-assisted and microsuture-only repairs, suggesting minimal impact of microhooks on nerve tissue.

Robot-Assisted Laparoscopic Transvesical Repair of Rectovesical Fistula After Open Radical Prostatectomy: Use of Allograft Human Dermis Interposition

Introduction: Rectovesical fistula repair is a rare occurrence after radical prostatectomy. Several operative approaches to fistula repair have been described. In this video, we describe a novel technique using a robotic approach with allograft human dermis interposition. Objective: To provide a guide to robot-assisted laparoscopic transvesical repair of rectovesical fistula after open radical prostatectomy with the use of allograft human dermis interposition. Materials and Methods: We started the procedure by doing a cystoscopy to identify the fistula. Bilateral ureteral stents were then placed. Ports were placed, each slightly more cephalad than traditional for robotic prostatectomy. The colon and colostomy limb were retracted laterally using a dual blade atrial retractor. Dense scarring was encountered during the initial dissection between the bladder and rectum and we thus decided to open the bladder along the posterior midline. Three unidirectionally barbed stay sutures were placed to maintain access to the operative field. The fistula was circumferentially delineated with curved monopolar scissors. A plane was developed between the rectum and bladder with Potts scissors. The rectum was repaired with a 3-0 Vicryl continuous suture. The repair was tested using a colorectal anastomotic evaluator, which showed a small leak that was reinforced with 4-0 Monocryl. Since the retrovesical space was densely scarred and we opted not to split the trigone, a free interposition graft was deemed necessary. We used a small patch of allograft human dermis that was tailored to the commensurate size of the defect and tacked in place using 4-0 Vicryl. The detrusor and bladder mucosa were then approximated in a tension-free manner over the graft with 3-0 unidirectionally barbed suture. The stay sutures were removed and the bladder was closed in two layers, again using 3-0 unidirectionally barbed suture. Results: This is the first time we have used this approach for rectovesical fistula repair. The drain was removed on postoperative day 1 and the patient was discharged on postoperative day 2. A cystogram was performed 3 weeks later that showed a normal bladder without evidence of leak or communication with the rectum. The patient has good urinary continence. Colostomy takedown occurred 7 weeks postoperatively with excellent return of bowel function. Conclusion: This video demonstrates the feasibility of robot-assisted rectovesical fistula repair. Since we did not split the trigone and the rectovesical space was densely scarred, an omental interposition was not feasible. We, therefore, opted to use allograft human dermis to reinforce the repair. In carefully and appropriately selected patients, a robotic approach to rectovesical fistula repair may allow a minimally invasive option for patients with this complex clinical entity, providing superb visibility of the pathology, the ability for precise suture placement, and avoid the potential morbidities of an abdominal, perineal, or parasacral incision, with or without muscular flap interposition. No competing financial interests exist. Runtime of video: 9 mins 3 secs

V7-04 MULTI-INSTITUTIONAL BLADDER EXSTROPHY CONSORTIUM: COMPLETE PRIMARY REPAIR OF EXSTROPHY

You have accessJournal of UrologyPediatrics1 Apr 2015V7-04 MULTI-INSTITUTIONAL BLADDER EXSTROPHY CONSORTIUM: COMPLETE PRIMARY REPAIR OF EXSTROPHY Joseph G. Borer, Evalynn Vasquez, Anthony J. Schaeffer, Douglas A. Canning, John V. Kryger, and Michael E. Mitchell Joseph G. BorerJoseph G. Borer More articles by this author , Evalynn VasquezEvalynn Vasquez More articles by this author , Anthony J. SchaefferAnthony J. Schaeffer More articles by this author , Douglas A. CanningDouglas A. Canning More articles by this author , John V. KrygerJohn V. Kryger More articles by this author , and Michael E. MitchellMichael E. Mitchell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1935AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For bladder exstrophy (BE) repair, gaining necessary surgical experience is challenging due to the rarity of BE. We created a multi-institutional collaboration for the purposes of sharing collective expertise, to efficiently maximize surgical proficiency, and to standardize surgical technique and subsequent care of complete primary repair of exstrophy (CPRE). Our objective is to demonstrate the surgical technique adopted by this collaboration. METHODS Boston Children's Hospital, Children's Hospital of Philadelphia and Children's Hospital of Wisconsin alternately served as host site for scheduled surgeries, with observation, commentary and critique by surgeons from the other sites. Technique was CPRE with bilateral iliac osteotomy performed at 1-3 months of age. Video recording was used for real-time observation both locally and remotely, teaching, future analysis, editing, and review. RESULTS From February 2013 through September 2014, CPRE was performed in 23 patients: 12 boys and 8 girls with classic bladder exstrophy; 1 boy and 2 girls with epispadias. Three surgical modifications were adopted by the group. The first concerned approach to the urethral plate dissection in the boy. The current approach uses a ventral dissection along the medial aspect of the corpora cavernosa using bipolar electrocautery. The second was the deliberate attempt to form a bladder neck in an effort to increase continence by elongating the urethra and creating a more acutely angled transition from proximal urethra to bladder neck into bladder. The third was made after urethral obstruction was noted in 3 girls. Preplacement of perineal and urethral meatus sutures prior to approximation of the pubis allowed optimal exposure of the tissue for accurate and precise suture placement. Complications in girls included 4 episodes of pyelonephritis, 3 urethral obstructions (1 resulted in bladder rupture and 2 required temporary clean intermittent catheterization), and 1 partial labial separation. Complications in boys included 3 urethrocutaneous fistula, 1 hypospadias, return to operating room for 1 suprapubic tube removal, and 1 spica cast change. All closures were successful without dehiscence. CONCLUSIONS We report the surgical method adopted by a multi-institutional collaboration. The increased volume of patients, expert opinions shared, and proficiency gained were immediate benefits observed. This effort increased the annual experience of each institution involved from 3 to 9-fold to ultimately benefit patient care. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e660 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph G. Borer More articles by this author Evalynn Vasquez More articles by this author Anthony J. Schaeffer More articles by this author Douglas A. Canning More articles by this author John V. Kryger More articles by this author Michael E. Mitchell More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Aesthetic Refinement of the Dog Ear Correction: The 90° Incision Technique and Review of the Literature

The closure of any circular or asymmetric wound results in puckering or excess of tissue known as dog ears. Tissue dynamics, wound geometry, surface contour, and surgical technique affect dog ear formation [1,2]. Despite good preoperative planning for skin management techniques including Burow's triangle, V-Y advancement flap, M-plasty [3], and S-plasty [4], and despite following intraoperative procedures including proper undermining of a shallow wound, proper 90° angle of the scalpel blade, precise suture placement, and removal of excess underlying fat, sometimes a dog ear occurs anyhow. Methods for correcting dog ears include excision of the excess tissue in the shape of a triangle, crescent or ellipse; excision of conical folds of tissue at the end of the wound in the same direction as the long axis of the original wound; and excision of the dog ear at a 120° angle to the long axis of the existing excision line in a shape resembling a hockey stick [5]. They are extensively described in the literature, but they all lead to wound extension. Only M-plasty allows for reduction in the scar's length but produces a double-tailed scar, so if the total length with the two tails is considered, the new scar is still longer than the original one. We have developed a new and easy technique for dog ear correction without extending the length of the original wound.

A simple exercise to encourage precise suture placement

Surgical simulation is becoming increasingly important due to a reduction in operative exposure during surgical training. We describe a method to encourage precise suture placement using simple equipment that can be practised outside the skills laboratory.

Real-time three-dimensional Fourier-domain optical coherence tomography video image guided microsurgeries

The authors describe the development of an ultrafast three-dimensional (3D) optical coherence tomography (OCT) imaging system that provides real-time intraoperative video images of the surgical site to assist surgeons during microsurgical procedures. This system is based on a full-range complex conjugate free Fourier-domain OCT (FD-OCT). The system was built in a CPU-GPU heterogeneous computing architecture capable of video OCT image processing. The system displays at a maximum speed of 10 volume/s for an image volume size of 160 × 80 × 1024(X × Y × Z) pixels. We have used this system to visualize and guide two prototypical microsurgical maneuvers: microvascular anastomosis of the rat femoral artery and ultramicrovascular isolation of the retinal arterioles of the bovine retina. Our preliminary experiments using 3D-OCT-guided microvascular anastomosis showed optimal visualization of the rat femoral artery (diameter<0.8 mm), instruments, and suture material. Real-time intraoperative guidance helped facilitate precise suture placement due to optimized views of the vessel wall during anastomosis. Using the bovine retina as a model system, we have performed "ultra microvascular" feasibility studies by guiding handheld surgical micro-instruments to isolate retinal arterioles (diameter ~0.1 mm). Isolation of the microvessels was confirmed by successfully passing a suture beneath the vessel in the 3D imaging environment.

A simple exercise to encourage precise suture placement

A simple exercise to encourage precise suture placement

A novel "no-touch" robot-assisted laparoscopic technique facilitates ureteral reconstructive surgery

Objectives: One of the current limitations of robotic surgery is the lack of haptic feedback. In order to overcome this drawback we developed a “No-Touch” (NT) technique utilizing the distal portion of a feeding tube to intubate and manipulate both the ureter and the renal pelvis during anastomosis. Materials and Methods: Ureteral spatulation and pelvic reduction were performed as necessary. An 8 centimeter distal end segment of a 3 to 5 French feeding tube was used to intubate and manipulate the lumen of the proximal ureter and renal pelvis or recipient ureter during anastamosis. Manipulation of the discarded segment of the pelvis served as a handle to control and limit tissue handling. The NT technique allows for precise suture placement and prevented inadvertent backwall suture placement, thus ensuring luminal patency. No nephrostomy tubes or ureteral stents were utilized during these procedures. Patients were followed every three months for the first year with renal ultrasonography. Review of operative videos and surgical results was performed. Results: Ten robotic pyeloplasties, one robotic pyeloureterostomy, and one robotic distal ureteroureterostomy were performed using the NT technique. No backwall suture placements, tissue crush or crimping injuries or occurred in any case. There were no intraoperative or post-operative complications. Resolution of hydronephrosis and symptoms was demonstrated in all patients after post-operative examination and ultrasonography. Conclusions: A “No-Touch” robotic technique utilizing the distal blunt end of a feeding tube is a safe, effective, and inexpensive adjunct tool that minimizes tissue handling in robot-assisted laparoscopic surgery.

Effect of Nasal Tip Surgery on Asian Noses Using the Transdomal Suture Technique

The past two decades have ushered in a new era of nasal tip surgery. The new philosophy focuses on preserving and reorienting nasal tip structures. Modern suture techniques can give predictable results because of more precise suture placement. Only a few reports, however, have objectively evaluated the suture techniques for Asians. Accordingly, the authors aimed to assess the efficacy of the tip suture technique through projection and rotation analysis. We focused on transdomal sutures because they involve one of the most popular suture techniques. Preoperative and postoperative photographs of 85 patients who underwent rhinoplasty at Inha University Hospital between June 2002 and June 2004 were analyzed. The patients were categorized into four groups according to the techniques used. Tip projection was measured by the modified Heuzinger's method and tip rotation by the nasolabial angle. The pre- and postoperative indexes were compared within each group and among the four groups. Paired and unpaired t tests were used for statistical analysis. When the pre- and postoperative indexes were compared within each group, only the combined technique (transdomal suture with onlay graft) showed significant tip projection improvement. All tip surgeries resulted in insignificant tip rotation increase. Comparison among the four groups showed no significant difference based on the type of tip surgery performed. The suture technique has many advantages, although it has some limitations with Asian noses, especially if used alone. Therefore, we recommend using the suture technique in combination with other tip surgical procedures, such as onlay grafts, to achieve significant tip projection.

A Simple Guide to Inframammary-Fold Reconstruction

In breast reconstruction, the inframammary fold (IMF) is one of the most difficult anatomic structures to faithfully recreate. Nonetheless, it is critical to achieving optimal aesthetic outcome. We describe our technique for reconstructing the IMF as a secondary procedure after breast reconstruction using a Steinman pin template based on the curvature of the normal contralateral IMF. Twelve cases of IMF reconstruction using this technique have been performed with good aesthetic outcome and high reliability, with the longest follow-up being over 10 years. Advantages include (1) use of the Steinman pin template based on the contralateral side maximizes attainable symmetry, (2) an additional incision is not required, (3) precise suture placement is facilitated by visualization of the pin inside the breast cavity, and (4) use of a running internal mattress suture avoids a scalloped appearance, and smooth curvature of the IMF over its entire width is easily and reliably obtained. This technique is applicable to postoperative deformities from breast reconstruction using flaps, implants, or both.

NextStitch: double-stranded suture chain, a tool to optimize approximation of sutures in valve surgery with echocardiographic correlation.

Suture technique for valve replacement surgery has often focused on decreasing the soft tissue injury that leads to pseudoaneurysm formation and associated latent infection. There is universal recognition that precise suture placement is essential for avoiding adverse sequelae while allowing flexibility during the implantation of the prosthesis. The use of a continuous chain of linked horizontal mattress sutures (NextStitch) has allowed maximal precision in the approximation of sutures within the valve annulus. The product was used in a series of consecutive mitral and aortic valve replacements, and typical echocardiographic images from each type of implantation are presented. Postoperative echocardiography images revealed that no perivalvular leaks occurred and that NextStitch did not obscure detailed interrogation or assessment of the valve prosthesis.

Arthroscopic Meniscal Repair Using the Outside-In Technique

The outside-in technique has been demonstrated to be effective for repair of most meniscal tears Peroneal nerve injury is easily avoided during lateral meniscal repair using this technique because the starting point for needle entry is controlled. There are several advantages of this technique sutures can be placed without the need for a rigid cannula, precise suture placement is possible because only small needles are used, visualization is facilitated because there are no instruments between the meniscus tear and the arthroscopic view, and the repair can be performed with small incisions with minimal dissection. This technique can be adapted for use of either permanent or absorbable suture, and is useful for suturing a meniscal replacement device (such as a meniscus allograft or collagen meniscus implant) or for securing materials such as a fibrin clot or a carrier containing growth factors to a repair site.

Sixteen-month experience with video-assisted extraperitoneal laparoscopic bladder neck suspension.

After an extensive favorable experience with the Lapides-Ball open retropubic bladder neck suspension, we chose to perform this operation laparoscopically. We describe video-assisted extraperitoneal laparoscopic bladder neck suspension (VELBNS), in which we employ a single laparoscopic cannula and a laparoscopic bladder suspension set for suturing and simultaneously use video-assisted cystoscopy and laparoscopy for precise suture placement. Over 16 months, we operated on 70 patients with stress urinary incontinence secondary to hypermobility of the urethra. We describe the patient evaluation and selection and the surgical principles and techniques. Five procedures were converted to open operations because of bladder lacerations (two cases) or inability to dissect the space of Retzius because of scar tissue (three cases). At 3 months, 4 patients had unresponsive de novo urgency incontinence, and 61 patients were dry and without protection. One patient had a recurrence at 6 months that was corrected by open surgery. All 12 patients seen at 1 year were dry. We intend to survey our patients annually to obtain long-term results.

Technique of repair of atrioventricular septal defect with a common atrioventricular orifice

SummaryWe advocate primary repair of atrioventricular septal defect with a common atrioventricular orifice in symptomatic children presenting with intractable congestive heart failure. The single patch technique has been utilized as our procedure of choice. A low operative mortality and a low incidence of residual ventricular septal defect and regurgitation of the left atrioventricular valve requiring reoperation has been achieved. This report emphasizes the technical details of the repair. Careful delineation of anatomic detail is considered to be of the utmost importance. Precise suture placement, tailoring the patch, and reconstruction of the left atrioventricular valve are essential to achieve complete closure of the atrial and ventricular septal defects and functional integrity of the left atrioventricular valve.