Purse-string Suture Technique Research Articles

Endoscopic purse-string suture and naso-jejunal tube feeding for duodenal cutaneous fistula and gastric cutaneous fistula.

The Endoscopic Purse-string Suture (EPSS) technique has gained attention for its potential in closing large defects following gastrointestinal procedures. However, its application in fistula closure is not as widely reported. This study aims to evaluate the safety and efficacy of EPSS and naso-jejunal tube feeding in the closure of duodenal cutaneous fistulas and gastric cutaneous fistulas. This single-center retrospective study, conducted from September 2020 to September 2023 at Tongji University in Shanghai, China, examined the outcomes of EPPS and nasojejunal feeding for patients with gastric and duodenal cutaneous fistulas (n = 10). Demographic data, fistula characteristics, procedure technique and outcomes were evaluated. In this study, the average size of a fistula opening was 7.9 ± 4.6mm. The operations took an average of 25.8 ± 5.6min. Patients typically needed naso-jejunal tube feeding for a median of 14.0days, with an interquartile range (IQR) of 7.7-19.0days. The median duration of hospital stay post-operation was 16.5days, with an IQR of 7.0-25.0days. Nine patients were successful in their initial fistula closure using the EPSS technique. The other patient underwent a second EPSS and, ultimately, all patients experienced complete healing and fully recovered. There were no major adverse events reported. EPSS and naso-jejunal tube feeding are a safe and effective treatment option for duodenal and gastric cutaneous fistulas. Larger, prospective studies are needed to validate these findings and establish the long-term safety and efficacy of this approach.

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis

BackgroundRobotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes.MethodsFrom September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3.In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3–0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique.ResultsThe matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien–Dindo grade III or any anastomosis-related complications.ConclusionsThe RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

Reconstruction of Chronic Soft Tissue Mallet Fingers: Outcomes of Step-Plasty vs. Purse-String Suture.

After failed conservative therapy or in the absence of any intervention, a rupture of the digital subcutaneous extensor tendon at the distal interphalangeal (DIP) joint, known as mallet finger, may lead to a chronic extension deficit due to excessive scarring and tendon elongation. Various surgical techniques to restore the extension of the distal phalanx have been proposed, but an optimal approach has not yet been established. To tighten the extensor tendon, a purse-string suture can be applied. Although it has shown efficacy, it can result in significant bulging and scar formation. Using the "abbreviato" technique, the elongated part of the extensor tendon is excised, and the tendon is re-sutured. Also, tenodesis has been described, particularly in pediatric cases. In this retrospective follow-up study, we aimed to investigate if the step-plasty procedure previously described by Baumeister provides comparable, if not superior, functional and aesthetic outcomes compared to existing techniques for patients with chronic mallet finger. In this retrospective study, a consecutive series of 68 patients with chronic mallet fingers was enrolled. Patients were treated surgically using step-plasty of the respective extensor tendon. After skin incision and tenolysis, the elongated extensor tendon was incised in a Z-like fashion and stepwise resected in the transverse portion of the Z. The functional and aesthetic effects of this step-plasty technique were compared with results of 44 patients previously treated using purse-string sutures of the extensor tendon and evaluated using Crawford's and Levante's criteria. In all patients undergoing the step-plasty procedure, the extension deficit was significantly reduced from an average of 42 degrees preoperatively to 11 degrees postoperatively. In contrast, the control group treated by purse-string sutures showed a slightly higher postoperative extension deficit of 15 degrees. According to Levante's criteria, the results of our step-plasty procedure were significantly better than those achieved with purse-string sutures. Our study demonstrated that the treatment of older or chronic subcutaneous extensor tendon ruptures using the step-plasty technique led to a significant reduction in extension deficits. According to Levante's criteria, the postoperative outcome was significantly better in comparison to the purse-string suture technique. Additionally, no skin resection was required to improve the extension capability of the distal finger joint, compared to established surgical procedures.

Safety and Effectiveness of Brachial Artery Preclosure by Purse-String Suture Technique for Left Subclavian Artery Revascularization in Stanford B Aortic Dissection.

To assess the safety and efficacy of the combination of brachial artery (BA) cutdown with purse-string suture (PSS) for BA preclosure during fenestrated thoracic endovascular aortic repair (f-TEVAR). We reviewed the consecutive data in our center from January 2022 to May 2023. Clinical data were analyzed retrospectively, including the baseline characteristics, procedural details, complications, and outcomes. Dichotomous data were summarized as absolute values and percentages. Continuous variables were presented as median values and interquartile ranges (IQRs). All patients underwent arterial cutdown with the PSS technique for BA preclosure. The technique was considered successful when complete hemostasis was achieved and confirmed by ultrasonography 24h postoperatively. The patients were followed up 30days postoperatively for access-related complications. Forty-eight patients who underwent f-TEVAR with 48 BA access sites were included [36 males and 12 females; median age: 62 (IQR: 30-78) years]. The median body mass index was 27.3 (IQR: 21.2-32.7) kg/m2. The median access establishing and closing times were 7.8 (IQR: 6-9.3) min and 3.7 (IQR: 2.5-5) min, respectively. The median operative time and length of stay were 75 (IQR: 63-87) min and 7 (IQR: 5-9) days, respectively. Although the success rate was 100%, partial numbness in the median nerve distribution was noted in 1 patient in the forearm. This resolved spontaneously and no permanent neurological problem was seen. No other access-related complications were noted, and the total complication rate was 2.1% (1/48). BA preclosure with the PSS technique is safe and effective for left subclavian artery revascularization in Stanford B aortic dissection and can be another option for access closure during f-TEVAR.

Sequential breast and nipple-areolar complex reconstruction after soft tissue necrosis following augmentation mastopexy: a case report

Breast augmentation mastopexy is a common procedure in cosmetic plastic surgery. Augmentation mastopexy has proven to be a relatively safe operation, but surgeons should be aware of and able to cope with disastrous complications such as soft tissue necrosis and nipple loss. The most important consideration in breast reconstruction is the recovery of breast shape and symmetry, as well as the maintenance of the shape of the nipple-areolar complex without any complications. We experienced a case of sequential breast and nipple-areolar complex reconstruction, in which the purse-string suture technique was used to repair medium-sized circular defects accompanied by nipple loss in the central area of both breasts and to preserve the shape of both breast mounds. Modified CV flaps were performed for left nipple reconstruction, and the Elsahy method and the purse-string suture technique were used to reconstruct the right nipple. Tattooing was performed on both breasts for areolar reconstruction. Through sequential reconstruction, the patient achieved satisfactory aesthetic results. In medium-sized, round defects on the central breast accompanied by nipple loss, the pursestring technique is a simple and effective reconstructive option that enables maintenance of the breast mound shape without requiring additional incision or distortion of surrounding structures.

Impact of purse-string uterine suture on scar healing after a cesarean delivery: a randomized controlled trial

Uterine closure technique can affect scar healing, potentially resulting in unfavorable gynecologic and life-threatening obstetrical outcomes. Double-layer continuous unlocked suture has been demonstrated to promote optimal residual myometrial thickness. Recently, the purse-string uterine suture technique has emerged as a viable method to enhance the healing of scars. However, the current lack of randomized trials assessing the relevance of this technique warrants further investigation. This study aimed to evaluate the impact of purse-string uterine sutures on scar healing after cesarean delivery when compared with double-layer continuous unlocked suture. This was a randomized controlled trial; 126 patients with singleton pregnancies undergoing primary cesarean delivery were enrolled in 2 groups. The primary outcome was the mean residual myometrial thickness measured by saline infusion sonography 6 months after surgery by 2 sonographers blinded to uterine closure techniques. Operative time, calculated blood loss, total number of needed threads, and perioperative scar width were used for the perioperative analysis. Healing ratio and cesarean scar defect measurements were used for the 6-month analysis. There was no significant difference in terms of residual myometrial thickness (9.38±2.3 vs 8.4±3.9 mm; P=.187), blood loss (540 [146-982] vs 495 [241-903] mL; P=.815), or operative time (6.2 [5.2-7] vs 6 [5.3-7] minutes; P=.977). Achievement of purse-string uterine suture required significantly fewer threads (1 [1-1] vs 2 [1-2]; P<.001) and fewer hemostatic complementary sutures (1 [1-1] vs 1 [1-2]; P=.013). Scar width was significantly lower with purse-string uterine sutures (50 [40.5-50.5] vs 70 [60-70.5] mm; P<.0001). Purse-string uterine sutures allowed a higher healing ratio (1 [0.9-1] vs 0.84 [0.59-1]; P=.003) and significantly fewer cesarean scar defects (12% vs 35%; P=.018) compared with double-layer continuous unlocked suture. Despite resulting in no difference in residual myometrial thickness, purse-string uterine closure seems to be associated with better uterine scar healing on the basis of a higher healing ratio, and a lower rate of cesarean scar defects compared with double-layer continuous unlocked suture.

Comparison of purse-string suture versus over-the-scope clip for gastric endoscopic full-thickness closure: traction and leak pressure testing in ex vivo porcine model

BackgroundThe recently developed endoscopic full-thickness resection technique requires reliable closure. The main closure methods are the purse-string suture (PSS) technique and over-the-scope clip (OTSC) technique; however, basic data on the closure strength of each technique are lacking. This study was performed to compare the closure strengths of these two methods in an ex vivo porcine model.MethodsIn the traction test, a virtual 5-cm full-thickness closure line was closed by the following six methods three times each: conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture. The primary endpoint was the tension at the starting point of dehiscence, measured in Newtons (N) by an automatic traction machine. In the leak test, a 15-mm gastric full-thickness defect was closed by PSS or OTSC six times each, and the closed stomach was then pressurized in a water container. The primary endpoint was the leak pressure when air bubbles appeared. The secondary endpoints were the procedure time and presence of complete inverted closure.ResultsThe mean tension was 2.16, 3.68, 5.15, 18.30, 19.30, and 62.40 N for conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture, respectively. Complete inverted closure was observed for seromuscular PSS, seromuscular OTSC, and surgical suture. The mean leak pressure was 13.7 and 24.8 mmHg in the PSS and OTSC group, respectively (P < 0.01). The mean procedure time was 541 and 169 s in the PSS and OTSC group, respectively (P < 0.01). Complete inverted closure was observed in OTSC alone.ConclusionThe OTSC, which allows complete inverted closure, showed greater closure strength than PSS. Considering the size limitation suitable for single OTSC, a therapeutic strategy for closing the larger size is further warranted.

Development of Magnetic Anastomat for Laparoscopic Bilioenterostomy

This work introduces the design and operating procedure of a novel magnetic anastomat for laparoscopic bilioenterostomy. Three techniques (magnetic compression technique, mechanic control technique and purse string suture technique) are used to design this device. The anastomat is mainly composed of two parts, a magnetic head and a handle. The surgical procedure for laparoscopic bilioenterostomy with this novel anastomat is similar to performing an end-side enteroenterostomy with the circular stapler. After the anastomosis is achieved, the magnetic head is placed at the anastomoses to maintain the digestive tract continuity. The magnetic head would fall into the jejunal lumen when the anastomoses is formed. This surgical approach would bring an innovation to the laparoscopic bilioenterostomy. Performing laparoscopic bilioenterostomy with this magnetic anastomat is safe, reliable and feasible.

Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

BackgroundWith the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis.MethodsAfter stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired.ResultsThe clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period.ConclusionTwo purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

Laparoscopic inguinal hernia repair in children: Article review and the preliminary Maltese experience

BackgroundIn the past two decades, laparoscopy has provided an alternative approach to inguinal hernia repair. The aim of this review is to carry out a retrospective systematic analysis of articles dealing with laparoscopic hernia repair in children and a review of the Maltese experience. MethodsData was obtained from publications from 2002 to 2019. The endpoints include: patient demographics, clinical presentations, laparoscopic tools, ports, suture used, technical remarks, length of surgery, hospital stay, complications and follow-up. Results32 studies were included with a total of 10,183 patients. Most articles documented the use of 1 port. Length of surgery ranged from an average of 10 to 138 min. Ipsilateral recurrences were reported in 0.83% of cases, while 0.17% required conversion to open. Preliminary Maltese ExperienceIn our centre, a population of 514, 564 is covered (16% under the age of 18). A total of 14 cases of laparoscopic inguinal hernia repair were carried out from August 2018 till October 2020. The neonatal laparoscopic set-up involves a 30⁰ laparoscope, inserted via a 5 mm umbilical port, with 2 stab incisions allowing the use of 3 mm devices. Intra-corporeal purse string suture technique is used. The length of surgery ranged from 1 hr to 2 hr 30 min. There was 1 case of ipsilateral recurrence and another requiring conversion to open surgery. ConclusionsLaparoscopic inguinal hernia repair in children is a versatile and safe procedure that can be carried out with minimal complications and low reoperation rates.Level of Evidence: Level IV

Application of Mohs Technique for Squamous Cell Carcinoma of the Nipple

Cutaneous squamous cell carcinoma (SCC) of the nipple areolar complex (NAC) is a rare entity with only a few cases reported in the medical literature. The standard treatment for invasive squamous cell carcinoma includes complete surgical excision of the lesion with postoperative assessment of free margins. Although this skin cancer involves the NAC it should be considered as a completely separate entity from other breast cancers, and therefore may be treated differently than breast cancers involving the NAC. Mohs micrographic surgery is a well-accepted technique for non-melanoma skin cancers (NMSC) with its remarkable precision for tumor eradication and tissue-sparing properties which favor excellent aesthetic outcome. We present a clinical case of 75-year-old Caucasian female who presented to our clinic with a papulose, scaly lesion located at her right nipple that was confirmed to be SCC of the nipple. The patient underwent complete excision of the tumor using Mohs micrographic technique with immediate reconstruction of spared NAC using purse-string suture technique. Free surgical margins were determined intra-operatively by Mohs’s cryosurgery method and further assessed by permanent evaluation. Follow-up was assessed for 3 years without evidence of local recurrence, and high patient satisfaction with the final aesthetic outcome. To the best of our knowledge, this is the first report that validates the feasibility of application of the Mohs technique for nipple SCC excision with immediate nipple reconstruction. Our results suggest that Mohs micrographic surgical technique may be a safe treatment modality for SCC lesions of the NAC allowing superior tissue preservation and enhanced aesthetic results compared to standard wide local excision.

Usefulness of vacuum-assisted closure after stoma closure with purse string suturing: a retrospective trial.

Surgical site infection (SSI) is a problematic complication after stoma closure. The purse string suture (PSS) technique eliminates this problem, but the area takes longer to heal. The present retrospective study was performed to evaluate the usefulness of a vacuum-assisted closure (VAC) system for the promotion of wound healing after stoma closure. Consecutive patients undergoing stoma closure with the PSS technique were divided into two groups: those treated with and without use of the VAC system. The volume of dead space and the size of the wound were measured after stoma closure in both groups. The same measurements were performed on days 3 and 7 after closure. The time needed for wound closure was also examined in both groups. Outcomes were also evaluated according to age, body mass index, operative time, bleeding volume, wound consistency, patient satisfaction, perioperative inflammatory response, occurrence of SSI, and hospitalization days. The VAC group comprised 31 patients, and the non-VAC group comprised 34 patients. The volume of dead space on days 3 and 7 after closure was significantly smaller in the VAC group than in the non-VAC group (P=0.006 and P<0.001, respectively). The number of SSIs was significantly lower in the VAC group than in the non-VAC group (P=0.014). The dead space volume on days 3 and 7 after stoma closure with PSS significantly decreased by using the VAC system. The incidence of SSI after stoma closure also significantly decreased by using the VAC system.

Bracket-like suture method: a novel, circular marked, simplest sided purse-string suture technique for intracorporeal circular-stapled oesophagojejunostomy during laparoscopic total gastrectomy.

Total laparoscopic total gastrectomy (TLTG) has been limited in application because of the difficulty of intracorporeal oesophagojejunostomy. Theoretically, an intracorporeal single-stapling oesophagojejunostomy using a circular stapler could be commonly used and provide favourable outcomes for TLTG, as in open total gastrectomy(OTG), in which the use of circular staplers in oesophagojejunostomy is common and the standard procedure. This could be possible if use of a laparoscopic purse-string suture along the distal oesophagus were made easy and simple. However, the simple and optimal use of this procedure remains to be developed. Between October 2018 and March 2020, 21 consecutive patients with gastric cancer underwent TLTG using the bracket-like suture method (BLSM) for intracorporeal circular-stapled oesophagojejunostomy in our institution. The surgical details and postoperative outcomes were analysed to evaluate this method. The mean operation time was 227.6 ± 13.6min. The median time for the two-sided purse-string suture was 4min (range, 3-5min). It took an average of 11.5min for the completion of purse-string suture and anvil placement. Tumour-free margins were achieved in 21 patients with a median length of 2.5cm (range, 2-6cm) proximal margin. Three patients developed postoperative complications. There was no mortality. During the median follow-up period of 12months, no anastomosis-related complications were observed. The results suggest that the method cannot only facilitate safe and easy purse-string creation, using the simplest two-sided suture in a short amount of time by circular marking of the intended transection level for intracorporeal circular-stapled oesophagojejunostomy, but can also be completed by laparoscopic surgeons with basic laparoscopic suturing skills.

Distal Üretrayı İçine Alan Sirküler Glans Penis Defektlerinde Purse-String Sütür Tekniğiyle Onarım: Gözlemsel Çalışma

Objective: Circular necrotic wounds, including the urethral meatus and distal urethra, can be seen on the glans penis of patients in intensive care units (ICU) due to long-term application of urethral catheters. In this article, we aimed to explain the purse-string suture (PSS) technique that we use in such wounds in the urethral meatus. Material and Methods: Twelve male patients who were treated in Kütahya Health Science Univesity Evliya Çelebi Research and Training Hospital between January 2017 and January 2020 in the neurology and general ICU and who developed circular necrotic pres- sure wounds in the urethral meatus due to long-term use of urethral catheters were included in the study. Wounds were repaired with PSS technique in all patients. The data of the patients were collected retrospectively. Demographic data of the patients, urethral defect lengths, postoperative success rates, complications and managing these complications were evaluated. Results: The mean age of the 12 patients included in the study was 67.5±16.76 years. The mean length of the urethral defect formed in the patients during the operation was calculated as 2.25 (interquartile range 0.7) cm. The number of patients who came and were reached for regular control was 8 (66.7%). Two (16.7%) patients died due to their main diseases. Wound infection developed in 2 (16.6%) patients and urethra-cutaneous fistula developed in 1 (8.3%) of the patients, and these 3 (25%) patients were treated by re-operation. Conclusion: PSS is an easy-to-use technique with good cosmetic and functional results in the closure of circular defects of the distal urethra.

Laparoscopic Management of Unruptured Interstitial Pregnancy Using Purse-string Suture Technique.

Laparoscopic Management of Unruptured Interstitial Pregnancy Using Purse-string Suture Technique.

Umbilical Reconstruction Techniques: A Literature Review.

There are many instances in which sacrificing the umbilicus is unavoidable. Umbilical reconstruction (umbiliconeoplasty) is an important surgical procedure to complete the abdomen's reconstruction and to give again a pleasant cosmetic appearance. To provide a complete overview of all surgical techniques for umbiliconeoplasty described in the literature. PubMed database was queried using 'umbilical and reconstruction', 'umbilicus and reconstruction', 'navel and reconstruction', 'umbiliconeoplasty', 'neo-omphaloplasty' or 'umbilicaneoplasty' to select the papers dealing with the reconstruction of the umbilicus. Sixty different techniques for the reconstruction of the missing umbilicus were described in 77 papers. Local skin flaps and the purse-string suture technique were the most frequently described techniques. The Three flaps technique, the Four flaps technique and the 2 Lateral rectangular pedicle lateral flaps technique were the most popular local flap techniques. Indications ranged from congenital pediatric defects to reconstruction during abdominoplasty. Several surgical techniques were described for umbilicus reconstruction. While there is not a universal algorithm for the choice of the technique, the surgeon may decide which technique to use based on other surgeons' experiences reports. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predominant classic circular-stapled double-tract reconstruction after totally laparoscopic proximal gastrectomy: safe, feasible, time-saving anastomoses by technical tie-up.

The double-tract reconstruction (DTR) could be a preferable option in avoiding the postoperative esophageal reflux and anastomotic stenosis during totally laparoscopic proximal gastrectomy (TLPG). An optimal procedure to achieve the DTR in TLPG remains to be established. During March 2018 to April 2019, 15 consecutive patients with gastric cancer in the upper third of the stomach underwent intracorporeal DTR after TLPG at our hospital. The intracorporeal esophagojejunostomy (E-J), gastrojejunostomy (G-J) and jejunojejunostomy (J-J) were, respectively, performed using circular staplers by the Self-Pulling and Holding Purse-String Suture Technique, Intraluminal Poke Technique and U-shaped Parallel Purse-string Suture Technique (Technical Tie-Up). Demographic and clinicopathologic characteristics, perioperative details and postoperative outcomes were analyzed. The mean operating time was 216.1 ± 18.2min. Total time for three anastomoses was 49.8 ± 6.1min, and the time for E-J, G-J, J-J was 22.4 ± 5.0min, 13 (range 11-16) min, 14.2 ± 2.8min, respectively. The median proximal and distal resection margins were 2.5 (range 2-4) cm and 6 (range 5-7) cm, respectively, which were all tumor-free in 15 patients. No major complications and mortality occurred. During the median follow-up period of 14months (range 7 to 20.5months), there were no postoperative anastomosis-related complications observed, such as anastomotic bleeding, leakage or stenosis. No patients complained the symptoms indicating esophageal reflux and remnant gastritis. Predominant classic circular-stapled double-tract reconstruction is safe, feasible and time-saving in TLPG by the technical tie-up.

Nipple-coring and purse-string suture technique – A modification of the nipple-sparing risk-reducing mastectomy

Nipple-coring and purse-string suture technique – A modification of the nipple-sparing risk-reducing mastectomy

Urethral fistulae following surgery for scrotal or perineal hypospadias: A 20-year review

Urethral fistulae (UF) following hypospadias surgery can be a frustrating complication with reports of even 15 attempts to close a difficult fistula (Richter 2003). UF occurring in scrotal or perineal hypospadias (SPH) pose a further challenge because of the under-virilised penis. To review the outcomes of a single surgeon's experience over 20 years of managing UF in SPH. To analyse the traditional approach of fistula closure and three alternative techniques. A prospectively maintained database of patients who underwent hypospadias surgery for SPH from January 1997 to September 2018 was reviewed. Patients with UF were identified and their data recorded. The techniques of fistula closure were: a-Traditional approach. b Purse-string closure. c. Right angle intersection technique where the skin and urethra are closed at right angles to each other. d Anchoring skin to corpora away from the fistula closure. 32 patients with 41 fistulae were identified. Follow-up ranged from 1 to 18 years. 10/32 (31%) had concomitant meatal stenosis or urethral strictures. The sites of UF were: penoscrotal 19/41 (46%), midpenile 14/41 (34%), coronal or subcoronal in 8/41 (20%). One fistula resolved spontaneously after a single urethral dilatation. 4 patients with a coronal fistula were laid open to the glandular meatus creating a coronal hypospadias, with redo-urethroplasty later (in 2 a buccal graft was used). Of the rest, 29 fistulae were cured after one surgery, while 7 needed two attempts. No patient needed more than two surgeries to close the fistula. The recurrence rates were as follows- Purse-string suture: 10%, Right angle intersection technique: 14.3%, Anchoring skin to corpora: 16.7%, Traditional approach: 21.7%. Although the purse-string suture technique had the lowest recurrence rate, the figures did not reach statistical significance (P-0.95). Urethral fistulae occurring in SPH pose challenges because of the under-virilised penis. A third of patients may have meatal stenosis or urethral strictures which must be identified and dealt with. The three novel techniques we employed helped drive down our recurrence rate. Purse string sutures reduce the weak area to a dot and are an excellent way to deal with small fistulae (<5mm). Other innovations include offsetting the skin suture line by anchoring it to the penile shaft well away from the fistula repair or closing the fistula and skin at right angle to each other. The fact that no patient needed more than two operations to lose the UF, was gratifying.

Chest drains: purse string suture 4.0.

There are many discussions about the technique of removal of chest drains. In our hospital, we have used an intracutaneous suture technique with non-absorbable suture material for the purse-string suture for a few years now. Thus the cosmetic results improved considerably. Nevertheless, the thread has to be removed after 10-14days. To further improve patient comfort we developed a purse-string suture technique using an absorbable barbed suture. We noticed better cosmetic results and less painfull drain removal. Furthermore, there is no more need for a stitch removal which reduces material costs and also pain.