Standard Closure Research Articles

Difficult Percutaneous Closure of Axillary Access.

This case illustrates step-by-step troubleshooting in difficult axillary access closure. A standard balloon-assisted dry closure technique; escalation of wire support; trial of different closure devices with understanding in their mechanisms of failure; meticulous deployment of closure devices under fluoroscopy; a novel approach in deliverance of Angio-Seal device in a hydrophilic braided sheath all contributed to successful hemostasis.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Variability in wound closure technique in midline posterior lumbar fusion surgery. International survey and standardized closure technique proposal.

Surgical wound complications represent an important risk factor, particularly in multilevel lumbar fusions. However, the literature regarding optimal wound closure techniques for these procedures is limited. We performed an online survey of 61 spinal surgeons from 11 countries, involving 25 different hospitals. The study included 26 neurosurgeons, 21 orthopedists, and 14 residents (Neurosurgery - 6 and orthopedics 8). The survey contained 17 questions on demographic information, closure techniques, and the use of drainage in posterior lumbar fusion surgery. We then developed a "consensus technique." The proposed standardized closure techniques included: (1) using subfascial gravity drainage (i.e., without suction) with drain removal for <50 ml/day or a maximum duration of 48 h, (2) paraspinal muscle, fascia, and supraspinous ligament closure using interrupted-X stitches 0 or 1 Vicryl or other longer-lasting resorbable suture (i.e., polydioxanone suture), (3) closure of subcutaneous tissue with interrupted inverted Vicryl 2-0 sutures in two planes for subcutaneous tissue greater >25 mm in depth, and (4) skin closure with simple interrupted nylon 3-0 sutures. There is great variability between closure techniques utilized for multilevel posterior lumbar fusion surgery. Here, we have described various standardized/evidence-based proven techniques for the closure of these wounds.

Application of amniotic membranes in reconstructive surgery of internal organs-A systematic review and meta-analysis.

Amniotic membrane (AM) has great potential as a scaffold for tissue regeneration in reconstructive surgery. To date, no systematic review of the literature has been performed for the applications of AM in wound closure of internal organs. Therefore, in this systematic review and meta-analysis, we summarize the literature on the safety and efficacy of AM for the closure of internal organs. A systematic search was performed in MEDLINE-PubMed database and OVID Embase to retrieve human and controlled animal studies on wound closure of internal organs. The Cochrane Risk of Bias tool for randomized clinical trials and the SYRCLE risk of bias tool for animal studies were used. Meta-analyses (MAs) were conducted for controlled animal studies to assess efficacy of closure, mortality and complications in subjects who underwent surgical wound closure in internal organs with the application of AM. Sixty references containing 26 human experiments and 36 animal experiments were included. The MAs of the controlled animal studies showed comparable results with regard to closure, mortality and complications, and suggested improved mechanical strength and lower inflammation scores after AM application when compared to standard surgical closure techniques. This systematic review and MAs demonstrate that the application of AM to promote wound healing of internal organs appears to be safe, efficacious, and feasible.

HUGHES REPAIR VERSUS VERTICAL MATTRESS SUTURE FOR LAPAROTOMY WOUND CLOSURE- A COMPARATIVE STUDY

Background: Laparotomy is one of the most common surgeries performed by general surgeons in emergency as well as elective settings. The most frequent complications following midline laparotomy includes incisional hernias, which develop in 10-15 % of patients and surgical site infections in 15-25 % of cases. 1 Thus, the placement of incision and suturing of the abdominal layers is the most common procedure done in operative surgery. Acute wound failure occurs in approximately 1% to 3% of patients who undergo an abdominal operation. Dehiscence most often develops 7 to 10 days postoperatively but may occur any time after surgery, from 1 to more than 20 days.2 Hughes repair combines a standard mass closure (two loop 1-PDS sutures) with a series of horizontal and two vertical mattress sutures within a single suture (1 Nylon). Evaluate the Objectives: efcacy of Hughes technique versus vertical mattress closure in patient undergoing midline laparotomy in terms of 1. Surgical site infection 2. Wound dehiscence 3. Post-operative pain 4. Duration of hospital stay. Materials&amp; Methods: Prospective, comparative study, A total of 30 patients undergoing abdominal midline laparotomy from March 2020 to August 2020 in Department Of General Surgery at R.L Jalappa Hospital and Research Centre, Tamaka, Kolar were considered for this study. Conclusion: We concluded that there is no difference between the two groups but Hughes repair had lesser post-operative pain but was more time consuming and prolonged the duration of the surgery. Whether to recommend this still remains doubtful and requires longer follow up and a larger sample size.

OC-064 TISSUE KINDNESS: A COMPARISON OF TISSUE MANIPULATION BETWEEN A NOVEL SUTURING DEVICE FOR STANDARDIZED ABDOMINAL CLOSURE AND MANUAL NEEDLE TECHNIQUE

Abstract Aim Wound healing is influenced by contamination, wound tension, and tissue handling. Suturing includes tweezer compression and medial traction that might compromise the fascia. This study compared forces involved in suturing with a novel suturing device for standardized abdominal closure and curved suture needles of two sizes. Method A model to measure suturing-forces was developed. Ten theatre nurses and 25 surgeons were introduced to the novel suturing-device. Participants performed 10×3 needle-pull-throughs using the device and two sizes of conventional suture needles: 36mm Large Needle (LN) and 26mm Small Needle (SN). Tweezer force and medial tissue traction force were recorded. Needle pull-through time, maximum and Area Under Curve forces (AUC) were calculated. Results Device training time was 4min 25s. Maximum tweezer-force was 892g (420.4) for the device, 1037g (457.5) for LN and 1097g (491.1) for SN (p&amp;lt;0.001). Maximum traction-force was 62g (57.6) for the device, 61g (45.4) for LN and 54g (50.0) for SN (p=0.117). Tweezer-force AUC was 2422gs (1797.2) for the device, 3442gs (1550.0) for LN and 3221gs (1588.9) for SN (p&amp;lt;0.001). Traction-force AUC was 148gs (239.0) for the device, 174gs (160.8) for LN and 142gs (161.0) for SN (p=0.068). Needle-pull through time was 3.4s (2.15) for the device, 4.4s (2.12) for LN and 3.9s (1.90) for SN (p&amp;lt;0.001) Conclusion The suturing device was faster and less traumatic to tissue for tweezer-force. Medial traction forces were similar. The novel suturing device is quick to learn and gentle to the tissue and device seems promising in facilitating fascial closure.

DD-05 INCISIONAL HERNIA PREVENTION - INVESTIGATION OF A NOVEL DEVICE FOR STANDARDIZED ABDOMINAL CLOSURE

Abstract Aim Surgeons can reduce incisional hernia formation by adhering to standardized techniques for incisional wound closure. This is often neglected at the end of a long operation which can lead to wound infection, wound rupture and incisional hernia formation. To address this issue, a suturing device was developed for swift and standardized abdominal closure. Preclinical studies have shown an adherence to Suture-Length/Wound-Length ratio ≥4 (SL/WL ratio) of 95% with the device compared to 69% for manual suturing and a &amp;gt;30% reduction in closure time. The aim is to perform a first in man study to verify the device performance and user safety. Method The study will be performed in a four month period at a single center. Principal investigator are appointed and research nurse funded. Forty patients undergoing elective open surgery for colorectal disease will be assigned to the study and follow up time will be 45 days. Endpoints will be adherence to SL/WL ratio of 4, abdominal closure time and wound infection. The study will include usability assessment and scoring of surgeon satifaction. Results If previous promising results from preclinical studies in animal tissue models and cadavers are verified in patients, this novel suturing device can be an important tool to reduce abdominal wall closure related complications. This will have an impact on patient quality of life, save surgical resources and contribute to a more predictable postoperative pathway.

P-032 FASCIOTENS: FIRST CASE IN THE HOSPITAL OF MéRIDA

Abstract Aim Anterior abdominal wall incisional hernias are a problem present in approximately 11–20% of patients undergoing laparotomy. Incisional hernias with loss of right of abode are associated with many physical, physiological and psychological problems. In order to surgically repair these incisional hernias with loss of right of abode, we need to perform a prehabilitation of the incisional hernias. Effective prehabilitation is required in order to close the aponeurotic defect without tension and to return the hernial contents to the abdominal cavity. Material and methods A 59-year-old female patient with a history of open cholecystectomy and incisional hernia repaired on three occasions, presenting with multisaccular midline incisional hernia (M1-M4 W3) containing colon and greater omentum. Results After application of botulinum toxin and Fasciotens, it is possible to perform Rives-Stoppa retrorectus repair, being able to reduce the hernial content without tension and without increasing intra-abdominal pressure. Conclusions Prehabilitation in complex abdominal wall surgery is essential to repair large aponeurotic defects without tension. In addition, the application of Fasciotens after administration of botulinum toxin allows closure of the aponeurotic defect using standard abdominal wall closure techniques.

OC-069 EFECTIVENESS OF PROPHYLACTIC ONLAY MESH FOR PREVENTION OF TROCAR HERNIA: PRELIMINARY RESULTS OF A RANDOMIZED CLINICAL TRIAL

Abstract Aim Trocar site hernia (TSH) incidence is a common complication of laparoscopic surgery. In the literature there is a lack of tools to prevent it. Our aim was to assess the effectiveness and safety of a prophylactic measure to decrease it. Methods A multicentric randomized clinical trial was performed in high-risk patients (diabetes mellitus and/or age ≥70 years and/or BMI ≥30 Kg/m2 and/or extended incision for specimen retrieval) who underwent laparoscopic cholecystectomy in an elective or emergency setting. Patients were allocated to prophylactic onlay polypropylene mesh fixation (intervention) or standard trocar closure (control). The main aim was to analyze the efficacy of the intervention, being TSH incidence the primary outcome. Clinical and radiological follow up was atleast 1 year after surgery. Secondary endpoints were technique-related complications. Results 134 patients were included (70 and 62 to intervention and control arm, respectively). Groups were homogeneous. Mean [SD] age, 64.8 (17.3) years; 80 (60, 6%) women. The cumulative TSH incidence was lower in the intervention group although not reaching significant differences, either when were radiologically (16 [26.7%] vs 17 [37%], p = 0.294) or clinically assessed (9 [17.6%] vs 9 [24.3], p = 0.593). No differences in surgical site infection, hematoma or seroma were detected. Mean follow-up was 736 days (min. 365 – max. 1294). Conclusions Our preliminary results points out that the overall TSH incidence is extremely high when properly assessed. A polypropylene onlay mesh would not be an effective measure to decrease the TSH incidence. Radiological evaluation would show more accuracy.

Use of a novel endoscopic overtube with bilateral tool channels for endoscopic resection of experimental lesions and repair of intestinal defects in the right colon: preclinical trial.

Endoscopic tumor resection and intestinal defect repair are technically challenging leading to invasive surgery and colectomy performed for resection of benign polyps. In this study, we evaluated the use of an endoscopic overtube with bilateral tool channels for these procedures. Using a fresh porcine colorectum in a 3D ex vivo model, 3cm lesions at the posterior wall of the transverse colon were removed by two different techniques: standard endoscopic submucosal dissection (ESD) technique (STD, n = 12) and ESD using the overtube with an endoscopic snare and grasper through the bilateral channels (OT, n = 12). Procedure times and the number of muscular injuries were evaluated. Using the same model, 5-10mm full-thickness perforations within a 3cm mucosal defect at the posterior wall of the transverse colon were closed by two different techniques: standard endoscopic closure technique (STD, n = 12) and endoscopic closure using the overtube with two graspers (OT, n = 12). The outcomes measured included bursting pressure and the number of endoscopic clips used for closure. Endoscopic resection of lesions was performed by the OT group in a significantly shorter total procedure time (STD vs. OT = median 38.9min vs. 17.3, p < 0.001) and with fewer muscular injuries (median 0 vs. 2, p = 0.002), compared with the STD group. After repair of intestinal defects, the OT group showed higher median bursting pressures (STD vs. OT = 11.2mmHg vs. 57.1, p = 0.008) despite using fewer clips (median 13 vs. 10, p < 0.001). This study demonstrates a novel traction technique with an endoscopic overtube using multiple instruments to remove lesions and repair intestinal defects in the colon more effectively. This endoscopic platform could provide a safe alternative to invasive surgical treatment.

Impact of a Surgical Wound Infection Prevention Bundle in Pediatric Cardiothoracic Surgery

BackgroundThe aim of this project was to decrease the incidence of surgical wound infection (SWI) to <1.5% in our pediatric cardiothoracic surgery patients using a prevention bundle and quality improvement process. MethodsAn SWI prevention bundle addressing preoperative, intraoperative, and postoperative risks was implemented. The primary outcome was SWI based on Society of Thoracic Surgeons criteria (superficial, deep, or mediastinitis). Novel aspects of the bundle included standardization of surgical closure and wound coverage for 14 days with a negative pressure dressing or a silicone dressing. Data were collected from January 2017 to November 2021; bundle intervention began in December 2019. SWIs were tracked using a g-chart. Preintervention and postintervention cohorts were compared by standard descriptive statistics. There were no changes in SWI tracking methods during the study. ResultsDuring the study, 1159 individuals underwent 1768 surgical interventions. Preintervention (n = 931) and postintervention (n = 837) groups were clinically similar, with fewer neonatal surgeries in the postintervention group. SWI decreased in all patients (preintervention period: 1 SWI per 22 surgeries; postintervention period: 1 SWI per 62.6 surgeries) and in neonates (preintervention period: 1 SWI per 12 surgeries; postintervention period: 1 SWI per 26.7 surgeries). Special cause variation was achieved in the entire cohort by March 2021 and in neonates by April 2021. Decreases in SWI occurred in superficial and deep wounds but not in mediastinitis. Annual rate of total SWIs decreased from 2.83% in 2019 to 1.15% in 2021. Intensive care unit and hospital length of stay did not change. ConclusionsWe demonstrated a reduction in SWI rates after implementing an SWI prevention bundle including standardized surgical closure and prolonged wound protection.

Assessment of a Novel Augmented Closure Technique for Surgical Wounds Associated with Transmetatarsal Amputation: A Preliminary Study.

Transmetatarsal amputation (TMA) is a viable option to avoid major amputation and limb loss in patients with forefoot sepsis, infection, or tissue loss. However, TMAs are associated with a significant incidence of dehiscence, readmission, and reoperation rates ranging from 26% to 63%. To encourage tissue healing, neovascularization, and durable closure, a nonwoven, resorbable, synthetic hybrid-scale fiber matrix whose architecture is similar to native human extracellular matrix was used in an augmented closure technique. We comparatively evaluated clinical outcomes and complication rates in TMA procedures with and without augmented closure. A retrospective analysis of ten patients who underwent TMA with augmented closure using the synthetic matrix and ten patients who underwent TMA with standard primary closure was conducted. After TMA, 80% of the patients who underwent augmented closure demonstrated complete wound healing compared with 60% of the control group. Patients undergoing augmented closure demonstrated five instances of wound dehiscence and 20% limb loss compared with eight instances of wound dehiscence and 40% limb loss in the control group. After TMA and augmented closure, patients required eight interventional procedures before complete healing compared with patients undergoing standard closure, who required 13 interventional procedures before complete healing. Augmented closure of surgical wounds after TMA using a synthetic hybrid-scale fiber matrix provided a unique means of reducing time to healing (18%), wound dehiscence (29%), number of procedures performed (39%), and rate of limb loss (20%). Augmented closure, therefore, offers a means of improving quality of life and reducing risk for patients undergoing TMA, and potentially reducing total cost of care.

Physical Reasoning of Double- to Single-Loop Transition in Industrial Reactors using Computational Fluid Dynamics

Double- to single-loop pattern transition and a significant reduction in the power number with a decrease in the clearance of the Rushton turbine impeller in a baffled reactor was elucidated in earlier research works. The present work investigates the physical reasons behind these phenomena using the computational fluid dynamics approach. The Reynolds Averaged Navier–Stokes equations with standard turbulence model closure were used to model the turbulent flow conditions in the reactor vessels. The Multiple Reference Frame (MRF) approach was adopted to model the impeller baffle interactions in the reactor vessels. The implicit Volume of Fluid (VOF) method was employed to simulate the aeration process in the reactor configurations considered. The development of a low pressure region below the impeller of a low clearance vessel deflects the discharge streams downward, leading to the formation of a single-loop pattern. The downward movement of the discharge streams reduces the vortex activity behind the impeller blades, leading to weaker form drag and a decrease in the power number of the impeller. Similarly, a high clearance vessel provides a low pressure region above the impeller which deflects the discharge streams above the impeller, resulting in a single-loop pattern and a considerable increase in the air entrainment due to superior vortex and turbulence activity present near the free liquid surface. The standard reactor vessel was found to provide superior bulk mixing of fluid as the overall turbulent dissipation rate is 35% more than that associated with low and high clearance vessels.

Does small bite closure reduce the incidence of incisional hernia compared to standard mass closure for midline laparotomy?

A best evidence topic was constructed using a defined protocol. The three-part question addressed was: in closure of midline laparotomy, which technique had lower incidence of incisional hernia: small bite closure or mass closure? The best evidence demonstrated that small bite technique has lower incidence of hernia.

EP-69 The use of IFAbond© tissue adhesive to reduce seroma rates and improve breast reconstruction outcomes

Abstract Introduction Tissue adhesives have had uses in surgery for over 45 years. Evidence for use in haemostasis and cavity closure is growing. Seromas are a common (up to 85% incidence) but potentially serious complication in implant-based breast reconstruction (IBBR). If infected can cause implant loss and reconstruction failure. Tissue adhesives may reduce seroma rates. Aims and Methods Our study considered whether IFAbond© significantly reduces seroma formation following IBBR and as a pilot to evaluate the optimum use and application of IFAbond©. 7 consecutive patients undergoing pre-pectoral IBBR were recruited to the control arm (standard closure) and a further 7 patients undergoing pre-pectoral IBBR were recruited to the intervention arm (standard closure including IFAbond©). Qualitative assessment of seroma formation and IBBR objective early outcomes were assessed at 1 week, 2 weeks and 30 days. Results Cohorts were comparable for demographics, mastectomy weight and implant size. No wound infection, healing concerns or implant loss at thirty days in either cohort. No patients developed clinically significant seroma (requiring drainage) in either arm. 4 of 7 control arm patients developed clinically noticeable seroma at 30 days compared to none in the intervention arm. Conclusions IFAbond© is safe and easily applied during IBBR adding little time to closure. This study suggests that IFAbond© can reduce clinically evident seroma formation in IBBR compared to standard closure. This pilot will inform a larger study to explore the statistical significance of this intervention and with longer term follow-up whether this correlates to lower rates of implant loss/failure.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART).

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery. A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed. Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011). The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years. ISRCTN25616490 (http://www.controlled-trials.com).

Hughes abdominal closure versus standard mass closure to reduce incisional hernias following surgery for colorectal cancer: the HART RCT.

Incisional hernias can cause chronic pain and complications and affect quality of life. Surgical repair requires health-care resources and has a significant associated failure rate. A prospective, multicentre, single-blinded randomised controlled trial was conducted to investigate the clinical effectiveness and cost-effectiveness of the Hughes abdominal closure method compared with standard mass closure following surgery for colorectal cancer. The study randomised, in a 1 : 1 ratio, 802 adult patients (aged ≥ 18 years) undergoing surgical resection for colorectal cancer from 28 surgical departments in UK centres. Hughes abdominal closure or standard mass closure. The primary outcome was the incidence of incisional hernias at 1 year, as assessed by clinical examination. Within-trial cost-effectiveness and cost-utility analyses over 1 year were conducted from an NHS and a social care perspective. A key secondary outcome was quality of life, and other outcomes included the incidence of incisional hernias as detected by computed tomography scanning. The incidence of incisional hernia at 1-year clinical examination was 50 (14.8%) in the Hughes abdominal closure arm compared with 57 (17.1%) in the standard mass closure arm (odds ratio 0.84, 95% confidence interval 0.55 to 1.27; p = 0.4). In year 2, the incidence of incisional hernia was 78 (28.7%) in the Hughes abdominal closure arm compared with 84 (31.8%) in the standard mass closure arm (odds ratio 0.86, 95% confidence interval 0.59 to 1.25; p = 0.43). Computed tomography scanning identified a total of 301 incisional hernias across both arms, compared with 100 identified by clinical examination at the 1-year follow-up. Computed tomography scanning missed 16 incisional hernias that were picked up by clinical examination. Hughes abdominal closure was found to be less cost-effective than standard mass closure. The mean incremental cost for patients undergoing Hughes abdominal closure was £616.45 (95% confidence interval -£699.56 to £1932.47; p = 0.3580). Quality of life did not differ significantly between the study arms at any time point. As this was a pragmatic trial, the control arm allowed surgeon discretion in the approach to standard mass closure, introducing variability in the techniques and equipment used. Intraoperative randomisation may result in a loss of equipoise for some surgeons. Follow-up was limited to 2 years, which may not have been enough time to see a difference in the primary outcome. Hughes abdominal closure did not significantly reduce the incidence of incisional hernias detected by clinical examination and was less cost-effective at 1 year than standard mass closure in colorectal cancer patients. Computed tomography scanning may be more effective at identifying incisional hernias than clinical examination, but the clinical benefit of this needs further research. An extended follow-up using routinely collected NHS data sets aims to report on incisional hernia rates at 2-5 years post surgery to investigate any potential mortality benefit of the closure methods. Furthermore, the proportion of incisional hernias identified by a computed tomography scan (at 1 and 2 years post surgery), but not during clinical examination (occult hernias), proceeding to surgical repair within 3-5 years after the initial operation will be explored. This trial is registered as ISRCTN25616490. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 34. See the NIHR Journals Library website for further project information.

Inlay Patellofemoral Arthroplasty: A Readily Reproducible Technique

Background: Patients with recalcitrant anterior knee pain and isolated patellofemoral osteoarthritis (PFOA) may benefit from patellofemoral arthroplasty. Arthroplasty with an inlay implant may be beneficial given recreation of native biomechanics and potentially avoiding anterior overstuffing. Indications: Patellofemoral arthroplasty is indicated in patients with anterior knee pain from isolated PFOA in patients with neutral alignment and intact menisci and ligaments. To highlight these indications, we present a 32-year-old female with severe anterior knee pain from PFOA, not resolved by conservative measures. Preoperative imaging demonstrated full-thickness chondral loss of the lateral patellar facet and trochlea, with neutral alignment and no significant trochlear dysplasia. Technique Description: This technique utilized the HemiCap Wave Implant manufactured by Anika Therapeutics (Franklin, MA, USA). A standard midline approach and medial parapatellar arthrotomy is performed. The patella is everted, and the trochlea is exposed. A guide pin is placed perpendicular to the trochlear bony surface and centrally in the defect. The pin is advanced, and the surrounding area is reamed. A guide block is placed over the pin in the trochlea and over-reamed. The area is prepared and centrally drilled, then tapped. A taper post is implanted. The trochlear implant is then secured to the taper post with an impactor and mallet. On the patellar side, a guide pin is placed in the center of the patella. Consideration is given to medialization of the button to decrease Q-angle. The patella is reamed to the diameter of an appropriately sized patellar button. A trial button is used to ensure satisfactory tracking. A real patellar implant is then cemented into place. Standard closure is performed. Results: Overall outcomes following inlay patellofemoral arthroplasty have been positive, with up to 89% of patients engaging in sports at 2 years status post surgery and 83% survival free of total knee arthroplasty at 5 years postoperatively. Discussion/Conclusion: Patellofemoral arthroplasty can provide good satisfaction and high rates of return to sport in patients with symptomatic, isolated patellofemoral arthritis. The surgical technique video presented provides reproducible steps, tips, and tricks for performing this procedure.

The clinical impact of modified transpancreatic mattress sutures with polyglactin 910 woven mesh on postoperative pancreatic fistula in distal pancreatectomy

BackgroundWe previously reported the stump closure method for the remnant pancreas in distal pancreatectomy, in which soft coagulation and polyglycolic acid felt attached with fibrin glue were utilized. Transpancreatic mattress suture with polyglactin 910 woven mesh was recently reported as a novel stump closure technique. We developed the modified transpancreatic mattress suture with polyglactin 910 woven mesh method, which combined our polyglycolic acid felt method with the transpancreatic mattress suture with polyglactin 910 woven mesh method. MethodsThe polyglycolic acid felt group included patients undergoing distal pancreatectomy in whom the pancreatic stump was closed with the polyglycolic acid felt method from 2017 to 2018 (n = 54); whereas the modified transpancreatic mattress suture with polyglactin 910 woven mesh group included those whose stump was closed with the modified transpancreatic mattress suture with polyglactin 910 woven mesh method from 2019 to 2020 (n = 51). Perioperative parameters, including grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula), were assessed according to the stump closure method. ResultsThe incidence of clinically relevant postoperative pancreatic fistula was significantly lower in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group than in the polyglycolic acid felt group (7.8% vs 22.2%, P = .036). In multivariate analysis, the use of neoadjuvant chemoradiotherapy and the transpancreatic mattress suture with polyglactin 910 woven mesh method were independent factors for preventing clinically relevant postoperative pancreatic fistula (P = .011 and 0.0038, respectively). Moreover, in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group, the incidence of clinically relevant postoperative pancreatic fistula in patients with a thick pancreas (≥13 mm, 6.7%) was comparably as low as that in patients with a thin pancreas (<13 mm, 9.5%). ConclusionThe modified transpancreatic mattress suture with polyglactin 910 woven mesh method is an effective stump closure technique to prevent clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Our results warrant further prospective investigation to evaluate the efficacy of the modified transpancreatic mattress suture with polyglactin 910 woven mesh method compared with other standard closure methods (eg, stapler closure or hand-sewn closure).

Individualized Wound Closure-Mechanical Properties of Suture Materials.

Wound closure is a key element of any procedure, especially aesthetic and reconstructive plastic surgery. Therefore, over the last decades, several devices have been developed in order to assist surgeons in achieving better results while saving valuable time. In this work, we give a concise review of the literature and present a biomechanical study of different suturing materials under mechanical load mimicking handling in the operating theatre. Nine different suture products, all of the same USP size (4-0), were subjected to a standardized crushing load by means of a needle holder. All materials were subjected to 0, 1, 3 and 5 crushing load cycles, respectively. The linear tensile strength was measured by means of a universal testing device. Attenuation of tensile strength was evaluated between materials and between crush cycles. In the pooled analysis, the linear tensile strength of the suture materials deteriorated significantly with every cycle (p < 0.0001). The suture materials displayed different initial tensile strengths (in descending order: polyglecaprone, polyglactin, polydioxanone, polyamid, polypropylene). In comparison, materials performed variably in terms of resistance to crush loading. The findings were statistically significant. The reconstructive surgeon has to be flexible and tailor wound closure techniques and materials to the individual patient, procedure and tissue demands; therefore, profound knowledge of the physical properties of the suture strands used is of paramount importance. The crushing load on suture materials during surgery can be detrimental for initial and long-term wound repair strength. As well as the standard wound closure methods (sutures, staples and adhesive strips), there are promising novel devices.