Sutureless Repair Research Articles

Surgery for left ventricular pseudoaneurysm: thoracotomy or sternotomy

We experienced 2 cases of left ventricular pseudoaneurysm located at the posterolateral wall. Case 1 was an 80-year-old woman who developed a left ventricular pseudoaneurysm 4 months after sutureless repair of left ventricular free wall rupture due to acute myocardial infarction. The pseudoaneurysm was repaired through a left thoracotomy. Case 2 was a 77-year-old woman who was diagnosed with left ventricular pseudoaneurysm incidentally by computed tomography. Aneurysmorrhaphy was conducted through a standard median sternotomy.

Off-Pump Multilayered Sutureless Repair for a Left Ventricular Blowout Rupture Caused by Myocardial Infarction in the Second Diagonal Branch Territory

A left ventricular (LV) free wall rupture is a highly lethal condition. A 78-year-old female, who collapsed while riding a bike, was admitted to our emergency service 7 days after experiencing chest pain. During admission, she had cardiopulmonary arrest. Though cardiopulmonary resuscitation was successful, computed tomography (CT) showed cardiac tamponade. Emergency surgery was then performed. Pericardiotomy revealed a postinfarction blowout rupture of an aneurysm (2 × 3 × 1 cm) on the anterolateral wall of the LV. The top of the aneurysm had a 2-mm wide blowing blood column. Intra-aortic balloon pumping was initiated. An off-pump multilayered sutureless repair using squares of collagen fleece with fibrinogen-based impregnation (i.e., TachoComb) and gelatin-resorcin-formalin glue (GRF glue) was performed. Postoperative coronary angiography revealed occlusion of the second diagonal branch. The patient was free from re-rupture or aneurysm enlargement. An LV blowout rupture, which was caused by myocardial infarction with a limited tear and necrotic area at the second diagonal branch territory, was successfully treated with an off-pump multilayered sutureless repair by using a TachoComb and GRF glue patch. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.

Primary Sutureless Repair and Anterior Translocation of the Atrial Septum for Cardiac Total Anomalous Pulmonary Venous Connection

The incidence of pulmonary vein stenosis after correction of a cardiac total anomalous pulmonary venous connection in neonates may be underestimated because of the small population of patients; however, it is associated with significant mortality and morbidity. This report describes a primary sutureless repair and anterior translocation of the atrial septum to create a large left atrial cavity and avoid post-repair pulmonary vein stenosis.

Primary sutureless repair for simple total anomalous pulmonary venous connection with a risk of postoperative pulmonary venous stenosis

Late mortality following surgical repair of total anomalous pulmonary venous connection (TAPVC) is often associated with pulmonary venous stenosis. We describe here two successful cases of primary sutureless repair for simple TAPVC in patients who had a potential risk of postoperative pulmonary venous stenosis. A 10-day-old neonate with mixed-type TAPVC and a 30-day-old infant with supracardiac TAPVC underwent primary sutureless repair with our modification. In the early follow-up, both patients are now doing well and have no signs of pulmonary venous stenosis. The sutureless repair can be applied as a primary surgical option to prevent postoperative pulmonary venous stenosis in selective patients with simple TAPVC.

Invited Commentary

Invited Commentary

Sutureless repair for postinfarction cardiac rupture: A simple approach with a tissue-adhering patch

Sutureless repair for postinfarction cardiac rupture: A simple approach with a tissue-adhering patch

“Closed-Vein” Technique for Primary Sutureless Repair of Anomalous Pulmonary Venous Connection

Deep hypothermic circulatory arrest or low-flow bypass are commonly used in primary repair of total anomalous pulmonary venous connection, or individual veins may be dissected to allow clamp or snare application, in order to provide a bloodless field for anastomosis by the direct or sutureless marsupialization technique. In the described technical modification, the marsupialization of the opened atrium to the posterior pericardium is completed before opening the pulmonary venous confluence, allowing bloodless exposure during full-flow normothermic bypass. In addition, vein branch dissection is avoided.

Sutureless technique for recurrent pulmonary vein stenosis after pericardial patchplasty in an adult

Postoperatively, posterior leaflet tethering tended to be ameliorated, just as was the anterior leaflet tethering. AML, Anterior mitral leaflet; PML, posterior mitral leaflet; LA, left atrium; LV, left ventricular; LVDd, left ventricular diastolic diameter; LVEF, left ventricular ejection fraction;MR,mitral regurgitation; NS, not significant; PA, pulmonary artery; PG, pressure gradient. Surgical Techniques

Primary correction of total anomalous pulmonary venous return with a modified sutureless technique

The objective was to evaluate primary sutureless repair of total anomalous pulmonary venous return (TAPVR) in neonates using a modified technique that minimizes hypothermia and circulatory arrest times. From 2009 to 2011, seven consecutive patients underwent primary sutureless repair for the treatment of TAPVR, by which the prepared posterior pericardium was sutured to an opening in the left atrium. Three patients had the obstructed infracardiac type, and four patients had the unobstructed supracardiac type of TAPVR. Moderate hypothermia was used in all patients with a median temperature of 28°C (26-32). Circulatory arrest was not used except for the opening of the collector, which lasted between 3 and 5 min. The connecting vein was ligated in all seven patients (five during repair and two early postoperatively). The follow-up was 100% complete, with a median duration of 652 (range 370-1023) days. There was no operative mortality and no late death. No patient required reoperation. Postoperative echocardiography showed unobstructed pulmonary venous flow in all patients. Recurrent pulmonary venous stenosis was not seen during the follow-up in any patient. The sutureless technique is an effective technique with potential advantages even for the primary correction of TAPVR. With the described technique, the need for circulatory arrest is substantially reduced. Not handling the pulmonary venous collector by avoiding a direct anastomosis may contribute to better compliance, better growth and the absence of subsequent stenosis.

EComment. The patch and glue technique with or without TachoSil(R)?

I read with great interest the paper by Pocar and colleagues regarding the use of TachoSil® (Nycomed, Zurich, Switzerland) as a modification of the classic patch and glue sutureless repair for left ventricular free wall rupture secondary to myocardial infarction [1]. They successfully treated three patients with postinfarction free wall rupture using cardiopulmonary bypass without cardiac arrest. Instead of applying the glue directly on the infarction area and then covering it with a biological or synthetic patch, they initially applied several layers of a fibrinogen/thrombin-coated collagen patch on the oozing surface of the heart [1].The authors stated that no false aneurysm was observed during the follow-up period, however the duration of the follow-up in this paper is unclear. In 1988, Padro and colleagues [2] reported the first case of postinfarction cardiac rupture successfully treated with a sutureless technique using a Teflon patch and biocompatible glue. Since then, many alternatives have been described in the literature to cover myocardial perforations, involving Teflon, Dacron, Goretex or pericardial patches and different biological glues [3]. Encouraging results of the sutureless technique without the use of TachoSil® have led some authors to advocate the patch and glue repair over the classic infarcectomy repair [4].The patch and glue technique is considered simple, safe and effective, but the number of patients treated is limited with different techniques. Another major drawback of this technique is the absence of long-term imaging follow-up results. Recently, Zoffoli and colleagues [5] reported no early or late myocardial ruptures (mean follow-up of 6.7 years) at the treatment site in 25 consecutive patients with postinfarction cardiac rupture. Others have published less favourable results with 37% (3 out of 8 patients) developing aneurysms at the site of the repair [3]. Long-term follow-up is important to determine whether this technique is promising and durable. Close imaging follow-up is paramount in this patient population.

An Alternative Sutureless Repair Technique with Amelogenin for Duodenal Perforation

Background : Among the various sutureless techniques, fibrin glue has proved to be effective in the treatment of peptic ulcer perforation as an alternative to classical suture repair. Albeit rare, a potential disadvantage of fibrin glue use is viral transmission or anaphylaxis. The aim of this study is to introduce a new technique for the closure of duodenal perforation using a novel recombinant enamel protein called amelogenin.Methods : In this case-control experimental study, 32 adult male Wistar Albino rats weighing 250–300 g were randomly divided into four groups, each containing 8 rats. Duodenal perforation of 0.2 cm were performed in the postpyloric region in all rats. Each group received primary repair, primary repair with omentoplasty, fibrin glue, and amelogenin, respectively. All animals were killed on the postoperative day five and the bursting pressure measurements, hydroxypro-line levels and histopathologic values of the wound site were evaluated.Results : Bursting pressure levels of the fibrin glue and amelogenin groups were significantly lower than the primary repair and primary repair with omentoplasty groups (P < 0.05) However, no significant difference existed between the fibrin glue and amelogenin groups in this respect (P > 0.05). There was also no statistically significant difference among all groups regarding tissue hydroxyproline levels and histopathologic values (P > 0.05).Conclusion : Application of amelogenin as an alternative sutureless repair technique did not improve wound healing in this animal model of duodenal perforation.

Sutureless repair of the facial nerve using biodegradable glass fabric

To compare a sutureless method of facial nerve repair using a biodegradable glass fabric with the standard method of microsurgical suture. The facial nerve was transected in groups of six sheep and repaired by either entubulation with a biodegradable glass fabric or standard microsurgical epineurial suture repair. Both methods of repair were compared with each other and with a normal control group using electrophysiological and morphometric analysis. Maximum conduction velocity, axon and fiber diameter, and myelin-sheath thickness were all reduced in the repaired nerves when compared with the normal nerves. There was no significant difference among any of the outcome variables between the repair groups. Repair of nerve injuries by entubulation has several theoretical advantages over standard suture repair: less trauma to nerve ends, no need for microsurgical skills, and delivery of neurotrophic growth factors. It is concluded that repair of the facial nerve by glass-wrap entubulation offers an alternative to standard suture repair without the demands of microsurgery on both time and surgical expertise.

Early Outcomes of Primary Sutureless Repair of the Pulmonary Veins

The "sutureless" repair technique has improved outcomes for post-repair pulmonary vein (PV) stenosis. The purpose of this study is to determine the early outcomes of primary sutureless repair of pulmonary venoocclusive disease in infants with congenital PV stenosis-hypoplasia or PVs at high risk for progressive stenosis. This is a retrospective review of infants who had primary sutureless repair of the PVs from October 2002 to April 2010. Twenty-five infants had primary sutureless repair of the PVs. Eighteen infants had total anomalous pulmonary venous return; 14 with obstruction, 10 with heterotaxy syndrome, and 9 with univentricular anatomy. Seven infants had congenital PV stenosis. There were 24 perioperative survivors (96%; 95% confidence interval [CI], 75% to 99%) and 2 late deaths from extracardiac causes. Follow-up was available on 21 out of 22 survivors at a median duration of 34 months (range, 9 to 100 months). Persistence-recurrence of PV stenosis occurred in 3 veins (3%) of 2 infants (8%). On follow-up echocardiography, right ventricular systolic pressure was normal in 13 out of 14 infants with a biventricular heart and 60% of systemic blood pressure in 1 infant. Kaplan-Meier 1-year cumulative survival was 88% (95% CI, 66% to 96%). Kaplan-Meier cumulative disease-free survival was 96% (95% CI, 75% to 99%) at 30 days and 84% (95% CI, 58% to 95%) at 1 year. By Cox proportional hazards, age, univentricular anatomy, and atrial isomerism-heterotaxy syndrome were not associated with an increased risk of death or persistence-recurrence. One-year disease-free survival was lower in infants with prematurity (p=0.0055) and low birth weight (p=0.0011). Primary sutureless repair is a feasible, safe, and relatively effective method of addressing congenital PV stenosis and (or) high-risk PVs, particularly in infants with single ventricle anatomy and (or) heterotaxy syndrome.

Pulmonary vein stenosis in ex-preterm infants – a challenging but important diagnosis for neonatalogists

ObjectiveTo raise awareness of pulmonary vein stenosis (PVS) to neonatologists.BackgroundPVS is rare, affecting approximately 2 per 100 000 children under the age of 2 years. Recent evidence suggests many children...

Normalization of Pulmonary Vascular Resistance Long After Successful Primary Sutureless Repair for Congenital Pulmonary Vein Stenosis

A 3-month-old infant with perimembranous ventricular septal defect (VSD) and pulmonary hypertension presented at our center. Cardiac catheterization showed a systolic pulmonary-to-systemic arterial pressure ratio of 0.99 and a pulmonary vascular resistance of 9.32 μm(2). Pulmonary angiography showed focal orifice stenosis in the right lower and left lower and upper pulmonary veins, whereas the right upper pulmonary vein was atretic. Sutureless pericardial marsupialization concomitant with VSD patch closure was used to repair the three stenotic veins. Administration of home oxygen therapy and sildenafil citrate was continued after surgical repair. Postoperative catheterization 1.5 years after surgery showed patency of the three repaired veins and normalization of pulmonary vascular resistance.

Primary sutureless repair for “simple” total anomalous pulmonary venous connection: Midterm results in a single institution

We have previously reported the use of an atriopericardial or "sutureless" repair for surgical management of postoperative pulmonary vein stenosis. The potential of avoiding geometric distortion of pulmonary venous suture lines and preventing post-repair pulmonary vein stenosis encouraged us to extend the use of this technique for primary "simple" total anomalous pulmonary venous connection repair. Between January 1997 and July 2009, 57 consecutive patients (median age, 15 days; median weight, 3.4 kg) underwent sutureless or conventional total anomalous pulmonary venous connection repair. Types of total anomalous pulmonary venous connection included supracardiac in 31 patients (54%), cardiac in 15 patients (26%), and infracardiac in 11 patients (19%). Median follow-up time was 2.9 years. Preoperative mean pulmonary vein score, a composite measure of stenosis in all 4 pulmonary veins, was 0.3/0-12, and vertical vein obstruction was found in 35 patients (61.4%). A primary sutureless repair was carried out in 21 patients (36.8%; supracardiac, n=12; cardiac, n=4; infracardiac, n=5). The sutureless repair group had proportionally greater high-risk infracardiac total anomalous pulmonary venous connection (24% vs 16%, P=.05). Primary outcomes of death or reoperation for pulmonary vein stenosis and postoperative pulmonary vein scores (0.2 ± 0.7 vs 0.7 ± 1.7, P=.26) were not different between the techniques. The sutureless repair group had proportionally more infracardiac total anomalous pulmonary venous connection and a higher rate of decline in postoperative right ventricular systolic pressure. Despite increased preoperative risk, no difference was observed in primary outcomes of death and reoperation in the conventional repair group.

Primary pulmonary vein stenosis: The impact of sutureless repair on survival

Primary pulmonary vein stenosis is often associated with relentless restenosis and early death. During the last 2 decades, we have developed a sutureless repair to improve prognosis. Hospital records for patients undergoing repair of primary pulmonary vein stenosis from 1989 to 2008 were reviewed. Pulmonary vein stenosis was quantified with a pulmonary vein stenosis score. Survival was determined by Kaplan-Meier analysis. Twenty-three patients underwent surgical repair. Mean ages at diagnosis and index repair were 23.3 ± 45.6 and 24.1 ± 40.9 months, respectively. Systemic or suprasystemic pulmonary artery pressures were present in 13 of 18 patients (72%). Seven (31%) had single-ventricle circulation. A sutureless technique was used in 19 of 23 cases (83%). Other types of repair were used in 4 of 23 (17%). There were 11 recorded deaths (47%). Survivals were 64%, 47%, and 31% at 1, 5, and 10 years, respectively. Five patients (22%) required 1 reintervention. Surgical repair significantly reduced the total pulmonary vein stenosis score (5.6 ± 2.10 before repair, 2.6 ± 2.72 after repair, P=.0057). The preoperative pulmonary vein stenosis score was the only independent predictor of mortality (hazard ratio, 1.732; P<.01). A preoperative pulmonary vein stenosis score of greater than 4 was a poor prognostic indicator (area under the curve, 0.83). Mortality and restenosis rates remained high despite the adoption of a sutureless technique. A preoperative pulmonary vein stenosis score of greater than 4 was a strong predictor of poor prognosis.

Surgical Management of Post-repair Pulmonary Vein Stenosis

Obstructed pulmonary venous drainage - either in association with total anomalous pulmonary venous drainage, congenital stenosis, or post-repair stenosis - is associated with poor outcome. Post-repair stenosis typically involves fibrotic scar tissue extending from the site of anastomosis. "Sutureless" repair techniques avoid direct left atrial-pulmonary vein suture lines by instead reconstituting atrial tissue to posterior pericardium. Hence, the repair leaves widely decompressed pulmonary veins in the posterior mediastinum draining directly into the left atrium as a 'controlled bleed.' In our experience, late outcomes are significantly more favorable with sutureless repair techniques versus conventional pulmonary vein surgery. Therefore, after these encouraging results, we have now extended the application of this repair strategy to all scenarios of pulmonary vein surgery, including primary repair of unobstructed total anomalous pulmonary venous connection. The sutureless repair is versatile and facile. In particular, complex geometry of multiple decompressed veins can be easily accommodated by wide left atrial-pericardial suture lines. Common pitfalls can be avoided by mobilizing and protecting the phrenic pedicle and preserving the integrity of the areolar connective tissue and pleuro-parietal membrane. Overall, sutureless repair of anomalous or stenotic pulmonary veins appears safe and effective. Furthermore, in patients known to be at high risk of recurrent stenosis, sutureless techniques appear to offer improved freedom from recurrent stenosis.

Comparison of classical surgery and sutureless repair with DuraSeal or fibrin glue for duodenal perforation in rats

The purpose of the study was to compare classical primary suture repair and sutureless repair with fibrin glue or DuraSeal adhesion barrier for the closure of duodenal perforation in rats. Forty adult female Wistar Albino rats weighing between 250-300 g were randomly divided into four equal groups. Primary repair, primary repair and omentoplasty, or application of fibrin glue or DuraSeal adhesion barrier was performed in each of the four groups, respectively. The bursting pressure, tissue hydroxyproline levels and histopathology were evaluated. Bursting pressure values of the primary repair and primary repair and omentoplasty groups were significantly higher than in the fibrin glue and DuraSeal groups (p < 0.001). There were no significant differences between the experimental groups regarding hydroxyproline levels and histological parameters. The sutureless methods (Fibrin glue, DuraSeal) have no superior effects when compared with the conventional repair techniques. We observed similar results between the sutureless repair groups; thus, DuraSeal can be considered an alternative to fibrin glue for this purpose. This suggestion must be supported with new studies, however, which would be planned with other wound healing markers and different designs.

Crucial steps in the evolution of the preperitoneal approaches to the groin: an historical review

Preperitoneal approaches to the repair of primary, bilateral, recurrent, inguinal, and femoral herniae, the most common abdominal protrusions, now dominate techniques of repair. The purpose of this review is to outline crucial steps which have led to this result. Abernethy (Surgical cases and remarks. Of the operation for the aneurysm. Cadell and Davies (Strand), London, pp. 149-176, 1797) introduced an operation to treat aneurysms of the external iliac artery, which was endorsed by Cooper (The anatomy and surgical treatment of abdominal hernia. Longman and Co, London, 1804). Bogros (Essai sur l'anatomie chirurgical de la region iliac et description d'un nouveau procede pour faire la ligature des arteries epigastric et iliaque externe. Th. Paris, no. 153. A Paris, de l'imprimerie de Didot le Jeune, imprimeur de la Faculte de Medicine, rue des Macons, Sorbonne no. 13, 1823) described his preperitoneal space which continues into the suprapubic space of Retzius. Annandale (Edinb Med J 21:1087-1091, 1876) initiated anterior preperitoneal repair. Cheatle (Br Med J 2:68-69, 1920, Br Med J 2:1025-1026, 1921) demonstrated the median posterior preperitoneal approach, resurrected by Henry (Lancet 1:531-533, 1936). McEvedy (Ann R Coll Surg Engl 7:484-496, 1950) modified the Cheatle-Henry procedure by using a unilateral oblique incision in the rectus sheath and underlying transversalis fascia with medial retraction of the rectus muscle. Estrin et al. (Surg Gynecol Obstet 116:547-550, 1963) reinforced this repair with prostheses attached to Cooper's ligament, thereby, eliminating tension. Anterior prosthetic preperitoneal repair was introduced by Usher et al. (Am Surg 24:969-974, 1958) using polyethylene and, later, polypropylene meshes which were not slit, since the spermatic cord was lateralized. Stoppa et al., beginning in 1965, performed giant prosthetic reinforcement of the visceral sac, covering Fruchaud's myopectineal orifice preperitoneally with extensive overlap. They used a posterior approach to avoid scarring in recurrent cases and to allow the exposure of large, bilateral, inguinal, and femoral sacs (Rev Med Picardie 1:46-46, 1972). Wantz (Surg Gynecol Obstet, 169:408-417, 1989) proposed a unilateral version. Gilbert (Am J Surg 163:331-335, 1992) described the anterior preperitoneal sutureless repair of groin herniation. He employed a two-layered prosthesis, the upper resting on the transversalis fascia, the lower in the space of Bogros. They were connected by a plug passed through the internal inguinal ring. Kugel (Am J Surg 178:298-302, 1999) described his anterior preperitoneal prosthetic repair of groin herniation through an abdominal gridiron incision. Laparoscopic repair of groin protrusions began in 1982 (Ger; Ann R Coll Surg Engl 64:342-344, 1982). In 1992, Arregui et al. (Surg Laparosc Endosc 2:53-58, 1992) and Dion and Morin (Can J Surg 35:209-212, 1992) reported on their transabdominal preperitoneal (TAPP) approach. To avoid intraperitoneal complications, Dulucq (Cahiers Chir 79:15-16, 1991) recommended a totally extraperitoneal (TEP) approach. These techniques incur fewer recurrences than open techniques and diminish postoperative pain. However, the operating time is longer, they are more expensive, and special skills are needed. In addition, general anesthesia is required. Thus, late in the 18th century, surgeons began incising the groin to treat aneurysms there. This experience led to the discovery of the preperitoneal space of Bogros, which, in the 1870 s, was employed for the anterior repair of groin herniation. The posterior preperitoneal approach became established in the 1920s-1960s, along with the use of prostheses. Laparoscopy was applied near the end of the century.