Traction Stitch Research Articles

Three-Point Contact Repair Technique for Partial Subscapularis Tears Using U-Stitch and Cow Hitch Knot Loaded on a Single Knotless Anchor: Simple, Reliable and Quick Method

The importance of repairing the subscapularis tendon to facilitate restoration of the rotator cuff force couple is obvious. However, identifying and repairing subscapularis tears can be challenging for surgeons. In this technical note, we present our preferred surgical method for Lafosse type 1, 2, and 3 and Yoo and Rhee type 1-2A and 2B subscapularis tears, providing a 3-point suture contact achieved with FiberTape (Arthrex) and knotless anchors. In this technique, fiber suture is placed into the superolateral edge of the subscapularis tendon as a traction stitch (cow hitch knot). Second, the FiberTape is passed through the medial upper and lower parts of the tendon, just perpendicular to the fibers, using a suture passer. The FiberTape’s free ends remain on the tendon’s anterior side, shaping a U form. The U-shaped FiberTape and traction suture are loaded to a knotless anchor and placed on the footprint area. This creates a 3-point contact between the FiberTape U-suture and the cow hitch knot on the area. We believe that this technique provides fast and reliable fixation due to its 3-point contact application and simplicity.

Capsular Management at the Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Varies With Geography and Surgeon Subspecialty Training: A Cross-Sectional, Multinational Surgeon Survey

PurposeTo perform a multi-national survey and identify patterns in capsular management at the time of hip arthroscopy. MethodsAn anonymous, non-validated survey was distributed by the American Orthopedic Society for Sports Medicine, Arthroscopy Association of North America, European Society of Sports Traumatology, Knee Surgery, and Arthroscopy, International Society for Hip Arthroscopy, and Turkish Society of Sports Traumatology, Arthroscopy, and Knee Surgery. Questions were broken down into 6 categories: demographics, capsulotomy preference, traction stitches, capsular closure, postoperative rehabilitation, and postoperative complications. ResultsThe survey was completed by 157 surgeons. Surgeons who used a half or full T-type capsulotomy had 2.4 higher odds of using traction sutures for managing both the peripheral and central compartment during hip arthroscopy for femoroacetabular impingement (FAIS) (p=0.024). Surgeons who felt that there was sufficient literature regarding the importance of hip capsule closure had 1.9 higher odds of routinely performing complete closure of the capsule (p=0.044). Additionally, surgeons who practiced in the United States had 8.1 higher odds of routinely closing the capsule relative to international surgeons (p<0.001). Moreover, those who received hip arthroscopy training in residency or fellowship had 2.4 higher odds of closing the capsule completely compared to surgeons who did not have exposure to hip arthroscopy during their training (p=0.009). ConclusionGeographic and surgeon-related variables correlate to capsular management preferences during hip arthroscopy. Surgeons who utilized a half or full T-capsulotomy more often utilized traction stitches for managing both the peripheral and central compartment. Surgeons performing routine capsular closure are more likely to believe that sufficient evidence is available to support the practice, with surgeons in the United States more likely to perform routine capsular closure in comparison to their international colleagues.

Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft and Concomitant Meniscal Ramp Repair

Background: Quadriceps autograft, though well established for anterior cruciate ligament reconstruction, is underutilized in posterior cruciate ligament (PCL) reconstruction largely due to slow adoption. All-inside meniscal ramp repair and quadriceps tendon autograft PCL reconstruction have been described in isolation, but not concomitantly in a video journal. Indications: PCL reconstruction is indicated in grade 3 isolated tears with instability that have not improved with nonoperative management and in instances with associated injuries such as meniscal ramp tears, as observed in this 18-year-old division I football player. Graft selection is dependent upon surgeon and patient preference, with quadriceps autograft delivering a viable option with desirable long-term outcomes. Technique Description: A partial-thickness quadriceps tendon autograft was harvested, the remnant PCL stump was debrided, and a reamer was used to drill the all-inside tibial tunnel for traction suture passage. An accessory low anterolateral portal was utilized to drill the femoral tunnel for passage of the femoral traction stitch. Traction sutures were withdrawn, and the graft was passed into the tibia, docked into the femur, fixated with an interference screw, and tensioned over the tibial button. A medial meniscal ramp tear was also identified and repaired in all-inside fashion with a 90° SutureLasso, polydioxanone suture (PDS), and suturetape via standard arthroscopic knot tying. Following the procedure, the patient began a PCL reconstruction rehabilitation protocol with a PCL rebound brace. Due to the meniscal ramp repair, toe touch weightbearing with the knee in extension during ambulation was completed for 6 weeks. Physical therapy (PT) focused on early quadriceps and patellar mobilization as well as active-assisted range of motion exercises. Results: At 6 months postoperation, the patient continued to progress in PT without major concerns. A full recovery and return to sport are expected approximately 9 to 12 months after surgery, as is consistent with the standard protocol. Discussion/Conclusion: This study describes the treatment of chronic PCL with concomitant meniscal ramp tear in a division I athlete. Further adoption of PCL reconstruction utilizing quadriceps autograft, even in the context of concomitant ligamentous or meniscal reconstruction, such as medial meniscal ramp repair, will aid in the widespread treatment of PCL injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection

To describe the management of recurrent bowel endometriosis after previous colorectal resection. Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

Robot-assisted pyeloplasty: How to deal with anatomic variants? A step-by-step video presentation

Pyeloplasty (open or Robot-assisted) is the gold standard of a symptomatic UPJ stenosis. Sometimes anatomic variants make the procedure challenging. This video describes a step-by-step approach in three settings: a crossing blood vessel and two different presentations of incomplete duplicated system. Under general anesthesia, patient positioned in lateral decubitus, three trocars are placed. After mobilization of the colon, the Gerota's fascia is opened, and the renal pelvis is dissected off the surrounding structures. Ureter and obstructed pyelum were subsequently identified, mobilized, and hinged on a traction stitch. The pyelum and ureter are divided and spatulated according to the Anderson-Hynes technique; anastomosis is achieved. In variants, the drainage is one of the challenging steps, needing custom-made drainage of both moieties. Correct positioning of the drainage is confirmed with reflux of methylene blue from the bladder. JJ stent was removed 6 weeks postoperatively in surgical day-clinic, additional drainage was removed 1 week after surgery in the outpatient clinic. All three children remain asymptomatic with over a year of follow-up. A step-by-step plan for pyeloplasty in case of anatomic variants is presented with a video demonstrating a robot-assisted approach in duplicated systems. Moiety drainage can be challenging.

Efficacy of I- gel™ for airway management of neonates with Pierre Robin sequence undergoing glossopexy: A prospective study

This paper aims to review the utility of I- gel as a successful airway management device for infants with Pierre robin sequence (PRS) undergoing glossopexy. A prospective study was conducted on PRS neonates. The algorithm followed was putting a ‘Tongue traction stitch’ followed by the following sequence – two trials with direct laryngoscope intubation, two attempts with fiberoptic endoscope intubation followed by insertion of I-gel™ to manage difficult airway during glossopexy procedure. 6 patients were intubated with direct laryngoscope, 12 patients were intubated with fibreoptic endoscope and the rest 13 patients were intubated using I-gel™. Successful management of difficult airway was achieved with this airway management protocol during glossopexy and nil postoperative complications were encountered. Within the limitations of the study it seems that, I-gel™ is a relevant alternative toprovide a reliable and secure airway access to carry out glossopexy procedure in such patients.

Optimizing Exposure for Mitral Repair: Anterior Annulus–to–Leaflet Stitch Technique

Exposure of anatomic landmarks is key in mitral valve repair. We report a technique to improve exposure of the mitral valve posterior leaflet during video-assisted procedures. It consists of a traction stitch placed on the leaflet free edges after triangular resection and through the anterior left atrial wall close to the mitral annulus. Gentle traction on this suture pulls the posterior leaflet on the plane of the mitral annulus to improve exposure and to expedite the reconstruction.

Top Ten Pearls for Successful Hip Arthroscopy for Femoroacetabular Impingement

Hip arthroscopy is an increasingly popular procedure used to treat femoroacetabular impingement. However, the procedure is technically challenging with a steep learning curve. To prevent complications and to optimize patient outcomes, proper patient positioning, correct portal placement, and adequate capsular closure are necessary. For central compartment procedures, creation of a minimal interportal capsulotomy, placement of traction stitches, adequate rim trimming, and balanced labral repair are recommended. For peripheral compartment procedures, adequate osteochondroplasty should be performed and assessed intraoperatively. The purpose of this technical note is to describe the senior author's top 10 pearls for a successful hip arthroscopy procedure to treat femoroacetabular impingement.

Mechanical and surgical interventions for treating primary postpartum haemorrhage.

Mechanical and surgical interventions for treating primary postpartum haemorrhage.

New Peritoneal Traction Device for Laparoscopic Paraaortic Lymphadenectomy.

Background:The development of devices that can be used to tract organs or other structures and secure an appropriate surgical field during laparoscopic surgery is clinically important.Methods:We developed a novel traction stitch, the Laptraction, which can be used to achieve peritoneal traction during laparoscopic surgery. This study examines the utility and safety of using the Laptraction to achieve peritoneal traction during laparoscopic transperitoneal paraaortic lymphadenectomy (as part of comprehensive staging surgery) in seven endometrial cancer patients.Results:Peritoneal traction was successfully and safely achieved using the Laptraction in all cases, without causing any complications. In all cases, time to deploy Laptraction was <5 min.Conclusions:Laptraction, a newly developed stitch, allows peritoneal traction to be achieved easily and facilitates the identification of essential landmarks during robotic-assisted laparoscopic hysterectomy, which helps to save time and prevent surgical complications.

Modified technique for two ports laparoscopic cholecystectomy: combined safety and economic value

Context The surgeons have tried to reduce the size and number of ports to reduce morbidity and improve the cosmetic appearance in laparoscopic surgery. Aims Assessment of safety and economic value of two-port laparoscopic cholecystectomy using traction stitches after adding left-sided traction stitch to Hartman’s pouch (third stitch) to increase the range of movement (dynamicity) of gall bladder neck (puppet show technique). Patients and methods Between July 2017 and January 2019, 50 patients with symptomatic cholelithiasis were involved into this study (36 females and 14 males) their age 18–65 years (mean±SD=41.6±11.4 years). All the cases were done using two ports; umbilical and epigastric. Three traction stitches were used; one to the fundus and two to the Hartman’s pouch to its right and left sides to increase its range of movement during dissection of the Calot’s triangle (puppet show technique). Statistical analysis used The decreptive data were presented as mean & standard deviation (SD). Data were analyzed using the SPSS package for Windows, version 23, SPSS Inc., Chicago, Illinois, USA. Results The mean operative time was 55.80±18.60 min (30–120 min). There was no need for more trocars or conversion to open surgery. Intraoperative complications occurred in three cases; one had a small liver tear in the gall bladder fossa. The second case had a small diaphragmatic injury (was repaired) and the third case had bleeding from the posterior branch of the cystic artery (was controlled) and spillage of gall stones (were extracted). The postoperative pain was mild in majority of patients (48 cases) and moderate in two patients. All patients started oral feeding and movements 4 h postoperative. The mean hospital stay was 0.950±0.35 days (0.5–2 days). Economically, about $600 were saved for every case (the price of unused disposable two trocars and two graspers). Conclusion Two ports laparoscopic cholecystectomy with three traction stitches (after adding third stitch) (puppet show technique), is an applicable and a safe technique with more patients’ satisfaction due to less scars and better economic value.

Novel Plicating “Wrap” Technique for Treating Anterior Urethral Ballooning

To describe an original approach, inspired by the technique proposed by Kalicinsky, which has the advantages of not requiring opening of the urethra, modeling the urethra to a suitable caliber without urethral anastomosis and providing the urethra with a solid and stretchable ventral support. We operated on 3 cases of anterior urethral ballooning between November 2013 and June 2014. Retrograde and micturition urethrography ruled out any urethral anastomosis and disclosed the ballooning. A 10-F silicone catheter was placed in all 3 cases with the purpose of monitoring the tailoring. Complete dissection of the urethral "sac" was carried out regarding circumference and length, and the result was a normal urethra with respect to both the penoscrotal angle and the glans. Urethral tapering was then undertaken with a continuous 5-0 polyglactin suture, which produced a straight urethra just a little wider than the previously placed monitoring catheter. The remnants of the dilated urethra were wrapped around the urethra with the aid of 2 traction stitches. Urethral tailoring was completed with a longitudinal suture that fixed the wrap. The urethral catheter was left 1 week after. The children urinated without problems and with a good micturition jet that remained unaltered over the ensuing months. A novel technique for treating a rather infrequent pathology has been described. The reported technique is simple and reproducible, and our 3 cases had excellent cosmetic and functional results.

Invited Commentary

Invited Commentary

Digital photographic measurement in hypospadias: Validation and comparison to intraoperative measurement

BackgroundWe propose a standardized method of photographing the hypospadias penis to capture penile dimensions that may be relevant for surgery. We also validate the use of digital imaging software for calculating penile dimensions as a substitute for intraoperative caliper-based measurements. MethodsPhotographs were taken of hypospadias penises in four different views after placement of a traction stitch and retraction of the preputial hood. Intraoperative measurements were obtained with a caliper. Digital measurements were taken of the same parameters postoperatively. All measurements were obtained in triplicate by multiple participants, and averages were tested for equivalency by determining the correlation coefficient for each parameter. Inter-observer correlation was also calculated for each parameter. Results180 intraoperative and 180 digital measurements were taken from 60 dimensions on 10 hypospadiac penises. Strong correlation existed between most digital and intraoperative measurements. Average inter-observer correlations ranged from 0.91 to 0.99 for each of the intraoperative measurements, and 0.90 to 1.00 for each of the digital measurements. ConclusionsStandardized imaging is effective in capturing penile dimensions and measurements during hypospadias surgery. When compared with intraoperative measurements, digital measurements are reliable and precise; digital photography has the potential to both aid in surgical planning and improve documentation.

Median sternotomy for double lung transplantation with cardiopulmonary bypass in seven consecutive patients

We describe our technique of using median sternotomy to perform double lung transplantations with cardiopulmonary bypass. By sparing the respiratory muscles, median sternotomy is probably less invasive and preserves lung function. Furthermore, it causes less long-term discomfort than intercostal thoracotomy. Although exposure of the pleural space is less optimal, abundant pleural adhesions can be dissected, particularly in the left posterior pleural cavity, using pericardial traction stitches, exposing the retrocardiac pleura with minimal manipulation of the heart.

Simplified technique for minimally invasive repair of congenital diaphragmatic hernia using hollow-needle snare and transthoracic traction stitches

Background Minimally invasive (MI) congenital diaphragmatic hernia (CDH) repair can be challenging. Placing rib-anchoring stitches without creating skin incisions and closing wider defects are some of the difficulties. In Bochdaleck hernia repair, maintaining visceral reduction and minimizing pneumothorax use are additional obstacles. We describe the use of hollow-needle snares (HNS) and transthoracic traction stitches (TTS) to overcome these challenges. Methods Hollow-needle snares is assembled by passing a prolene stitch through a hollow needle creating a retractable snare, which is used to extract the placed anchoring stitches by passing it over the ribs but through the same stitch's skin entrance site. In Bochdaleck hernia, the early placement of TTS using HNS can facilitate visceral reduction, patch lay down, and tension-free closure of possible residual V-shaped defects. Results Between July 2009 and April 2011, we performed 10 consecutive MI CDH repairs for 9 patients, including 7 Bochdaleck and 3 Morgagni hernias. The median age was 8 days (range, 3-172 days), and the mean operative time was 148.5 ± 37.8 minutes for Bochdaleck hernia repairs. For Morgagni hernia, the median age was 18.3 months (range, 10.5-37 months), and the mean operative time was 100 ± 26.5 minutes. All cases were completed without conversion. One patient had a hernia recurrence and was repaired similarly, whereas the others had uneventful recovery at a median follow-up of 5.8 months (range, 1.1-23.7 months). Conclusion Hollow-needle snare and TTS are simple and available tools that can facilitate MI repair of CDH. This initial experience demonstrates the technique's effectiveness and its excellent cosmetic outcomes.

Colecistectomía laparoscópica transumbilical. Resultados con el dispositivo de gel y revisión de la literatura

Introduction The appearance of single transumbilical incision surgery has opened a new era in the minimally invasive approach of cholecystectomy. Specific ports for this technique have made it easier to perform. We report our initial experience, from July 2008 to June 2009 and give an updated bibliographic review. Patients and methods A prospective, longitudinal and interventional study that included 30 patients with symptomatic cholelithiasis, from 10 July 2008 to 30 June 2009, on whom a single transumbilical incision laparoscopic cholecystectomy was performed (LESS technique), without other minilaparoscopic ports or traction stitches. A gel port was used for all surgeries (R-Port, Tri-Port ®), as well as straight and roticulating laparoscopic graspers. Surgical time, analgesia requirements, postoperative hospital stay, conversions and complications were registered. Results The median age was 34.8 years (range, from 21 to 53), with a BMI between 21 kg/m 2 and 39.5 kg/m 2 (mean 25.8 kg/m 2). Surgical time was 65.1 minutes (ranging from 40 to 150) and postoperative length stay was less than 24 hours. Postoperative pain was measured with the VAS scale, giving a low score. Up to now, two wound infections and a bile leak have been observed. Conclusions LESS cholecystectomy is a safe and feasible technique performed by experienced surgeons in minimally invasive surgery, and requires a greater learning curve than that of the conventional laparoscopic cholecystectomy.

A simple and rapid vascular anastomosis for emergency surgery: a technical case report

A 22-year old male presented with a transected femoral artery following a gunshot wound. He underwent a successful primary repair following limited segmental resection of the injured segment. End-to-end anastomoses after resection of injured arteries include, but are not limited to, interrupted and continuous suturing with, or without "parachuting" of the graft and/or vessel. We offer a rapid and reliable repair using a conceptually and operationally simple technique. Major advantages include: 1) the operating system is always oriented towards the surgeon, 2) the posterior row of sutures is placed as both ends are readily visualized, avoiding the need for potentially obscuring traction stitches, and 3) flushing is easily performed prior to completing the anterior suture row.

Arthroscopic Treatment of Glenoid Fractures

Abstract The patient was placed in the lateral decubitus position. The arthroscope was introduced through the posterior approach. The probe hook was introduced through a working cannula through the anterosuperior portal performed in an inside-out technique. The mobilization possibilities of the osteochondral fragments were then assessed. The use of a shaver was always necessary to clean the fracture site and evacuate clots. A nonabsorbable suture was passed through the labrum and the capsule tissue of the displaced articular fragment in its superior edge. The first suture was used as a traction stitch and allowed replacing the fragment in its original position and maintaining it during the placement of others sutures. A hole was made in the anterosuperior edge of the nonfractured glenoid and then a long drill was passed backward according to the transglenoid suture technique of Caspari or Morgan. Stitches were passed through the glenoid to the infraspinatus fossa. When articular congruity was judged satisfactory, the stitches were tied on the fascia of the infraspinatus muscle. The patients were immobilized in a sling for 3 weeks.

Use of Lowsley Tractor during Laparoscopic Prostatectomy to Reduce Urethrovesical Anastomotic Tension*

We describe a technique to reduce the tension on the urethra while performing the urethrovesical anastomosis during a laparoscopic radical prostatectomy. A Lowsley tractor is passed through the urethral stump, and a single traction stitch is placed in the posterior bladder neck. The first anastomotic stitch is placed through the urethra and bladder neck at the 6 o'clock position but not tied. The traction stitch is then grasped with the wings of the Lowsley and retracted into the urethra, bringing the bladder neck and urethral stump into close proximity. While maintaining traction on the bladder neck, the previously placed 6 o'clock suture is tied. Before releasing the traction stitch from the Lowsley tractor and bladder neck, two additional stitches are placed at the 4 and 8 o'clock positions, completing the posterior anastomosis. Grasping the traction stitch with the Lowsley tractor relieves tension on the posterior urethra and places it on the bladder neck. This prevents urethral tears and gaps in the posterior wall. The anterior portion of the urethra and bladder neck remains open, maintaining vision. Creating a secure posterior anastomosis allows the remaining sutures to be placed under minimal tension. This technique uses an instrument readily available in the urology operating room and facilitates completion of the difficult anastomosis under minimal tension, resulting in a high-quality anastomosis with fewer gaps.