Transcutaneous Sutures Research Articles

Percutaneous laparoscopic assisted gastrostomy (PLAG)—a new technique for cases of pharyngoesophageal obstruction

Percutaneous endoscopic gastrostomy (PEG) is the preferable method to provide enteral nutrition for a longer time period. Safe placement of a PEG tube requires passage of the esophagus and transillumination of the stomach through the abdominal wall. Surgical placement of a PEG tube has been shown to be feasible although the local complication rate ranges above the endoscopic procedure. We are presenting a new technique (percutaneous laparoscopically assisted gastrostomy, PLAG) to provide enteral access for patients with pharyngoesophageal obstruction not suitable for PEG placement. We have developed a laparoscopic method that allows full control of the stoma location at the anterior gastric wall. The tube has a deployable bumper mechanism, which can be inserted through a minimal gastric incision. Combined with the fixation by transcutaneous sutures, the risk for leakage or dislodgement is low. Fifty-one PLAGs were inserted in 45 male and six female patients suffering from pharyngoesophageal obstruction due to malignancy. Patients were referred after unsuccessful endoscopic PEG placement (n = 39) or received their PLAG when they underwent staging laparoscopy (n = 12). Success rate was 96.2%. No procedure-related mortality was observed. Infectious complications occurred in three (5.9%) cases. In five patients, minor leaks were managed conservatively (n = 4) or required relaparoscopy (n = 1) and placement of an additional suture (overall complication rate of 15.8%, n = 8). Nutritional goals were reached after 7.8 ± 2.3 days. PLAG is a safe and easy procedure. It can well be used to provide enteral access for patients with pharyngoesophageal obstruction not suitable for endoscopic PEG placement.

Continuous versus interrupted sutures for repair of episiotomy or second‐degree perineal tears: a randomised controlled trial

To evaluate the repair techniques of continuous and interrupted methods for episiotomy or perineal tears. A randomised controlled trial. The Hospital Universitario Principe de Asturias, a state hospital belonging to the community of Madrid. Four hundred forty-five women who had undergone vaginal deliveries with episiotomies or second-grade tearing of the perineum between September 2005 and July 2007. One group was repaired with continuous, nonlocking sutures involving the vagina, perineum, and subcutaneous tissues. The other group had continuous, locking sutures of the vagina, interrupted sutures in the perineal muscles, and interrupted transcutaneous sutures. The threads used for stitching were identical in both groups. The participants were questioned regarding the sensation of pain and the use of painkillers on the second and the tenth days, and 3 months postpartum. When comparing the group with continuous suture to the group with interrupted sutures, the differences included less repair time (1 minute; P= 0.017) and less suture material used (relative risk [RR], 3.2, 95% CI: 2.6-4.0). The comparison of pain on the second and tenth days, and 3 months postpartum were not statistically different between the two techniques (RR, 1.08, 95% CI: 0.74-1.57; RR, 0.96, 95% CI: 0.59-1.55; and RR, 0.68, 95% CI: 0.19-2.46, respectively). Although we did not demonstrate that one technique was better than the other in the incidence of pain in the short or long term, we showed that episiotomy and perineal tear repairs with continuous suturing were quicker and used less suture material without an increase in complication than interrupted suturing.

Arcus Marginalis Release in Blepharoplasty I: Technical Facilitation

Resection of intraorbital fat compartments in lower-lid blepharoplasty has been widely replaced by their realignment over the orbital rim. For older patients this usually includes an open subciliary approach with skin resection and orbicularis muscle modification. In younger patients this may be done transconjunctivally. Fixation of the adipose tissue is controversial. Whereas reliance of realignment on spontaneous prolapse may be unpredictable, suture fixations may be tedious and even cause scleral show or ectropion. A monofilament, double-armed, polypropylene suture on bent straight needles can be used safely to transfix the three compartments across maxilla and zygoma. These transcutaneous pullout sutures are simply fixed with steri-strips. After only 2 days the orbital fat will be sufficiently adherent to its new bed.

Transcutaneous laparoscopic hernia repair in children: a prospective review of 275 hernia repairs with minimum 2-year follow-up

Inguinal hernia in children is traditionally repaired through a groin incision by dissecting the hernia sac from the spermatic cord and suture ligating its base. A laparoscopic modification of this procedure involves placement of a transcutaneous suture around the neck of the sac through a 2-mm stab incision under visualization with an umbilically placed 2.7-mm 30 degrees lens. We reviewed the clinical outcome of this novel procedure at our institution. Prospective review of 275 hernias in 187 children (144 male, 43 female) performed laparoscopically by a single surgeon between September, 2002 and June, 2005. Data analyzed included side of hernia, incarceration, prematurity, recurrence rate, and complications. 30 left, 69 right, and 25 bilateral hernias were repaired. Sixty-three unilateral hernias had a contralateral patent processus vaginalis that was repaired. Mean operative time for a bilateral repair was 17 min. Two procedures were for recurrence after open repair. Forty-nine patients were ex-premature infants, accounting for 79 repairs. Fifteen cases followed reduction of incarcerated hernias, nine of whom were in preterm infants. Four out of 275 hernias (1.5%) recurred in four patients (mean age 4.5 years; 3 male, 1 female). There were four superficial wound infections, two umbilical granulomas, two hydroceles, and six self-resolving hematomas. There were no spermatic cord injuries, testicular atrophy, or symptoms of ilioinguinal nerve injuries. This novel laparoscopic inguinal hernia repair is an effective method in children, with recurrence rates comparable to the traditional approach. Advantages of the laparoscopic operation include a "no-touch" approach to the spermatic cord structures, a virtually virgin operative field in cases of recurrence, and excellent cosmesis. Disadvantages include peritoneal access and nonhermetic seal in males.

Submandibular gland endoscopic resection: acadaveric study

Recent advancement of head and neck surgery has been marked by the development of endoscopic and video-assisted minimally invasive surgery. This study reports the feasibility of endoscopic submandibular gland resection in human cadavers. Twelve submandibular gland resections were performed in six human cadavers. A 30° angle endoscope and conventional surgical instruments were inserted through two 15 mm submandibular incisions. Dissection was carried out bluntly with scissors in an avascular plane superficial to the gland. No insufflation was needed since transcutaneous sutures lead to effective retraction. Facial vessels, the lingual nerve and Wharton's duct were identified and protected. Vascular ligatures were performed using surgical miniclips. After the procedure, an open submandibular dissection was performed to control the integrity of the anatomical structures. In all cases, the resection of the submandibular gland was successful without the need for an additional incision. Injuries of the facial artery and lingual nerve occurred when the procedure was carried out initially. The operative time decreased with training, from 120 min for the first cases to 35 min for the later ones. In conclusion, endoscopic submandibular gland resection is possible without major difficulty. Training and experience reduce the operative time and the complication rate.

A prospective randomized trial of closing laparoscopic trocar wounds by transcutaneous versus subcuticular suture or adhesive papertape

Several methods for closure of trocar wounds are known in laparoscopic surgery. The choice of technique (mostly transcutaneous or subcuticular suture or adhesive papertape) is often based on the surgeon’s personal experience. Thus, the objective of this trial was to assess the impact of these closure methods on potential complications of wound healing, cosmetic outcome, and patient satisfaction. Sixty patients undergoing operative laparoscopic surgery for gynecologic indications were enrolled in this prospective randomized trial. Five-millimeter port-site incisions were closed either with subcuticular or transcutaneous absorbable sutures (4–0 polyglactin 910) or with adhesive papertape. Postoperative complications, pain, and patient satisfaction with scars were evaluated at 3-month follow-up after operation using a questionnaire. Data from 52 patients who returned the questionnaire were analyzed. Dissatisfying cosmetic results were reported significantly more frequently after subcuticular sutures (p < 0.05). Assessment of patient satisfaction with cosmetic outcome on a visual–analogue scale revealed significantly better results after transcutaneous skin closure than with other approaches (p < 0.05). Adverse wound healing (e.g., infections and dehiscence) was observed most frequently in the subcuticular suture group. Also, the rate of painful scars was highest with this technique. Transcutaneous closure with absorbable suture material seems to be the most suitable technique for closure of laparoscopic port-site incisions.

Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques

Background. Intracutaneous suture technique has been our standard method for closing sternal wounds in cardiac surgery, mainly for cosmetic reasons. However, an increased rate of postoperative infections has been reported in cosmetic surgery with this method compared with the percutanous or transcutaneous closure technique. A comparison of these two techniques in cardiac surgery is presented. Methods. In a randomized study, 300 patients were selected to intracutaneous suture (n = 150) or percutanous suture (n = 150). The endpoints were superficial and deep sternal wound infections within 6 weeks postoperatively. Results. The total infection rate was lower in the percutanous group compared with the intracutaneous group (3% versus 8%) ( p = 0.007). The superficial infection rate was lower in the percutaneous group (2.3% versus 6.7%) ( p = 0.01), whereas there was no statistically significant difference in the deep infection rate between the groups. Conclusions. The percutaneous suture technique reduces the incidence of superficial wound infections, but not the deep infection rate in open heart surgery. There was no difference in the cosmetic results on a visual scale, assessed by the patients.

Postinterventional transcutaneous suture of femoral artery access sites in patients with peripheral arterial occlusive disease: a study of 930 patients.

The purpose of this study was to evaluate a percutaneous vascular suture (PVS) device in patients with peripheral arterial occlusive disease (PAOD) for achievement of immediate hemostasis at the vascular access site and early ambulation of fully anticoagulated patients after peripheral interventional procedures. From June 1995 to March 2000, a vascular suture using a PVS device (6-10 Fr) was applied in 930 patients with PAOD. All patients had received an endoluminal intervention in the pelvic and/or the contralateral femoropopliteal region via a retrograde access through the common femoral artery (CFA). The incidence of complications within 12 hr after intervention, prior to discharge, and at 30-day follow-up was assessed employing clinical examination, treadmill test, and color Doppler ultrasound and the safety of the PVS device was determined. The efficacy of the system was measured by the percentage of achieved immediate hemostasis and early ambulation. PVS was technically successful in 92.2% independently from the degree of calcification at the access site. In 7.8%, an appropriate suture delivery could not be performed and these patients were successfully treated by conventional compression technique. Device malfunction or insufficient suture closure occurred in 1.7% and 2.1%, respectively. In 7.0%, groin-related complications occurred. Ambulation within 2-4 hr after successful suture was possible in 96.1%. All patients were free of any local symptoms at 30-day follow-up. The PVS device provides a safe and effective solution to achieve immediate hemostasis, thus permitting early ambulation in fully anticoagulated patients with PAOD after peripheral interventional procedures.

The elimination of complications in hypospadias surgery: a training in analytical thought or a mission impossible?

This is a critical review of 376 patients with hypospadias that were treated by the first author. The techniques used were a one-stage procedure for the correction of hypospadias without chordee (type I) and a two-stage procedure for hypospadias with chordee (type II). Development of these techniques was based on several conjectures: (a) A curvature of the penis can be caused by skin shortage alone; (b) persistent chordee is due to inadequate release of the corpora or to inadequate resurfacing of the corporal defect; and (c) fistulas can be caused by devascularisation of skin, by tension on the suture line, by superposition of skin wound and urethra, by infection, by perforation of skin, and by the evacuation of urine causing a separation of the wound edges. These conjectures were tested over a period of 30 years by a combination of measures involving: (a) The rotation in one or two stages of well-vascularised dorsal skin, using a backcut; (b) the omission of transcutaneous sutures and dressing; and (c) the diversion of urine through drainage incisions or fenestrated stent. These measures resulted in a dramatic reduction of the number of patients in need of a type II procedure. Persistent chordee, although rare, could always be corrected before a definitive urethroplasty was performed. Fistulas were almost completely eliminated.

Augmentation of the columella-labial angle to prevent the "smiling deformity" in rhinoplasty.

Aesthetic diagnosis of the smiling deformity, which is functional rather than anatomical, is essential to provide the best treatment in rhinoplasty. The nasal tip tends to rotate inferiorly during smiling, and the central upper lip moves superiorly. A posteriorly sloping upper lip with a retrodisplaced columella-labial junction gives an unaesthetic appearance. Downward movement of the tip and a sharper nasolabial angle are usually aesthetically unpleasant. In 28 nasal surgeries, augmentation of the columella-labial angle with cartilage strip grafts has been performed. The augmentation of the angle and additionally cutting of the depressor septi muscle created a wider nasolabial complex, and this angle looks full and more pleasant. This procedure has mainly been used as an additional procedure to standard reduction rhinoplasty in order to improve smiling deformity. Strip cartilage grafts were inserted subcutaneously into the upper lip extending half way to the columella and secured with a transcutaneous suture under the columella-labial angle to prevent misslocation. Augmentation by the cartilage graft together with cutting the depressor septi muscle prevented elevation and shortening of the upper lip, and also drooping of the nasal tip. This procedure provided an aesthetically pleasant appearance both at rest and during smiling.

Continuous versus interrupted sutures for perineal repair.

Millions of women worldwide undergo perineal repair after childbirth and the type of repair may have an impact on pain and healing. The objective of this review was to assess the effects of continuous subcuticular versus interrupted transcutaneous sutures on women following perineal repair. We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: June 1999. Randomised trials comparing continuous subcuticular versus interrupted transcutaneous sutures for the closure of perineal skin after vaginal delivery. Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. Study authors were contacted for additional information. Four studies involving 1864 women were included. The trials were heterogeneous with respect to operator skill and training. Compared with interrupted sutures, a continuous subcuticular suture technique of perineal repair was associated with less pain for up to 10 days post partum (odds ratio 0.68, 95% confidence interval 0.53 to 0.86). No differences were seen in the need for analgesia, need for resuturing of the wound or in dyspareunia. Based on one trial only, there was no difference in long-term pain and failure to resume pain-free intercourse within three months of the birth. The continuous technique was associated with less need for the removal of sutures. The continuous subcuticular technique of perineal repair may be associated with less pain in the immediate postpartum period than the interrupted suture technique. The long-term effects are less clear.

Skin closure at laparoscopy

To discern the best method of wound closure after laparoscopy based on patient acceptability of pain, complications, and cosmetic result. Randomized, prospective study. A university-affiliated hospital. Fifty-four women. Interventions. The women received interrupted 3-0 nylon sutures, subcuticular 3-0 polyglactin 910 sutures, or adhesive strips for skin closure. At the umbilical port site the rectus sheath was closed with a single 0 polyglactin suture and then one of the three materials for skin closure. The lateral ports were closed with a combination of these materials, allowing each patient to act as her own control. Pain was significantly less in wounds closed by subcuticular technique than in those closed by either transcutaneous suture or adhesive strips. This was seen for the 5-mm, 10-mm, and umbilical port sites. There was no statistically significant difference in the rate of reported complications or patient satisfaction between subcuticular and transcutaneous wound sites. We believe these results support subcuticular methods of wound closure after laparoscopic procedures.

Load affects remodeling of transplanted, autogenous bone‐patellar tendon‐bone segments in a rabbit model

The question of whether or not load affects the remodeling of a transplanted autogenous free graft was addressed by removal of the patella-patellar tendon-tibial tubercle complex from the right knees of 15 New Zealand White rabbits. The tubercle was split, and the tendon was divided with each half trimmed to an equal width. The autograft complex was transplanted into a subcutaneous tunnel on the back of the rabbit. Controlled cyclic loads were applied via transcutaneous sutures to half of the graft, while the other half remained unloaded. The mechanical stiffness and strength and the cell density of loaded and unloaded halves of the autograft were measured in nine animals at 3 weeks and in six animals at 6 weeks. Five autografts from four additional rabbits served as unimplanted controls. An analysis of variance showed that the loaded portions of the autografts had a significantly higher failure strength (mean of 90%) and were significantly stiffer (mean of 62%) than the unloaded halves at 3 and 6 weeks. Failure strength was significantly greater (mean of 90%) at 3 weeks than at 6 weeks. The autografts were less stiff and had a lower failure strength than the unimplanted controls, with the greatest difference occurring in the unloaded segments at 6 weeks. Histology revealed that both loaded and unloaded segments demonstrated an increase in cellularity at 6 weeks compared with 3 weeks. This report introduces a model for the study of the effect of load on soft-tissue grafts and demonstrates that loading affects the remodeling process of a transferred autograft.

The Southmead perineal suture study. A randomized comparison of suture materials and suturing techniques for repair of perineal trauma

Commonly used suture materials and techniques for perineal repair following vaginal delivery were compared in a randomized controlled trial involving 1574 women. Three comparisons were made using a modified factorial design. In the comparison of teflon-coated polyglycolic acid (Dexon plus) with chromic catgut for repair of the vagina and deep perineal tissues there was no clear difference other than less short-term analgesia being required in association with polyglycolic acid. Outcome was also similar after skin repair with either polyglycolic acid or chromic catgut or silk, although silk repair required more packets of material and was associated with delay in resuming sexual intercourse; polyglycolic acid was more likely to need removal than chromic catgut but it appeared to reduce the need for resuturing. There was no clear difference between continuous subcuticular and interrupted transcutaneous sutures for repair of perineal skin.