Patients are Willing and Successful With Home Suture Removal After Mohs Surgical Procedures.

BACKGROUND: Suture removal after surgery is low risk; however, it is often performed by a medical provider. The current SARS-CoV-2 pandemic has forced providers to assess means of reducing in-person contact. OBJECTIVE: To determine whether patients undergoing Mohs surgery are willing and successful with home suture removal. MATERIALS AND METHODS: A prospective study was performed with patients undergoing Mohs surgery. Before their surgery, patients were assessed for their willingness to remove sutures before and after viewing educational material. Patients who were willing to attempt removal were contacted after expected suture removal date to verify success and assess their experience. RESULTS: One hundred fifty patients were enrolled in the study. 90.1% were willing to attempt home suture removal. Patients were more willing ( p = .003), more confident ( p = .024), and had lower anxiety ( p = .049) with removal after viewing educational resources. Patients with a history of suture removal were more likely to attempt removal after their procedure ( p = .036). Ninety-seven percent of patients who were willing to attempt suture removal were successful. There were no major complications with removal. CONCLUSION: Patients were overwhelmingly successful with suture removal after an educational intervention. Providers should consider providing this option after surgical procedures when clinically appropriate.

Challenges of developing and executing a multi-site registry for a novel device with evolving indications for use.

BACKGROUND: The introduction of new technologies in endoscopy has been met with uncertainty, skepticism, and lack of standardization or training parameters, particularly when disruptive devices or techniques are involved. The widespread availability of a novel endoscopic suturing device (OverStitch™) for tissue apposition has enabled the development of applications of endoscopic suturing. METHODS: The American Gastroenterological Association partnered with Apollo Endosurgery to develop a registry to capture in a pragmatic non-randomized study the safety, effectiveness, and durability of endoscopic suturing in approximating tissue in the setting of bariatric revision and fixation of endoprosthetic devices. RESULTS: We highlight the challenges of the adoption of novel techniques by examining the process of developing and executing this multicenter registry to assess real-world use of this endoscopic suturing device. We also present our preliminary data on the safety and effectiveness of the novel device as it is applied in the treatment of obesity. CONCLUSIONS: The Prospective Registry for Trans-Orifice Endoscopic Suturing Applications (ES Registry) was an effective Phase 4, postmarketing registry aimed at capturing pragmatic, real-world use of a novel device. These findings serve to solidify the role of endoscopic suturing in clinical practice.

Face-to-face versus distance learning of basic suturing skills in novice learners: a quantitative prospective randomized trial.

BACKGROUND AND AIM: Traditionally, practical skills are taught on face-to-face (F-F) basis. COVID-19 pandemic brought distance learning (DL) to the spotlight because of the social distancing mandates. We sought to determine the acceptability and effectiveness of DL of basic suturing in novice learners. METHODS: A prospective randomized controlled trial involving 118 students was conducted. Participants were randomized into two groups for learning simple interrupted suturing: F-F and DL-groups. Evaluation was conducted by two assessors using a performance checklist and a global rating tool. Agreement between the assessors was calculated, and performance scores of the participants were compared. Participants' satisfaction was assessed via a questionnaire. RESULTS: Fifty-nine students were randomized to the F-F group and 59 to the DL-group. Satisfactory agreement between the assessors was demonstrated. All participants were successful in placing three interrupted sutures, with no significant difference in the performance between the groups. 25(44.6%) of the respondents in the DL-group provided negative comments related to the difficulties of remotely learning visuospatial concepts, 16(28.5%) preferred the F-F approach. CONCLUSION: DL of basic suturing is as effective as the F-F approach in novice learners. It is acceptable by the students despite the challenges related to the remote learning of practical skills.

Effectiveness of the world's first 1-Day online hands-on laparoscopic suturing training during COVID-19 pandemic.

We aimed to investigate the effectiveness of an online laparoscopic suturing training course conducted via an online meeting program. The mean needle loading, stitching, and knot-tying times were 77.3 s, 63.0 s, and 140.3 s, respectively on the initial test. Total laparoscopic suture time before the course was 273.8 s. After the course, time measures across all parameters decreased significantly (p < .001). The mean needle loading, suture passing, and knot tying times were 25.0 s, 31.0 s, and 34.6 s on the final test. The total intracorporeal suture time after the course was 90.0 s. The Objective and Structured Assessment of Technical Skills Scores significantly increased from 16.8 at the initial test to 25.4 at the final test (p < .001).IMPACT STATEMENTWhat is already known on this subject? Training models like box trainers and virtual reality simulators have frequently been shown to significantly improve laparoscopic skills.What the results of this study add? A 1-day online laparoscopic suturing course significantly reduces the intracorporeal suturing time.What the implications are of these findings for clinical practice and/or further research? Basis the results, online laparoscopic suturing training might become the new norm for training over conventional training given the benefits of cost and time savings.

Monofilament vs multifilament suture for uterine closure at the time of cesarean delivery: a randomized clinical trial.

BACKGROUND: Different factors may influence the closure of the uterine wall, including suture material. Suture materials may indeed influence tissue healing and therefore the development of scar defects. OBJECTIVE: To test whether uterine closure using synthetic absorbable monofilament sutures at the time of cesarean delivery would reduce the rate of cesarean scar defects compared with uterine closure using synthetic absorbable multifilament sutures. STUDY DESIGN: Parallel-group, nonblinded, randomized clinical trial of women with singleton pregnancies undergoing cesarean delivery at term in a single center in Italy. The inclusion criteria were singleton pregnancy, first or second cesarean delivery, scheduled and emergent or urgent cesarean deliveries, and gestational age between 37 0/7 and 42 0/7 weeks. Eligible participants were randomly allocated in a 1:1 ratio to either the monofilament group (polyglytone 6211 [Caprosyn]; Covidien, Dublin, Ireland) or the multifilament suture group (coated polyglactin 910 suture with Triclosan [Vicryl Plus]; Ethicon, Inc, Raritan, NJ). The primary outcome was the incidence of cesarean scar defect at ultrasound at the 6-month follow-up visit. The secondary outcomes were residual myometrial thickness and symptoms. RESULTS: Overall, 300 women were included in the trial. Of the randomized women, 151 were randomized to the monofilament group and 149 to the multifilament group. However, 27 women were lost to follow-up: 15 in the monofilament group and 12 in the multifilament group. Of note, 6 months after delivery, the incidence rates of cesarean scar defect were 18.4% (25 of 136 patients) in the monofilament group and 23.4% (32 of 137 patients) in the multifilament group (relative risk, 0.79; 95% confidence interval, 0.41-1.25; P=.31). The mean residual myometrial thicknesses were 7.6 mm in the monofilament group and 7.2 mm in the multifilament group (mean difference, +0.40 mm; 95% confidence interval, -0.23 to 1.03). There was no between-group substantial difference found in the incidence of symptoms, including pelvic pain, painful periods, and dyspareunia. CONCLUSION: In singleton pregnancies undergoing primary or second cesarean delivery, the use of synthetic absorbable monofilament sutures at the time of uterine wall closure was not associated with a reduction in the rate of cesarean scar defect 6 months after delivery compared with the use of synthetic absorbable multifilament sutures.

Telementoring of Open and Laparoscopic Knot Tying and Suturing Is Possible: A Randomized Controlled Study.

AIM: Several motor learning models have been used to teach highly complex procedural skills in medical education. The aim of this randomized controlled trial was to assess the efficiency of telementoring of open and laparoscopic suturing of medical students compared to conventional in-person teaching and training. METHODS: After randomization, 23 medical students were assigned to either the telementoring or the in-person training group. Both groups were taught by surgically trained residence with a student-teacher ratio of 1:1 (teacher-student). Open suturing was assessed in a model of congenital diaphragmatic hernia and laparoscopic suturing in a model of bowel anastomosis. All subjects were trained according to the spaced learning concept for 3 hours. Primary end points were time, knot quality, precision, knot strength, and overall knotting performance/competency. Furthermore, we utilized the Surgery Task Load Index to evaluate the cognitive load of both teaching techniques. Students' subjective progress regarding skill acquisitions and acceptance of telementoring was assessed using a nine-item questionnaire. RESULTS: All 23 trainees significantly improved after training in all knot attributes. More than 90% of all subjects reached proficiency in both groups. In-person training and telementoring were similarly practical, and no significant differences regarding speed, knot quality, precision, knot stability, and procedure performance/competency were found. Students perceived no difference in acquisition of factual or applicational knowledge between the two groups. General acceptance of telementoring was moderate in both groups before training, but increased during training in students actually assigned to this group, in comparison to students assigned to conventional teaching. CONCLUSION: The current study shows that telementoring of open and laparoscopic suturing is an ideal answer to the current coronavirus disease 2019 pandemic, ensuring continuous training. On-site training and telementoring are similarly effective, leading to substantial improvement in proficiency in intracorporeal suturing and knot tying. Likewise, students' subjective progress regarding skill acquisitions and cognitive load does not differ between teaching methods. Skepticism toward telementoring decreases after exposure to this learning method. Given our results, telementoring should be considered a highly effective and resource-saving educational approach even after the current pandemic.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study.

BACKGROUND: Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). METHODS: In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2-3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. RESULTS: Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training. CONCLUSION: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

Acquisition of Surgical Skills in Medical Students via Telementoring: A Randomized Controlled Trial.

BACKGROUND: Pandemic related changes have radically altered the delivery of medical teaching. The practical skills of medicine which students should be proficient in at time of graduation have tended to require in-person tutelage, with reduced access resulting in the risk of skill deficits in newly qualified doctors. Small group teaching sessions are amenable to a virtual mode of delivery, with the ability of the virtual platform to confer practical skills unproven. The objective of the study was to evaluate the use of teleproctoring in acquisition of suturing skills in medical students. METHODS: This was a single blinded two- armed randomized control trial. Medical students undergoing clinical rotations in their penultimate and final years who were able to complete the suturing tutorial were invited to participate in this study. Control groups underwent conventional suturing training under direct supervision, with the interventional group undergoing the tutorial in a remote learning setting via live streaming. Pre- and post-test assessment was carried out using validated suturing Global Rating Scale tool. RESULTS: A total of 24 participants were recruited, with 23 participants completing the task. Adequacy of sampling was demonstrated in both groups using Box's M test (P = 0.9). Participants' individual and composite scores were comparable at baseline (P = 0.28) and following the tutorial (P = 0.52). Participants improved to a statistically significant degree regardless of method of teaching delivery, in all skill parameters (P < 0.001). CONCLUSIONS: Teleproctoring is an effective tool in the provision of teaching basic suturing skills in medical students. Research on its use in more complex practical skills is warranted.

Laparoscopic repair of giant Morgagni hernia by direct suturing with V-Loc.

BACKGROUND: Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for surgical management. The purpose of this study was to analyze a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure with V lock (Medtronic, Covidien). METHODS: This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients, a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen, and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data such as BMI and operative and postoperative data were collected. RESULTS: Retrospectively collected data for 9 patients were analyzed. There were 1 (11.1%) males and 8 (88.8%) females. The median BMI was 29.14±52 kg/m². The median operative time was 80±25 minutes. There were no intraoperative complications or conversions to open surgery. Patients began a fluid diet on the first postoperative day and were discharged after a median hospital stay of 3±1.87 days. In a median follow-up of 36 months, we did not observe any recurrences. CONCLUSIONS: Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for the repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.

The use of barbed sutures in the Pulvertaft weave: a biomechanical study.

The use of barbed sutures in tendon repair and reconstruction is advantageous because it allows for a knotless suturing technique. In this biomechanical study, we compared barbed sutures with conventional sutures in tendon transfers using the Pulvertaft weave technique in a human cadaveric model. Thirty human cadaveric finger flexor tendons were transected and divided into three groups of ten tendons, which were then reconstructed by the Pulvertaft weave technique using 3-0 Prolene (Ethicon, Inc., Somerville, NJ, USA), 3-0 Ethilon (Ethicon, Inc., Somerville, NJ, USA) or 3-0 V-Loc (Covidien Deutschland GmbH, Neustadt, Germany) sutures. Biomechanical testing showed that repairs in the V-Loc group had significantly greater ultimate tensile strength and stiffness than conventional sutures. The time taken to complete the weave and the length of sutures used were also the least in the V-Loc group. Our study has shown that the barbed suture has a better biomechanical performance than conventional suture types when used in the Pulvertaft weave technique.

Biomechanical Studies for Glenoid Based Labral Repairs With Suture Anchors Do Not Use Consistent Testing Methods: A Critical Systematic Review.

PURPOSE: The purpose of this systematic review was to investigate variability in biomechanical testing protocols for laboratory-based studies using suture anchors for glenohumeral shoulder instability and SLAP lesion repair. METHODS: A systematic review of Medline, Embase, Scopus, and Google Scholar using Covidence software was performed for all biomechanical studies investigating labral-based suture anchor repair for shoulder instability and SLAP lesions. Clinical studies, technical notes or surgical technique descriptions, or studies treating glenoid bone loss or capsulorrhaphy were excluded. Risk of bias (ROB) was assessed with the ROBINS-I tool. Study quality was assessed with the Quality Appraisal for Cadaveric Studies. Heterogeneity was assessed with the I2 statistic. RESULTS: A total of 41 studies were included. ROB was serious and critical in 27 studies, moderate in 13, and low in 1; 6 studies had high quality, 21 good quality, 10 moderate quality, 2 low quality, and 2 very low quality. Thirty-one studies used and 22 studies included cyclic loading. Angle of anchor insertion was reported by 33 studies. The force vector for displacement varied. The most common directions were perpendicular to the glenoid (n = 9), and anteroinferior or anterior (n = 8). The most common outcome measures were load to failure (n = 35), failure mode (n = 23), and stiffness (n = 21). Other outcome measures included load at displacement, displacement at failure, tensile load at displacement, translation, energy absorbed, cycles to failure, contact pressure, and elongation. CONCLUSION: This systematic review demonstrated a clear lack of consistency in those cadaver studies that investigated biomechanical properties after surgical repair with suture anchors for shoulder instability and SLAP lesions. Testing methods between studies varied substantially with no universally applied standard for preloading, load to failure and cyclic loading protocols, insertion angles of suture anchors, or direction of loading. To allow comparability between studies standardization of testing protocols is strongly recommended.

In-person versus virtual suturing and knot-tying curricula: Skills training during the COVID-19 era.

BACKGROUND: The coronavirus disease 2019 restrictions on in-person simulation activities necessitated modifying the traditional boot camp skills curriculum for matriculating PGY1 general surgery residents to a virtual format. This study investigated the relative effectiveness of in-person versus virtual instruction on the development of suturing and knot-tying skills. METHODS: In all, 55 residents participated in a validated, proficiency-based, preinternship skills curriculum, 26 in 2019 and 29 in 2020. Both groups received an introduction to the curriculum, were given time for practice and offered one-on-one tutoring by faculty by request, and completed a filmed posttest. The 2019 class received in-person instruction during a boot camp at the end of June, while the 2020 class was provided with suture kits and received instruction via Zoom throughout June. The 2 groups were compared by post-test performance, date of task proficiency, and additional coaching required. RESULTS: In 2019, 5.7% of the posttest tasks were graded as proficient versus 87% in 2020. The 2020 class outperformed the 2019 class on every metric in every task (P < .001). In 2019, faculty spent 55.5 hours with residents in one-on-one remediation, resulting in proficiency in 64% of the tasks by November. In 2020, 18 hours of one-on-one remediation resulted in proficiency in 92% of the tasks by September. CONCLUSION: Learners who received virtual instruction with access to materials at home gained proficiency in suturing and knot-tying skills earlier and with less coaching. These data demonstrate that the virtual curriculum is effective and an improvement on the previous in-person curriculum.

Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications.

We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4-37) after injury in 2020. The delay was longer than usual due to the COVID-19 pandemic. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral suture. This was followed by an early, partial-range, active flexion exercise programme. Adhesions in four digits required tenolysis. These patients were not with longest delay. Outcomes of two improved after tenolysis. The other two patients declined further surgery. One finger flexor tendon ruptured in early active motion. This was re-repaired, and final outcome was good. Overall excellent and good results using the Tang criteria were in 27 out of 31 fingers and thumbs (87%). The time elapsed between the injury and surgery is not an important risk factor for a good outcome, rather it depends on proper surgical methods, the surgeon's experience and early mobilization, properly applied. Adhesions may occur, but they can be managed with tenolysis.Level of evidence: IV.

Development of an Interactive Remote Basic Surgical Skills Mini-Curriculum for Medical Students During the COVID-19 Pandemic.

Introduction. Teaching surgical skills has historically been a hands-on activity, with instructors and learners in close physical proximity. This paradigm was disrupted by the COVID-19 pandemic, requiring innovative solutions to surmount the challenges of teaching surgical skills remotely. In this work, we describe our institution's path and early results of developing an interactive remote surgical skills course for medical students in the surgical clerkship. Methods. 31 third-year medical students were distributed a set of surgical equipment and 3D printed phone dock. Each participant completed a baseline questionnaire and underwent 3 structured interactive remote sessions on surgical instruments, knot tying, and suturing techniques. Students were instructed on sharing their first-person viewpoint and received real-time feedback on their knot tying and suturing techniques from the course instructor. Pre- and post-session surveys were conducted and analyzed. Results. All students were able to complete the remote surgical skills course successfully, as defined by visually demonstrating successful two-handed knot and simple suture techniques. Students' aggregate confidence score in their knot tying ability (pretest mean 7.9, SD 0.7 vs posttest mean 9.7, SD 0.9, t-statistic -2.3, P = .03) and suturing ability (pretest mean 8.0, SD 1.3 vs posttest mean 13.8, SD 0.9 t-statistic -5.5, P < .001) significantly improved after the intervention. Qualitative feedback from the students underscored the utility of the first-person perspective for teaching surgical technique. Conclusion. This study demonstrates that remote teaching of knot tying and simple suturing to medical students can be effectively implemented using a remote learning curriculum that was well received by the learners.

The Use of New Technology for Wound Management Following Total Knee Arthroplasty: Implications for the COVID-19 Crisis.

With constantly evolving materials and techniques used in wound closure management for total knee arthroplasty (TKA), it is imperative that we continuously evaluate new modalities and techniques to optimize healing. This article provides a concise review of the current closure and wound management methods for each of the following three layers and dressing: 1) deep fascia layer, or arthrotomy; 2) subdermal layer or subcutaneous layer; 3) skin and subcuticular layer; and 4) dressing application. By introducing a comprehensive and systematic approach to TKA wounds, this report also incorporates newer modalities such as barbed sutures and adhesive dressings, which have increasingly replaced traditional suture and staple methods. Furthermore, we examine how various layers of modern wound closure compare to conventional methods while discussing both the clinical and economic impacts of each. Newer wound management methods, such as the adhesive and occlusive dressings with varying monofilament subcuticular sutures, can eliminate the need for staple and suture removal, increase the value of care provided, limit unnecessary postoperative visits, and potentially address wound issues by communicating safely with patients via telemedicine, an ever-relevant discussion in the era of coronavirus disease 2019 (COVID-19).

Home Program for Acquisition and Maintenance of Microsurgical Skills During the Coronavirus Disease 2019 Outbreak.

BACKGROUND: During the current global crisis unleashed by the severe acute respiratory syndrome coronavirus 2 outbreak, surgical departments have considerably reduced the amount of elective surgeries. This decrease leads to less time in the surgical room to develop and improve the surgical skills of residents. In this study, we developed a training program to obtain and maintain microsurgical skills at home, using a smartphone camera and low-cost materials, affordable for everyone. METHODS: Using a smartphone camera as a magnification device, 6 participants performed 5 exercises (coloring grids, grouping colors, unraveling of a gauze, knots with suture threads, and tower of Hanoi), both with the dominant and with the nondominant hand, for 4 weeks. We compared performance at the beginning and at the end of the training process. Each participant filled out an anonymous survey. RESULTS: When we compared the performance at the beginning and at the end of the training process, we found significant improvements (P = 0.05) with the dominant as well as the nondominant hand in all the exercises. All participants were satisfied or very satisfied with the definition of the objectives of the training process, material availability, the exercises performed, the choice of the time to train, and general satisfaction with the training program. CONCLUSIONS: We developed a microsurgical skills training program to be performed at home, which can be easily reproduced. It allows residents to improve manual coordination skills and is regarded as a feasible adjunct for ongoing training for surgical residents.

Remote corneal suturing wet lab: microsurgical education during the COVID-19 pandemic.

PURPOSE: To study the feasibility and efficacy of a new remote wet lab for microsurgical education using a corneal suturing task. SETTING: Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA. DESIGN: Prospective randomized controlled study. METHODS: Ten ophthalmology residents were stratified by postgraduate year and randomized to perform a corneal suturing task consisting of placing the 4 cardinal sutures for a penetrating keratoplasty in porcine eyes with or without remote ophthalmology attending feedback. Subsequently, both groups repeated the same task without remote feedback to test whether initial remote feedback affected subsequent performance. Finally, the group without feedback was crossed over to repeat the same corneal suturing task with remote feedback. The effectiveness of the remote wet lab was assessed subjectively by survey and objectively by grading each suture pass. RESULTS: Resident-reported comfort with corneal suturing improved significantly after the remote wet lab for all residents. Residents and attendings rated the remote wet lab as equally or more effective compared with previous in-person wet labs and overall effective in corneal suturing. Attendings rated the remote wet lab as effective in multiple domains of microsurgical education using a modified microsurgical global rating scale. Objective corneal suturing performance was similar for both groups. CONCLUSIONS: The remote wet lab was feasible and effective for training ophthalmology residents in corneal suturing. This represents a new social distancing compliant platform for microsurgical education during the COVID-19 pandemic.