Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma.

BACKGROUND: Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. METHODS: The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). RESULTS: From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. CONCLUSION: The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be "lost arts" in modern trauma care.

Time to closure of orthopaedic surgical incisions: a novel skin closure device versus conventional sutures.

OBJECTIVE: New technologies are being developed to optimise healing of surgical incisions. BandGrip (US) is a micro-anchor skin closure device that replaces the need for subcuticular suturing and further dressing. The purpose of this study is to perform a matched cohort analysis comparing time to closure of surgical incisions between sutures and the novel skin closure device. METHOD: Patients undergoing orthopaedic surgery in 2019 underwent skin closure with either conventional sutures or the novel skin closure device. Patients were divided into three groups according to their procedural incisions: anterior cruciate ligament reconstruction (ACLR); simple arthroscopy; and general incisions. Patients who underwent closure of their surgical incision with the novel skin closure device were matched with patients undergoing superficial closure with sutures. Statistical analysis was performed to compare time to closure per centimetre of skin incision between the groups. RESULTS: A total of 86 patients were included in the study. Overall mean time to closure using the novel skin closure device was less than with sutures (8.6 seconds/cm versus 42.8 seconds/cm, respectively, p<0.001). Mean time to closure for ACLR incisions was 3.7 seconds/cm using the novel skin closure device and 35.5 seconds/cm using sutures (p<0.001). Mean time to closure for simple arthroscopy portals was 19 seconds/cm using the novel skin closure device and 47.6 seconds/cm using sutures (p<0.001). CONCLUSION: BandGrip is a novel skin closure device that allows for efficient surgical incision closure. Time to surgical skin incision closure is significantly less with the use of the novel skin closure device when compared with conventional sutures.

[Future trend of minimally invasive surgery platform and surgical procedure].

In the past 30 years, minimally invasive surgery has been greatly improved with the development of the energy platform, instrument platform, and imaging platform. Taking colorectal cancer surgery as an example, the five elements of surgical procedure have developed to a certain extent. The surgical approach has undergone a process from large to small. The range of resection ranges from simple bowel resection to radical resection/extended radical resection, and then to surgery that focuses on preserving organ function. With the recognition of the direction of normal lymphatic drainage and the characteristics of tumor lymphatic metastasis, lymph node dissection has been gradually standardized. The reconstruction of the digestive tract has changed from manual sutures to full endoscopic anastomosis, and then to the concept of functional anastomosis. The removal of the specimen has improved from large incision through the abdominal wall, to small laparoscopic incision, and then to the natural cavity. The evolution of these procedures depends on the advancement of technology platforms and equipment, and the recognition of new concepts. The development of minimally invasive platform must be in the direction of ensuring the implementation of the most optimized surgical approach. The platform is more secure, integrated, multifunctional, and intelligent. In the future, minimally invasive procedures must be aimed at maximizing the benefits of patients. The procedures are more scientific, functional, comfortable and diverse. Surgical innovation has promoted the development of the platform. The platform and the surgical procedure promote each other's development.

Continuous dural suturing for closure of grade 3 leaks after tumor removal via an endoscopic endonasal approach.

Cerebrospinal fluid (CSF) leakage is a major complication after extended endonasal transsphenoidal surgery (EETSS), which is commonly used in the treatment of anterior skull base tumors. Dural suturing and graded reconstruction are promising techniques to further decrease the incidence of postoperative CSF (poCSF) leakage. The effect of continuous dural suturing in endoscopic surgery was investigated in this retrospective study. A total of 79 EETSS patients were included; the procedures were performed for subdural tumor removal by a single endoscopic neurosurgical team. Comparisons were applied between patients who did and did not undergo endoscopic dural suturing after tumor removal. Multivariate logistic regression analysis was performed to identify variables that significantly influenced the incidence of poCSF leakage. In all, 79 adult patients developed Esposito's grade 3 intraoperative high-flow CSF leakage. Ten patients (12.7%) experienced poCSF leakage. One of the 36 patients who underwent intraoperative dural suturing developed poCSF leakage, compared with nine of 43 patients who did not undergo dural suturing (p = 0.016). Regression analysis showed that dural suturing could significantly decrease the incidence of poCSF leakage (p = 0.049, OR 0.108, 95% CI 0.013-0.899). Prophylactic lumbar drainage could also help decrease the CSF leakage rate. Dural suturing under endoscopy is a promising and effective method for application in skull base reconstruction after subdural skull base tumor removal. With future progress, lumbar drainage and even nasoseptal flap placement could be replaced in certain groups of patients undergoing EETSS.

Future trend of minimally invasive surgery platform and surgical procedure / 中华胃肠外科杂志

In the past 30 years, minimally invasive surgery has been greatly improved with the development of the energy platform, instrument platform, and imaging platform. Taking colorectal cancer surgery as an example, the five elements of surgical procedure have developed to a certain extent. The surgical approach has undergone a process from large to small. The range of resection ranges from simple bowel resection to radical resection/extended radical resection, and then to surgery that focuses on preserving organ function. With the recognition of the direction of normal lymphatic drainage and the characteristics of tumor lymphatic metastasis, lymph node dissection has been gradually standardized. The reconstruction of the digestive tract has changed from manual sutures to full endoscopic anastomosis, and then to the concept of functional anastomosis. The removal of the specimen has improved from large incision through the abdominal wall, to small laparoscopic incision, and then to the natural cavity. The evolution of these procedures depends on the advancement of technology platforms and equipment, and the recognition of new concepts. The development of minimally invasive platform must be in the direction of ensuring the implementation of the most optimized surgical approach. The platform is more secure, integrated, multifunctional, and intelligent. In the future, minimally invasive procedures must be aimed at maximizing the benefits of patients. The procedures are more scientific, functional, comfortable and diverse. Surgical innovation has promoted the development of the platform. The platform and the surgical procedure promote each other's development.

The efficacy of bidirectional barbed sutures for incision closure in total knee replacement: A protocol of randomized controlled trial.

BACKGROUND: Barbed suture is a novel type of suture introduced in different surgical specialties. Nevertheless, its effect in total knee replacement is still unclear in terms of wound complications and cost effectiveness. The purpose of the present work is to evaluate the safety and efficacy of bidirectional barbed suture in reducing postoperative wound complications in the patients undergoing total knee replacement. METHODS: This prospective, randomized, and controlled study was performed from January 2017 to December 2018. It was authorized via institutional review committee of Yuebei People's Hospital (GDYB1002189). Hundred participants were divided randomly into 2 groups, namely, control group (n = 50) and the study group (n = 50), respectively. All operations were performed using the Miller-Galante prosthesis (Zimmer; Warsaw, IN). For study groups, the joint capsule (Stratafix1-0) and subcutaneous (Stratafix2-0) and intracutaneous (Stratafix3-0) tissues were sutured by a bidirectional barbed suture. At the end, extra 4 to 5 stitches were made to avoid detachment and incision rupture. For control group: the joint capsule was sutured by a traditional absorbable suture (Ethicon VICRYL* Plus 1-0), and the subcutaneous tissue was sutured by an absorbable suture (Ethicon VICRYL* Plus 2-0). The skin was sutured by staples. Incision length, suture time, operation time, postoperative length of hospital stay, and incision complications (such as effusion, infection, hematoma, and skin necrosis) were recorded. All data analyses are implemented through utilizing SPSS for Windows Version 20.0. RESULTS: The results will be shown in Table 1. CONCLUSION: This study can reach a reliable evidence for utilizing bidirectional barbed suture in wound closure in total knee replacement. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5823).

An odyssey of suturing cardiac wounds: Lessons from the past.

BACKGROUND AND AIM OF THE STUDY: Cardiac wounds have been described for centuries and still remain to be fatal. For a long period of time, the suturing of a myocardial laceration was thought to be absolutely impossible if not sacrilege. METHODS: It is only at the end of the 19th century that pioneers decided to defy such a dogma in desperate cases. RESULTS: Nowadays, it seems obvious that a cardiac stab wound requires emergent surgery whenever possible. CONCLUSIONS: The story of cardiac wounds highlights nicely the change of mind that is required to accept progress and new procedures in medicine.

Innovations in Endoscopic Therapy for Gastroesophageal Reflux Disease.

Minimally invasive endoscopic antireflux therapies are critical for bridging the gap between medical and surgical treatments for gastroesophageal reflux disease (GERD). Although multiple endoscopic devices have been developed, perhaps some of the most exciting options that are currently evolving are the full-thickness suturing techniques using widely available and low-cost platforms. Full-thickness endoscopic suturing can allow for a highly durable recreation of the anatomic and functional components of a lower esophageal sphincter, which are deficient in patients with GERD. Proper patient selection, endoscopic hiatal hernia evaluation, and standardized suturing methods are necessary to ensure success of endoscopic suturing for antireflux therapy.

Current trends in hernia surgery in NHS England.

BACKGROUND: Mesh is recommended for the repair of most hernias when prevention of recurrence is the primary endpoint. However, mesh may be associated with increased complications for the patient. The aim of this study was to quantify the use of mesh for abdominal wall hernia surgery in NHS England in recent years. MATERIALS AND METHODS: The NHS Digital Secondary Uses Service database for 2016/17 and 2017/18 was interrogated for numbers of patient undergoing elective primary hernia surgery. Using the specific hernia code inguinal (T201-9), umbilical (T241-9), incisional (T251-9) and other abdominal wall hernia (T271-9), the use of mesh or suture repair was determined. Recurrent and emergency hernia surgery were excluded. All data were provided by NHS RightCare. RESULTS: There are almost 100,000 hernia repairs performed annually in NHS England. For every four hernias, three are repaired with mesh. The percentage repaired by mesh varies by hernia type. Mesh repairs in inguinal, umbilical and incisional hernias accounted for 95%, 50% and 82%, respectively. CONCLUSIONS: Mesh repair for all hernia types is more common than suture repair. However, for umbilical and other abdominal wall hernias, a significant proportion are repaired without the use of mesh.

Comparison of three fixation techniques for arcuate fractures.

PURPOSE: Proximal fibula avulsion fractures, or "arcuate fractures", are an often discussed but poorly defined injury pattern which represent a destabilizing injury to the posterolateral corner of the knee. Historical and recent literature discussing reconstruction and repair techniques exist, but there has been little biomechanical evaluation of repair techniques. The purpose of this study was to evaluate the strength of three type of fixation techniques for arcuate fractures: bone tunnels, a screw and washer, and a novel suture anchor technique. METHODS: A laboratory model of the arcuate fracture pattern was developed. This was used to create an arcuate fracture in 24 cadaveric specimens. Knees were randomized into fixation with either suture tunnel (ST), screw and washer (SW), or suture anchor (SA) repair. A previously published model for inducing varus stress was applied and a MTS testing system was used to assess fixation ultimate and yield strength. RESULTS: Fibular fracture occurred during the fixation of one specimen from the ST group and one from the SA group. Analysis of the remaining 22 specimens revealed a mean ultimate strength of 2422.48 N for the ST group, 2271.78 for SW, and 3041.66 for SA (p = 0.390). Yield strengths were 2065.28 for ST, 1882.43 for SW, and 2871.92 for SA (p = 0.224). Analyses of stiffness and total energy applied were not statistically different (p = 0.111 and 0.601, respectively). CONCLUSION: Biomechanical analysis of three types of arcuate fragment fixation revealed robust fixation among all methods, supporting surgeon preference for fixation. Fixation may depend on the size of bony fragment and whether or not the injury is a bony or soft tissue injury.

Achilles tendon rupture repair: Biomechanical comparison of the locking block modified Krackow technique and the Giftbox technique.

BACKGROUND: Open Giftbox repair of the Achilles tendon has good biomechanical advantages, but it is not minimally invasive. We designed a peritendon fixation technique, the "Locking Block Modified Krackow" (LBMK) technique, to meet minimally invasive needs. This study used a simulated protocol of early rehabilitation to compare the biomechanics of LBMK with those of the Giftbox technique. METHODS: Twenty fresh bovine Achilles tendon specimens were randomly assigned to either the LBMK group or the Giftbox group. The LBMK technique and the Giftbox technique were used as the main suture configurations, and transverse sutures were used as secondary suture configurations in both groups. Each repaired specimen was subjected to two cyclic loading protocols (20-100 N, 20-190 N). The gapping between the tendon ends was measured after each stage of loading. Finally, all specimens underwent a load-to-failure test at a stretching rate of 25 mm/s. RESULTS: After the first loading stage, the mean tendon gapping was 0.76±0.44 mm in the LBMK group and 0.86 ± 0.47 mm in the Giftbox group (p = 0.620). After the second loading test, the average gapping measures of the LBMK and Giftbox groups were 3.8 ±â€¯1.9 mm and 4.2 ±â€¯2.2 mm, respectively (p = 0.466). Finally, the catastrophic load to failure was 732.8 ±â€¯138 N in the LBMK group and 645.5 ±â€¯121 N in the Giftbox group. The difference was statistically significant (p = 0.023). CONCLUSION: Both the LBMK and Giftbox techniques meet the requirements of early rehabilitation, but the suture strength in the LBMK group was significantly higher than that in the Giftbox group.

Suturing Achilles tendon and mesh simultaneously in augmented repair resists gap formation foremost: an experimental study.

BACKGROUND: The common calcanean tendon (Achilles tendon) is the strongest and largest tendon and is one of the most commonly affected by spontaneous rupture. Different suture techniques are used to repair the tendon rupture. We compare the biomechanical properties of three different modalities of suture pattern in a mechanical experiment in rabbits with the purpose of evaluating the use of polypropylene mesh augmentation for Achilles tendon repair to find out the best surgical option. METHODS: The study tests single cycle to failure tensile strength characteristics of three different combinations of the 3-loop pulley (3-LP) suture technique with polypropylene mesh, and statistically compares the biomechanical properties as the maximum load at failure for all 3-LP repair. RESULTS: The normal Achilles tendon-control group-failed at a mean load of 25.5 + 13.6; the experimental groups failed at a significantly lower load (p < 0.001), with the group of 3-LP suture with polypropylene mesh included in the suture being the more similar to controls, but all the groups exhibited statistically significant differences with regard to normal tendons (p < 0.001). The distance at which each group failed was also significant between control and experimental groups (p < 0.001) with the exception of the suture-only group and the group with the mesh over the suture (p = 0.15). CONCLUSION: Results from this study suggest that incorporating the mesh within the suture provides benefit to the Achilles tendon repair by improving strength and resistance to pull through. However, further in vivo studies will be necessary to confirm these results and incorporate this technique to the routine human and veterinary surgery.

Minimally Invasive Thoracoscopic Mitral Valve Replacement in Rheumatic Disease With Continuous Suture Technique.

Minimally invasive mitral valve surgery has become routine in many institutions. Disadvantages of this approach include prolonged aortic cross-clamp and cardiopulmonary bypass times. Mitral valve replacement with a continuous suture technique may reduce operative times. We present a case of a 51-year-old man suffering from severe rheumatic mitral disease to highlight our continuous suture technique for minimally invasive mitral valve replacement. We also report preliminary results from our series of 15 patients suffering various rheumatic mitral pathology treated with this technique.

Comparison of surgical trends in zone 2 flexor tendon repair between Turkish and international surgeons.

OBJECTIVES: The aim of this study was to evaluate Turkish trends in zone 2 flexor repair with regards to surgical technique, suture materials, anesthesia and post-operative rehabilitation and compare this with international surgeons by modifying Gibson's survey. METHODS: A printed and online survey consisting of 19 questions modified from Gibson's survey was sent to 590 Turkish and international surgeons. The surgeon's years in practice, province of practice, residency type, number of zone 2 flexor tendon repairs done in a year, preferred surgical technique, suture material, complications and postoperative protocols were asked to the respondents. RESULTS: A total of 194 surgeons completed the survey (a 25% response rate). Of those who completed the survey, 91 were international (mostly from far eastern countries) and 103 were Turkish surgeons. Years in practice and educational background had influence on the decision-making. There were differences between the Turkish and international surgeons in the core and epitendinous suture thickness preference and flexor tendon sheath repair. There was a statistically significant relationship between the province of practice and the use of WALANT (Wide awake local anesthesia no tourniquet) (p < 0.05). While the majority of respondents who preferred postoperative early passive motion protocol were from Turkey (61.5%), the majority of respondents who preferred early active motion protocol were practicing abroad (73.9%). CONCLUSION: Despite some variations the surgeons involved in this study follow to a large extent the current literature.

Association of Surgical Overlap during Wound Closure with Patient Outcomes among Neurological Surgery Patients at a Large Academic Medical Center.

BACKGROUND: Several studies have explored the effect of overlapping surgery on patient outcomes, but impact of surgical overlap during wound closure has not been studied. OBJECTIVE: To examine the association of overlap during wound closure and suture time overlap (STO) with patient outcomes in a heterogeneous neurosurgical population. METHODS: Over 4 yr (7/2013-7/2017), 1 7689 neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. STO was defined as all surgeries for which an overlapping surgery occurred, exclusively, during wound closure of the index case being studied. We excluded nonelective cases and overlapping surgeries that involved overlap during surgical portions of the case other than wound closure. Tests of independence and Wilcoxon tests were used for statistical analysis. RESULTS: Patients with STO had a shortened length of hospital stay (100.6 vs 135.1 h; P < .0001), reduced deaths in follow-up (1.59% vs 5.45%; P = .0004), and lower 30- to 90-d readmission rates (3.64% vs 7.47%; P = .0026). Patients with STO had no increase in revision surgery. Patients with STO had longer wound closure times (26.5 vs 23.9 min; P < .0001) but shorter total surgical times (nonclosure surgical time 101.8 vs 133.3 min; P < .0001; and total surgical time 128.3 vs 157.1 min; P < .0001). CONCLUSION: Surgical overlap during wound closure (STO) is associated with improved or at least noninferior patient outcomes, as it pertains to readmissions and wound revisions.