Suturing with or without surgical glue is superior to surgical glue alone for sealing ex vivo swine gallbladders.

OBJECTIVE: To assess the effectiveness of various sealing techniques in cholecystotomies under maximum intraluminal pressure stress using an ex vivo swine model. SAMPLE: 30 gallbladders from different animals were used. METHODS: The experiment was conducted ex vivo, with the formation of 3 groups, each comprising 10 samples. Group 1 utilized a traditional single-layer Cushing suture made from polydioxanone material. Group 2 employed a single layer of Cushing suture, also made from polydioxanone material, but in conjunction with surgical glue (n-butyl cyanoacrylate). Group 3 relied solely on the use of surgical glue (n-butyl cyanoacrylate) for sealing the edges of the surgical wound. The intraluminal pressure was gauged with a pressure transducer. RESULTS: The maximum intraluminal pressures (mean ± SD) sustained in G1, G2, and G3 were, respectively, 48.70 ± 21.32 mm Hg, 110.90 ± 37.52 mm Hg, and 10.9 ± 4.07 mm Hg. Comparisons between groups showed that G2 supported significantly higher pressures (56.1% higher) than G1 (P < .001) and G3 (90.2% higher; P < .001). When G1 was compared with G3, a significantly higher pressure (77.6%) was also observed (P < .01). CLINICAL RELEVANCE: The study's conclusions demonstrated the safest suture techniques for the gallbladder and provided advice regarding the use of surgical glue.

Effect of Cross-Linkers on Mussel- and Elastin-Inspired Adhesives on Physiological Substrates.

Surgical adhesives can be useful in wound closure because they reduce the risk of infection and pain associated with sutures and staples. However, there are no commercially available surgical adhesives for soft tissue wound closure. To be effective, soft tissue adhesives must be soft and flexible, strongly cohesive and adhesive, biocompatible, and effective in a moist environment. To address these criteria, we draw inspiration from the elasticity and resilience of elastin proteins and the adhesive of marine mussels. We used an elastin-like polypeptide (ELP) for the backbone of our adhesive material due to its elasticity and biocompatibility. A mussel-inspired adhesive molecule, l-3,4-dihydroxyphenylalanine (DOPA), was incorporated into the adhesive to confer wet-setting adhesion. In this study, an ELP named YKV was designed to include tyrosine residues and lysine residues, which contain amine groups. A modified version of YKV, named mYKV, was created through enzymatic conversion of tyrosine residues into DOPA. The ELPs were combined with iron(III) nitrate, sodium periodate, and/or tris(hydroxymethyl)phosphine (THP) cross-linkers to investigate the effect of DOPA- and amine-based cross-linking on adhesion strength and cure time on porcine skin in a warm, humid environment. Incorporation of DOPA into the ELP increased adhesive strength by 2.5 times and reduced failure rates. Iron cross-linkers improved adhesion in the presence of DOPA. THP increased adhesion for all proteins tested even in the absence of DOPA. Using multiple cross-linkers in a single formulation did not significantly improve adhesion. The adhesives with the highest performance (iron nitrate mixed with mYKV and THP mixed with YKV or mYKV) on porcine skin had 10-18 times higher adhesion than a commercial sealant and reached appreciable adhesive strength within 10 min.

The use of surgical adhesive and suture fixing meshes to the abdominal wall: an experimental study in rats / O uso de cola cirúrgica e sutura na fixação de tela em parede abdominal: estudo experimental em ratos

ABSTRACT - BACKGROUND: Proper fixation of the surgical mesh determines the success of a herniorrhaphy. Understanding the inflammatory response and the mechanical properties of the mesh helps to define whether a fixation method is superior. AIM: This study aimed to evaluate the healing of defects in the abdominal wall of rats, comparing the repair of macroporous polypropylene meshes fixed with surgical glue and polypropylene thread. METHODS: In 20 Wistar rats, a defect was produced in the abdominal wall, with the integrity of the parietal peritoneum. For correction, the meshes were fixed with surgical glue (2-octyl cyanoacrylate) (subgroup C1), or polypropylene suture (subgroup C2). The two subgroups of 10 animals were euthanized on the 90th postoperative day, and the fragments of the abdominal wall were submitted to macroscopic, histological, and tensiometric analysis. RESULTS: Macroscopic analysis did not show any abnormalities. Tensiometry on the 90th postoperative day in subgroup C1 showed mean rupture tension of 28.47N and in subgroup C2 32.06N (p=0.773). The inflammatory process score revealed that both groups are in the subacute phase (p=0.380). CONCLUSION: The fixation of a polypropylene macroporous mesh to repair an abdominal wall defect can be performed with surgical glue (2-octyl cyanoacrylate) or polypropylene suture, both methods being equally effective.

RESUMO - RACIONAL: A adequada fixação da tela cirúrgica determina o sucesso de uma herniorrafia. Entender a resposta inflamatória e as propriedades mecânicas da tela contribui para definir se há superioridade de um método de fixação. OBJETIVO: Avaliar a cicatrização de defeitos em parede abdominal de ratos, comparando-se o reparo das telas de polipropileno macroporosas fixadas com cola cirúrgica e fio de polipropileno. MÉTODOS: Foi produzido defeito na parede abdominal de 20 ratos Wistar com integridade do peritônio parietal. Na correção, as telas foram fixadas com cola cirúrgica 2-octil cianoacrilato (C1) ou sutura (C2). Os dois subgrupos de 10 animais foram eutanasiados no 90º dia de pós-operatório e os fragmentos da parede abdominal foram submetidos a análise macroscópica, histológica e tensiométrica. RESULTADOS: A análise macroscópica não mostrou qualquer anormalidade. A tensiometria no 90º dia de pós-operatório no subgrupo C1 demonstrou tensão média de ruptura de 28,47N e no subgrupo C2 de 32,06N (p=0,773). O escore de processo inflamatório revelou que ambos os grupos se encontram na fase subaguda (p=0,380). CONCLUSÃO: A fixação de tela macroporosa de polipropileno para reparo de defeito em parede abdominal pode ser realizada com cola cirúrgica (2-octil cianoacrilato) ou sutura de polipropileno, sendo ambos os métodos igualmente eficazes.

Engineering elastic sealants based on gelatin and elastin-like polypeptides for endovascular anastomosis.

Cerebrovascular ischemia from intracranial atherosclerosis remains difficult to treat. Although current revascularization procedures, including intraluminal stents and extracranial to intracranial bypass, have shown some benefit, they suffer from perioperative and postoperative morbidity. To address these limitations, here we developed a novel approach that involves gluing of arteries and subsequent transmural anastomosis from the healthy donor into the ischemic recipient. This approach required an elastic vascular sealant with distinct mechanical properties and adhesion to facilitate anastomosis. We engineered two hydrogel-based glues: an elastic composite hydrogel based on methacryloyl elastin-like polypeptide (mELP) combined with gelatin methacryloyl (GelMA) and a stiff glue based on pure GelMA. Two formulations with distinct mechanical characteristics were necessary to achieve stable anastomosis. The elastic GelMA/mELP composite glue attained desirable mechanical properties (elastic modulus: 288 ± 19 kPa, extensibility: 34.5 ± 13.4%) and adhesion (shear strength: 26.7 ± 5.4 kPa) to the blood vessel, while the pure GelMA glue exhibited superior adhesion (shear strength: 49.4 ± 7.0 kPa) at the cost of increased stiffness (elastic modulus: 581 ± 51 kPa) and reduced extensibility (13.6 ± 2.5%). The in vitro biocompatibility tests confirmed that the glues were not cytotoxic and were biodegradable. In addition, an ex vivo porcine anastomosis model showed high arterial burst pressure resistance of 34.0 ± 7.5 kPa, which is well over normal (16 kPa), elevated (17.3 kPa), and hypertensive crisis (24 kPa) systolic blood pressures in humans. Finally, an in vivo swine model was used to assess the feasibility of using the newly developed two-glue system for an endovascular anastomosis. X-ray imaging confirmed that the anastomosis was made successfully without postoperative bleeding complications and the procedure was well tolerated. In the future, more studies are required to evaluate the performance of the developed sealants under various temperature and humidity ranges.

A Novel Skin Closure Technique for the Management of Lacerations in Thin-Skinned Individuals.

Suturing thin, fragile skin, particularly in elderly patients, is often problematic and presents a challenge to many clinicians. We describe a novel technique that re-enforces the edges of such thin fragile skin, with the use of topical skin adhesive, 2-octyl cyanoacrylate (Dermabond™; Ethicon, Somerville, NJ). This allows secure suture placement and application of tension to facilitate wound closure.

A Simple Technique for Intraoperative Scalp Skin Graft Depilation Using Dermabond®.

Skin grafting is an essential aspect of burn and wound reconstruction. Split-thickness skin grafts (STSGs) harvested from the scalp are used for wound and burn reconstruction. Skin grafts from the scalp bear hair and hair particles. Residual hair fragments and pieces of hair in the graft have been associated with many complications, including foreign body reaction similar to pseudofolliculitis and chronic inflammation that can lead to infections. It is important to remove the hair and the hair particles from the scalp graft before its application to the donor site. Traditionally, surgeons have employed some techniques including saline agitation and mechanical removal of the hair particles with forceps. These techniques are time consuming and can subject the graft to mechanical damage. There is another technique that has been described using an adhesive tape. This technique uses Ioban™ (3M Healthcare, St. Paul, MN), followed by a saline wash to remove hair from grafts prior to grafting. In this paper, we introduce a novel technique for intraoperative hair depilation prior to graft application to recipient site. We used Dermabond® (Ethicon, Bridgewater, NJ) to remove residual hair particles from the STSG donor. Our technique has several advantages: it is expeditious, it allows minimal mechanical damage to the graft, and can be used for patients with allergies to Ioban. Intraoperative Dermabond depilation of scalp STSGs is safe, easy, and effective.

Hangnails: Paste them back.

Hangnails are short torn down part of skin surrounding the nails. At times they are very painful. The usual treatment advised is cutting the excess skin with clippers or scissors. To provide an instant relief to the patients, we describe a simpler and effective way to use a surgical glue to paste them back in their original position.

Laparoscopic Approach to Inguinal Disruption in Athletes: a Retrospective 13-Year Analysis of 198 Patients in a Single-Surgeon Setting.

BACKGROUND: Inguinal disruption (ID) is a condition of chronic groin pain affecting mainly athletes. ID cannot be defined as a true hernia. Pathogenesis is multifactorial due to repetitive and excessive forces applied to the inguino-pelvic region. Examination reveals tenderness to palpation of the inguinal region. Differential diagnosis is challenging; imaging is helpful for excluding other pathologies. Surgery is the treatment of choice when conservative treatment fails. Primary aim of the study was to evaluate the time to return to full sport activity after transabdominal preperitoneal patch plasty (TAPP) technique in ID. Secondary aim was to evaluate the postoperative complication rate both in the immediate post-operative time and in 1 year follow-up and to verify the relapse rate after surgery. In this study, we consider time to return to full sport activity as the time needed to return to pre-injury sport activity. RESULTS: A retrospective study is reported by evaluating 198 cases of ID from a single surgeon experience. All patients failed a previous conservative treatment. All cases were treated with the TAPP approach. Time to return to full sport activity was 4 weeks for 94.4% of patients, with a total of 98.5% of active patients at 9 months. Post-operative inguinal pain was the main complication (9.1%). On 13 years follow-up, we report a recurrence rate of 2.5%. CONCLUSIONS: Current management algorithm for ID, in professional athletes, supports the role of surgery after at least 2 months of conservative treatment. Recently, the role of surgery has been highlighted for a definitive treatment and a faster full recovery to sport activity, especially for elite professional athletes. In our opinion, laparoscopic surgery is the mainstay for non-responsive ID treatment. We present a long-term retrospective evaluation of a wide cohort of professional athletes diagnosed and treated in a systematic way.

Unexpected intraoperative coronary malperfusion after primary repair of acute type A aortic dissection with surgical glue.

In the surgical treatment of acute aortic dissection, the attachment of the dissected wall using surgical glue can be an effective procedure to stabilize the fragile dissected wall. A 42-year-old man underwent aortic root replacement for acute type A aortic dissection. However, after aortic declamping, he experienced severe myocardial impairment, which required an additional procedure of coronary artery bypass grafting. The unexpected myocardial ischaemia can be attributed to the inattentional use of surgical glue.

Use of Whey Protein as a Natural Polymer for Tissue Adhesive: Preliminary Formulation and Evaluation In Vitro.

The use of sutures is still the most widely practiced solution for wound closure and tissue reconstruction; however, scarring is a common defect resulting from sutures on topical use. In some cases, the conventional sutures are unable to seal the sites where fluid and air leakage could occur. Tissue adhesives though have lower tensile strength than sutures, may make scarless surgery possible, or prevent fluid and air leakage. A product called BioGlue® (CryoLife Inc, Kennesaw, GA, USA), based on bovine serum albumin (BSA, a protein) and glutaraldehyde (GTA, crosslinker), has been approved for clinical use in the USA. Whey protein, a byproduct of cheese-making, comprised mainly of ß-lactoglobulin, α-lactalbumin and BSA. Even though the molecular weight of BSA is about three times larger than the molecular of ß-lactoglobulin and α-lactalbumin, all three proteins are rich in free ε-amino groups (can react with GTA) and globular proteins. This similarity make whey protein a potential candidate to replace BSA in the tissue adhesive since whey protein is abundant and much cheaper than BSA. In this study, whey protein isolate (WPI) was used as a protein polymer with GTA as a crosslinker to evaluate the feasibility of whey protein for tissue adhesive formulation. Results showed that the WPI/GTA adhesive exhibited a comparable adhesive strength to BioGlue® control.

Cyanoacrylate Adhesive Reduces Seroma Production After Modified Radical Mastectomy or Quadrantectomy With Lymph Node Dissection-A Prospective Randomized Clinical Trial.

INTRODUCTION: The accumulation of fluid, a seroma, is a frequent complication after modified radical mastectomy or quadrantectomy with lymph node dissection. The aim of the present study was to examine whether a new adhesive material made of cyanoacrylate can effectively provide a sealing coat to tissues and thus reduce the incidence of seroma significantly. PATIENTS AND METHODS: The present prospective, randomized case-control study included 128 women with a breast cancer diagnosis and scheduled for modified radical mastectomy or quadrantectomy with lymph node dissection in Thessaloniki, Greece. In 64 patients (cases), a cyanoacrylate adhesive was applied at the operative field after removal of the tumor and lymph nodes; the remaining 64 patients served as the controls. RESULTS: Seroma production (P = .001), drainage duration (P = .001), and drainage amount (P = .001) were all significantly less for cases than for controls. The results from a stepwise multiple regression model incorporating the use of adhesive, body mass index, tumor size, and number of infiltrated lymph nodes were significant and able to explain 51.6% of the variability in seroma amount. CONCLUSION: The results of our study have demonstrated that the cyanoacrylate adhesive can contribute to the reduction of seromas produced after mastectomy and subsequently decrease the duration of postoperative drainage and the frequency of seroma aspirations. However, because the pathogenesis of seroma formation is multifaceted and complex, further research of larger sample sizes is required to confirm the results of our study.

Natural healing-inspired collagen-targeting surgical protein glue for accelerated scarless skin regeneration.

Skin scarring after deep dermal injuries is a major clinical problem due to the current therapies limited to established scars with poor understanding of healing mechanisms. From investigation of aberrations within the extracellular matrix involved in pathophysiologic scarring, it was revealed that one of the main factors responsible for impaired healing is abnormal collagen reorganization. Here, inspired by the fundamental roles of decorin, a collagen-targeting proteoglycan, in collagen remodeling, we created a scar-preventive collagen-targeting glue consisting of a newly designed collagen-binding mussel adhesive protein and a specific glycosaminoglycan. The collagen-targeting glue specifically bound to type I collagen in a dose-dependent manner and regulated the rate and the degree of fibrillogenesis. In a rat skin excisional model, the collagen-targeting glue successfully accelerated initial wound regeneration as defined by effective reepithelialization, neovascularization, and rapid collagen synthesis. Moreover, the improved dermal collagen architecture was demonstrated by uniform size of collagen fibrils, their regular packing, and a restoration of healthy tissue component. Collectively, our natural healing-inspired collagen-targeting glue may be a promising therapeutic option for improving the healing rate with high-quality and effective scar inhibition.

Comparative study of safety and efficacy of synthetic surgical glue for mesh fixation in ventral rectopexy.

BACKGROUND: Ventral mesh rectopexy (VMR) is a surgical option to treat rectal prolapse with pelvic floor dysfunction (PFD). Using synthetic surgical glue to fix the mesh to the anterior rectal wall after ventral dissection could be advantageous in comparison with sutured or stapled fixation. This study aimed to evaluate the safety and efficacy of synthetic surgical glue for mesh fixation compared with suture mesh fixation in VMR. METHODS: This observational cohort study is a retrospective analysis conducted in a University Hospital Pelvic Surgery Center. All consecutive female patients (n = 176) who underwent laparoscopic or laparotomic VMR between January 2009 and December 2014 were included. Two groups were defined based on mesh fixation technique of the rectal wall: VMR with synthetic glue (n = 66) and VMR with suture (n = 110). The recurrence-free survival after VMR was determined by Kaplan-Meier method and multivariate analysis by Cox regression. Short-term postoperative complications, postoperative symptom improvement, the need for complementary treatment postoperatively, and procedure length were evaluated. RESULTS: A total of 176 females patients (mean age, 58.6 ± 13.7 years) underwent VMR with synthetic mesh. Mean recurrence-free survivals after VMR were 17.16 (CI 95% 16.54-17.80) and 17.33 (CI 95% 16.89-17.77) months in the glue group and the suture group, respectively (p > 0.05). Cox regression identified an independent effect on the recurrence risk of the external rectal prolapse, alone, or in combination with other anatomical abnormalities (HR = 0.37; CI 95% 0.14-0.93; p = 0.03). There was no significant difference of short-term postoperative morbidity, procedure length, postoperative symptom improvement, or need for complementary treatment postoperatively between suture versus glue groups (all p > 0.05). CONCLUSIONS: Use of glue to fix the mesh in VMR was safe and had no impact on outcomes. External prolapse was the unique significant predictive factor for recurrence.

A bioinspired elastin-based protein for a cytocompatible underwater adhesive.

The development of adhesives that can be applied and create strong bonds underwater is a significant challenge for materials engineering. When the adhesive is intended for biomedical applications, further criteria, such as biocompatibility, must be met. Current biomedical adhesive technologies do not meet these needs. In response, we designed a bioinspired protein system that shows promise to achieve biocompatible underwater adhesion coupled with environmentally responsive behavior that is "smart" - that is, it can be tuned to suit a specific application. The material, ELY16, is constructed from an elastin-like polypeptide (ELP) that can be produced in high yields from Escherichia coli and can coacervate in response to environmental factors such as temperature, pH, and salinity. To confer wet adhesion, we utilized design principles from marine organisms such as mussels and sandcastle worms. When expressed, ELY16 is rich in tyrosine. Upon modification with the tyrosinase enzyme to form mELY16, the tyrosine residues are converted to 3,4-dihydroxyphenylalanine (DOPA). Both ELY16 and mELY16 exhibit cytocompatibility and significant dry adhesion strength (>2 MPa). Modification with DOPA increases protein adsorption to glass and provides moderate adhesion strength (∼240 kPa) in a highly humid environment. Furthermore, this ELP exhibits a tunable phase transition behavior that can be formulated to coacervate in physiological conditions and provides a convenient mechanism for application underwater. Finally, mELY16 possesses significantly higher adhesion strength in dry, humid, and underwater environments compared with a commercially available fibrin sealant. To our knowledge, mELY16 provides the strongest bonds of any rationally designed protein when used completely underwater, and its high yields make it more viable for commercial application compared to natural adhesive proteins. In conclusion, this ELP shows great potential to be a new "smart" underwater adhesive.

Assessment and management of patients with minor traumatic wounds.

Patients with minor traumatic wounds are a common and universal presentation to emergency departments, and their assessment and management requires the use of cognitive and motor skills. Knowledge of anatomy and physiology, combined with decision-making skills, are essential for clinicians to undertake a thorough assessment, develop a care plan and provide effective wound management. This article discusses the importance of wound irrigation and debridement, as well as different methods available for wound closure. It is important that clinicians are competent in the motor skills required to perform these tasks to enable effective care delivery. Nurses should be aware of the latest research in the field and implement best practice in their clinical settings.

Strong poly(ethylene oxide) based gel adhesives via oxime cross-linking.

There is a demand for materials to replace or augment the use of sutures and staples in surgical procedures. Currently available commercial surgical adhesives provide either high bond strength with biological toxicity or polymer and protein-based products that are biologically acceptable (though with potential sensitizing potential) but have much reduced bond strength. It is desirable to provide novel biocompatible and biodegradable surgical adhesives/sealants capable of high strength with minimal immune or inflammatory response. In this work, we report the end group derivatization of 8-arm star PEOs with aldehyde and amine end groups. Gels were prepared employing the Schiff-base chemistry between the aldehydes and the amines. Gel setting times, swelling behavior and rheological characterization were carried out for these gels. The mechanical-viscoelastic properties were found to be directly proportional to the crosslinking density of the gels, the 10K PEO gel was stiffer in comparison to the 20K PEO gel. The adhesive properties of these gels were tested using porcine skin and showed excellent adhesion properties. Cytotoxicity studies were carried out for the individual gel components using two different methods: (a) Crystal Violet Staining assay (CVS assay) and (b) impedance and cell index measurement by the xCELLigence system at concentrations >5%. Gels prepared by mixing 20% w/w solutions were also tested for cytotoxicity. The results revealed that the individual gel components as well as the prepared gels and their leachables were non-cytotoxic at these concentrations. STATEMENT OF SIGNIFICANCE: This work presents a new type of glue that is aimed at surgery applications using a water soluble star shaped polymer. It show excellent adhesion to skin and is tough and easy to use. We show that it is very biocompatible based on tests on live human cells, and could therefore in principle be used for internal surgery. Comparison with other reported and commercial glues shows that it is stronger than most, and does not swell in water to the same degree as many other water based bioadhesives.

Tests of experimental tissue adhesive sealants: analysis of strength effects in relation to tissue adhesive sealant standards.

The sealing efficiencies (SE% = surfaces sealed/surfaces tested) of 2 experimental tissue adhesive sealants (TASs), L.C. TAS and glutaraldehyde TAS (GA TAS), were determined by applications in 12 mixed-breed pigs (weight range, 40-60 kg) that had been anticoagulated with heparin and divided into groups of 6: Group I, L.C. TAS; and Group II, GA TAS. Leaking tissue surfaces used were 5-mm aortic punch holes and lacerated splenic, hepatic, and lung surfaces (2 of each, in each pig). First-application SEs were as follows: for aortic punch holes, 91% in Group I and 16.6% in Group II (P <0.001; 95% confidence interval [CI], 49%-100%); for splenic leaking tissue surfaces, 83.3% in Group I and 0 in Group II (P < 0.001; 95% CI, 78%-88%); for hepatic leaking tissue surfaces, Group I, 83.3%; Group II, 16.6%; P <0.001 (95% CI, 37%-97%); and for lung leaking tissue surfaces, 75% in Group I and 0 in Group II (P <0.001; 95% CI, 50%-99%). For both 1st and 2nd applications on all leaking tissue surfaces, SEs were 98% in Group I and 29% in Group II (P <0.001; 95% CI, 37%-99%). These results are consistent with the hypothesis that a TAS with higher cohesive and adhesive strengths, such as L.C. TAS (cohesive strength, >6.5 kg/cm(2); adhesive strength, >1.5 kg/cm(2)), will have higher SEs for leaking tissue surfaces than will a TAS with lower cohesive and adhesive strength. An analysis of these data in relation to TAS standards is discussed.