Robotically assisted aorto-femoral bypass grafting: lessons learned from our initial experience.

OBJECTIVE: The da Vinci trade mark Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) is a computer-enhanced telemanipulator that may help to overcome some limitations of traditional laparoscopic instruments. This prospective study was performed to assess the safety and feasibility of robotically assisted aorto-femoral bypass grafting (AF). METHODS: Five patients undergoing elective AF were enrolled in this study. In three patients, a laparotomy of 6 cm was first performed, the aorta being exposed using an Omnitract degrees retractor. In two patients, aortic dissection was performed with laparoscopy, with the patient in a modified right lateral decubitus position. In all patients, the proximal anastomosis was attempted with the da Vinci trade mark system by a remote surgeon. The role of the assistant at the patient's side was limited to exposure, haemostasis and maintaining traction on the running sutures performed by the robot. Six weeks after the operation, all patients underwent a duplex scan of the graft. RESULTS: Mean operative time was 188 min. Robotically assisted aortic anastomoses were successfully completed in four out of five patients. In these four patients, adequate blood flow was observed within the graft with no need for conversion for haemostasis. In the fifth patient, despite an adequate laparoscopic aortic dissection, the anastomosis was impossible to perform due to external conflicts between the robotic arms. A conversion using conventional suture was successfully performed. No robot-related complications were noted. Six weeks after the operation, the duplex scans demonstrated a graft patency of 100%. CONCLUSION: Robotically assisted anastomoses are possible by their unique ability to combine conventional laparoscopic surgery with stereoscopic 3D magnification and ultra-precise suturing techniques due to the flexibility of the robotic-wristed instruments using different motion scaling of surgeon hand movements. In addition, prior training in laparoscopic aortic surgery is not necessary for surgeons to obtain the level required for suturing. Further clinical trials are needed to explore the clinical potential and value of robotically assisted AF.     

Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients

Background

Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture.

Methods

Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses.

Results

Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n = 15), colocolostomy (n = 1), esophagojejunostomy (n = 5), and jejunojejunostomy (n = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6 months of follow-up evaluation.

Conclusions

The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.     

Mechanical circular colorectal anastomosis using a transanal approach. Apropos of a series of 51 cases

Automatic circular suture forceps offer new technical possibilities for the confection of colorectal anastomosis. A retrospective study was conducted in 51 patients, representing a homogeneous group of anastomoses performed by the same surgeon using the same operative technique and with routine review by barium enema examination on the 8 th postoperative day. Technical difficulties during operation were encountered in 10 patients (19.6%) requiring supplementary sutures in 3 cases and protective colostomies in 3 others. Review examinations revealed anastomotic dehiscence in 7 cases (13.7%), only 3 (5.9%) of these radiologic fistulae provoking clinical manifestations, and only one of these (1.9%) necessitating recovery operation. Perfect compliance with conditions of use of the mechanical forceps and a minute technique identical to those of manual sutures produced excellent early result with circular mechanical suturing using EEA forceps when compared with manual suturing methods. This was particularly true in Goligher's series in which there were 51% of radiologic fistulae. Under certain difficult conditions, the use of EEA forceps simplifies performance of a colorectal anastomosis, mechanical anastomosis using the circular forceps constituting an undeniable technical progress in colorectal surgery with conservation of anal sphincter.     

Evaluation of a new vascular suture system for aortic laparoscopic surgery: an experimental study on pigs and cadavers.

OBJECTIVES: The aim of this study was to assess the feasibility and efficacy of a new laparoscopic vascular suturing device. METHODS: Animal study: six pigs underwent surgery using a retroperitoneal laparoscopic approach. Aorto-prosthetic side-to-end and end-to-end anastomoses were performed laparoscopically on each pig using SuDyn. Clamping and anastomosis times, as well as the properties of the anastomoses, were recorded. Study on cadavers: four aorto-prosthetic end-to-end anastomoses were performed using the direct transperitoneal laparoscopic approach to assess the feasibility of the SuDyn device on atherosclerotic aortas. RESULTS: Animal study: No pigs died and 12 patent and impermeable anastomoses were obtained. Mean anastomosis time was 38(+/-8)min for end-to-side anastomoses and 37(+/-5)min for end-to-end anastomoses. Study on cadavers: Totally laparoscopic anastomoses were performed in 4 human cadavers with a mean anastomosis time of 37(+/-3)min. CONCLUSIONS: SuDyn makes laparoscopic aorto-prosthetic anastomoses easier to perform, produces good results and does not require a learning curve.     

A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents

BACKGROUND: Robotic surgery offers all the advantages of laparoscopy with additional increased accuracy. The use of robotic surgery has increased in the past 5 years. It has proven particularly useful in complex surgical procedures such as intracorporeal intestinal anastomosis. As the prevalence of robotic surgery increases, so will the need for residents to be able to perform surgery using the robotic system. Our goal was to compare hand-sewn, laparoscopic, and robotic suturing techniques performed by midlevel residents using a porcine intestinal model. METHODS: Fifteen residents unfamiliar with the robotic suturing technique participated in performing an initial hand-sewn suture line and then were randomized with cross-over to laparoscopic or robotic suturing. Completion time, leak pressure, number of sutures per cm, and difficulty level were assessed. RESULTS: The mean leak pressure for hand-sewn, laparoscopic, and robotic suturing was 9.5, 3.2, and 11.4 mm Hg, respectively. The laparoscopic group had 6 and the robotic group had 1 suture line that was inadequate for testing. Suture breakage was common in the robotic group. The anastomosis was considered hard by 92% in the laparoscopic group versus 17% in the robotic group. The time it took to complete 1 cm of anastomosis was .9, 8.7, and 8.3 minutes for hand-sewn, laparoscopic, and robotic suturing, respectively. CONCLUSION: The robotic suture line performed by midlevel residents was superior to laparoscopy, although the time for anastomosis was equivalent.     

Reconstructive-restorative operations by the method of invagination in colorectal surgery

The authors made an analysis of results of surgical treatment of 41 patients who underwent reconstructive large bowel anastomosis by the Hartman procedure. In 19 (46.3%) patients the anastomoses were performed by traditional methods (end-to-end and end-to-side) using a two-row suture. In 22 (53.7) patients the anastomoses were made by one-row sutures. The authors conclude that the results of formation of invaginated colorectal anastomosis depend on the method of forming anastomosis, with the performing of colorectal anastomosis by traditional method fraught with the development of the content reflux in the outlet. The authors proposed a method of forming colorectal anastomoses by invagination using a one-row suture. The obtained function of the valve prevents regurgitation of the intestinal content and is considered to be a measure for preventing reflux.     

Use of Barbed Sutures in Laparoscopic Gastrointestinal Single-Layer Sutures

Methods:Between August 2012 and March 2014, 15-cm-long barbed sutures (V-Loc 180; Covidien, Mansfield, MA, USA) were used for laparoscopic intestinal anastomoses, including intestinal hole closure for esophagojejunal and gastrojejunal anastomoses after mechanical anastomoses and gastric wall closure after partial resection.Results:In total, 38 patients underwent 40 laparoscopic anastomoses (esophagojejunostomies, 26; gastrojejunostomies, 7; and simple closure of gastric defect, 7); no cases required conversion to open surgery. Two cases exhibited positive air leak test results during surgery (1 case of esophagojejunostomy and 1 case of simple closure of gastric defect). Two cases of intestinal obstruction were noted; of those, one patient with postoperative intestinal paresis (grade II) was managed conservatively, and the other underwent repeat laparoscopic surgery (grade IIIb) for internal herniation unrelated to V-Loc use. No postoperative complications at the anastomosis site and no surgery-related deaths were noted.Conclusion:Single-layer entire-thickness running suturing with the V-Loc 180 barbed suture after stapled side-to-side intestinal anastomosis was found to be safe and feasible in the reported cases.     

A comparison of interrupted and continuous sutures for tracheal anastomoses in sheep.

OBJECTIVE: To study the tensile strength of tracheal anastomoses. DESIGN: Experimental study. SETTING: University medical school laboratory, Germany. ANIMALS: 15 sheep. INTERVENTIONS: Tracheal anastomoses with three different suturing techniques: a continuous suture and interrupted sutures with either a monofilament or a polyfilament material. Anastomoses were tested to breaking after being in place for 1, 2, 4, 8 or 24 weeks. RESULTS: After one week, with all three materials, the trachea broke at the anastomosis. In animals that survived longer, the trachea broke further away from the anastomosis. There was no significant difference between the mean values of the breaking force for continuous sutures and single interrupted sutures (p = 0.9). CONCLUSION: The suturing technique (continuous or interrupted) has less relevance for the tensile strength of the anastomosis than in vitro experiments suggest.     

Hand-sewn intra-abdominal anastomosis performed via video laparoscopy during colorectal surgery

STUDY OBJECTIVE: Laparoscopic colectomies have been recently shown to be feasible and safe, with the use of stapling devices to fashion the anastomosis. The aim of this study was to evaluate the feasibility and safety of laparoscopic intra-abdominal hand-sewn anastomosis. PATIENTS AND METHODS: Seven patients (four males and three females, mean age 48 years) were included. There were two ileocolic resections for recurrence of Crohn's disease, two right colectomies (one for Crohn's disease and one for carcinoid tumor of the appendix), two left colectomies for diverticulitis and one segmental colectomy for sigmoid volvulus. There were: four side-to-side anastomoses, two side-to-end anastomoses and one end-to-end anastomosis. Anastomoses were fashioned with interrupted single layer sutures in four cases (two ileo-colic and two colorectal anastomoses) and with single layer running sutures in three cases (two ileo-colic and one colo-colic anastomoses). The specimens were retrieved by means of a plastic bag through a 3 to 5 cm long minilaparotomy in five cases and through the rectum in two cases. RESULTS: Mean additional time to perform hand-sewn intra-corporeal anastomosis was 90 +/- 15 min. There was no operative mortality and no intraoperative complications. Postoperative course was uneventful in six patients. Patients were started on an oral fluid diet on day 2 and discharged on day 5, except for one patient with Crohn's disease who had a severe anastomotic bleeding on postoperative day 2 and who required laparotomy for hemostasis through a service colotomy with a single suture. He was discharged on day 8. CONCLUSION: Intra-abdominal hand-sewn anastomoses are feasible and seem reliable. This represents a new step making laparoscopic procedures even closer to conventional techniques. This technique must be evaluated in larger series.     

Robot-assisted laparoscopic intestinal anastomosis

Introduction: Robotic telemanipulation systems have been introduced recently to enhance the surgeon's dexterity and visualization in videoscopic surgery in order to facilitate refined dissection, suturing, and knot tying. The aim of this study was to demonstrate the technical feasibility of performing a safe and efficient robot-assisted handsewn laparoscopic intestinal anastomosis in a pig model. Methods: Thirty intestinal anastomoses were performed in pigs. Twenty anastomoses were performed laparoscopically with the da Vinci robotic system (robot-assisted group), the remaining 10 anastomoses by laparotomy (control group). OR time, anastomosis time and complications were recorded. Effectiveness of the laparoscopic anastomoses was evaluated by postoperative observation of 10/20 pigs of the robot-assisted group for 14 days and by testing mechanical integrity in all pigs by measuring passage, circumference, number of stitches, and bursting pressure. These parameters and anastomosis time were compared to the anastomoses performed in the control group. Results: In all cases of the robot-assisted group the procedure was completed laparoscopically. The only perioperative complication was an intestinal perforation, caused by an assisting instrument. The median procedure time was 77 min. Anastomosis time was longer in the laparoscopic cases than in the controls (25 vs 10 min; p <0.001). Postoperatively, one pig developed an ileus, based on a herniation of the spiral colon through a trocar-port. For this reason it was terminated on the sixth postoperative day. All anastomoses of the robot-assisted group were mechanically intact and all parameters were comparable to those of the control group. Conclusion: Technical feasibility of performing a safe and efficient robot-assisted laparoscopic intestinal anastomosis in a pig model was repeatedly demonstrated in this study, with a reasonable time required for the anastomosis.     

Internal configuration of saphenous-coronary anastomoses as studied by the cast-injection technique.

A study of the internal configuration of saphenous vein--to--coronary artery anastomoses was undertaken to examine the effect of technical factors. One hundred fifty anastomoses were constructed in isolated swine hearts and epoxy-resin casts were made of the anastomoses by pressure-injection. The effects of interrupted sutures, continuous suture, vein tailoring, vein-to-artery size ratio, and end-to-side and side-to-side anastomoses were evaluated. We made several observations: (1) The external appearance of an anastomosis is not a reliable indicator of internal configuration. (2) Interrupted suturing consistently produces an internal configuration with minimal deformity. (3) Unless special precautions are taken with continuous suturing, severe deformities may occur. Very fine suture spacing and knotting distal corner sutures are recommended. (4) Proper vein-to-artery size ratio and "cobra-head" vein tailoring are desirable. (5) Side-to-side anastomoses are similarly significantly affected by suture techniques, vein graft size, venotomy size, and orientation. The study of the internal configuration of saphenous-coronary anastomoses is a simple and readily available method which should be useful to all coronary surgeons in assessing and perfecting their techniques.     

Breaking strength of native and sutured trachea. An experimental study on sheep trachea.

Tracheal anastomoses are, even more so than other sutures, often only possible to prepare under tension and thus in danger of breakage. No information is available regarding native tracheae and freshly sutured tracheae. For this reason, our objective was to examine the tensile strength of native tracheae and compare it with freshly sutured specimens. Fresh tracheae were collected from the local slaughterhouse within 30 min of slaughter. With the help of a suitable holding device, 24 fresh tracheae were mounted on a material testing machine and stretched to breaking point, during which the force and distance required were recorded. The same study was carried out on each 10 freshly anastomosed tracheae using three different suturing techniques. The mean value of the maximum force required for native tracheae was 198 N. With continuous suturing (polypropylene), a mean value of 171 N was attained, and with single interrupted suturing (polydioxanone and polyglactin 910), 123 N, respectively, 108 N. Differences between the groups proved to be highly significant. With respect to the mechanical strain from traction, the continuous suture proved to be statistically identical to native tracheae, whereas single interrupted sutures revealed a considerably lower stability under burden. Therefore, the continuous suture is of advantage in respect of the mechanical strain from traction and the suture protection of tracheal anastomoses. Further studies with differing survival times in vivo with this method provide insight into the stability of tracheal anastomoses during the healing process.     

The Heartflo device for distal coronary anastomoses: clinical experiences in 60 patients

BACKGROUND: The Heartflo anastomotic device automates the suturing process with simultaneous delivery of 10 standard polypropylene sutures through the graft and the coronary vessel wall to construct the anastomosis. We performed clinical testing in 60 patients undergoing coronary artery bypass grafting. METHODS: One automated distal coronary anastomosis was initially placed in each patient, the other anastomoses were created with standard running sutures. After a "flat foot"-shaped prototype was deployed in 30 patients (group I), the design of the foot was modified and deployment of the new device performed in the next 30 patients (group II). RESULTS: In group I, automated anastomoses were completed in 16 patients (53%) using 1.7 +/- 1 additional stitches. In 26 group II patients (86%), a hemostatic anastomosis using 1.2 +/- 1 additional stitches was achieved. Anastomoses were completed in 19.0 +/- 3 minutes in group I and in 15.6 +/- 2 minutes in group II. CONCLUSIONS: We have shown the feasability of coronary anastomoses using the Heartflo device. The modified version improved tissue capture, resulting in a higher rate of completed anastomoses. Because anastomotic time is still prolonged, an easier suture management is mandatory in the next developmental step.     

Barbed Versus Usual Suture for Closure of the Gastrojejunal Anastomosis in Laparoscopic Gastric Bypass: a Comparative Trial

Background

Laparoscopic Roux-en-Y gastric bypass is one of the main bariatric procedures that require safe and reproducible anastomosis. The objective of this study is to compare the risk of leaks and stenosis of a mechanical gastric pouch jejunal anastomosis between the usual interrupted sutures and a continuous barbed suture for gastrojejunotomy, in order to reduce procedure time and costs.

Methods

A comparative trial of 100 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass was performed between October 2010 and July 2011. The population was divided into two groups of 50 consecutive patients. In the first group, gastrojejunotomy was sutured with resorbable interrupted sutures and the second with continuous barbed suture. Diabetes, body mass index and the American Society of Anaesthesiology score were compared. The time required for suturing and the incidence of anastomotic leaks and stricture were also compared after 6 months.

Results

No fistulas or anastomotic stenoses had occurred at post-operative month 6 in either group. Gastrojejunotomy suture time was significantly shorter in the barbed suture group (11 versus 8.22 min; p?<?0.01). Total costs of material to complete the reconstruction were significantly lower in the barbed suture group (€26.69 versus €18.33; p?<?0.001).

Conclusions

The use of barbed suture is as safe as usual sutures and allows easier and faster suture in the closure of gastrojejunotomy. This suture could be incorporated in the standard laparoscopic Roux-en-Y gastric bypass technique.     

Stapled aortic anastomoses: a minimally invasive, feasible alternative to videoscopic aortic suturing?

Widespread applications of totally laparoscopic aortic reconstructions have been limited by the long cross-clamp time required to suture the aortic anastomosis despite improvement in instrumentation. The authors' hypothesis was that a "one-step anastomosis concept" using an intraluminal stapler would allow shorter cross-clamp time but similar patency and imperviousness as videoscopic suturing techniques. An intraluminal stapler (Endopath-ILS, Ethicon) with a modified anvil was used to perform videoscopic-assisted thoracic aorta-to-iliac artery bypass with a 21 mm by 8 mm polytetrafluoroethylene (PTFE) graft in 22 sheep through a minimally invasive approach using a 5 cm thoracotomy. The graft-to-iliac artery anastomoses were hand sutured through a flank incision. Twelve sheep were used to establish the technique and 10 subsequent animals constituted the study group. Aortic cross-clamp time, imperviousness, and need for additional sutures were recorded and compared to previously reported data using videoscopic suturing in pigs. Patency was assessed by comparing lower limb arterial pressures. Macroscopic and microscopic examinations of the anastomoses were performed at different time-points within the first 3 months. Videoscopic-assisted stapled anastomoses were also performed on atherosclerotic aortas of 3 human cadavers. Stapled anastomoses between the thoracic aorta and PTFE graft were completed in 8 of 10 animals. Two animals were euthanized after stapler failure and anastomotic bleeding. Sutures to strengthen the anastomosis had to be used in 4 cases. Mean aortic cross-clamp time in 8 successful cases was 4.3 +/-2.9 minutes (range 2-11 minutes) and was significantly shorter than clamp time of videoscopic suturing technique (48.7 +/-9.4 minutes, p < 0.0001). Imperviousness was good or excellent in 4 animals and fair in 4 animals. All anastomoses were patent at the end of the procedure. Examination of the anastomosis of the 2 failed interventions showed medial aortic tear surrounding the anastomosis in 1 case and misfired staples in the other. No graft occlusion was noted during follow-up ranging from 0 to 12 weeks. At the time of harvest, no bleeding was noted after epinephrine and volume infusion to increase mean arterial pressure to 200 mm Hg for 15 minutes. Macroscopic examination of the anastomoses revealed adequate healing with circumferential stapling of the prosthesis to the aortic wall and no stenosis or thrombus except in 1 false aneurysm (1/7, 14%). Surface electron microscopy showed cells coverage of the anastomosis surface. When applied on human cadaver thoracic and abdominal aorta with atherosclerotic changes, clamping times of less than 5 minutes were achieved. However, imperviousness tested with saline was poor. An automatic stapling device allows performance of a graft-to-aorta anastomosis through a minimally invasive approach with shorter clamping time than a videoscopic suturing technique. However, the current technique of aortic stapling is unreliable and further improvements are needed.     

Comparison of laser vascular welding,interrupted sutures,and continuous sutures in growing vascular anastomoses

Background and Objectives: The argon laser-assisted vascular anastomosis may solve the problems of conventional sutured anastomosis, such as vascular stenosis and arrest of growth owing to a foreign-body reaction to suture material. Study Design/Materials and Methods: Twelve argon laser-assisted vascular anastomoses, seven conventional anastomoses with interrupted sutures, and five conventional anastomoses with continuous sutures were performed in 12 young mongrel dogs. Results: Five months later, the external diameter at the anastomosis had increased 70.5% in the laser group, 67.0% in the interrupted suture group, and 22.9% in the continuous suture group. Histological examination of the laser-assisted anastomoses showed almost complete healing, with no granulomatous response around the anastomotic site. In the interrupted suture group, marked scaring and foreign body reactions were observed on the vessel wall at the site of the anastomosis. The continuous suture group showed more remarkable disorientation of the vascular layer and intimal hyperplasia than the interrupted suture group. Conclusion: Vascular anastomosis using the argon laser offers advantages over the conventional procedure in growing vessels.     

Creation of ureteropelvic junction obstruction and its correction by chemical glue-assisted laparoscopic dismembered pyeloplasty

PURPOSE: We established a porcine model of ureteropelvic junction (UPJ) obstruction using a laparoscopic technique and assessed the outcome of standard suture-assisted and chemical glue-assisted laparoscopic pyeloplasty. MATERIALS AND METHODS: Female domestic pigs (N = 20) underwent laparoscopic suture-ligature to create UPJ obstruction. One month later, laparoscopic end-to-end anastomosis was performed to correct the obstruction: with standard suturing techniques in 10 animals and with chemical (cyanoacrylate) glue in the other 10. Postoperative ureteral stents were not used. Four weeks postoperatively, intravenous urography was performed to evaluate the patency of the anastomoses. The UPJ was procured by laparotomy to assess the anastomoses and periureteral fibrosis histologically. RESULTS: The UPJ obstruction was created in an average of 15 +/- 6 minutes. There was no early postoperative mortality. Eighteen pigs survived for at least 1 month, and UPJ obstruction developed in 17 (95%). Microscopically, the lumen of the UPJ was partially occluded, measuring an average of 40% +/- 5% of normal. After laparoscopic correction, a patent UPJ was found in seven of nine animals treated with traditional sutures. Among the eight animals with chemically glued anastomoses, none had a patent UPJ, and severe periureteral adhesions and intraluminal fibrosis were noted at the pyeloplasty site. Marked ureteral tortuosity was present in six of the eight pigs receiving glue-assisted pyeloplasty but in none of the animals having suture-assisted pyeloplasty. CONCLUSIONS: Ureteropelvic junction obstruction was established by laparoscopic suture-ligature in a porcine model with a 95% success rate. Chemical glue-assisted anastomosis was inferior to standard laparoscopic sutures for pyeloplasty to correct the obstruction.     

Evaluation of a novel modified suture material designed to facilitate intracorporeal knot tying during laparoscopic surgery

BACKGROUND AND PURPOSE: Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is an arduous process with a long learning curve. While recent advances in instrumentation have allowed easier suturing and tying, until now, no attempts have been made to modify the suture material in order to facilitate this process. We present an evaluation of a novel modified suture material designed to allow inexperienced surgical residents to tie intracorporeal knots laparoscopically using conventional laparoscopic needle drivers. SUBJECTS AND METHODS: Surgical residents with no prior experience in laparoscopic surgery were invited to take part in this investigation. Each of the 14 participants was given a 10-minute demonstration of laparoscopic intracorporeal knot tying and then allowed a mentored practice session of 10 minutes. In the first trial, they were then randomized to tie a laparoscopic knot with either a standard or a modified dry suture. Time and accuracy scores were recorded. They then performed the same task with the other type of suture. On the second trial, wet standard and modified sutures were used, and the order of the sutures used in the first trial was reversed. RESULTS: The average time taken to tie an intracorporeal knot laparoscopically was significantly less when the modified suture was used in both dry and wet conditions (162.71 +/- 10.79 seconds v 270.86 +/- 22.76 seconds; P = 0.0039, and 123.29 +/- 4.70 seconds v 247.57 +/- 23.17 seconds; P = 0.0032, respectively). No significant difference in accuracy scores was noted with the two sutures. CONCLUSIONS: Our modified suture design allowed inexperienced surgical residents to perform intracorporeal laparoscopic knot tying on average faster than the standard suture did. The concept of modifying suture design to facilitate laparoscopic suturing and knot tying deserves further investigation and development.     

Use of fibrin glue to minimize bleeding of microvascular repairs in hypertensive rats.

The purpose of this study is to describe our technique of applying fibrin glue at the microvascular anastomotic site and to evaluate the effect of fibrin glue on anastomotic hemostasis and patency under various high pressure states using dopamine-induced acute hypertension in rats. A total of 72 male Wistar Kyoto rats, 10 weeks old, were used in this study. Under urethane anesthesia, end-to-end anastomosis of the left femoral artery was performed using 10-0 nylon suture by the standard interrupted suture technique. Pasteurized fibrin glue was then topically applied upon the suture line of the anastomosis. Thirty-six normotensive rats were divided into three groups based on the number of sutures (4, 6, or 8) used to complete the anastomosis. Groups were subdivided, half receiving fibrin glue application and half without. Thirty-six dopamine-induced acutely hypertensive rats were divided into three groups based on the blood pressure levels of 150, 200, and 250 mmHg, respectively. These groups were again subdivided, with half receiving glue applications. Microvascular anastomosis was performed using 6 nylon sutures. Patency rates and anastomotic bleeding were evaluated. The results revealed that successful anastomoses could be performed with fewer sutures when fibrin glue was used as a reinforcement at the anastomosis. Fibrin glue was also effective at the maximum blood pressure (250 mmHg) with no anastomotic leakage and no decrease in postoperative patency rate. These results suggest that conventional microsurgical suturing technique combined with fibrin glue would be effective in the prevention of leakage in microsurgical repairs, even under conditions of high blood pressure.