An automated interrupted suturing device for coronary artery bypass grafting: automated coronary anastomosis

BACKGROUND: The purpose of this study was to have a preliminary assessment of the safety and efficacy of an automated vascular suturing device. METHODS: The device (Heartflo, Perclose/Abbott Labs, Redwood City, CA), which delivers 10 interrupted 7-0 polypropylene sutures between side-to-side arteriotomies, was evaluated in animals (8 Yorkshire pigs). RESULTS: Tissue edge capture and quality of anastomosis were highly rated. Time of anastomoses averaged 22 minutes. This time was prolonged primarily due to suture management, tying of interrupted sutures, and learning curve effects. Six of the anastomoses were hemostatic and two required an additional stitch each. Angiography and histology of the anastomosis confirmed patency and quality of the anastomosis. CONCLUSIONS: Our preliminary results indicate that the Heartflo automated anastomotic device is safe and effective. Preclinical and clinical studies to validate its acute and long-term effectiveness will commence shortly.     

An experimental model for side-to-side microvascular anastomosis

Side-to-side microvascular anastomosis may be required in certain clinical situations, although the technique is difficult and the incidence of usage remains low. A new experimental model using rat femoral vessels for side-to-side microvascular anastomosis is presented, in which 100 percent patency was accomplished immediately and was maintained for 7 days after anastomosis. This model can provide a training tool for acquisition of advanced microsurgical technique for side-to-side anastomosis of small vessels.     

Posterior-wall-first continuous suturing combined with conventional interrupted suturing for microvascular anastomosis

Vascular anastomosis with conventional interrupted suturing is often difficult to perform when the vascular clamp is not reversed, because of a narrow operative field or a short vascular pedicle. A posterior-wall-first continuous suture technique combined with the standard interrupted suture technique is one method of solving this problem. The authors conducted a comparative study of posterior-wall-first continuous suturing combined with standard interrupted suturing and conventional interrupted suturing in rat vessels. There was no statistically significant difference in patency rates or suturing times. Electron microscopy demonstrated no significant difference in recoverability of the intima. The posterior-wall-first continuous suture technique combined with the standard interrupted suture technique is a useful alternative to the conventional interrupted suture technique.     

Multiple-organ failure and sepsis without bacteria. An experimental model

Multiple-organ failure is generally attributed to bacterial infection, although a correlation with positive blood cultures is not consistently found. Consequently, we studied the effects of a local nonbacterial inflammatory stimulus on distant organ functions and metabolism. Wistar rats were inoculated intraperitoneally with zymosan. Heart and ventilatory rates, oxygen consumption, and body temperature were measured. Survivors were killed at day 12 for blood analysis, weighing of organs, and microscopy. Intraperitoneal zymosan resulted in an early hyperdynamic "septic" response with a 35% mortality. After a few days, oxygen consumption decreased, serum lactate levels increased, and the function of multiple organs deteriorated, while blood cultures remained sterile. The experiment was repeated in germ-free rats with similar results but a lower mortality. We concluded that a severe inflammatory response in itself is capable of inducing multiple-organ failure with "sepsis."     

Bidirectional-barbed sutured knotless running anastomosis v classic Van Velthoven suturing in a model system

BACKGROUND AND PURPOSE: Robotic prostatectomy is exploding into popular utilization throughout much of the United States. It is expected that the rise in the number of these cases into 2006 will continue exponentially. A significant amount of research has begun to focus on the anastomosis, because the robot allows unprecedented illumination and dexterous control to make the quality of this repair equal to that of a microscopic approach. Here, we report our results with a circular anastomosis technique using an innovative bidirectional-barbed suture material for knotless, tension-free repair and compare it with a standard polyglecaprone single-knot technique. MATERIALS AND METHODS: Using a previously described in-vitro model of microfiber synthetic material, a running anastomosis was performed using the da Vinci Surgical System by one surgeon. Two pre-tied 3-0 polyglecaprone sutures on a tapered Rb-1 needle were compared with a bidirectional-barbed suture (3-0 PDO) designed specifically for our use (Quill Sutures, Research Triangle Park, NC). The times needed to perform the anastomosis, the accuracy in idealized phantoms, and the surgeon's security in the quality of his work (linear scale) were all recorded for 10 consecutive anastomoses. RESULTS: The PDO suture was faster to deploy (17.3 minutes v 19.2 minutes), and the security score by the surgeon was greater. The accuracy was equivalent for both types of running closure comparing the classic van Velthoven with the PDO-sutured anastomosis. CONCLUSIONS: It appears from our preliminary work that a bidirectional-barbed suture might improve the vesicourethral anastomosis during a robotic radical prostatectomy. Further investigations should be done to measure the disruptive force necessary to distract these sutures, whether the applied forces of the barbs are adequate for maintaining a watertight seal, and the reproducibility of our results by other surgeons. All of these investigations are in progress in our laboratory.     

Half-Halsted suturing technique for anastomosis on edematous bowel

Background

Bowel anastomoses are prone to dehiscence or leakage under various circumstances, including that of the small and large bowel parts being not completely healthy. The edematous or hypertrophic bowel ends that are left after excision or removal of an obstacle, are either exteriorized, or, with increased risk of leakage, sutured or anastomosed.

Methods

During the period 1/2014-8/2017, the half-Halsted suturing technique was used in the construction of intestinal anastomoses on edematous and/or hypertrophic small and large bowel in 35 patients (19 males, 16 females) with a mean age of 58 years and ASA status II-III. Of these, 22 patients were suffering from malignant and 13 from benign disease. Emergency surgery was performed in 19, and the rest had semi-emergency (2) or elective (14) surgery. All the cases were characterized by bowel wall ends that were not totally normal after excision or removal of an obstacle, while in 30 patients one or both of the bowel ends to be anastomosed presented significant edema or hypertrophy. The anastomoses that were constructed connected small to small bowel (21 patients), small to large bowel (11) or large to large bowel (3). Anastomoses were fashioned either end-to-end (19 patients), side-to-side (10) or end-to-side (6).

Results

No death occurred in this series, and no anastomotic leak, bleeding or abscess developed. Minimal complications (non-anastomosis related) developed post-operatively in 10 patients. The mean postoperative hospitalization was 8.2 days.

Conclusions

The half-Halsted suturing technique is safe and effective for anastomoses of edematous or hypertrophic small and large bowel.

     

An improved technique for coronary vascular anastomosis.

A vein holder is described that is used for anastomosis of both ends of aortocoronary bypass grafts. It minimizes handling of the graft, ensures precision in placing sutures with excellent visualization, and provides maximum patency at the anastomotic sites.     

Continuous suturing for microvascular anastomosis. Technical note.

A continuous suture technique for the microsurgical end-to-side anastomosis of extracranial to intracranial arteries is described. This method combines the speed and even tension of a continuous suture line with improved visualization of the arteries to be anastomosed.     

Coupled suturing: a new technique for microvascular anastomosis

The left carotid artery of 12 Sprague-Dawley rats was sectioned and anastomoses immediately performed utilizing a new technique termed coupled suturing. Patency and constriction were assessed immediately postoperatively and at 1, 2, and 3 weeks. Specimens were also evaluated by light microscopy and scanning electron microscopy. Vessels healed well with excellent patency and edge eversion. With the development of a specialized needle, coupled suture could prove to be a reasonable alternative to current methods of anastomosis. Its main advantage is better intimal eversion, which decreases the risk of thrombosis.     

Manual robot assisted endoscopic suturing: Time-action analysis in an experimental model

Background Robotic surgery systems were introduced to overcome the disadvantages of endoscopic surgery. The goal of this study was to assess whether robot assistance could support endoscopic surgeons in performing a complex endoscopic task.Methods Five experienced endoscopic surgeons performed end-to-end anastomosis on post-mortem porcine small intestine. The procedure was performed both with standard endoscopic techniques and with robotic assistance (da Vinci system, Intuitive Surgical, Sunny vale, CA). It was performed in three different working directions with a horizontal, vertical, and diagonal position of the bowel. Anastomosis time, number of stitches, knots, time per stitch, suture ruptures, and the number of stitch errors were recorded. Also, an action analysis was performed.Results Anastomosis time, number of stitches, and the number of knots did not differ significantly between the two groups. The time needed per stitch was significantly shorter with robot assistance (81.4 sec/stitch vs 95.9 sec/stitch, p = 0.005). More suture ruptures occurred in the robot group (0 (0–2) vs 0 (0–0), p = 0.003). In the standard group more stitch errors were found (2 (0–5) vs 0 (0–3), p = 0.017). These results were comparable for three different working directions. The action analysis, however, showed significant benefits of robotic assistance. The benefits were greatest in a vertical bowel position.Conclusion Robot assistance might offer added value to experienced endoscopic surgeons in the performance of a small-bowel anastomosis in an experimental setup, even though total anastomosis time could not be demonstrated to be shorter and some suture tears occurred due to the lack of force feedback.