Page 48 - World Journal of Laparoscopic Surgery

John Tillou et al
in our series, as well as in the few case reports which
exist, if free suture ends are left exposed, the barbs have
the potential to catch on nearby tissues – such as small
bowel, mesentery, or omentum – leading to possible
serosal injury, obstruction, or small bowel volvulus. 4-10
11
Recently, a group from New York reported two cases
of small bowel obstruction 3 to 4 weeks after robotic-
assisted sacral colpopexy. At reoperation, both individu-
als were found to have small bowel loops adherent to
exposed barbed suture segments that had been used to
retroperitonealize newly implanted mesh. Barbed suture
material serving as a nidus for volvulus has been reported
5
as well. Thubert et al reported the case of a 61-year-old
female who suffered from a small bowel volvulus 1 month
Fig. 5: Transition point (arrow) in the distal ileum at the level of after undergoing laparoscopic sacral colpopexy during
the sacral promontory
which a V-loc V90™ suture had been used to close the
pelvic peritoneum. Upon reexploration, the exposed su-
prolapse as well as clinical POP-Q stage II uterovaginal ture end was noted to be adherent to the nearby ileum
prolapse presented on postoperative day number 46 with serving as a rotational axis. In 2014, Salminen et al
3
a multiple-day history of abdominal pain, distention, described three cases of barbed-suture-associated small
and emesis. During the redo operation, the previously bowel obstruction in the setting of laparoscopic ventral
placed rectopexy mesh was found to be loose and was rectopexy during which a V-loc 180™ suture was utilized
resecured to the sacrum just below the sacral promon- for periotoneal closure. The authors deliberately left 2 to
tory with tacks, and added support was provided to 3 cm of the cut barbed suture end exposed in order to
the rectopexy by using a permanent 2-0 V-loc™ suture ensure adequate peritoneal fixation. In all three instances,
to secure the rectum on both sides of the sacrum. The the exposed suture was found to be adherent to either
posterior vagina was secured with an additional piece of small bowel or omentum. Despite these reports, V-loc™
mesh to the sacral promontory as well. An absorbable 2-0 suture-related complications likely remains an under-
V-loc™ suture was then used to close the peritoneum over recognized event.
the implanted mesh in a running manner. At the time Due to concerns for barbed-suture-related complica-
of presentation to the emergency room, a CT scan was tions, Salminen et al noted that it is author’s standard
3
notable for a small bowel obstruction with a transition practice to trim the suture back to be flush with the
point in the mid-ileum at the level of the rectopexy (Fig. 5). peritoneum. Whether this has made a difference in the
She was brought to the operating room for diagnostic long run was not reported. Interestingly, based on re-
laparoscopy, which demonstrated a loop of ileum adher- cent animal models, trimming the cut end of the barbed
ent to an exposed portion of the nonabsorbable V-loc™ suture flush with the tissue or burying the end under
suture that had been used for the rectopexy. The suture peritoneum may not reduce the likelihood of these
had protruded through the peritoneal closure. The adhe- complications 4,12,13 as the barbs may become exposed
sion was lysed and the exposed portion of the stitch was if there is slippage of tissue. At the beginning of their
debrided flush with the peritoneum. She was discharged experience with the V-loc™ device for peritoneal clo-
home on postoperative day number 2 after an otherwise sure during laparoscopic ventral rectopexy, Sakata et al
4
uneventful course.
typically left several centimeters of the cut barbed suture
end exposed. However, after managing the resultant
DiSCuSSiON
barbed-suture-related small bowel obstruction in four
We present here three cases of postoperative bowel ob- postoperative patients, the authors modified their tech-
struction requiring reoperation due to the use of barbed nique and trimmed the cut barbed end flush with the
suture material during minimally invasive surgery for peritoneum in subsequent cases. Despite this change in
POP – a complication which has gained relatively little technique, they reported several additional early postop-
exposure in the current literature and which many sur- erative small bowel obstructions related to the use of the
geons are likely not aware of. While the use of barbed barbed suture. On reoperation, previously buried barbed
sutures, such as the V-loc™ provides some technical ad- suture segments were noted to be exposed. The authors
vantages, including the potential for decreased operative theorize that over time the closed peritoneum contracts,
time, they are not without drawbacks. As demonstrated leading to potentially exposed suture material. As we
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