Page 16 - World Journal of Laparoscopic Surgery

Barbed vs Polyglactin 910: A Comparative Study of the Efficacy in Laparoscopic Vaginal Cuff Closure
Table 3: Mean suturing time In the present study, we observed a significant decrease in
Polyglactin 910 Barbed suture time required for vaginal vault closure with the use of barbed
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group (n = 50) group (n =50) p value suture compared to polyglactin 910 suture. Kim et al. compared
Suturing time (minute), 6.91 (1.27) 5.39 (0.76) <0.0001 V-Loc (n = 64) and Vicryl sutures (n = 106) for laparoscopic vaginal
mean (SD) cuff closure and they reported a significant reduction in vaginal
Degree of surgical 8.16 (0.77) 3.18 (0.85) <0.0001 cuff closure time (7.2 minutes, SD: 1.2 minutes for V-Loc and 12.2
difficulty (VAS) minutes, SD: 3.3 minutes for Vicryl; p < 0.0001) which is consistent
Intraoperative 1 (2%) 2 (4%) 0.6 with the finding of this study.
Similar results were observed in a single-port total laparoscopic
complications hysterectomy done by Song and Lee, where laparoscopic suturing
Duration of hospital 2 (96%) 2 (98%) NA was adopted for cuff closure in both the groups with experimental
stay (days) group using V-Loc suture (43 cases) and control group applying
SD = Standard deviation
conventional laparoscopic vaginal cuff suture (59 cases). The
V-Loc suture group not only dramatically decreased vaginal stump
due to increased use of thermal energy by electrocoagulation. 8–11 suturing time (11.4 vs 22.5 minutes; p value < 0.001) and total
These limitations are mostly due to longer learning curve required operation time (92 minutes vs 105.2 minutes; p value = 0.002) but
for laparoscopic procedures as well as for laparoscopic closure of also reported reduced difficulty in suture procedure. 17
vaginal vault. 9 Furthermore, a randomized trial by Alessandri et al. comparing
In laparoscopic surgeries, the surgeon enters the body cavity unidirectional barbed suture with the traditional continuous suture
through a small incision and operates with a limited range of for laparoscopic myomectomy found that the time required to
motion. The endpoints of the instruments move in the opposite suture the uterine wall defect and intraoperative blood loss was
direction to the movement of the surgeon’s hands making the much less while using barbed sutures. Barbed sutures have
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procedure laborious and difficult to learn. In addition to this, the significantly reduced the time required for suturing and the degree
proximity to vital anatomical structures and the limitation in gaining of surgical difficulty in a randomized clinical study by Ardovino et
direct access to it in case of an emergent situation adds on to the al. comparing the feasibility and safety of barbed bidirectional
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complexity of laparoscopic procedures. A recent survey done by sutures vs standard sutures for vaginal cuff closure following total
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Weizman et al. suggested that the key factor limiting laparoscopic laparoscopic hysterectomy and lymph node dissection for early
surgery includes laparoscopic suturing along with other technical endometrial cancer.
and practical limitations. Laparoscopic intracorporeal suturing Generally, for gynecologists, transvaginal suturing is widely
remains one of the most challenging and time-consuming tasks preferred, as it is technically easier and has shorter learning curve.
for surgeons, with the primary reason for this being the need to tie However, statistical analysis suggests that in TLH procedure, barbed
the knots in a confined space with limited visibility. sutures used in vaginal cuff closure reduced the suturing duration
Suturing during vaginal cuff closure is considered a challenging as well as technical difficulty experienced by the surgeon, which is
step in laparoscopic hysterectomy, and the surgical difficulties can in accordance with the above-mentioned literature reports.
result in vault complications such as vaginal cuff dehiscence. Uccella With the introduction of a new technology, complications will
et al. reported a higher incidence of vaginal cuff dehiscence (0.64%) invariably arise. One of the rare yet potentially serious complication
for laparoscopic when compared to open transvaginal cuff closure from the use of barbed suture is bowel obstruction. If the cut end
(0.18%). Probable reason for this is that the magnified view during of the barbed suture is left long, it may become attached to the
laparoscopic procedure causes the surgeon to involve less tissue overlying bowel or mesentery producing kinking and acting as a
and tension in closure. 14 transition point of obstruction. Rombaut et al. reported a case of
Although widely used, conventional sutures carry the bowel obstruction due to bidirectional suture causing terminal ileal
drawbacks of requirement for tying knots for anchorage, need to strangulation following laparoscopic myomectomy. In another
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maintain constant tension on the suture which requires traction case report by Thubert et al., the patient was diagnosed 1 month
by the operating surgeon or an assistant, leading to prolongation after undergoing laparoscopic sacrocolpopexy with peritoneal
of suturing. Thus, it becomes essential to simplify intracorporeal closure using a barbed suture, with small bowel volvulus and
laparoscopic suture, knotting skills and reduce the relative technical mesenteric rupture. However, there were bowel complications
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requirements. Numerous strategies were undertaken, one such has among patients in both groups in the present study.
been the introduction of barbed sutures.
Barbed sutures are absorbable sutures with a surgical needle
at one end and an annular coil component at the other end. This conclusIon
suture self-anchors at approximately every 1 mm of tissue, resulting In conclusion, this study demonstrated that the use of barbed
in an evenly distributed tensile strength along the total length of sutures for laparoscopic vaginal vault closure reduces the suturing
the wound without the need for tying knots. The presence of tiny time as well the operative difficulty. Based on the results and
barbs spaced evenly in a helical array require less technical skill literature, the use of barbed sutures is an efficient alternative to
for performing swift suturing and less time than conventional conventional sutures for laparoscopic vaginal vault closure.
suturing. 15
The first use of barbed sutures in gynecologic surgery was
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reported in 2008 by Greenberg and Einarsson. Since then it has references
been used in procedures such as laparoscopic myomectomy, 1. Begum M, Zulfiqar N, Yasmin F. Total laparoscopic hysterectomy: a
hysterectomy as well as re-anastomosis of fallopian tubes and two-year experience in Apollo hospitals Dhaka. Pulse 2016;8(1):21–29.
sacro-colpopexies. DOI: 10.3329/pulse.v8i1.28097.

World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020) 115