Abstract
Background/Aim: The adoption of intracorporeal anastomosis in minimally invasive surgery for colon cancer has gradually expanded owing to its many advantages. However, intracorporeal anastomosis has the disadvantage of a longer operative time than extracorporeal anastomosis. One reason that intracorporeal anastomosis takes longer to perform is the closure of the common enterotomy. The present study evaluated the effect of bidirectional barbed sutures on the duration of common enterotomy closure in intracorporeal anastomosis for minimally invasive colectomy. Materials and Methods: The time required for common enterotomy closure was measured with a simulator using an intestinal model. A two-layer suture with continuous full-thickness suture followed by a continuous serosal-muscular suture was adopted. The time required to close the common enterotomy using two unidirectional barbed sutures and one bidirectional barbed suture was measured five times each. Results: The duration of common enterotomy closure using bidirectional barbed suture was significantly shorter than that using two conventional barbed sutures. Conclusion: Bidirectional barbed sutures are useful for closing the common enterotomy in intracorporeal anastomosis for minimally invasive colectomy.
- Bidirectional barbed sutures
- common enterotomy closure
- intracorporeal anastomosis
- minimally invasive colectomy
In recent years, the adoption of intracorporeal anastomosis in minimally invasive surgery for colon cancer has gradually increased. Intracorporeal anastomosis is superior to extracorporeal anastomosis because of less mobilization of the colon and less mesenteric traction (1-3), earlier recovery of postoperative bowel function (2, 4), shorter length of hospital stay (2, 3), and reduced incidence of incisional hernia due to smaller incisions for specimen extraction (5, 6). However, intracorporeal anastomosis has the disadvantage of a longer operative time than extracorporeal anastomosis (2, 6).
One reason that intracorporeal anastomosis takes longer to perform than extracorporeal anastomosis is the closure of the common enterotomy. In the case of functional end-to-end anastomosis, the common enterotomy can be closed with a stapler, but in the case of overlap anastomosis, it is often closed by hand. Barbed sutures are used to shorten the duration of common enterotomy closure. As a conventional unidirectional barbed suture contains a loop end and barbs to anchor tissues and does not require knots to secure the device, this product helps improve the stability of the procedure and reduce the time needed to perform it.
However, a conventional unidirectional barbed suture requires passing the needle through the loop to secure the fixation loop portion to robust tissue. In ileocolic/colo-colic anastomosis, this process is often performed twice because it is more reliable to close the common enterotomy in two layers rather than in one (7-9). Bidirectional barbed sutures can be used to solve this problem. This product contains bidirectionally oriented barbs that anchor tissues. The central transition zone of the thread acts as an anchor to the edge of the incision, eliminating the need to pass the needle through the loop for fixation.
Although the usefulness of bidirectional barbed sutures for the closure of common enterotomy in clinical practice has been clearly perceived, no objective evaluation of the effect of this procedure on the duration of common enterotomy closure has yet been carried out. Due to the fact that this procedure was only recently introduced, a sufficient number of cases are still not available after adjusting for differences in the approach, such as robot-assisted surgery, laparoscopic surgery and operator experience. In addition, it is necessary to consider the duration of common enterotomy closure after eliminating factors such as any case-specific bias.
The present study evaluated the effect of bidirectional barbed suture on the duration of common enterotomy closure in intracorporeal anastomosis for minimally invasive colectomy with a simulator.
Materials and Methods
The procedure for common enterotomy closure using barbed suture. A continuous two-layer suture was applied for common enterotomy closure (Figure 1). A 3-0 braided absorbable suture (Vicryl®; ETHICON, Inc., Raritan, NJ, USA) was used for the stay suture, and one 3-0 absorbable monofilament bidirectional barbed suture (STRATAFIX® Spiral PDS® Plus Suture, 14+14 cm; ETHICON, Inc.) or two 4-0 absorbable monofilament unidirectional barbed sutures (STRATAFIX® Spiral PDS® Plus Suture, 15 cm; ETHICON, Inc.) were used for the common enterotomy closure. Firstly, a stay suture was placed at the distal edge of the incision. Secondly, the first full-thickness layer closure was initiated from the proximal edge of the incision towards the distal edge. With regard to fixation of the proximal edge of the incision, with unidirectional barbed sutures, the edge was fixed with a loop at the end of the thread, whereas with bidirectional barbed sutures, it was fixed with a center transition zone of the thread. Finally, the second seromuscular closure was performed in the same manner as suturing of the first layer.
The procedure of common enterotomy closure using a single bidirectional barbed suture. A: Lifting of the stay suture placed on the distal edge of an incision. B and C: The full-thickness layer closure started from the proximal edge of an incision. D and E: After fixing with a center transition zone of the thread, second and subsequent sutures were performed. F: The start of the second layer was obscured by the fatty appendage. G: By pulling the thread, the starting point became visible, and the suturing became easier. H: Performing the continuous suture for the second layer.
Measurement of the duration of common enterotomy closure. The time required for common enterotomy closure was measured with a simulator using an intestinal model, two-layer structures made of silicon with different colors (Double Layer Bowel OD-25 mm; TMC, Osaka, Japan). A two-layer suture with a continuous full-thickness suture, followed by a continuous serosal-muscular suture, was used (Figure 2 and Figure 3). The length of the enterotomy was 2 cm. The first layer was sutured with five stitches, and the second layer with four stitches. The time required to close the common enterotomy using two unidirectional barbed sutures or one bidirectional barbed suture was measured five times each. The procedure was performed by an expert in colorectal surgery with over 20 years of experience and a young gastroenterological surgeon with 4 years of experience.
Common enterotomy closure with a simulator using two unidirectional barbed sutures. A and B: Full-thickness layer closure starting from the proximal edge of an incision. C and D: The thread was fixed by passing the needle through the loop. E-G: Continuous suturing for the first layer. H and I: Performing second layer closure from the proximal edge of the first layer. J: The thread was fixed by passing the needle through the loop. K and L: Continuous suturing for the second layer was subsequently performed.
Common enterotomy closure with a simulator using a single bidirectional barbed suture. A and B: The full-thickness layer closure started from the proximal edge of the incision. C: The thread was fixed with a center transition zone of the thread. D-F: Performing continuous suturing for the first layer. G and H: Suturing of the second layer while using the thread for traction.
Ethics statement. This study on surgical technique was approved by the Ethics Committee of Osaka City University (approval number: 4182) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients.
Statistical analyses. Data analyses were conducted using IBM SPSS Statistics for Windows (version 26; IBM Corp., Armonk, NY, USA). The significance of differences between the duration of common enterotomy closure using the two suturing devices was analyzed using the Mann–Whitney U-test. A value of p<0.05 was considered to indicate a statistically significant.
Results
For the expert surgeon, the duration of common enterotomy closure using one bidirectional barbed suture was significantly shorter than that using two conventional barbed sutures (179 vs. 265 s, p=0.021) (Table I). Similarly, for younger surgeon, the duration of common enterotomy closure using one bidirectional barbed suture was significantly shorter than that using two conventional barbed sutures (median 340 vs. 395 s, p=0.008). As expected, younger surgeons needed significantly longer times than expert surgeons, but the selection of a bidirectional barbed suture was useful for shortening the time when performing a common enterotomy closure for both expert and younger surgeons.
Median (range) duration of common enterotomy closure according to experience and approach.
Discussion
This study demonstrated that bidirectional barbed sutures help to reduce the duration of common enterotomy closure in intracorporeal anastomosis for minimally invasive colectomy.
Although intracorporeal anastomosis reportedly does not increase the risk of peritoneal tumor cell dissemination or organ-space/deep surgical site infection compared to extracorporeal anastomosis (10), enterotomies created intra-abdominally for the anastomosis may cause fecal spillage and spread of tumor cells into the peritoneal cavity. Therefore, it is necessary to close a common enterotomy as quickly as possible. However, suturing under arthroscopy is time-consuming, even for skilled surgeons. The use of a bidirectional barbed suture can reduce the time required to close a common enterotomy.
As mentioned in the introduction, bidirectional barbed sutures do not require passing the needle through the loop, so the suturing process is simplified. In addition, there are several other reasons bidirectional barbed sutures can be used to facilitate suturing. Using unidirectional barbed sutures, the first 1-2 stitches are prone to loosening because there are no barbs near the edge. In contrast, with bidirectional barbed sutures, the stitches do not loosen from the beginning because there are barbs all the way to the end of the suture. Therefore, using a bidirectional barbed suture makes the first 1-2 stitches easier than using a unidirectional barbed suture. Secondly, the thread can be used to gain traction from the start of suturing of the second layer. Thirdly, the starting point of the suture in the second layer can easily be identified by pulling the thread. This is particularly useful because it can be difficult to locate the starting point of the second layer when there is a large number of fatty appendices in the colon.
Reconstruction should be handled with caution, as incomplete anastomosis is associated with anastomotic leakage. However, an operator may exhaust their concentration when performing lymph node dissection prior to reconstruction. Therefore, a tool that can easily and reliably perform anastomosis is required. The bidirectional barbed suture helps reduce the stress on the operator and ensure reproducibility of the anastomoses.
Furthermore, the bidirectional barbed suture has an advantage in terms of economy, as the cost of using a single bidirectional barbed suture is approximately 30 US dollars less than that of using two unidirectional barbed sutures.
Of note, bidirectional barbed sutures have disadvantages, although the product has been improved since its inception to facilitate its use. For example, a thread can become tangled when another thread is present near the suture line. Therefore, when suturing the first layer, the other thread must be placed far from the surgical field.
The present study has several limitations. Firstly, we performed common enterotomy closure using bidirectional barbed sutures in daily practice and did not observe any anastomotic complications. However, as this procedure has only recently been introduced into our practice, we did not have much experience with this procedure. Secondly, by using a training simulator, we were able to eliminate the bias of patient background, such as the diameter of the common enterotomy, amount of fat in the abdominal cavity, physique, and location of the anastomotic site. Therefore, results regarding the duration of suturing can be considered highly reliable. However, no clinical data are currently available. Large-scale prospective studies are needed to verify the safety and efficacy of this approach.
In conclusion, bidirectional barbed sutures are useful for closing the common enterotomy in intracorporeal anastomosis for minimally invasive colectomy.
Footnotes
Authors’ Contributions
MS designed the study, conducted the experiments, performed the statistical analysis, and drafted the article. HT designed the study, conducted the experiments, and critically reviewed the article. TF, HK and KM designed the study and critically reviewed the article. All Authors have read and approved the final article.
Conflicts of Interest
The Authors declare no conflicts of interest in association with the present study.
- Received August 19, 2023.
- Revision received October 10, 2023.
- Accepted October 12, 2023.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
