9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

RevObstetGynecol.20136(34):107115.

PMCID:PMC4002186

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetrics
andGynecology
JamesAGreenberg,MDandRandiHGoldman,MD
BrighamandWomensHospital,HarvardMedicalSchool,,Boston,MA
Copyright2014MedReviews,LLC

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract

Goto:

Surgicalknotsaresimplyanecessaryevilneededtoanchorsmoothsuturetoallowittofunctioninitsroleintissue
reapproximation.Surgicalknotsreducethetensilestrengthofallsuturesbythinningandstretchingthematerial.
Thetyingofsurgicalknotsintroducesthepotentialofhumanerrorandinteruservariability.Knotsecuredsmooth
suturemustcreateanunevendistributionoftensionacrossthewoundwiththehighertensionburdensplacedatthe
knots.Giventheexcessiverelativewoundtensionontheknotandthereasonableconcernsofsurgeonsforsuture
failureduetoknotslippage,thereisanaturaltendencytowardovercomingtheseconcernsbyovertighteningknots
however,tighterknotsmaybeworseforwoundhealingandstrengththanlooserknots.Inminimallyinvasive
laparoscopicsurgeries,theabilitytoquicklyandproperlytiesurgicalknotspresentsanewchallenge.Incasesin
whichknottyingisdifficult,theuseofknotlessbarbedsuturecansecurelyreapproximatetissueswithlesstime,
cost,andaggravation.Thisarticlereviewsthetechnologybehindbarbedsutureswithafocusonunderstanding
howtheydifferfromtraditionalsmoothsuturesandhowbarbedsutureshaveperformedininvitroandanimal
modeltesting,aswellasinhumanclinicaltrials.
Keywords:Laparoscopicmyomectomy,Barbedsuture,Smoothsuture,Softtissuereapproximation
In2008,GreenbergandEinarsson1reportedthefirstuseofabarbedsuturefortissuereapproximationina
laparoscopicmyomectomy.Inthe5yearssincethatearlyreport,theuseofbarbedsutureinobstetricand
gynecologicprocedureshasexploded,withtensofthousandsoftheseoperationsnowemployingthistechnology.
Thisarticlereviewsthetechnologybehindbarbedsutureswithafocusonunderstandinghowtheydifferfrom
traditionalsmoothsuturesandhowbarbedsutureshaveperformedininvitroandanimalmodeltesting,aswellas
inhumanclinicaltrials.

WhyNotKnots?

Goto:

Afullappreciationofthetechnicaladvantagesofbarbedsuturesnecessitatesabasicunderstandingofthedownside
ofsurgicalknots.Tomostsurgeons,knotsareasintegraltotheuseofsutureasgasolineoncewastotheoperation
ofautomobilesthatis,itisdifficulttoimaginetheproperfunctioningofonecomponentwithouttheother.Yet
surgicalknotsaresimplyanecessaryevilneededtoanchorsmoothsuturetoallowittofunctioninitsroleintissue
reapproximation.Otherthanitsanchoringfunction,thesurgicalknotoffersnobenefitwhatsoeverandintroducesa
varietyofuntowardfeatures.
Surgicalknotsreducethetensilestrengthofallsuturesbythinningandstretchingthematerial.Amodeled
representationofthiseffectcanbeappreciatedbytyingaknotinapieceofrubbertubing(Figure1).Theweakest
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

1/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

portionofanysuturelineistheknotandthesecondweakestpointistheportionimmediatelyadjacenttotheknot,
withreductionsintensilestrengthreportedfrom35%to95%,dependingonthestudiesandsuturematerialused.2
Figure1
(A)Pieceoflatextubingearlyintheknotformation.(B)Pieceoflatex
tubingastheknotbeginstotighten.Noticethethinningofthediameterof
thetubing.(C)Pieceoflatextubingaftertheknotistightened.Noticethe
thinningofthediameter...
Thetyingofsurgicalknotsintroducesthepotentialofhumanerrorandinteruservariability.Intuitively,knotsecured
smoothsuturemustcreateanunevendistributionoftensionacrossthewoundwiththehighertensionburdens
placedattheknots.Giventheexcessiverelativewoundtensionontheknotandthereasonableconcernsof
surgeonsforsuturefailureduetoknotslippage,thereisanaturaltendencytowardovercomingtheseconcernsby
overtighteningknots.However,Stoneandcolleagues3demonstrated,intheirclassic1986study,thattighterknots
maybeworseforwoundhealingandstrengththanlooserknots.Surgicalknots,whentiedtootightly,cancause
localizedhypoxia,reducedfibroblastproliferation,andexcessivetissueoverlap,leadingtoreducedstrengthinthe
healedwound(Figure2).3
Figure2
Tensilestrengthandenergytofailureoftightlyandlooselyapproximated
fascialincisions.ReproducedwithpermissionfromStoneIKetal.3

Asurgicalknotyieldsthehighestdensityofforeignbodymaterialinanygivensuturelineandthevolumeofaknot
isdirectlyrelatedtothetotalamountofsurroundinginflammatoryreaction.4Ifminimizingtheinflammatory
reactioninawoundisimportantforoptimizedwoundhealing,thenminimizingknotsizesoreliminatingknots
altogethershouldbebeneficialaslongasthewoundholdingstrengthofthesuturelineisnotcompromised.
Finally,withminimallyinvasivelaparoscopicsurgeries,theabilitytoquicklyandproperlytiesurgicalknotshas
presentedanewchallenge.Incasesinwhichknottyingisdifficult,theuseofknotlessbarbedsuturecansecurely
reapproximatetissueswithlesstime,cost,andaggravation.5,6Althoughtheskillsnecessarytoproperlyperform
intraorextracorporealknottyingforlaparoscopicsurgerycanbeachievedwithpracticeandpatience,itisa
difficultskillthatmostsurgeonsneedtomasterinordertoproperlyperformclosedprocedures.Inaddition,
laparoscopicknottyingismorementallyandphysicallystressfulonsurgeons7,8and,moreimportantly,
laparoscopicallytiedknotsareoftenweakerthanthosetiedbyhandorrobotically.9,10

HistoryofBarbedSutures

Goto:

ModernbarbedsuturecantraceitsoriginstoDr.JohnH.Alcamo,whosubmittedhisideatotheUSPatentoffice
onAugust13,1956andwasissuedUSPatentnumber3,123,077onMarch3,1964forasuturesoformedthat
itpreventsslippageinsuturedincisionsorwounds(Figure3).11AlthoughDr.Alcamodescribedthedesignfor
thissuture,thefirstreportsoftheclinicaluseofbarbedsuturedonotappearuntil1967,whenDr.A.R.McKenzie
reporteditsuseinvitroinhumancadaversandinvivoindogsfortherepairoflongflexortendons.12However,
theseearlyspearlikebarbedsuturedesignsneededtobepushedintothepatientstissuetherefore,theyhadtobe
ofsufficientstiffnessanddiametertobecapableofbeingpushedintothetissue.Between1967and1999,various
authorsandinventorspresentedanarrayofevolvingthoughtsandtechniquesinthisniche,withthemostnotable
beingDr.HarryJ.Buncke(thesocalledfatherofmodernmicrosurgery)whoreceivedUSPatent5,931,855on
August3,1999forseveralsurgicalproceduresforbindingtogetherlivingtissueusingonewaysutureshaving
barbsontheirexteriorsurfacesandaneedleononeorbothends.13HispatentswereacquiredbyQuillMedical
(acquiredbyAngiotechPharmaceuticals[Vancouver,BC,Canada]in2006)in2002and,inconjunctionwiththe
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

2/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

inspiredworkofDr.GregoryRuff,thefirstwidelycommercializedbarbedsuture,QuillKnotlessTissueClosure
Device(AngiotechPharmaceuticals),wasapprovedbytheUSFoodandDrugAdministration(FDA)in2004.In
2009,CovidienintroducedVLoc(CovidienHealthcare,Mansfield,MA)unidirectionalbarbedsuturewitha
fixedloop,andin2013bothAngiotechPharmaceuticalsandEthiconEndoSurgery(Cincinnati,OH)introduced
unidirectionalbarbedsutureswithavariableloopattheendforfacilitatedfixation.
Figure3
Originaldrawingsforbarbedsuture.ReproducedfromAlcamoJH.11

ProductionofBarbedSuture

Goto:

Tofullyappreciatetheuses,characteristics,andlimitationsofbarbedsuture,arudimentaryunderstandingoftheir
productionishelpfulspecifically,howthesamematerialsthataretraditionallyusedtoproducestrandsofsmooth
suturearereconfiguredtoproducesuturewithbarbsontheirsurfaces.Moreorlessthesamemethodisusedinthe
manufacturingofQuill,VLoc,andSTRATAFIXSpiral(EthiconEndoSurgery),andinvolvescuttingintothe
shaftofastrandofsmoothsuturewithsometypeofblade(Figure4).14,15Althoughthismethodpresentsmany
manufacturingadvantages,perhapsthemostimportantdrawbackfromaclinicalperspectiveisthatcuttingbarbs
intosuturereducesthetensilestrengthofthesuturebyweakeningitscoreandnarrowingitsfunctionaldiameter.
Thus,itisvitalthatcliniciansunderstandtheindividualtensilestrengthoftheparticularsuturebeingusedrather
thanrelyingonmeasurementsoftraditionalsmoothsutures.Further,thisdifferencehasasignificantpractical
implicationallcutbarbedsutures(Quill,VLoc,andSTRATAFIXSpiral)carryanFDAmandatedwarningin
theirinstructionsforusestatingthesafetyandeffectivenesshasnotbeenestablishedforuseinfascialclosures
(abdominalwall,thoracic,extremityfascialclosures)1618
Figure4
(A)QuillKnotlessTissueClosureDevice(AngiotechPharmaceuticals,
IncVancouver,BC,Canada).(B)VLocWoundClosureDevice
(CovidienMansfield,MA).(C)QuillKnotlessTissueClosureDevice.

InVitroandAnimalTestingofBarbedSutureProducts

Goto:

Strengthandtissuereactivityareintegraltothefunctionalityofsuturematerialand,therefore,understandingthese
propertiesisessentialwhenchoosingsutureforvariousprocedures.Directlyassessingthesefeaturesinhuman
clinicaltrialspresentsnumerouslogisticalandethicalchallengesthatmakeinvitroandanimalstudiesbettersuited
fordeterminingthesecharacteristics.Althoughmanyofthesetrialswerenotperformedinanobstetricor
gynecologicsetting,theirfindingscanlikelybetranslatedtoallsurgicalspecialties.
SutureStrength
Tensilestrengthisanessentialfeaturethatsurgeonsmustconsiderwhenchoosingasuture.Putsimply,themeasure
oftensilestrengthofasutureisthelinearforcerequiredtocauseittobreak.Severalinvitrostudieshavemeasured
differencesinstrengthbetweenbarbedandsmoothsuture.In2011,Vakilandcolleagues19hypothesizedthatusing
#2Quillpolydioxanone(PDO)barbedsuturewouldhaveequivalentclosureintegrityto#1VICRYL(Ethicon
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

19

3/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

EndoSurgery)interruptedsuturesinarthrotomyclosureoncadavericknees.19Theyalsosurmisedthatbarbed
sutureclosureswouldbemorelikelytofailshouldtherebeacutinthesutureline.Supportingtheirhypothesis,
theyfoundthatafter2000flexioncycles,neithertheclosuresusingthesmoothnorthebarbedsuturehadasingle
failure.Theauthorsfurthertestedtheintegrityofthesuturesbycuttingsequentialthrows/stitchesandcontinuing
cyclicaltesting.Perhapssurprisingly,theyfoundthatalthoughbothsmoothandbarbedsutureclosuressurvived
firstthrowcutting,thebarbedsuturefaredmuchbetterwhenmultiplecutsweremade.Onceinterruptedsuture
closuressustainedthreecuts,theyallfailed,whereasthebarbedsutureclosuresendureduptosevencuts.The
authorsfoundthatbarbedsutureisbetterabletomaintaintissuetensionwhencutsaremadeandmaymaintainthe
integrityofthefullclosure.
Arecentstudyintheveterinarysurgicalliteratureusedacadavericcaninegastropexymodeltocomparetensile
strengthbetween20and30standardglycomer631with20and30VLoc90.20Theauthorsperformed4cm
incisionalgastropexiesonfourgroups,thensuturedtheincisionsinasimplecontinuousfashionusingoneofthe
suturesabove.Strengthofthesuturewasmeasuredusingloadtofailure,definedastheforce(inNewtons)required
tocausesuturebreakageortissuetearing.Tomeasureloadtofailure,adistractiondevicewasusedtostressthe
sampleatarateof0.4mm/s.Theauthorsfoundthattheknotlessbarbedsutureshadgreaterloadtofailurethanthe
smoothstandardsuture.Theyfoundthatfailureoccurredduetotissuetearing,notsuturebreakage,andconcluded
thatthebarbsthemselvesenabledthehigherloadtofailureinthosesamples.Thisislikelyduetothebarbsability
todistributetheforceoveralargercontactarea,reducingpressureonthetissue.
HemostasisandLeakage
Hemostasisandleakagepreventionareparamounttoasuturesperformance.In2012,Gzenandcoworkers21
demonstratedthesuperiorperformanceofknotlessbarbedsuturesfollowingclosureofcadavericpigbladders
comparedwithsmoothsuture.Porcinebladderswereusedtocreatebladderdefectsthatwereclosed
laparoscopicallyusing(1)barbedpolyglyconateinarunningfashion,(2)polyglactin910inarunningfashion,or
(3)polyglactin910inaninterruptedfashion.Leakpressureswereevaluatedusingcystometry.Significantlyhigher
leakpressureswerenotedinthebarbedsuturegroupthanineitherofthesmoothsuturegroups,andaverage
bladdercapacityatthetimetoleakagewassignificantlyhigherinthebarbedsuturegroup(419.7mL)compared
with353.8mLinthesmoothsutureinarunningfashiongroupand276.2mLintheinterruptedsuturegroup.
SimilarfindingswerefoundinastudybyNettandcolleagues,22whodemonstratedthesuperiorityofbidirectional
knotlessbarbedabsorbablesutureoverconventionalinterruptedabsorbablesutureinproducingawatertightknee
arthrotomyclosureusingcadavericknees.Theyfoundthatafter3minutesofsimulatingatensehemarthrosis,
arthrotomyleakagewasonly89mLinthebarbedsuturegroupcomparedwith356mLintheinterrupted
absorbablesmoothsuturegroup.
Efficiency
Oneofthemostcostlypartsofasurgicalprocedureistimeintheoperatingroom.Withrisinghealthcarecosts,
efficiencyintheoperatingroomisbecomingmoreofapriority.23Newandinnovativetoolsthatcanhelp
experiencedsurgeonsoperatefastercontinuetoplayalargeroleinimprovingoperatorefficiency.24
IntheporcinebladderstudybyGzenandcolleagues,21oneoftheprimaryoutcomeswastimetocompletethe
closureofabladderdefectlaparoscopically.Asingleexpertsurgeonwithextensivelaparoscopicexperience
performedeachclosure.Theexpertsurgeonwasabletocompletetheclosureinsignificantlylesstimeusingbarbed
suture(7.13min)thanwithbothsmoothsuturegroups(9.14minwithrunningsutureand15.2minwithinterrupted
suture).
Significantlyfasterclosuretimeswithbarbedsuturewerealsoseeninseveralinvivostudies.Inaprospective,
randomizedstudyperformedattheClevelandClinic(Cleveland,OH),Tingandcoworkers25demonstrateda32%
fasterclosuretimewhenusingbarbedsuture(9.3min)comparedwithanaverage13.6minuteclosureinthe
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

4/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

traditionalsuturegroupduringprimarytotalhipandkneearthroplasties.Similarfindingshavebeenseeninthe
plasticsurgeryliterature.GrigoryantsandBaroni26comparedclosuretimeoflipoabdominoplastywoundsusing
barbedsutureinatwolayerclosuretoconventionalsmoothsutureinathreelayerclosure.Eachsurgeonclosed
halfofthewoundwithbarbedsutureandtheotherhalfofthesamewoundwithsmoothsuture.Attheconclusion
ofthisstudy,authorsdemonstratedanapproximately36%fasteraverageclosuretimeusingthebarbedsuture.
Finally,inabariatricsurgerystudybyDeBlasiandcoworkers,27jejunalanastamosisusingVLocbarbedsuture
was25%fasterthananastomosisusingsmoothsuture(ofnote,thereisanFDAwarningagainstitsusein
gastrointestinalanastomoses).17Costrequiredtocompletetheclosurewassignificantlylessinthebarbedsuture
group.
InflammationandWoundHealing
Althoughbarbedsuturemayprovetobeasuperiortechnologywithregardtobothefficiencyandstrength,itis
equallyimportanttoconsiderhowbarbedsutureinteractswithtissueovertimeandhowthattranslatestowound
healingandinflammatorypotential.Einarssonandcolleagues28usedasheepmodeltoexploretheimpactofbarbed
sutureversustraditionalsmoothsutureontheadhesionformationfollowingclosureofmyometrium.Inthisanimal
study,5cmmyometrialdefectswerecreatedineachhornofasheepsbicornuateuterus.Onehornwasthenclosed
with20VICRYL,andtheotherwithbarbed0PDO.Inthisway,eachsheepactedasherowncontrolsubject.
Threemonthslatertheanimalsweresacrificedandnecropsywasperformedtogrosslyassessadhesionformation.
Theauthorsfoundthatadhesionformationwasnotdifferentbetweenthetwogroups.Themajorityoftheanimals
thatformedadhesionsdidsoatbothhorns.Similartopriorstudies,thesideoftheuterusclosedwithbarbedsuture
wasmoreefficient.
Asafollowuptothisstudy,Einarssonandcolleagues29demonstratedthatatthemicroscopiclevel,barbedsuture
andstandardsmoothsuturehadsimilareffectsoncellularcompositionfollowingmyometrialclosureinthesheep
model.Theuterinetissueofthesacrificedanimalswasfixedandimmunohistochemistrywasperformedto
determinetheratiobetweensmoothmusclecellsandconnectivetissueelements,whicharegenerallyincreased
duringwoundhealing.Theauthorsagainfoundnodifferencebetweengroups:connectivetissuecellstypicalofa
proliferatingwoundwerefoundinequalamountsinmyometriumsuturedwithbarbedandsmoothsuture,
suggestingthatbothsuturesconfersimilarhealingcharacteristics.Suturedmyometriuminbothgroupshadmore
connectivetissuecellsandfewersmoothmusclecellsthanmyometriumthatwasnotsuturedatall.Althoughthese
earlyanimalclinicaldataareencouraging,morestudiesareclearlyneededbeforeanyfinalconclusionsregarding
inflammationandwoundhealingcanbemade.

ClinicalTrialsUsingBarbedSuture

Goto:

Myomectomy
Theobstetricsandgynecologyliteraturehasexpandedinrecentyearstoincludeclinicaltrialsassessingtheuseof
barbedsuture.Oneofthemostcommonproceduresperformedbygynecologistsusingbarbedsuturesis
myomectomy.Huangandcolleagues30devisedastudythattookplaceinTaiwantoevaluatethesafetyand
effectivenessofbarbedsutureduringaminilaparotomymyomectomy.Eachprocedurewasperformedbyasingle
experiencedsurgeon.Patientsundergoingminilaparotomymyomectomieshadtheiruterinedefectsclosedwith
eitherbarbedsutureinacontinuousfashionortraditionalsutureinaninterruptedfashion.Authorsfoundthat
overallsurgicaltimewassignificantlylessinthegroupwhoseuteriwereclosedusingthebarbedsuture.
Intraoperativebloodlosswaslowerinthisgroupaswell,althoughthedifferenceinbloodlosswasnotstatistically
significant.Similarly,tworecentstudieshaveassessedtheuseofbarbedsutureforclosureduringlaparoscopic
myomectomy.Angioliandcolleagues31usedeitherbarbedsutureortraditionalsmoothsuturewithintracorporeal
knottyingtocloseuterinewalldefectsfollowinglaparoscopicmyomectomy.Theyfoundthatinthebarbedsuture
group,suturingtimewasshorterandintraoperativebloodlossanddropinpostoperativehematocritlevelswere
lower.InasimilarstudyperformedbyAlessandriandcoworkers,32womenundergoinglaparoscopic
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

5/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

myomectomiesforsymptomaticmyomawererandomizedtoreceiveeitherbarbedsutureortraditionalsmooth
sutureinacontinuousfashionduringclosureofuterinedefects.AsinthestudybyAngioliandassociates,31the
authorsfoundthatdefectclosuretimewasfasterinthebarbedsuturegroup.Similarly,intraoperativebloodlosswas
lowerinthebarbedsuturegroup.Inaddition,theseauthorsassessedthedegreeofsurgicaldifficultybyeach
surgeonatthecompletionoftheprocedureandconcludedthattheoveralldifficultyinthebarbedsuturegroupwas
lower.
Manypatientsundergomyomectomiesinanattempttoincreasefertility.Itisthereforeprudenttostudypregnancy
outcomesaftermyomectomytodeterminewhethertheshorttermbenefitsofbarbedsuturesuchasefficiencyare
congruouswithlatergoals.Tothisend,Sandbergandcolleagues33retrospectivelylookedatpregnancyoutcomes
amongwomenwhohaduterinedefectclosureswithbarbedsuture.Inadditiontoreviewingmedicalrecords,
patientsweresentasurveytofurtherelucidatepregnancyoutcomes.Theauthorsfoundthat>50%ofwomenwho
attemptedpregnancyfollowingmyomectomyclosurewithbarbedsuturewereabletodoso,withanaveragetime
toconceptionof9.6monthsaftersurgery.Ofthewomenwhobecamepregnant,morethanhalfresultedinlive
birthsand>10%hadongoingpregnancies.Approximately35%resultedinmiscarriage.Theseoutcomeswere
comparablewithpregnancyoutcomesfollowinguterinedefectclosureswithtraditionalsmoothsutureduring
myomectomy.
HysterectomyCuffClosure
Cuffdehiscenceisararebutseriouscomplicationofhysterectomythatcanresultinsignificantmorbidityfora
patient.Assurgeonsincreasinglyperformtotalhysterectomiesusingbarbedsutureforclosureofthecuff,itis
importanttoestablishtheoveralleffectivenessandsafetyofthepractice.InaretrospectivecohortstudybySiedhoff
andcolleagues,34theimpactofbarbedsutureoncuffdehiscencewasstudiedovertheperiodof1year.Theauthors
foundthatalthoughtherewasanapproximate4%occurrenceofcuffdehiscenceamongallwomenwhounderwent
laparoscopicvaginalclosure,therewerenocasesinwomenwhohadclosureusingthebidirectionalbarbedsuture.
Additionally,therewerelowerincidencesofpostoperativebleeding,cellulitis,andgranulationtissueamong
womenwithbarbedsutureclosures.ThesedatawererecentlycorroboratedbyEinarssonandcoworkers35ina
randomizedtrialinwhich63womenreceivedeitherbidirectional0PDObarbedsutureorrunning20VICRYL
suture.35Therewerenodifferencesincuffdehiscence,complications,orsexualdysfunctionbetweenthegroups.
Finally,inanabstractpresentedin2011,GiddingsandNaumann36retrospectivelyreviewedoutcomesofpatients
undergoingcuffclosureswitheitherVLoc90orVLoc180barbedsutureduringtotallaparoscopichysterectomy.
Intheirsmallcohortof86patients,therewereonlytwocuffdehiscences(2.3%),butbothoccurredinpatientson
whomVLoc90wasused.Thisledsometoquestiontheappropriatesutureabsorptionprofileinthesepatients,
whichisanavenuethatmeritsfurtherinvestigation.
CesareanDelivery
Todate,noarticleshavelookedattheuseofbarbedsutureforclosingtheuterusduringcesareandeliveryin
humans.In2006,Murthaandcolleagues37designedarandomizedcontrolledtrialtostudycosmeticoutcomesof
dermalclosureofPfannenstielskinincisionsduringcesareandeliveries.Theauthorsrandomlyassignedwomento
receiveeithersmoothorbarbedsutureforskinclosure,andtheincisionswereevaluated5weekslaterbyan
independentplasticsurgeon.Therewasnodifferenceincosmesisbetweenthegroups.Similarly,therewereno
differencesintimetoclose,infection,wounddehiscence,orpain.
Inasheepmodel,Greenbergandcolleagues38assessedtheeffectsofsuturetypeonuterineandfascialhealing
duringcesareandeliveryinpregnantewes.Theewesservedastheirowncontrolsubjectsbyhavingtwodifferent
suturetypesrandomizedforboththemyometrialandfascialclosures.Theuterinesuturesincludedbarbed
Monoderm(EthiconEndoSurgery),smoothMonocryl(EthiconEndoSurgery),VICRYL,andchromic.The
fascialsuturesincludedbarbed0PDO,barbed0Monoderm,0Vicryl,smooth0Monocryl,and0chromic.The
fascialclosuresonfouroftheewes(44%)thatwererandomizedtoreceiveeitherchromicorbarbedMonoderm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

6/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

failedprematurely.Inthissmalltrial,bothchromicandMonodermwereinadequatefortissuereapproximationon
thefascia.Giventheirtensilestrengthprofiles,thiswasnotsurprising.Inallnineewes,allthesutureswere
adequatetoreapproximatetheuterus.Fromthislimitedstudy,theauthorsconcludedthatbarbedsutureswereas
goodasknottedsmoothsuturesforreapproximatingthehysterotomyclosureinewes.Additionalhumanstudiesare
requiredtodeterminetheadequacyofbarbedsutureduringcesareandeliveries.Basedontheextensiveuseof
chromicandpolyglycolicacidsuturesontheclosureofhysterotomiesduringcesareandelivery,aswellasthe
absorptionprofilesofthecurrentlyavailablebarbedsutures,wesuspectthatbarbedsuturemaybesuitableforuse
duringthesedeliveries.

Conclusions

Goto:

Technologicadvancesandtheevolutionofincreasinglycomplexsurgicalproceduresinevitablyprogresshandin
hand.Whetheroneleadstheotherisamatterofdebate,buttheirsymbiosisisundeniable.Theintroductionand
evolutionofbarbedsuturematerialelegantlyservesasareminderofthisrelationship.Fromitsearliestdaysasa
crudelyfabricateddevicefortendonreapproximationtoitscurrentmassproduced,highqualityrealitywith
numerousbroadapplications,thisexcitingtechnologyisunquestionablystillinitsinfancy.
Theclinicalliteraturereviewedhereinsupportstheperformanceofabsorbablebarbedsuturesis,atleast,equivalent
toconventionalabsorbablesmoothsuturesforsofttissuereapproximationinobstetricsandgynecology.Inaddition,
theliteraturereviewedhasshownthattheuseofbarbedsuturescanshortensurgicaltimeandpossiblyreduce
intraoperativebloodloss.Withtheintroductionofnewerbarbedsutureproducts,theapplicationsofthisexciting
technologywillundoubtedlyexpand,althoughmorerandomizedclinicaltrialsareneededtobetterelucidateitsfull
potential.
MainPoints
Surgicalknotsaresimplyanecessaryevilneededtoanchorsmoothsuturetoallowittofunctioninits
roleintissuereapproximation.Otherthantheiranchoringfunction,surgicalknotsoffernobenefitand
introduceavarietyofuntowardfeatures.Surgicalknotsreducethetensilestrengthofallsuturesby
thinningandstretchingthematerial.
Asurgicalknotyieldsthehighestdensityofforeignbodymaterialinanygivensuturelineandthe
volumeofaknotisdirectlyrelatedtothetotalamountofsurroundinginflammatoryreaction.If
minimizingtheinflammatoryreactioninawoundisimportantforoptimizedwoundhealing,then
minimizingknotsizesoreliminatingknotsaltogethershouldbebeneficialaslongasthewoundholding
strengthofthesuturelineisnotcompromised.
Withminimallyinvasivelaparoscopicsurgeries,theabilitytoquicklyandproperlytiesurgicalknotshas
presentedanewchallengeforsurgeons.Incasesinwhichknottyingisdifficult,theuseofknotless
barbedsuturecansecurelyreapproximatetissueswithlesstime,cost,andaggravation.Theskills
necessarytoproperlyperformintraorextracorporealknottyingforlaparoscopicsurgerycanbe
achievedwithpracticeandpatience.
Significantlyfasterclosuretimeswithbarbedsuturehavebeenseeninseveralinvivostudies.
Clinicalliteraturesupportsthetheorythattheperformanceofabsorbablebarbedsuturesisequivalentto
conventionalabsorbablesmoothsuturesforsofttissuereapproximationinobstetricsandgynecology.

Footnotes

Goto:

Dr.GreenberghasworkedinthepastasaperdiempaidconsultantforEthicon(Somerville,NJ),themakersofthe
STRATAfIxsuture.Dr.Goldmanhasnodisclosurestoreport.Developmentofthisarticlewasmadepossiblebyagrantfrom
Ethicon.

References
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

Goto:
7/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

1.GreenbergJA,EinarssonJI.Bidirectionalbarbedsutureforlaparoscopicmyomectomy.JMinimInvasive
Gynecol.200815(suppl):S11.
2.ChuCC,vonFraunhoferJA,GreislerHP.WoundClosureBiomaterialsandDevices.BocaRaton,FL:CRC
Press1997.p.122.
3.StoneIK,vonFraunhoferJA,MastersonBJ.Thebiomechanicaleffectsoftightsutureclosureuponfascia.Surg
GynecolObstet.1986163:448452.[PubMed]
4.vanRijsselEJ,BrandR,AdmiraalC,etal.Tissuereactionandsurgicalknots:theeffectofsuturesize,knot
configuration,andknotvolume.ObstetGynecol.198974:6468.[PubMed]
5.HashemiL,HartS,MorseonM.Comparisonofsurgerytimeandcostinusingbarbedsutureversusthe
traditionalsutureinrobotichysterectomy:aretrospectivecohortstudy.JMinimInvasiveGynecol.
201219(suppl):S6.
6.MoranME,MarshC,PerrottiM.BidirectionalbarbedsuturedknotlessrunninganastomosisvclassicVan
Velthovensuturinginamodelsystem.JEndourol.200721:11751178.[PubMed]
7.BerguerR,SmithWD,ChungYH.Performinglaparoscopicsurgeryissignificantlymorestressfulforthe
surgeonthanopensurgery.SurgEndosc.200115:12041207.[PubMed]
8.BerguerR,ChenJ,SmithWD.Acomparisonofthephysicaleffortrequiredforlaparoscopicandopensurgical
techniques.ArchSurg.2003138:967970.[PubMed]
9.KadirkamanathanSS,SheltonJC,HepworthCC,etal.Acomparisonofthestrengthofknotstiedbyhandand
atlaparoscopy.JAmCollSurg.1996182:4654.[PubMed]
10.LopezPJ,VenessJ,WojcikA,CurryJ.Howreliableisintracorporeallaparoscopicknottying?JLaparoendosc
AdvSurgTechA.200616:428432.[PubMed]
11.AlcamoJH,inventor.Surgicalsuture.USpatent.1964Mar3
12.McKenzieAR.Anexperimentalmultiplebarbedsutureforthelongflexortendonsofthepalmandfingers.
Preliminaryreport.JBoneJointSurg.196749B:440447.[PubMed]
13.BunckeHJ,inventor.Surgicalmethodsusingonewaysuture.USpatent.1999Aug3
14.GenovaP,WilliamsRC,JewettW,inventors.QuillMedical,Inc,assignees.Methodforcuttingasutureto
createtissueretainersofadesiredshapeandsize.USpatent.2011Sep13
15.MaiorinoN,BuchterMS,PrimaveraM,KosaTD,inventors.TycoHealthcareGroupLP,assignees.Methodof
formingbarbsonasuture.USpatent.2012Apr24
16.QuillSelfRetainingSystem[instructionsforuse]Reading,PA:AngiotechPharmaceutics,Inc2009.
17.VLoc180AbsorbableWoundClosureDevice[instructionsforuse]Norwalk,CT:UnitedStatesSurgical,a
divisionofTycoHealthcareGroupLP2009.
18.STRATAFIXSpiralPDOKnotlessSyntheticAbsorbableSurgicalSutureMaterial[instructionsforuse]Blue
Ash,OH:EthiconEndoSurgery2012.
19.VakilJJ,OReillyMP,SutterEG,etal.Kneearthrotomyrepairwithacontinuousbarbedsuture:a
biomechanicalstudy.JArthroplasty.201126:710713.[PubMed]
20.ArbaughM,CaseJB,MonnetE.Biomechanicalcomparisonofglycomer631andglycomer631knotlessfor
useincanineincisionalgastropexy.VetSurg.201342:205209.[PubMed]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

8/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

21.GzenAS,ArslanM,SchulzeM,RassweilerJ.Comparisonoflaparoscopicclosureofthebladderwithbarbed
polyglyconateversuspolyglactinsuturematerialinthepigbladdermodel:anexperimentalinvitrostudy.J
Endourol.201226:732736.[PubMed]
22.NettM,AvelarR,SheehanM,CushnerF.Watertightkneearthrotomyclosure:comparisonofanovelsingle
bidirectionalbarbedselfretainingrunningsutureversusconventionalinterruptedsutures.JKneeSurg.
201124:5559.[PubMed]
23.SeimA,AndersenB,SandbergWS.Statisticalprocesscontrolasatoolformonitoringnonoperativetime.
Anesthesiology.2006105:370380.[PubMed]
24.AgnolettiV,BuccioliM,PadovaniE,etal.Operatingroomdatamanagement:improvingefficiencyandsafety
inasurgicalblock.BMCSurg.201313:7.[PMCfreearticle][PubMed]
25.TingNT,MoricMM,DellaValleCJ,LevineBR.Useofknotlesssutureforclosureoftotalhipandknee
arthroplasties:aprospective,randomizedclinicaltrial.JArthroplasty.201227:17831788.[PubMed]
26.GrigoryantsV,BaroniA.EffectivenessofwoundclosurewithVLoc90suturesinlipoabdominoplasty
patients.AesthetSurgJ.201333:97101.[PubMed]
27.DeBlasiV,FacyO,GoergenM,etal.Barbedversususualsutureforclosureofthegastrojejunalanastomosis
inlaparoscopicgastricbypass:acomparativetrial.ObesSurg.201323:6063.[PubMed]
28.EinarssonJI,GrazulBilskaAT,VonnahmeKA.Barbedvsstandardsuture:randomizedsingleblinded
comparisonofadhesionformationandeaseofuseinananimalmodel.JMinimInvasiveGynecol.201118:716
719.[PubMed]
29.EinarssonJI,VonnahmeKA,SandbergEM,GrazulBilskaAT.Barbedcomparedwithstandardsuture:effects
oncellularcompositionandproliferationofthehealingwoundintheovineuterus.ActaObstetGynecolScand.
201291:613619.[PubMed]
30.HuangMC,HsiehCH,SuTH,etal.Safetyandefficacyofunidirectionalbarbedsutureinminilaparotomy
myomectomy.TaiwanJObstetGynecol.201352:5356.[PubMed]
31.AngioliR,PlottiF,MonteraR,etal.Anewtypeofabsorbablebarbedsutureforuseinlaparoscopic
myomectomy.IntJGynaecolObstet.2012117:220223.[PubMed]
32.AlessandriF,RemorgidaV,VenturiniPL,FerreroS.Unidirectionalbarbedsutureversuscontinuoussuture
withintracorporealknotsinlaparoscopicmyomectomy:arandomizedstudy.JMinimInvasiveGynecol.
201017:725729.[PubMed]
33.SandbergEM,CohenSL,HillLydeckerCI,etal.Pregnancyoutcomesafterlaparoscopicmyomectomywith
barbedsuture.JMinimInvasiveGynecol.201219(suppl):S48.
34.SiedhoffMT,YunkerAC,SteegeJF.Decreasedincidenceofvaginalcuffdehiscenceafterlaparoscopicclosure
withbidirectionalbarbedsuture.JMinimInvasiveGynecol.201118:218223.[PubMed]
35.EinarssonJI,CohenSL,GobernJM,etal.Barbedversusstandardsuture:arandomizedtrialforlaparoscopic
vaginalcuffclosure.JMinimInvasiveGynecol.201320:492498.[PubMed]
36.GiddingsA,NaumannRW.Closureofthevaginalcuffafteratotallaparoscopichysterectomy(TLH)witha
runningbarbedsuture.JMinimInvasiveGynecol.201118(suppl):S84S85.
37.MurthaAP,KaplanAL,PagliaMJ,etal.Evaluationofanoveltechniqueforwoundclosureusingabarbed
suture.PlastReconstrSurg.2006117:17691780.[PubMed]
38.GreenbergJA,WaldenS,HammerCM,etal.Acomparisonofbarbedandsmoothsuturesforovinecesarean
delivery.IntJGynaecolObstet.2011113:215217.[PubMed]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

9/10

9/23/2016

BarbedSuture:AReviewoftheTechnologyandClinicalUsesinObstetricsandGynecology

ArticlesfromReviewsinObstetricsandGynecologyareprovidedherecourtesyofMedReviews,LLC

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002186/

10/10