Senior Project Proposal

Roshan Toopal

1. Title of Project:

Pediatric Surgery:  Barbed Sutures

2. Statement of Purpose:

Nearly every surgery starts with cutting an opening to enter the body, and ends with the closure of that opening with surgical sutures. Materials used for sutures have ranged from “wires of gold [and] silver” (Greenberg 2010) to “tree bark and other plant fibers” (Greenberg 2010). More specifically, some surgeries include splitting intestinal tubes and rejoining the free ends, called anastomosis. The closure of these openings can directly affect the patient’s post-surgical health, so the tiny material holding the wound closed can have a huge impact on the patient. I am going to examine the types of sutures used in anastomosis. Through my research, I intend to study the results of using unidirectional barbed sutures on the efficiency of anastomosis procedures. Do pediatric surgeons find barbed sutures easier to use than standard sutures?I will also be answering some other questions regarding the topic. Does the use of barbed sutures shorten the time it takes to complete an anastomosis? Are barbed sutures more preventative of post-surgical leaks?

3. Background:

As an athlete,  I am close with several other athletes who have gone through surgeries before. More specifically, a friend has undergone a surgery involving anastomosis Watching recoveries from multiple elbow surgeries and appendectomies, I have grown interested in both biology and anatomy, and would like to learn more about pediatric surgery.  Although I have not conducted any formal research on the topic of surgical sutures, my interest in surgery and the engineering aspects of biology has guided me to take certain classes in school. I have taken AP biology, both AP Calculus courses, AP Physics, and Anatomy and Physiology before starting this research project. These courses are at the start of a degree in biomedical engineering, which focuses on the creation of new medical devices, such as sutures.

4. Prior Research:

As the use of unidirectional  barbed sutures has not been approved for the use of anastomosis yet, there is limited prior research on the subject. There is, however, some research on the use of barbed sutures for other surgical procedures. According to Greenberg’s review (2010), “the choice and use of sutures in obstetrics and gynecology (ob-gyn) is based more on anecdote and experience than data.” There are currently two types of commercial sutures: the Quill™ SRS bidirectional barbed suture product line and the V-Loc™ Absorbable Wound Closure Device product line (Greenberg 2010), of which I will be using the second.

The American Academy of Orthopaedic Surgeons studied the difference between barbed sutures and knotted sutures in total knee arthroplasty. They found that the closure time while using the barbed sutures “significantly shorter (P < 0.001) at a mean of 9.8 minutes, compared with the closure time of 14.4 minutes” (Stanton 2014). The average closure cost of barbed sutures was also significantly less than that of knotted sutures. There were no significant differences regarding major or minor complications, which “extended to rates of wound infection” (Stanton 2014), as the patients were analyzed up to 6 weeks post-surgery.

Medical and Surgical Specialists in Florida researched the difference between bidirectional-barbed sutures and standard, single-knot sutures in Robotic prostatectomy. The Da Vinci Surgical System was used by one surgeon on a “in-vitro model of microfiber synthetic material” (Moran 2007). Comparing the classic van Velthoven with the PDO-sutured anastomosis, the researchers recorded a decrease in deployment time from “17.3 minutes [to] 19.2 minutes” (Moran 2007). Additionally, the safety score increased while using the barbed sutures while the accuracy score remained the same.

5. Significance:

Surgery is an extremely meticulous process, in which efficiency is of great importance. Sutures are used in intestinal and vascular surgery to join intestine to intestine or blood vessel to blood vessel by doing an ‘anastomosis’. Sutures are also used to close the incisions made in the skin fascia and muscles to open body cavities.  The process of an anastomosis or closing the surgical opening must be completed quickly and efficiently, and is directly affected by the sutures being used.

Regarding the production of the sutures being used, “no study or surgeon has yet identified the perfect suture for all situations” (Greenberg). I will be working with several pediatric surgeons to study the differences between using barbed suture and conventional suture. These surgeons, who work with children every day, will be able to give the perspective of operating on a child in the qualitative portion of the research.

6. Description:

I will be conducting experiments with practice models of blood vessels and intestines. I will be observing and recording data from anastomosis procedures on these models, which will be carried out by pediatric surgeons. The surgeons will complete the anastomosis procedures using a laparoscopic model to mimic the environment of an actual surgery. Finally, I will give a presentation, which will include the time differences, the survey results, and the leak test results, to explain the benefits of using barbed sutures, as compared to traditional sutures.

7. Methodology:

Because my research question examines the effects of using barbed sutures on the time of anastomosis and the difficulty of the procedure. I will use a laparoscopic surgery simulator, in which a surgeon joins the ends of two plastic tubes  and/or pig intestines to mimic a laparoscopic intestinal anastomosis. There are 4 pediatric surgeons in the office where I will be working. First, I will have each surgeon perform an anastomosis twice: once with standard sutures and once with barbed sutures. Each procedure will be timed and recorded, and each surgeon will thereafter complete a survey regarding the ease of the process after they finish. Next, the completed models for both types of sutures will be tested for leaks at a specific liquid pressure.Once the surgeons have finished their contributions to the research, the results of the surveys and the times will be organized to compare the two different types of sutures.  Using the results of the experiment, I will be able to answer whether the barbed sutures were more effective and easier to use than standard sutures.

8. Problems:

One problem is the acquisition of materials to perform the simulation of anastomosis with. My advisor will help me by obtaining the necessary suture material from vendors and renting a laparoscopic surgery simulator. We will also buy the organic materials needed for the experiment. If these materials are unavailable at the time, synthetic materials, such as plastic tubes and a workbench, will be sufficient to answer my research question.

The surgeons may need to return to their work at short notice, so they may not be available throughout the duration and testing. This is inevitable, as there are more pressing issues that they must attend to.  However, as I will be attending the hospital several times a week, I will be able to schedule times for them to participate in the research.

9. Bibliography:

• Stanton, Terry. “Study: Barbed Sutures Show Advantages in TKA.” American Academy of Orthopedic Surgeons. 2014. Web. 7 Dec 2014.
• Greenberg, James. “The Use of Barbed Sutures in Obstetrics and Gynecology.” National Center for Biotechnology Information. 2010. Web. 7 Dec 2014.
• Moran, Michael. “Bidirectional-barbed sutured knotless running anastomosis v classic Van Velthoven suturing in a model system.” 2007. PubMed. Web. 7  Dec 2014.
• LaMorte, Wayne. Basics of Wound Closure and Healing.” Boston University School of Medicine. Web. 7 Dec 2014.
• Covidien Wound Closure Products Web page. [Accessed Dec 7, 2014] http://www.syneture.com/syneture/pagebuilder.aspx?topicID=31357&breadcrumbs=0:66860
• Lai, Stephen. “Sutures and Needles.” Medscape. 2013. Web. Dec 7 2014.
• Serag Weissner. “Pocket Guide to Suture Materials” Web. Dec 7 2014
• Gililland, Jeremy. “Barbed vs. Standard Sutures for Closure in Total Knee Arthroplasty:
• A Multicenter Prospective Randomized Trial.” American Association of Hip and Knee Surgeons. Web. Dec 7 2014.
• Zaruby, Jeffrey. “Use of Knotless Barbed Sutures for Single Layer Closure of Gastrointestinal Tissues: an in Vivo Biomechanical Comparison of Two Devices.” Society of American Gastrointestinal and Endoscopic Surgeons. 2011. Web. 7 Dec 2014.