There are multiple challenges that make minimally invasive knot tying difficult skills to master. The loss of depth perception, the limited degree of movement, and loss of tactile feedback are obstacles that must be overcome to develop competency in a laparoscopic setting. Moreover, proficient knot tying in open surgical experience does not translate to laparoscopic knot tying ability and requires consistent practice . Robotic surgery recovers depth perception and increases the degree of operative movement, however, the loss of immediate feedback when suturing by hand in an open case often results in weaker knots or over-tightening leading to tissue ischemia [9, 12]. With barbed suture, knot tying is not necessary. This reduces the skill required to use it. The barbs of the suture self-anchor to provide consistent tissue apposition and eliminate the necessity of an additional hand to follow the thread (Fig. 2). Furthermore, knots introduce weak points in traditional suture. Without the need for knots in barbed suture, the risk of suture failure is decreased . Ultimately, the technical aspects of traditional suture use with laparoscopic instruments are eliminated with barbed suture. As such, we would expect a greater use in a minimally invasive setting as compared to an open procedure. We saw a statistically significant use of barbed suture in laparoscopic vs open, robotic vs open, and laparoscopic vs robotic procedures over non barbed suture. This data supports the utility of barbed suture in a minimally invasive approach.
A significant portion of our study population was overweight or obese. Obesity is a rapidly growing problem especially in the United States and these patients tend to have more concurrent comorbidities . In addition, operating on patients with an elevated BMI adds physical complexity to cases. To improve outcomes and quality of life, the least invasive approach should be offered regardless of BMI. With proper preparation and optimization of comorbidities, minimally invasive surgery is the safest approach with the lowest risk of complications [8, 14, 15]. Although more challenging in obese patients, an experienced anesthetic team, proper set up and entry can increase chances of a successful procedure. Unexpected complications like injury to the bladder may arise due to thick adhesions, limited visibility, and anatomical distortion . Immediate repair can be done if an injury is recognized intraoperatively and typically, when an injury occurs during a laparoscopic procedure, the repair is completed in the same fashion to avoid subsequent risks of laparotomy [2, 3]. However, a traditional bladder repair requires precise suturing and knot tying in order to prevent long-term sequelae and achieving this laparoscopically is among the most difficult skill to master, requiring many hours of practice in order to gain proficiency. The knotless barbed suture has been proposed to make laparoscopic suturing easier and more efficient. Several in vivo studies have demonstrated faster closure times and reduction of difficulty with the use of barbed suture [12, 16]. Angioli et al. assessed barbed suture use in laparoscopic myomectomy and found a significant decrease in suturing time and blood loss in the barbed suture group . Although we found no differences between total operative time, we did not record suturing time of the bladder repair. However, any measure to reduce time under anesthesia especially in obese patients with significantly altered respiratory physiology is paramount. We found a significantly higher BMI in the patients that had cystotomy repair utilizing barbed suture. We also found greater barbed suture utilization in a minimally invasive setting. Our study suggests that the advantages of barbed suture make it suitable or preferred in more challenging cases such as laparoscopic surgeries in obese patients.
Most of the patients in our study that underwent cystotomy repair had previous operations 41/68 (60.3%). A multitude of factors are considered before a patient undergoes an operation and usually the benefit of the procedure outweighs the risks of surgical intervention. An attempt to minimize these risks such as intraoperative complications should be made but can never be eliminated. A significant surgical history, baseline comorbidities, chronic infections or inflammation, and complexity of the surgical case are some of the risk factors for complications [5, 18]. Complications are an unfortunate part of any surgical procedure. The most common during cystotomy repair include urinary leak, urinary tract infection, urinary retention, and stone formation. In our study, 16.2% of patients developed a complication. Although this seems high, our definition of complication was broad and may not have been directly related to the type of suture used during the bladder repair. Also, there have been limited studies that have evaluated the type of suture used in bladder repair relative to complications. In our study, the number of complications associated with barbed suture was not significantly different than non-barbed suture, the standard of care. Similarly, a recent case series utilizing barbed suture for cystotomy repair did not result in additional complications .
This study has several limitations. With any study relying on electronic medical records, coding discrepancies could exist causing misclassification with data collection. Also, with limited post-operative follow up, it is difficult to discern whether the surgical outcomes were long lasting. In our practice, we typically follow up with the patients 4–6 weeks after surgery and voiding cystometrogram or cystoscopy are not routinely performed. This database may not have included all observable patient characteristics that could confound the association between the use of barbed suture and patient outcome. Also, it could be argued that selection bias exists on account of a disproportionate number of patients were overweight or obese. Although this might account for some of the results seen within our study, the patient demographics within the state of West Virginia do not demonstrate substantial diversity with regards to weight. Furthermore, it is possible that non-modifiable patient factors could explain our observed results. Finally, since all the data was collected from a single academic, tertiary care hospital, this may limit the generalizability to non-academic community hospitals.