1. Introduction

2. Inspection of the SBO and the Offending Barbed Suture

3. Releasing the Barbed Suture from any Mesentery or Bowel

4. Further Inspection of Hernia Repair and Barbed Suture

5. Inspection of Bowel Integrity

6. Cutting and Removing the Exposed Barbed Suture

7. Final Inspection

8. Post-op Remarks

Barbed suture is an increasingly popular type of suture used by surgeons across the world. It is an efficient suture that provides several benefits, including better distributed tensile strength, reduced surrounding inflammatory reaction and local tissue hypoxia, and less foreign body exposure. However, there have been a handful of cases of complications with barbed sutures over the past few decades. We present a case of a patient who initially underwent an uncomplicated robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and re-presented postoperative day two with a small bowel obstruction. We demonstrate our operative findings from our return to the operating room with the identification of a barbed suture that had become caught in the mesentery, causing kinking of the bowel.

<h4>CHAPTER 1</h4>

<p>Hello, my name is Kathleen Clement,
and I am one of the general surgeons
at Tripler Army Medical Center in Honolulu, Hawaii.
I'm going to present a case of a 29-year-old man
who presented to our clinic
with an incarcerated umbilical hernia with fat.
The fascial defect measured approximately 1.5 cm.
His past surgical history was notable
for an open appendectomy as a child.
We discussed options for repair
for an open umbilical hernia repair
with mesh versus a robotic repair,
and he elected to undergo an elective robotic transabdominal
preperitoneal ventral hernia repair.
We took him to the OR in standard procedure,
we placed a Veress needle to insulate his abdomen.
We docked the robot
on the left side of the patient's abdomen.
We did our dissection.
We reduced the fat in the ventral hernia.
We repaired the fascial defect
with an 0 absorbable barbed suture,
and then we also closed the peritoneal flap
with a 2-0 absorbable barbed suture
called the V-Loc suture.
During the dissection, which was notable
because we made a small peritoneal rent
that was also repaired
with another separate 2-0 absorbable barbed suture.
The patient did well, went home the same day.
Unfortunately, the patient presented on post-op day two
with an acute bowel obstruction
with nausea, vomiting, and abdominal pain.
He underwent a CT scan, which showed
a small bowel obstruction with a transition point
very close to where we repaired that peritoneal rent.
He was managed overnight with NPO NG tube
and actually improved overnight.
Had bowel movement in the morning and was doing great.
But given the location of the obstruction that was close
to the peritoneal rent that we repaired,
we were concerned that maybe there was a issue
with the closure of that peritoneal defect.
So we recommended we take the patient
back to the operating room for a diagnostic laparoscopy
to evaluate what occurred.
I'm also gonna introduce Dr. Keaton Altom,
who's one of my general surgery residents
who's involved in this case,
and he will discuss the rest of the case with you.</p>

<h4>CHAPTER 2</h4>

<p>So this was our view
whenever we inserted the laparoscopic camera
and instruments into the same port sites
that we had used for our initial operation.
We quickly identified that there was a strand
of barbed suture hanging down
from the anterior abdominal wall.
And it was intertwined in the bowel mesentery,
essentially in the groove between the bowel serosa
and the bowel mesentery, suspending the bowel anteriorly.</p>

<h4>CHAPTER 3</h4>

<p>So we grabbed the barbed suture
and then carefully began to tease out
the bowel mesentery away from it.
In the background, you can see adhesions
from his appendectomy as a child.</p>

<h4>CHAPTER 4</h4>

<p>Here we're inspecting our peritoneal flap closure
from the initial operation to make sure
there's no exposed suture.
Here we're just taking a closer look at
where the barbed suture is coming from,
which appears to be the right lateral side
of the patient's hernia defect -
the same location that the peritoneal defect was made
and repaired with the barbed suture.
And it appears that the end of the barbed suture
that we had ran back two throws had pulled through.</p>

<h4>CHAPTER 5</h4>

<p>Here we're just taking a closer look
at where the suture was intertwined in the mesentery.
Overall, it looks okay.
The valve just looks a little bit irritated.</p>

<h4>CHAPTER 6</h4>

<p>Here we are inserting laparoscopic scissors.
Then we simply cut and remove the suture
that was hanging from the peritoneum.</p>

<h4>CHAPTER 7</h4>

<p>Here we are taking a look at the rest of the abdomen.
And another look at our peritoneal flap closure.</p>

<h4>CHAPTER 8</h4>

<p>So at this time, the patient is now over a month post-op
with no further complications.
To summarize, this was a 29-year-old male
that presented initially with a
fat-containing umbilical hernia
and underwent an elective robotic transabdominal
preperitoneal hernia repair that was uncomplicated,
but the patient re-presented on post update two
with a small bowel obstruction caused by a barbed suture
that had come loose and intertwined in the bowel mesentery.
The patient had very thin peritoneum on our initial surgery,
which unfortunately led to us creating
a rent in that peritoneum.
So we proceeded as usual,
repairing that rent with the barbed suture,
running it closed,
and then also once the rent had been repaired,
running the barbed suture back a few throws
to make sure that it was secured in place.
At the time of the case completion,
there was no exposed barbed suture that we saw,
and so we concluded the case.
Barbed suture is overall a very great asset
to modern surgeons.
It's an efficient suture. It reduces operative time.
It reduces blood loss, increases tensile strength
by spreading out the strength of the suture
throughout its length rather than typical suture
where a lot of the tensile strength
is all in the knot at the end of the suture.
It also reduces surrounding inflammation
and local tissue hypoxia
by reducing the amount of constraint
on the tissue around the suture.
It's been around since the 1950s,
but has become ever increasingly popular
with the advent of modern robotic surgery
in the late 90s and early 2000s.
Despite all the benefits with barbed suture,
there have been a handful of complications
over the past few years,
including small bowel obstruction.
There's not a lot of data
published on these complications yet,
but one recent large literature review
looking at general surgery cases from 2011 to 2020
revealed a handful of cases that presented
with small bowel obstruction caused by barbed suture.
These patients often presented within a week to two weeks
after their initial operation,
but some presented several months after the index operation.
There's a few things that surgeons can do
to reduce these incidences, these complications.
First of all, once you complete running the barbed suture,
you should run it back a few throws
to make sure it secures into place.
Only use barbed sutures where it's not gonna be exposed
to intra-abdominal contents,
and if it is, consider using a different form
of absorbable suture.
After you do run the suture back a few throws,
you can cut the tail off.
Try not to cut it too short where it's gonna pull through,
but you also don't want it so long
that it's hanging out into the abdomen.
And then if there is exposed barbed suture,
which is often seen in in specific surgeries
such as ob/gyn, surgery on the uterus,
you can apply a barrier device
to help try to shield that barbed suture
from the intra-abdominal contents.
Ultimately, when this complication occurs,
it needs to be investigated promptly
and often only requires removing the exposed suture.</p>


Watcht this narrated surgical video exploring a small bowel obstruction complication caused by barbed suture following a robotic transabdominal preperitoneal ventral hernia repair (rTAPP).

Tripler Army Medical Center