Small Bowel Obstruction Following Robotic Transabdominal Preperitoneal Ventral Hernia Repair (rTAPP) Due to Barbed Suture

CHAPTER 1

Hello, my name is Kathleen Clement,and I am one of the general surgeonsat Tripler Army Medical Center in Honolulu, Hawaii.I'm going to present a case of a 29-year-old manwho presented to our clinicwith an incarcerated umbilical hernia with fat.The fascial defect measured approximately 1.5 cm.His past surgical history was notablefor an open appendectomy as a child.We discussed options for repairfor an open umbilical hernia repairwith mesh versus a robotic repair,and he elected to undergo an elective robotic transabdominalpreperitoneal ventral hernia repair.We took him to the OR in standard procedure,we placed a Veress needle to insulate his abdomen.We docked the roboton the left side of the patient's abdomen.We did our dissection.We reduced the fat in the ventral hernia.We repaired the fascial defectwith an 0 absorbable barbed suture,and then we also closed the peritoneal flapwith a 2-0 absorbable barbed suturecalled the V-Loc suture.During the dissection, which was notablebecause we made a small peritoneal rentthat was also repairedwith another separate 2-0 absorbable barbed suture.The patient did well, went home the same day.Unfortunately, the patient presented on post-op day twowith an acute bowel obstructionwith nausea, vomiting, and abdominal pain.He underwent a CT scan, which showeda small bowel obstruction with a transition pointvery close to where we repaired that peritoneal rent.He was managed overnight with NPO NG tubeand actually improved overnight.Had bowel movement in the morning and was doing great.But given the location of the obstruction that was closeto the peritoneal rent that we repaired,we were concerned that maybe there was a issuewith the closure of that peritoneal defect.So we recommended we take the patientback to the operating room for a diagnostic laparoscopyto evaluate what occurred.I'm also gonna introduce Dr. Keaton Altom,who's one of my general surgery residentswho's involved in this case,and he will discuss the rest of the case with you.

CHAPTER 2

So this was our viewwhenever we inserted the laparoscopic cameraand instruments into the same port sitesthat we had used for our initial operation.We quickly identified that there was a strandof barbed suture hanging downfrom the anterior abdominal wall.And it was intertwined in the bowel mesentery,essentially in the groove between the bowel serosaand the bowel mesentery, suspending the bowel anteriorly.

CHAPTER 3

So we grabbed the barbed sutureand then carefully began to tease outthe bowel mesentery away from it.In the background, you can see adhesionsfrom his appendectomy as a child.

CHAPTER 4

Here we're inspecting our peritoneal flap closurefrom the initial operation to make surethere's no exposed suture.Here we're just taking a closer look atwhere the barbed suture is coming from,which appears to be the right lateral sideof the patient's hernia defect -the same location that the peritoneal defect was madeand repaired with the barbed suture.And it appears that the end of the barbed suturethat we had ran back two throws had pulled through.

CHAPTER 5

Here we're just taking a closer lookat where the suture was intertwined in the mesentery.Overall, it looks okay.The valve just looks a little bit irritated.

CHAPTER 6

Here we are inserting laparoscopic scissors.Then we simply cut and remove the suturethat was hanging from the peritoneum.

CHAPTER 7

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

CHAPTER 8

So at this time, the patient is now over a month post-opwith no further complications.To summarize, this was a 29-year-old malethat presented initially with afat-containing umbilical herniaand underwent an elective robotic transabdominalpreperitoneal hernia repair that was uncomplicated,but the patient re-presented on post update twowith a small bowel obstruction caused by a barbed suturethat had come loose and intertwined in the bowel mesentery.The patient had very thin peritoneum on our initial surgery,which unfortunately led to us creatinga 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 throwsto 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 assetto modern surgeons.It's an efficient suture. It reduces operative time.It reduces blood loss, increases tensile strengthby spreading out the strength of the suturethroughout its length rather than typical suturewhere a lot of the tensile strengthis all in the knot at the end of the suture.It also reduces surrounding inflammationand local tissue hypoxiaby reducing the amount of constrainton the tissue around the suture.It's been around since the 1950s,but has become ever increasingly popularwith the advent of modern robotic surgeryin the late 90s and early 2000s.Despite all the benefits with barbed suture,there have been a handful of complicationsover the past few years,including small bowel obstruction.There's not a lot of datapublished on these complications yet,but one recent large literature reviewlooking at general surgery cases from 2011 to 2020revealed a handful of cases that presentedwith small bowel obstruction caused by barbed suture.These patients often presented within a week to two weeksafter their initial operation,but some presented several months after the index operation.There's a few things that surgeons can doto reduce these incidences, these complications.First of all, once you complete running the barbed suture,you should run it back a few throwsto make sure it secures into place.Only use barbed sutures where it's not gonna be exposedto intra-abdominal contents,and if it is, consider using a different formof 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 longthat it's hanging out into the abdomen.And then if there is exposed barbed suture,which is often seen in in specific surgeriessuch as ob/gyn, surgery on the uterus,you can apply a barrier deviceto help try to shield that barbed suturefrom the intra-abdominal contents.Ultimately, when this complication occurs,it needs to be investigated promptlyand often only requires removing the exposed suture.