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Strangulated ileus from barbed suture following robot-assisted radical cystectomy: A case report

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The barbed suture e.g. V-Loc™, are occasionally used in urological surgery due to the practical advantage of omitting the need for surgical knots and reducing surgical time. In this report, an 83-year-old man diagnosed as having invasive bladder cancer underwent robot-assisted radical cystectomy: on the thirteenth postoperative day, he was diagnosed as having strangulated ileus of the small bowel. The small bowel was strangulated by bands formed between the stump of V-Loc™ and the fatty appendices of the sigmoid colon. This is the first report of a small bowel ileus associated with the barbed suture in the field of urology.
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Urology Case Reports 40 (2022) 101916
Available online 22 October 2021
2214-4420/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Strangulated ileus from barbed suture following robot-assisted radical
cystectomy: A case report
Shugo Yajima, Yasukazu Nakanishi
*
, Shunya Matsumoto, Naoya Ookubo, Kenji Tanabe,
Hitoshi Masuda
National Cancer Center Hospital East, Chiba, Japan
ARTICLE INFO
Keywords:
Barbed suture
Robot-assisted radical cystectomy
Small bowel obstruction
V-loc
ABSTRACT
The barbed suture e.g. V-Loc, are occasionally used in urological surgery due to the practical advantage of
omitting the need for surgical knots and reducing surgical time.
In this report, an 83-year-old man diagnosed as having invasive bladder cancer underwent robot-assisted
radical cystectomy: on the thirteenth postoperative day, he was diagnosed as having strangulated ileus of the
small bowel. The small bowel was strangulated by bands formed between the stump of V-Locand the fatty
appendices of the sigmoid colon.
This is the rst report of a small bowel ileus associated with the barbed suture in the eld of urology.
1. Introduction
Radical cystectomy is a standard treatment for patients with multi-
ple, recurrent, and muscle-invasive bladder cancer (MIBC), and robot-
assisted radical cystectomy (RARC) with urinary diversion has
recently been explored as a viable surgical option.
In the procedure of RARC, the V-Loc(Covidien, Manseld, MA,
USA) suture is sometimes used for stitching and division of the prostatic
venous plexus. The V-Loc suture is composed of monolaments with
small barbs cut into the length of the surface, which self-x to the tissue:
this self-anchoring capacity eliminates the need for surgical knots and
facilitates laparoscopic surgery by reducing the operative time.
1
However, a potential disadvantage of this practice and the use of
such suture material is that the exposed suture barbs may catch on the
adjacent small bowel, mesentery, or omentum leading to serosa injury,
obstruction, or volvulus: there are several case reports of postoperative
small bowel obstruction (SBO) related to the V-Locafter trans-
abdominal preperitoneal laparoscopic hernia repair (TAPP)
2
and
myomectomy.
3
Although barbed sutures are frequently used in urological surgery,
bowel complications associated with their use were seldom reported.
Here we report a rare case of entrapment fatty appendices of the sigmoid
colon and strangulated ileus of the small bowel following the use of
barbed suture in RARC.
2. Case
An 83-year-old Japanese male diagnosed as having MIBC underwent
RARC with intracorporeal ileal conduit using a Da Vinci Xi surgical
system (Intuitive Surgical Inc., Sunnyvale, CA, USA), after four courses
of neoadjuvant chemotherapy with cisplatin and gemcitabine. An esti-
mated 250 ml of blood was lost during the surgical procedures; the total
operative time was 353 minutes. We used a 3-0 V-Locsuture to stitch
and divide the prostatic venous plexus (Fig. 1).
On the fourth postoperative day, he began to consume a liquid diet.
On the thirteenth postoperative day, the patient suddenly developed
lower abdominal pain and distension with associated vomiting and
intolerance of feed. Laboratory investigation demonstrated hemoglobin
of 11.4 g/dL, white blood cell count of 13,000/
μ
L, blood lactate con-
centration of 1.4 mmol/L, and C-reactive protein of 0.46 mg/dL.
Computed tomography of the abdomen and pelvis showed dilatation of
the small bowel and closed-loop ndings (Fig. 2). He was suspected of
having strangulated ileus. Therefore, exploratory laparoscopy was per-
formed by a gastrointestinal surgeon under general anesthesia. A 12-mm
port was placed in the umbilical region and two 5-mm ports were placed
in the right and left lower quadrant of the abdomen.
Abbreviations: MIBC, muscle-invasive bladder cancer; RARC, robot-assisted radical cystectomy; SBO, small bowel obstruction; TAPP, transabdominal preper-
itoneal laparoscopic hernia repair.
* Corresponding author. National Cancer Center Hospital East, 6-5-1 Kashiwa no ha, Kashiwa city, Chiba, 2778577, Japan.
E-mail address: yanakani@east.ncc.go.jp (Y. Nakanishi).
Contents lists available at ScienceDirect
Urology Case Reports
journal homepage: www.elsevier.com/locate/eucr
https://doi.org/10.1016/j.eucr.2021.101916
Received 27 September 2021; Accepted 22 October 2021
Urology Case Reports 40 (2022) 101916
2
The laparoscopic observation indicated that the small bowel was
strangulated by bands formed by fatty appendices of the sigmoid colon
(Fig. 3a). When the bands formed by the fatty appendices of the sigmoid
colon were resected, the V-Loccame out from inside (Fig. 3b). The
strangulated small bowel appeared dark and congested initially, and
even after releasing the strangulation, the bowel did not regain its
normal color (Fig. 3c). We resected the small bowel in the congested
area and performed functional end-to-end anastomosis using the linear
stapler. An estimated 85 ml of blood was lost during the surgical pro-
cedures; the total operative time was 69 minutes.
The patient presented a satisfactory postoperative course: clear liq-
uids were offered on the rst postoperative day, the patient resumed
food intake on the fourth postoperative day, and a signicant reduction
of the levels of white blood cells was progressively observed.
3. Discussion
The barbed suture was rst patented for use in surgical procedures in
1999, and the barbed suture V-Lochave been introduced into the
market in 2009.
While it has the practical advantage of eliminating the need for
surgical knots and reducing surgical time, the use of barbed sutures in
surgery has to be careful as it is not without risks.
One of the serious complications caused by the use of barbed suture
in surgery is SBO. Kindinger et al., 2012 reported a case of small bowel
entanglement and obstruction involving an unraveled V-Locsuture 4
weeks following a laparoscopic myomectomy: they highlighted that the
bowel obstruction was likely due to the presence of barbs that had
contributed to the bowel entanglement.
3
Similar small bowel obstruc-
tions or volvulus complications following the use of V-Locsutures
have been reported in the context of gastrointestinal surgery
4
and as
complications after TAPP.
2
In the context of gastrointestinal surgery,
SBO was caused by the V-locsuture directly strangling the small
bowel
4
; in the postoperative setting of TAPP, there were often cases of
SBO noted secondary to the cut end V-Locsuture, which had become
integrated into the small bowel mesenterium.
2
The manufacturer of V-Locsutures recommends that the suture
stump include additional peritoneal tissue surrounding the closure.
5
However, Api et al. found in a randomized controlled trial in rats in 2015
that the intraperitoneal use of barbed suture material was associated
with adhesion formation and that these adhesions could not be pre-
vented by peritonization
1
: therefore, in the safe use of V-Locand other
barbed sutures, it may not be enough to perform peritonization, and it
will be important to minimize the length of the exposed barbed suture
end and avoid exposing the barbed suture in the abdominal cavity if
possible.
In the eld of urology, to the best of our knowledge, this is the rst
report of SBO associated with barbed sutures, including V-Loc. In the
current case, unlike previous reports of Vloc-related SBO, the SBO
Fig. 1. The prostatic venous plexus (circle with white broken lines) was
stitched using a 3-0 V-Locsuture (white arrow).
Fig. 2. Computed tomography of the pelvis showed dilatation of the small
bowel (white arrowhead) and decompressed distal bowel (white arrow).
Fig. 3. Findings during the ileus repair.
(a) The small bowel (white arrow) strangulated by bands formed by fatty appendices of the sigmoid colon (white arrowhead) was reddish-black in color.
(b) The white arrow indicates dissected bands formed by the fatty appendices of the sigmoid colon. The V-Locsuture (white arrow) came out from the inside of the
resected band.
(c) The small bowel appeared dark and congested even after releasing the strangulation. . (For interpretation of the references to color in this gure legend, the reader
is referred to the Web version of this article.)
S. Yajima et al.
Urology Case Reports 40 (2022) 101916
3
occurred under a peculiar situation in which a band was formed through
adhesions between the fatty appendices of the sigmoid colon and V-
Loc, resulting in an internal hernia. This situation is thought to have
occurred because the sigmoid colon fell into the pelvic oor after radical
cystectomy. That could have been prevented by minimizing the length
of the exposed barbed suture end and avoiding exposure of the barbed
suture in the abdominal cavity.
Financial conict of interst
None.
Declarations of competing interest
None.
Acknowledgements
I gratefully acknowledge the members of our department.
References
1. Api M, Cikman MS, Boza A, Rabus MB, Onenerk M, Aker FV. Peritoneal closure over
barbed suture to prevent adhesions: a randomized controlled trial in an animal model.
J Minim Invasive Gynecol. 2015;22(4):619625.
2. Tagliaferri EM, Wong Tavara SL, Abad de Jesus JL, Bergmann H, Hammans S,
Seidlmayer CM. Small bowel obstruction SBO after TAPP repair caused by a self-
anchoring barbed suture device for peritoneal closure: case report. J Surg Case Rep.
2018;(7), 2018.
3. Kindinger LM, Setchell TE, Miskry TS. Bowel obstruction due to entanglement with
unidirectional barbed suture following laparoscopic myomectomy. Gynecol Surg.
2012;9(3):357358.
4. Oor J, de Castro S, van Wagensveld B. V-loccapable of grasping surrounding tissue
causes obstruction at the jejunojejunostomy after Roux-en-Y laparoscopic gastric
bypass. Asian J Endosc Surg. 2015;8(2):209211.
5. Filser J, Reibetanz J, Krajinovic K, Germer C-T, Dietz UA, Seyfried F. Small bowel
volvulus after transabdominal preperitoneal hernia repair due to improper use of V-
Locbarbed absorbable wire do we always read the instructions rst?
International Journal of Surgery Case Reports. 2015;8:193195.
S. Yajima et al.
... Yajima et al. reported a case of strangulated bowel obstruction caused by V-Loc TM after robot-assisted radical cystectomy. 3 Their case demonstrated a small intestinal strangulation caused by bands formed by fatty appendices of the sigmoid colon and V-Loc-TM , which was used to stitch and divide the prostatic venous plexus, causing the internal hernia. Stratafix TM demonstrated no cases of small intestinal obstruction during our PubMed search. ...
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