Knotless choledochoraphy with barbed suture, safe and feasible.

Luis C Fernandez, MD¹, A Toriz, MD¹, J Hernandez, MD¹, A Cuendis, MD², C F Cervantes, MD³. ¹Hospital General Zona Norte Puebla, ²Hospital General “Dr. Manuel Gea Gonzalez”, ³Hospital General ISSSTE Puebla

Purpose
Our purpose was to describe the safety and feasibility of a running continuous unidirectional barbed suture (V-Loc, Covidien, Mansfield, MA) for primary common bile duct closure at laparoscopic common bile duct exploration (LCBDE).

Introduction
Nowadays, LCBDE is actually the best approach for treating complex cases of common bile duct lithiasis or cases where the endoscopic retrograde cholangiopancreatography (ERCP) has failed. Also, it continues to gain widespread popularity among surgeons who want to avoid the risks of ERCP.
It is clear that the primary closure of the common bile duct must be preferred, over the T-tube drainage.
The actual technical aspects offer room for improvements.

The ideal bile duct suture that should offer a:
-material with an apropiate absorbable time, non traumatic needle/thread, minimally inflamatory response.
-simple technique ideal for avoiding bile leaks, without compromising tissue perfusion or bile filtration.
This suture hasn't been found.

We turn our sight on barbed suture, for which recently various fields of surgery have become interested in, which now has a series of studies that support it for wide uses, which offers a secure tension-free tissue approximation and that has demonstrated closure equivalence with maxon (monofilament polyglyconate), but with faster anastomotic times.

We started using this suture under the hypothesis that by its characteristics, it could fulfill the requirements of an ideal bile duct suture postulating an easier, safer and efficient reconstruction based on:
-material characteristics, ideal for biliary surgery
-easier and faster techniques
-non isquemic, knotless, running simple suture

Herein, we present our initial series with this novel technique.

Methods
Between July 2012 and July 2014, 54 consecutive patients with bile duct stones underwent LCBDE by a single surgeon, upon the completion of the exploration, 50 patients had primary common bile duct closure, 3 reconstruction with hepaticojejunostomy and one reconstruction with choledochoduodenostomy, using knotless unidirectional barbed 3-0 V-Loc 90 suture. All of the sutures were performed without knot tying. Perioperative outcomes and 30-day complications were recorded. Surgical criteria are shown in chart 1.

Outcomes measures
Prospective data was collected for standard perioperative variables, demographic, etiology, preoperative findings, surgical findings (diagnosis and bile duct size), bleeding, rate of convertion, adverse events, reconstruction times (recorded at video playback for all cases), postoperatory hospital stay, VAS pain score, bile leak, infection, reintervention or death. All patients have being followed closely after their hospital discharge and will be followed for at least 3 years.

Patients demographics, characteristics and postoperative outcomes are shown in tables 1,2 and 3 respectively. The procedure in all patients was successfully performed with no intra-operative complications. There were no bile leaks in the 54 patients, or other postoperative complications as infection, need for reintervention or death.

Conclusion
The use of unidirectional knotless barbed suture (V-Loc 90) is safe, feasible and effective on LCBDE for primary common bile duct closure.
The biliary leak rate is acceptably low and comparable to the reported in the literature. This is report on the initial experience that needs further clinical trials. Nothing to disclose.