Postoperative small intestinal obstruction caused by barbed suture after robot‐assisted laparoscopic sacrocolpopexy

Introduction We present a case of small intestinal obstruction due to a barbed suture used for peritoneal closure during robot‐assisted laparoscopic sacrocolpopexy. Case presentation A female patient with pelvic organ prolapse underwent robot‐assisted laparoscopic sacrocolpopexy uneventfully. Intestinal obstruction developed on postoperative Day 4. Conservative treatment with the ileus tube failed to improve abdominal symptoms. The laparoscopic examination on postoperative Day 14 revealed the barbed suture entangled with the small intestinal mesentery. The tail of the barbed suture was laparoscopically detached from the mesentery without damaging the small intestine. The tail of the barbed suture was trimmed; an antiadhesive material was applied to the peritoneal closure line and the trimmed tail of the barbed suture. Conclusion We recommend the use of conventional absorbable sutures in the peritoneal cavity because of the potential risk of intestinal obstruction caused by the barbed suture.


Introduction
Barbed sutures are widely used in general surgery as well as gynecological and urological procedures to reduce the time or prevent the suture from sliding back. 1 Since the FDA was alerted about mesh complications in 2014, laparoscopic sacrocolpopexy with or without robotic assistance has been replacing transvaginal mesh surgery for POP.Barbed sutures are sometimes used for the peritoneal closure during laparoscopic sacrocolpopexy.Herein, we present a case of postoperative small intestinal obstruction caused by the barbed suture used during RSC.

Case report
A female patient in her seventies had been suffering from POP for the past 2 years.She visited our department with a complaint of lower urinary tract symptoms, mainly poor urinary stream.Pelvic examination revealed stage IV POP (cystocele) on the POP-Q system.Her medical history revealed hypertension and diabetes mellitus.She had three vaginal deliveries with no history of abdominal surgery.She was not sexually active.Vaginal pessary treatment was attempted, but it failed to retain and fell out every time.We recommended surgical repair for POP, and she decided to undergo RSC.
We performed RSC (DaVinci Xi surgical system; Intuitive Surgical, Inc., Sunnyvale, CA, USA) with bilateral salpingo-oophorectomy and supracervical hysterectomy.We secured the mesh (ORIHIME TM ; CROWNJUN Co, Chiba, Japan) to the sacrum and closed the peritoneum using a running absorbable 3-0 V-Loc TM (Covidien TM , Mansfield, MA, USA).The console time was 123 min with minimal bleeding.The patient had vomiting and abdominal distension on postoperative Day 4.She was diagnosed with postoperative intestinal obstruction based on an abdominal X-ray (Fig. 1a).A computed tomography scan revealed a small intestinal obstruction in the lower right abdomen (Fig. 1b).Conservative treatment with an ileus tube failed to improve the condition.The diagnostic laparoscopy was performed on postoperative Day 14. Laparoscopic examination revealed the entanglement of the tail of V-Loc TM with the small intestinal mesentery (Fig. 2a).The tail of V-Loc TM was laparoscopically detached from the mesentery without damaging the small intestine.Furthermore, the V-Loc TM was adhered to fatty appendices of the sigmoid colon (Fig. 2b).That part was also detached to avoid an internal hernia.The tail of the V-Loc TM was trimmed, and an antiadhesive material (INTERCEED®; Johnson & Johnson, New Brunswick, NJ, USA) was applied to the peritoneal closure line and the trimmed tail of V-Loc TM (Fig. 2c).On postoperative Day 1, the ileus tube was removed and the patient was allowed to drink water.She was discharged from the hospital on postoperative Day 3.

Discussion
Herein, we presented a case of postoperative small intestinal obstruction caused by the barbed suture used during RSC.The barbed suture tail was entangled to the mesentery, causing a small intestinal obstruction.This case report mainly indicates that the use of barbed sutures in the peritoneal cavity may cause intestinal obstruction due to the suture tail entanglement to the intestines or mesentery.
Currently, several barbed sutures are available in the market, including Quill TM knotless tissue closure device (Angiotech TM , Vancouver, BC, Canada), V-Loc TM    conducted a randomized comparative study between barbed suture (unspecified) and conventional suture (polyglactin 910) materials for 100 patients who had undergone a laparoscopic total hysterectomy. 2Their cohort demonstrated no small intestinal obstruction and a similar incidence of complications between the two groups.They advocated barbed sutures as an excellent alternative to conventional suture materials with the advantages of reduced suturing time and technical difficulty.
Our PubMed search revealed that over 30 cases of small intestinal obstruction owing to barbed sutures have been reported in the English literature (Table 1).V-Loc TM was used in the majority of the reported cases, followed by Quill TM .Initial surgical procedures included inguinal hernia repair, colpopexy, rectopexy, myomectomy, hysterectomy, and Roux-en-Y gastric bypass.The median duration from the initial surgeries to the onset of the symptoms caused by small intestinal obstruction was 13 days (1 day-7 months).In most cases, the small intestinal obstruction was resolved by barbed suture detachment or trimming and intestinal release.However, severe strangulated ileus occurred and small intestinal resection was performed in some cases.Yajima et al. reported a case of strangulated bowel obstruction caused by V-Loc TM after robot-assisted radical cystectomy. 3Their 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.Stratafix TM and V-Loc TM have some structural differences in size and number of barbes.However, the Manufacturer and User Facility Device Experience Database also reported some cases of small intestinal obstruction caused by Stratafix TM . 4Notably, the use of any kind of barbed suture might be a potential risk for intestinal obstruction.
The use of barbed sutures during minimally invasive surgery is becoming more prominent.The use of barbed suture has a clear advantage of securely reapproximating tissues with less time, cost, and aggravation. 5Complications caused by barbed sutures must be avoided despite such benefits.The use of conventional absorbable sutures instead of barbed sutures should be considered, especially in the peritoneal cavity.Cutting the tail of the barbed suture short enough may help prevent entanglement of the suture with other organs if the use of barbed suture is inevitable. 6,7Furthermore, applying adhesion barrier materials to prevent direct intestinal contact with the barbed suture is also anoption. 8herefore, we have been using conventional absorbable sutures instead of barbed sutures for peritoneal closure during RSC.

Conclusions
We should be aware that barbed sutures might cause intestinal obstruction.We recommend the use of conventional absorbable sutures in the peritoneal cavity because of the potential risk of intestinal obstruction caused by barbed sutures.

Fig. 1
Fig. 1 (a) Abdominal X-ray on the 4th postoperative day showed bowel distension.(b) CT scan on the 11th postoperative day showed distended small bowel and compressed bowel (arrow).

Fig. 2
Fig. 2 (a) There was adhesion between the tail of V-Loc TM and the mesentery of the small bowel (circle).(b) There was adhesion between the V-Loc TM and fatty appendices of sigmoid colon (arrowhead).The arrow showed the tail of the V-Loc TM entangled to the mesentery.(c) Antiadhesive material was applied to the peritoneal closure line and the trimmed tail of V-Loc TM .

Table 1
Literature lists regarding small bowel obstruction caused by barbed suture threads.