the use of laparoscopic gastrectomy has recently increased , and its indications have expanded to proximal and total gastrectomy .
however , laparoscopic gastrointestinal anastomosis involves a high degree of difficulty and complexity . in gastrointestinal surgery , careful intestinal anastomosis  particularly in cases of esophagojejunal anastomosis  is important , as anastomotic leakage may occasionally be fatal .
stapled anastomosis is a fundamental step in all these methods , although it involves a hand - sewn technique .
thus , anastomotic methods are not commonly used because of the cumbersome laparoscopic intracorporeal sutures and tying involved .
however , various devices have been developed to simplify the placement of intracorporeal sutures , and barbed suture is one such device .
v - loc 180 ( covidien , mansfield , ma , usa ) is a new device for wound closure , and consists of a unidirectional barbed absorbable thread .
evenly spaced barbs have high tissue - adhesion ability , as they attach to tissue at numerous points .
moreover , the loop - end design avoids the need for tying a surgical knot ( figure 1 ) .
clinical efficacy and suitability of barbed sutures have been reported in dermal closure and orthopedic surgery , and their intracorporeal use has also been indicated in the fields of urology and gynecology .
the effective length , comprising the barbed portion , is approximately 12 cm , and no barbs are present in a length of 12 cm from the loop - end .
some reports have described the use of barbed sutures for digestive anastomosis , including gastric bypass surgery in obese patients . however , only a few have reported on the use of barbed sutures for reconstruction after radical gastrectomy in patients with cancer or for esophagojejunal anastomosis .
although single - layer entire - thickness running sutures are convenient and very cost - effective , several reports describe the use of double - layer running sutures to ensure safety . herein , we describe the surgical procedure for intracorporeal single - layer entire - thickness running suturing using the v - loc 180 device in cases involving esophagojejunal anastomosis and report on the short - term surgical outcomes .
the use of laparoscopic gastrectomy has recently increased , and its indications have expanded to proximal and total gastrectomy .
however , laparoscopic gastrointestinal anastomosis involves a high degree of difficulty and complexity . in gastrointestinal surgery , careful intestinal anastomosis  particularly in cases of esophagojejunal anastomosis  is important , as anastomotic leakage may occasionally be fatal .
stapled anastomosis is a fundamental step in all these methods , although it involves a hand - sewn technique .
thus , anastomotic methods are not commonly used because of the cumbersome laparoscopic intracorporeal sutures and tying involved .
however , various devices have been developed to simplify the placement of intracorporeal sutures , and barbed suture is one such device .
v - loc 180 ( covidien , mansfield , ma , usa ) is a new device for wound closure , and consists of a unidirectional barbed absorbable thread .
evenly spaced barbs have high tissue - adhesion ability , as they attach to tissue at numerous points .
moreover , the loop - end design avoids the need for tying a surgical knot ( figure 1 ) .
clinical efficacy and suitability of barbed sutures have been reported in dermal closure and orthopedic surgery , and their intracorporeal use has also been indicated in the fields of urology and gynecology .
the effective length , comprising the barbed portion , is approximately 12 cm , and no barbs are present in a length of 12 cm from the loop - end .
some reports have described the use of barbed sutures for digestive anastomosis , including gastric bypass surgery in obese patients . however , only a few have reported on the use of barbed sutures for reconstruction after radical gastrectomy in patients with cancer or for esophagojejunal anastomosis .
although single - layer entire - thickness running sutures are convenient and very cost - effective , several reports describe the use of double - layer running sutures to ensure safety . herein , we describe the surgical procedure for intracorporeal single - layer entire - thickness running suturing using the v - loc 180 device in cases involving esophagojejunal anastomosis and report on the short - term surgical outcomes .
in total , 38 patients ( 25 men and 13 women ) underwent laparoscopic intracorporeal suturing with the v - loc 180 device ( vlocl0604 ; taper point , 1/2 circle/26 mm ; size , 3 - 0 ; length , 15 cm ; covidien ) at toyama prefectural hospital between august 2012 and march 2014 .
two patients who underwent proximal gastrectomy with intracorporeal esophagojejunal and gastrojejunal anastomoses were also included .
the basic indication for laparoscopic gastrectomy in our department is ct1n0m0 cancer , and d1 + is the standard dissection range , based on the japanese classification of gastric carcinoma ( fourth edition ) and japanese gastric cancer treatment guidelines .
the diagnosis was made based on the findings of preoperative examinations , including gastrointestinal endoscopy , upper gastrointestinal series , and abdominal computed tomography .
the data were retrospectively collected from medical records , operative reports , and histopathologic reports .
patient characteristics ( age , sex , body mass index , indications , and operating procedures ) , surgery - related factors ( operation time , blood loss , transition to laparotomy , intracorporeal suturing time , and additional suture ) , and operative factors ( postoperative duration of hospital stay and intra-/postoperative complications ) were analyzed .
the clavien  dindo classification was used to categorize the postoperative complications ; cases categorized as grade ii and higher were regarded as having complications .
since 2012 , laparoscopic total gastrectomy ( ltg ) , laparoscopic proximal gastrectomy ( lpg ) , and laparoscopy and endoscopy cooperative surgery ( lecs ) have been introduced and are performed based on the primary disease and localization of the tumor . for these procedures ,
the patient is placed in a reverse trendelenburg position under general anesthesia . the first port is placed through the umbilicus by using an open method .
a laparoscope is inserted via the umbilical port and 4 operating ports ( bilateral subcostal and bilateral midabdominal ) .
, the duodenum is divided with a regular 60-mm linear stapler , with a camel cartridge ( tri - staple ; covidien ) , before the dissection of lymph node ( ln ) stations 7 , 8a , and 9 .
after full mobilization of the stomach and completion of nodal dissection , the esophagogastric junction is divided with a regular 60-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) .
thereafter , roux - en - y reconstruction is performed , including an esophagojejunal anastomosis according to the overlap method , with a 45-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) .
single - layer entire - thickness running suturing with v - loc 180 ( covidien ) was used to close the intestinal hole .
furthermore , a side - to - side jejunojejunostomy was performed , including transumbilical minilaparotomy ( usually 4 cm ) using a 45-mm linear stapler , with a camel cartridge ( tri - staple ; covidien ) , and hand - sewn sutures ( 3 - 0 vicryl ; ethicon , somerville , nj , usa ) . for lpg ,
the esophagus and stomach were divided with a 60-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) .
thereafter , double - tract reconstruction was performed , and the jejunojejunal anastomosis and esophagojejunal anastomosis were performed in the same manner as for ltg . with regard to gastrojejunostomy ,
the decision on whether the anastomosis should be made transumbilically or intracorporeally was left to the surgeon 's discretion .
a side - to - side gastrojejunostomy was performed with a 45-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) . only intracorporeal suturing with v - loc 180 ( covidien ) was used .
the mesentery defect was closed using 3 - 0 vicryl sutures ( ethicon , somerville , nj , usa ) , whereas petersen 's defect was not closed in the ltg and lpg cases . for lecs , after the gastric wall was devascularized laparoscopically , we penetrated the entire stomach layer endoscopically .
single - layer entire - thickness running suturing with the v - loc 180 ( covidien ) device was used to close the gastric wall defect .
the air leak test , performed with a nasal gastric tube , was used in all cases .
gastrointestinal hole closures were roughly divided into 2 groups : stapler insertion hole closure and gastric wall defect closure .
single - layer entire - thickness running sutures were placed by using the following method in all cases .
the first step in intestinal hole closure is to pass a needle through a loop ( figures 2a , 3a ) .
the first stitch may become loose , as there are no barbs adjacent to the loop .
therefore , at the start of the closure site , 1 or 2 additional bites may be needed ( figures 2b , 3b ) .
thus , single - layer entire - thickness running sutures are placed , which tightens at each bite ( figure 2c , 3c ) . at the end of the closure site
, 1 or 2 seromuscular bites are added after completing the intestinal hole closure , following which the suture is cut flush to the bowel without the necessity for tying a knot ( figures 2d , 3d ) . in cases with a broad suturing pitch ,
additional knotted sutures are made by using 3 - 0 monocryl ( ethicon ) based on the surgeon 's discretion .
schematic outline of intestinal hole closure in esophagojejunostomy using v - loc 180 for single - layer entire - thickness running suturing . (
a ) after side - to - side anastomosis , intestinal hole closure is initiated by passing the needle through a loop .
( b ) at the start of the closure site , 1 or 2 bites are added before the edge of the intestinal hole is sutured .
( c ) single - layer entire - thickness running suturing is performed , which tightens at each bite .
( d ) at the end of the closure site , 1 or 2 seromuscular bites are added after the completion of intestinal hole closure , and the suture is cut flush at the bowel , without the need for a knot .
( a ) initiation of intestinal hole closure using v - loc . by barely attaching the loop to the intestinal wall ,
( b ) one or 2 additional bites are needed before the edge of the intestinal hole is sutured ( white arrowheads ) .
( c ) single - layer entire - thickness running sutures are placed , which tighten at each bite .
( d ) one or 2 seromuscular bites are added after the completion of intestinal hole closure ( white arrowheads ) , and the suture is cut flush to the bowel without a knot .
an abdominal drain , bladder catheter , and nasal gastric tube were routinely placed . moreover , a postoperative radiographic contrast study was performed in all the patients .
a few sips of water , a semifluid diet , and a soft blended diet were given to patients on postoperative days 3 , 4 , and 6 , respectively .
on the first and third postoperative days , the amylase levels in the drain fluid were measured for the detection of a postoperative pancreatic fistula .
in total , 38 patients ( 25 men and 13 women ) underwent laparoscopic intracorporeal suturing with the v - loc 180 device ( vlocl0604 ; taper point , 1/2 circle/26 mm ; size , 3 - 0 ; length , 15 cm ; covidien ) at toyama prefectural hospital between august 2012 and march 2014 .
two patients who underwent proximal gastrectomy with intracorporeal esophagojejunal and gastrojejunal anastomoses were also included .
the basic indication for laparoscopic gastrectomy in our department is ct1n0m0 cancer , and d1 + is the standard dissection range , based on the japanese classification of gastric carcinoma ( fourth edition ) and japanese gastric cancer treatment guidelines .
the diagnosis was made based on the findings of preoperative examinations , including gastrointestinal endoscopy , upper gastrointestinal series , and abdominal computed tomography .
the data were retrospectively collected from medical records , operative reports , and histopathologic reports .
patient characteristics ( age , sex , body mass index , indications , and operating procedures ) , surgery - related factors ( operation time , blood loss , transition to laparotomy , intracorporeal suturing time , and additional suture ) , and operative factors ( postoperative duration of hospital stay and intra-/postoperative complications ) were analyzed .
the clavien  dindo classification was used to categorize the postoperative complications ; cases categorized as grade ii and higher were regarded as having complications .
since 2012 , laparoscopic total gastrectomy ( ltg ) , laparoscopic proximal gastrectomy ( lpg ) , and laparoscopy and endoscopy cooperative surgery ( lecs ) have been introduced and are performed based on the primary disease and localization of the tumor . for these procedures ,
the patient is placed in a reverse trendelenburg position under general anesthesia . the first port is placed through the umbilicus by using an open method .
a laparoscope is inserted via the umbilical port and 4 operating ports ( bilateral subcostal and bilateral midabdominal ) .
, the duodenum is divided with a regular 60-mm linear stapler , with a camel cartridge ( tri - staple ; covidien ) , before the dissection of lymph node ( ln ) stations 7 , 8a , and 9 .
after full mobilization of the stomach and completion of nodal dissection , the esophagogastric junction is divided with a regular 60-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) .
thereafter , roux - en - y reconstruction is performed , including an esophagojejunal anastomosis according to the overlap method , with a 45-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) .
single - layer entire - thickness running suturing with v - loc 180 ( covidien ) was used to close the intestinal hole .
furthermore , a side - to - side jejunojejunostomy was performed , including transumbilical minilaparotomy ( usually 4 cm ) using a 45-mm linear stapler , with a camel cartridge ( tri - staple ; covidien ) , and hand - sewn sutures ( 3 - 0 vicryl ; ethicon , somerville , nj , usa ) . for lpg ,
the esophagus and stomach were divided with a 60-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) .
thereafter , double - tract reconstruction was performed , and the jejunojejunal anastomosis and esophagojejunal anastomosis were performed in the same manner as for ltg . with regard to gastrojejunostomy ,
the decision on whether the anastomosis should be made transumbilically or intracorporeally was left to the surgeon 's discretion .
a side - to - side gastrojejunostomy was performed with a 45-mm linear stapler , with a purple cartridge ( tri - staple ; covidien ) . only intracorporeal suturing with v - loc 180 ( covidien )
the mesentery defect was closed using 3 - 0 vicryl sutures ( ethicon , somerville , nj , usa ) , whereas petersen 's defect was not closed in the ltg and lpg cases . for lecs , after the gastric wall was devascularized laparoscopically , we penetrated the entire stomach layer endoscopically .
single - layer entire - thickness running suturing with the v - loc 180 ( covidien ) device was used to close the gastric wall defect .
the air leak test , performed with a nasal gastric tube , was used in all cases .
gastrointestinal hole closures were roughly divided into 2 groups : stapler insertion hole closure and gastric wall defect closure .
single - layer entire - thickness running sutures were placed by using the following method in all cases .
the first step in intestinal hole closure is to pass a needle through a loop ( figures 2a , 3a ) .
the first stitch may become loose , as there are no barbs adjacent to the loop .
therefore , at the start of the closure site , 1 or 2 additional bites may be needed ( figures 2b , 3b ) .
thus , single - layer entire - thickness running sutures are placed , which tightens at each bite ( figure 2c , 3c ) . at the end of the closure site
, 1 or 2 seromuscular bites are added after completing the intestinal hole closure , following which the suture is cut flush to the bowel without the necessity for tying a knot ( figures 2d , 3d ) . in cases with a broad suturing pitch ,
additional knotted sutures are made by using 3 - 0 monocryl ( ethicon ) based on the surgeon 's discretion .
schematic outline of intestinal hole closure in esophagojejunostomy using v - loc 180 for single - layer entire - thickness running suturing .
( a ) after side - to - side anastomosis , intestinal hole closure is initiated by passing the needle through a loop .
( b ) at the start of the closure site , 1 or 2 bites are added before the edge of the intestinal hole is sutured .
( c ) single - layer entire - thickness running suturing is performed , which tightens at each bite .
( d ) at the end of the closure site , 1 or 2 seromuscular bites are added after the completion of intestinal hole closure , and the suture is cut flush at the bowel , without the need for a knot .
( a ) initiation of intestinal hole closure using v - loc . by barely attaching the loop to the intestinal wall ,
( b ) one or 2 additional bites are needed before the edge of the intestinal hole is sutured ( white arrowheads ) .
( c ) single - layer entire - thickness running sutures are placed , which tighten at each bite .
( d ) one or 2 seromuscular bites are added after the completion of intestinal hole closure ( white arrowheads ) , and the suture is cut flush to the bowel without a knot .
an abdominal drain , bladder catheter , and nasal gastric tube were routinely placed . moreover , a postoperative radiographic contrast study was performed in all the patients .
a few sips of water , a semifluid diet , and a soft blended diet were given to patients on postoperative days 3 , 4 , and 6 , respectively .
after the patient consumed the semifluid diet , the abdominal drainage tube was removed . on the first and third postoperative days , the amylase levels in the drain fluid were measured for the detection of a postoperative pancreatic fistula .
these patients had a mean age of 68.8  11.8 y ( range , 3788 ) and a body mass index of 22.2  11.8 ( range , 15.028.1 ) .
of those , 31 patients had gastric cancer ( 28 with early cancer and 3 with pyloric stenosis ) , and 7 had gastric submucosal tumor
. in total , 12 underwent ltg with roux - en - y reconstruction , 2 underwent laparoscopic distal gastrectomy with roux - en y reconstruction , 14 underwent lpg with double - tract reconstructions , 3 underwent gastrojejunal bypass , and 7 underwent partial gastrectomy .
the anastomoses performed included esophagojejunostomies in 26 , gastrojejunostomies in 7 , and simple closures of gastric defect in 7 ( table 1 ) .
of the 33 cases with esophagojejunostomies and gastrojejunostomies , additional knotted sutures were used in 13 .
background of the patients bmi , body mass index ; tg , total gastrectomy ; dg , distal gastrectomy ; pg , proximal gastrectomy . the mean operative time for gastrectomy was 236 min ( range , 155340 ) , and the estimated blood loss was 59 ml ( range , 0440 ) . for partial gastrectomy ( lecs ) and
gastrojejunal bypass , the mean operative times were 136 min ( range , 72200 ) and 90 min ( range , 65135 ) , respectively .
the mean duration of hospital stays for gastrectomy , lecs , and bypass were 14.1 , 9.1 , and 15 d , respectively ( table 2 ) .
when considering only the suturing time involving v - loc , the mean suturing time was 8.7 min ( range , 4.813.8 ) .
the mean suturing time with v - loc was 14.7 min ( range , 9.134.9 min ) .
operative data of each procedure : surgery - related factors two cases with positive air leak test results ( 1 case of esophagojejunostomy and 1 case of simple closure of gastric defect ) were noted during surgery after v - loc suturing and were managed by adding knotted sutures . no gastrointestinal injuries and bleeding
were noted during suturing . when postoperative factors were examined , no complications related to the anastomosis site and no surgery - related deaths were noted .
dindo grade ii . furthermore , 2 cases of intestinal obstruction were noted . of these , 1 patient had postoperative intestinal paresis ( grade ii ) and was managed conservatively , and the other was found to have internal herniation originating from a cord - like adhesion between the jejunojejunal anastomosis and colon ( grade iiib ) and underwent repeat laparoscopic surgery ( table 3 ) .
the barbed suture , which obviates the need for tying knots , has emerged as a new device for wound closure .
it has recently attracted interest as being useful in laparoscopic suturing . in the present study , we used v - loc 180 , which is an absorbable copolymer composed of glycolic acid and trimethylene carbonate  the same materials that are used in maxon ( covidien ) .
the tensile strength is maintained at 50% at 21 d , and complete absorption is observed in 180 d. in the current cases , we used a thread length of 15 cm , and it had excellent operability and maneuverability in the abdominal cavity . the effective length , comprising the barbed portion , is 12 cm .
although cases wherein a gastric wall defect can not be closed by a single thread due to a relatively short effective length have been noted , the use of a longer length of v - loc may not be cost effective .
hence , we used a length of 15 cm due to the associated operability and to facilitate easy suturing .
the barb and loop - end design of this device enables its adherence to tissues without the need for tying a knot .
however , v - loc does not have any barbs within 1 cm from the loop - end ( figure 1 ) , which is disadvantageous , in that it does not permit tight tissue adhesion at the first bite . therefore , we initiated suturing from the seromuscular portion , and the third bite was placed at the start of the intestinal incision , to avoid loosening . as tying a knot
is not recommended in the barbed portion , because the thread could be cut , the suturing was completed by adding 2 bites beyond the end of intestinal incision , after which the suture was cut without any knot .
however , the presence of a long barbed suture outside of the bowel has been reported to cause intestinal obstruction , and therefore , cutting this suture flush at the bowel is important . in the present study , 1 case of grade iiib intestinal obstruction
was noted , because of the thread between the colon and jejunojejunal anastomosis , and was not related to the use of v - loc sutures .
concept is being widely accepted in surgical procedures in various body locations as well as in fragile tissue , such as in cases of peritoneum closure . for intestinal anastomosis
, this procedure has been shown to yield a shorter suturing time and similar bursting pressure , as compared to common monofilament sutures in preliminary research and animal models .
furthermore , its usefulness and safety have been described in several large - scale trials involving laparoscopic bypass in obese patients . in patients with gastric cancer ,
barbed sutures have been used as a device for intestinal hole closure after side - to - side intestinal stapled anastomosis .
however , barbed sutures have primarily been used for gastrointestinal anastomosis as double - layer running sutures , and their safety has been described . nevertheless , the use of single - layer entire - thickness running sutures is more desirable , considering the shorter surgical time and ease of suturing .
although the present study was not controlled , the suturing time was found to be relatively short , and no anastomotic leakage was observed .
furthermore , we conclude that single - layer entire - thickness running sutures are acceptable and safe , as they offer tight closure by barbed sutures .
in addition , no anastomotic stenosis was observed , although we believe that this result is attributable to the side - to - side stapled anastomosis , not to the v - loc device .
an important limitation of v - loc use may be the development of anastomotic leakage due to seromuscular injury , when v - loc has been used for staple line reinforcement .
however , single - layer entire - thickness running sutures with the v - loc device showed a higher pressure and tightness test value ( defined as the pressure that can be exerted by the thread until a balloon bursts ) and no ruptures or leaks in a cadaver study .
these findings indicate that the unidirectional , evenly spaced barbs distribute the tension equally because they attach to the tissue at numerous points .
therefore , it appears that intestinal injury is a result of technical laparoscopy - related factors , such as the hand - sewn technique under direct vision , rather than a result of v - loc itself . in this report
we noted that surgeons encountered difficulty in suturing because the anastomotic hole became gradually smaller as suturing progressed .
however , to obtain a more secure suture and to avoid a positive air leak test result , it is essential to ensure tight closure as suturing progresses . in addition , of all the 40 case series
we consider the double - layer method to provide the most reliable anastomosis possible ; therefore , additional knotted sutures are added at the surgeon 's discretion depending on intraoperative findings .
we do not recommend the use of barbed suture alone ; a reliable suturing method is important .
single - layer entire - thickness running suturing with the v - loc 180 device after stapled side - to - side intestinal anastomosis is considered to be a safe and feasible option .
however , a greater number of such cases and careful and longer follow - up are necessary .
 background and objectives : laparoscopic anastomotic methods are not commonly used because of the cumbersome laparoscopic intracorporeal sutures and tying involved . 
 the barbed suture is one of the various devices developed to simplify the placement of intracorporeal sutures . 
 however , barbed sutures are not commonly used during reconstruction after radical gastrectomy in cancer patients or for single - layer entire - thickness running suturing for intestinal anastomoses . 
 we describe the procedure for using barbed sutures and report on the short - term surgical outcomes.methods:between august 2012 and march 2014 , 15-cm - long barbed sutures ( v - loc 180 ; covidien , mansfield , ma , usa ) were used for laparoscopic intestinal anastomoses , including intestinal hole closure for esophagojejunal and gastrojejunal anastomoses after mechanical anastomoses and gastric wall closure after partial resection.results:in total , 38 patients underwent 40 laparoscopic anastomoses ( esophagojejunostomies , 26 ; gastrojejunostomies , 7 ; and simple closure of gastric defect , 7 ) ; no cases required conversion to open surgery . 
 two cases exhibited positive air leak test results during surgery ( 1 case of esophagojejunostomy and 1 case of simple closure of gastric defect ) . 
 two cases of intestinal obstruction were noted ; of those , one patient with postoperative intestinal paresis ( grade ii ) was managed conservatively , and the other underwent repeat laparoscopic surgery ( grade iiib ) for internal herniation unrelated to v - loc use . 
 no postoperative complications at the anastomosis site and no surgery - related deaths were noted.conclusion:single-layer entire - thickness running suturing with the v - loc 180 barbed suture after stapled side - to - side intestinal anastomosis was found to be safe and feasible in the reported cases . 
INTRODUCTION
Background
METHODS
Patients
Surgical Procedures
Intestinal Hole Closure with Barbed Sutures
Postoperative Management
RESULTS
DISCUSSION
CONCLUSION