Plastic Surgery Research Council

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Application of a Novel Suture Anchor to Abdominal Wall Closure
Jason L. Green, BS1, Richard Glisson, BS2, Mohamed Ibrahim, MD3, Ken Gall, Ph.D4, Howard Levinson, MD5.
1Duke University School of Medicine, Durham, NC, USA, 2Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA, 3Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA, 4Duke University Department of Mechanical Engineering and Materials Science, Durham, NC, USA, 5Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.

Purpose
Mesh suture is a novel form of suture used to close high-tension wounds such as in hernia repair or laparotomy closure. This is because they have greater tensile strength and increased resistance to suture pulling through tissue compared to standard suture. However, mesh sutures can produce large knots that are susceptible to increased palpability, infection, and foreign body response. We previously developed a small anchor clip that outperformed knot and alternative mesh suture fixations in benchtop testing using silicone. The goal of this study was to determine the ability of the anchor clip to fixate mesh suture in abdominal wall tissue for application to hernia repair and laparotomy closure.
Methods
The anchor clip was iteratively developed using 3D design software (Fusion360®) and produced via 3D printing (Carbon3D® Printer) using a liquid polymer resin. The size of the anchor clip was compared to that of a mesh suture knot (width: 9mm, 4 throws). Next, cyclic fatigue testing of the anchor clip vs. knot and predicate fixation (corkscrew, ProTack™ Fixation Device, Medtronic) was performed using a benchtop abdominal wall suture model with porcine tissue (Figure 1-C). Suture fixation was tested in a single vs. double fixation format (Figure 2). Cyclic fatigue testing was applied at a force range of 10 to 20N (maximum physiologic force on the abdomen is 16N/cm) at 2Hz for 200 cycles, then pull to failure at a rate of 300mm/min. Completed cycles and failure load were recorded and compared.
Results
The size of the anchor clip (160mm3) was ~60% smaller than the mesh suture knot (420mm3) (Figure 1-D). During cyclic fatigue testing, the knot, anchor clip, and single corkscrew consistently sustained 200 cycles and underwent pull-to-failure while 2 of 3 double corkscrew samples did not complete cyclic testing. For single fixation, the standard knot (84±26N) and single corkscrew (82±8N) had a significantly higher failure load than single anchor clip fixation (39±10N) (P<0 .05). For double fixation, the double anchor clip (85±35N) had a similar failure load to a standard knot (84±26N) and significantly greater than double corkscrew fixation (34±0N) (P<0 .05).
Conclusions
The anchor clip is able to secure mesh suture under physiologic force ranges in abdominal wall tissue. Double anchor clip fixation has similar mechanical performance to a standard knot and single corkscrew fixation. Other advantages to the anchor clip include its reduced size relative to a knot and decreased tissue damage in comparison to a corkscrew which penetrates tissue. The inferior pull-to-failure performance of the single anchor clip fixation suggests a need to improve the locking mechanism to prevent disassembly. This study provides a preliminary indication for the use of anchor clips in abdominal wall closure, such as hernia repair and laparotomy closure.


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