Are we adaptable?

The Zoom platform was founded in April 2011. Online meetings were something we knew of, participated in for certain settings, but “in-person” attendance was the gold standard prior to approximately March 2020. Flash forward to our mid–COVID19 pandemic lives and we see the stark comparison with the expectations that are now in place for meetings, grand rounds, educational sessions, and even conferences (virtual conferences…who would have ever thought!). Coronavirus changed the way we use the internet with movement to use of Zoom, Google Classroom, Google Hangouts, Microsoft, and many others for communication that allows us to achieve our goals (1). We had to be adaptable given the circumstances.

In surgery, are we as willing to adapt to new techniques as we are to other technological advances? One such topic of interest relates to changes in the basics of minimally invasive surgery with the type of sutures that are used; barbed suture received its first patent in 1956 and the first US Food and Drug Administration approval occurred in 2004. Barbed sutures have entered the arena and are a contender for our attention. Arena et al. (2) in their article, “Comparison of Fertility Outcomes After Laparoscopic Myomectomy For Barbed Versus Non-barbed Sutures,” demonstrate a microcosm of what many surgeons intuitively see has occurred in minimally invasive surgery with increasing use of barbed suture growing significantly over time. Embracing new suture is truly an exciting although intimidating concept. Repair of a structure such as the uterus must be efficacious and safe. Ensuring a timely and secure closure of defects in the myometrium is absolutely essential. Should we do what we have always done or change to a material that is unfamiliar and not fully vetted for every outcome of interest?

Arena et al. (2) assist in providing evidence for a critical endpoint of using barbed suture for a specific surgery, laparoscopic myomectomy, by focusing on fertility outcomes. This is certainly applicable because uterine fibroids are the most common benign smooth muscle neoplasm in women, complicating the lives of many women of reproductive age. Fibroids can cause symptoms including abnormal uterine bleeding resulting in anemia, pelvic pain, dyspareunia, bowel and bladder dysfunction, and reproductive complications. These complications include impaired fertility, higher rates of preterm birth, cesarean section, breech presentation, and preterm labor. Often overlooked, these women also experience a significant decrease in quality of life. Medical management options are available for uterine fibroids, including new therapies such as elagolix with add-back treatment, however, for those desiring an immediate attempt at conception, myomectomy is often indicated. For women of reproductive age, this type of surgical management becomes especially important because it presents a management option that preserves fertility. Although a fertility-sparing option, laparoscopic myomectomy also comes with its own potential long-term risks including risk of uterine rupture as well as disorders of abnormal placentation (3, 4).

As laparoscopic surgery continues to evolve, metrics including surgical outcomes, complications, length of surgery, and cost are all assessed with each new innovation. The advent of barbed suture has demonstrated several advantages to conventional laparoscopic suturing. Barbed suture, unlike its conventional counterpart, has the ability to anchor itself and diffuse tension to the surrounding tissue. The suture requires no intracorporeal or extracorporeal knot tying, providing the opportunity for shorter operative time and decreased intraoperative blood loss. And, the weakest area in any surgical line is the knot, which also has the highest density of foreign body material. For operations such a myomectomies, which can have significant bleeding, the advantages of quick suturing and even tensile strength across the suture line are key.

Because of its impact on fertility, surgical technique with laparoscopic myomectomy continues to be explored. For fertility-sparing myomectomy, the goal should be to form a secure closure of the myometrium and minimize risk of rupture of a gravid uterus. Arena et al. (2) explore this by assessing whether or not the type of suture used affects the reproductive outcomes of women undergoing laparoscopic myomectomy. Their study goes beyond looking at the traditional fear of rupture and goes on to evaluate ability to achieve pregnancy, gestational age of delivery, method of delivery, as well as other pregnancy complications including first-trimester miscarriage and ectopic pregnancy. Ultimately, they are able to establish that there are no significant differences in reproductive outcomes (2). As barbed sutures are used more and more by gynecologic surgeons, this evaluation is an important one because it looks beyond the traditional factors of hemostasis and structural integrity. Their study asks the important questions of does the type of suture used impact ability to achieve pregnancy, and, of those pregnancies, how many result in live births? Beyond gynecology, the use of barbed sutures has grown in surgical specialties, both minimally invasive and open. Several studies have looked at the efficacy of barbed sutures and have shown almost unanimously decreased operating times and had similar outcomes to conventional suturing techniques even in surgeries such as gastric bypass and urologic procedures.

The question remains, if barbed sutures add to our surgical arsenal to improve outcomes for patients, how much does this matter? If a skilled surgeon is able to use techniques involving traditional smooth suture to achieve hemostasis and structural integrity in a timely fashion, will switching to barbed suture truly improve that surgeon’s outcomes? This remains to be seen. For the surgeon who resorts to an open approach for challenging myomectomies, however, barbed suture could be the deciding factor in surgical approach. As barbed suturing continues to become the standard of practice and facilitates the role of the minimally invasive surgeon, it encourages more surgeons to take the minimally invasive approach with cases that they would have traditionally pursued with an open technique. When comparing outcomes of those who undergo abdominal versus laparoscopic myomectomy, meta-analysis data comparing the two shows us that laparoscopic approach decreases blood loss, shortens the length of postoperative ileus, and reduces length of hospital stay (5). It also decreases postoperative pain in these patients, which can be a significant factor in patient’s perception of surgical success. These outcomes alone point us toward minimally invasive approaches as a better choice.

The data presented by Arena et al. (2) provide continued encouragement for the option of the use of barbed suture in the setting of myomectomy with the ultimate goal to preserve the ability for pregnancy. Barbed sutures provide an avenue for gynecologic surgeons to increase the ease of minimally invasive options for their patients in a safe and effective way. In surgeries that require excellent hemostasis and tissue security, such as myomectomies, barbed sutures can be relatively quick and less technically challenging than traditional smooth sutures/knot tying, but yet maintain all of the components of good surgical principles important for reproductive outcomes. So, let us Zoom ahead with changing times. We are able to adapt.