title: Barbed suture in minimally invasive hysterectomy: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Total laparoscopic or robotic hysterectomy represents one of the most performed gynecological procedures nowadays. Minimally invasive procedures seem to increase the risk of vaginal cuff dehiscence (VCD). Barbed suture is a new class of suture introduced to aid surgeons during laparoscopic suturing, with the aim to reduce operative time, blood loss, and vaginal dehiscence.
  
  
  METHODS
  We identified all articles that report a series of laparoscopic or robotic-assisted hysterectomy using barbed suture compared to conventional suture for vaginal cuff closure. The main outcome measures were vaginal cuff suturing time, vaginal bleeding, and vaginal dehiscence with or without small bowel evisceration. Suturing time was meta-analyzed as the standardized mean difference, which is the difference in means of two arms divided by pooled standard deviation with 95 % confidence intervals. For vaginal bleeding and dehiscence risk difference were calculated for each study and then meta-analyzed. Fixed models were considered if heterogeneity was low (I (2) < 50 %), otherwise random models were preferred.
  
  
  RESULTS
  We show that minor bleeding (RD = 0, 95 % CI 0.03-0.03; p value = 0.907) and VCD (RD = -0.01, 95 % CI 0.02-0.00; p value = 0.119) are comparable in minimally invasive hysterectomy with or without the use of barbed suture. The major bleeding (RD = -0.03; 95 % CI 0.05-0.00; p value = 0.047) appears borderline significant, but the difference between the two types of sutures is not high and the upper limit of 95 % IC is equal to 0 so they were considered comparable. Instead, meta-analysis on vaginal cuff suturing time demonstrates that suturing time is reduced with the use of barbed suture (SMD = -0.96, 95 % CI 1.26-0.70; p value <0.001).
  
  
  CONCLUSIONS
  Barbed suture is safe and well tolerated as traditional sutures and is associated with reduced operative time of laparoscopic vaginal vault closure.
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Viale Camillo Golgi 19, 27100, Pavia, Italy, s.bogliolo@smatteo.pv.it.
authors.forename: Stefano
authors.initials: S
authors.lastname: Bogliolo
authors.forename: Valentina
authors.initials: V
authors.lastname: Musacchi
authors.forename: Mattia
authors.initials: M
authors.lastname: Dominoni
authors.forename: Chiara
authors.initials: C
authors.lastname: Cassani
authors.forename: Chiara Roberta
authors.initials: CR
authors.lastname: Gaggero
authors.forename: Annalisa
authors.initials: A
authors.lastname: De Silvestri
authors.forename: Barbara
authors.initials: B
authors.lastname: Gardella
authors.forename: Arsenio
authors.initials: A
authors.lastname: Spinillo
mesh_terms: D016063:Blood Loss, Surgical; D020884:Colpotomy; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures; D061646:Operative Time; D011247:Pregnancy; D012371:Robotics; D013536:Suture Techniques; D013537:Sutures / Q000009:adverse effects; D016896:Treatment Outcome; D014592:Uterine Hemorrhage / Q000209:etiology; D014621:Vagina / Q000601:surgery*