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been suggested that suture closure is more secure, because suture bites can be placed individually and incorporate as much tissue as needed in contrast to the fixed dimensions of staple instruments (Caron & Brakenhoff, 2008 ). On the other hand, intra- corporeal lap- aroscopic suturing is technically demanding and requires consider- able training to be applied efficiently, with square knot formation and maintenance of suture tension during continuous pattern su- turing being the most challenging aspects (Fransson & Huhn, 2015 ). The use of barbed suture in minimally invasive surgery alleviates or evades these difficulties. First, knot tying is not required when using barbed sutures. Second, barbed sutures do not loosen or slide back- wards and therefore tissue apposition is maintained without contin- uous traction on the leading suture strand (Fransson & Huhn, 2015 ; Gardella et al., 2018 ; Huhn, 2016 ). With the introduction of barbed suture specifically designed for the use with the Endo Stitch™ au- tomated laparoscopic suturing device, the benefits of these two were combined to create an efficient instrument to facilitate and accelerate laparoscopic suturing (Hart & Sobolewski, 2013 ; Omoto- sho et al., 2011 ; Ruzickova et al., 2016 ). Because of the proposed benefits of barbed suture in combination with the Endo Stitch™ au- tomated laparoscopic suturing device, we started to use them for laparoscopic herniorrhaphy in foals. Although we did not measure the operating time and we do not
have a control group where conventional laparoscopic suturing was applied, all participating surgeons found suturing of the vaginal ring using barbed suture combined with the EndoStitch™ automated su- turing device technically less challenging and more time efficient. This is in agreement with others, who have reported similar expe- riences with the use of barbed sutures in open and in laparoscopic procedures (Adler et al., 2020 ; Einarsson et al., 2011 ; Giusto, Iussich, et al., 2019 ; Nelson & Hassel, 2014 ; Omotosho et al., 2011 ). Timesav- ing mainly arises from the absence of knot tying and the self- anchoring properties of the suture, which makes suturing more ergonomic (Adler et al., 2020 ; Giusto, Iussich, et al., 2019 ). An automated sutur- ing device can further accelerate and facilitate laparoscopic suturing (Adams et al., 1995 ; Nguyen et al., 2000 ; Ragle et al., 2013 ; Ruzick- ova et al., 2016 ), but when using smooth suture, knot strength might be reduced in comparison with conventional laparoscopic suturing because of the tendency not to tie complete alternate square knots (Pattaras et al., 2001 ). These concerns are overcome when using barbed suture, where knot tying is not necessary. Intraoperative complications directly associated with the surgi-
cal procedure were rare. To prevent body wall haemorrhage caused by laceration of larger blood vessels during paramedian instrument portal placement, one technique particularly useful in foals is to vi- sualise larger blood vessels by illuminating the body wall with the laparoscope from the inside while the lights in the surgery room are switched off. Effectiveness of the vaginal ring closure was evidenced by the
absence of hernia recurrence, indicating that the closure was not inferior to other herniorrhaphy procedures in foals in regard to the holding strength of the repair. Although the short needle length of the V- Loc™ barbed suture and the jaw dimensions of the Endo Stitch™
MAURER ET AL.
device limit the depth of the tissue bites (Pattaras et al., 2001 ), this was not considered disadvantageous for the herein- described pro- cedure. In foals, sufficient amounts of tissue were grasped from both edges of the vaginal rings to provide a seemingly robust continuous seal. This is in accordance with the reports by Ragle and colleagues, who were the first to describe the application of a unidirectional barbed suture in combination with an automated suturing instru- ment for the purpose of vaginal ring closure in an adult horse (Ragle et al., 2013 ). When re- evaluating the surgery sites laparoscopically 6 weeks after vaginal ring closure, complete healing of the suture lines and continued reduction in the ring size was observed bilater- ally, and the horse was without hernia recurrence 20 months postop- eratively (Ragle et al., 2013 ). The performance and strength of barbed suture was evaluated
for various applications in numerous ex vivo and in vivo experimen- tal studies (Albanese et al., 2016 ; Arbaugh et al., 2013 ; Demytte- naere et al., 2009 ; Giusto, Caramello, et al., 2019 ; Giusto, Iussich, et al., 2019 ; Major et al., 2017 ; Nelson & Hassel, 2014 ; Omotosho et al., 2011 ; Ruzickova et al., 2016 ; Sinovich et al., 2020 ). These studies supported the effectiveness and strength of barbed su- ture. Where barbed suture performed inferior to conventional su- ture, load at failure was well above loads expected in live animals (Nelson & Hassel, 2014 ; Sinovich et al., 2020 ). Reports about the use of barbed sutures in equine laparoscopic procedures in clinical cases are not abundant but promising. For example, laparoscopic nephrosplenic space ablation using barbed suture has been success- fully employed (Gandini et al., 2017 ; Gialletti et al., 2021 ) and was evaluated advantageous over mesh ablation (Gialletti et al., 2021 ). Corsalini and colleagues used unidirectional barbed suture for lap- aroscopic uteropexy in three mares (Corsalini et al., 2016 ). They concluded that the use of barbed suture was easy and practical and that it was effective in maintaining the uterus suspended dorsally as confirmed by rectal palpation 4– 6 months postoperatively. Fur- thermore, barbed suture was recently used in three horses to close a dorsally located diaphragmatic defect through a thoracoscopic ap- proach (Kamus et al., 2022 ). As reported by others (Caron & Brakenhoff, 2008 ; Klohnen
& Wilson, 1996 ; Mariën et al., 2001 ), recovery after laparoscopic herniorrhaphy was quick and postoperative complications were rare and mild. Case 2 was re- admitted to the clinic because of colic twice within 2 months after herniorrhaphy. While it remained elu- sive whether gastric ulcer syndrome was the sole reason for the colic episodes, adhesion formation in the area of the vaginal ring cannot be excluded. Abdominal adhesion formation after the use of barbed suture in laparoscopic procedures has been reported in human patients (Köhler et al., 2015 ). Paying meticulous atten- tion on avoiding free barbed suture ends protruding from tissues was therefore recommended (Köhler et al., 2015 ). Nevertheless, if proper technique is applied, the amount of exposed foreign material within the abdomen can possibly even be reduced with barbed su- ture, as no bulky knots are present (Giusto, Caramello, et al., 2019 ; Sinovich et al., 2020 ). Several studies in different species found no significant differences between barbed and conventional sutures
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