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Histology and fertility after microsurgical anastomosis of the rabbit fallopian tube with nylon and polyglactin sutures
FERTILITY AND STERILITY Copyright" 1983 The American Fertility Society
Vol. 39, No.5, May 1983 Printed in U.SA.
Histology and fertility after microsurgical anastomosis of the rabbit fallopian tube with nylon and polyglactin sutures
Diana Sojo, M.D.*t Juan Diez Pardo, M.D.:!: Manuel Nistal, M.D., Ph.D.§ Ciudad Sanitaria La paz and Autonomous University of Madrid School of Medicine, Madrid, Spain
Polyglactin and nylon suture material were compared in microsurgical anastomosis of oviduct of rabbits with regard to the histologic reaction, adhesion formation, and nidation index. Thirty days after surgery, the tissue inflammatory response was very similar in both groups. At 90 days, polyglactin had been totally absorbed in 80% of the cases, and no inflammatory reaction persisted at the site of the suture. At this time, multinucleated giant cell reaction to nylon sutures was persistent but minimal. The results reveal no significant functional differences between oviduct reanastomosed with nylon versus polyglactin suture. No significant difference in subsequent fertility due to suture selection was demonstrated. Fertil Steril39:707, 1983
The work of Swolin1 in the 1960s and that of Paterson and Wood, 2 Eddy and collaborators, 3 Winston,4 Diamond,5 and Gomel6 introduced microsurgery to gynecology and established its value as a research tool. Certainly, one of the greatest contributions that microsurgery has made has been in the study of fallopian tube physiology. 7 The advent of this technique in gynecology has stimulated the development of very fine suture materials.
Received September 10,1982; revised and accepted November 22, 1982. *Reprint requests: Dr. Diana Sojo, Servicio de Ginecologfa, Unidad de Fertilidad, Centro Especial Ram6n y Cejal, M-34 Madrid, Spain. tDepartment of Obstetrics and Gynaecology, Ciudad Sanitaria La Paz. :t:Laboratory of Experimental Microsurgery, Ciudad Sanitaria La Paz. §Department of Morphology, Autonomous University of Madrid School of Medicine. Vol. 39, No.5, May 1983
The studies of Khoo and Mackay 8 and those of Winston4 have shown that the use of catgut suture provokes extensive tissue reaction. Histologic investigations have studied 9-0 polyglycolic acid9 and compared catgut to nylon,4 8-0 braided polyglactin to 10-0 nylon,10 and polyglactin to polyglycolic acidll in reproductive tissue. Gomel et al.,12 in a recent histologic study, compared polyethylene, nylon, and PQlyglactin 10-0 monofilament and concluded that polyglactin was less reactive than nonabsorbable sutures. Since all of these studies are basically descriptive and do not specifically compare results from a functional point of view, it was thought that a comparative study of fertility following anastomosis with sutures of equal caliber but different material could contribute some insight into the selection of sutures in microsurgery of the female genital tract. This study was therefore designed to examine the anatomic and functional results of microsurgical anastomosis of the oviduct in rabbits, using nylon (Ethilon, Ethicon Company, Somerville, Sojo et al. Microsurgery: comparison of sutures
707
Table 1. Histologic Reaction at 30 Days in Ten Rabbits Nylon Histiocytes
Polyglactin
Giant cells
Others"
1 2 3 4 5
2 1 3 2 1
3 2 0 1 0
1
%
1.8
1.2
0.4
Histiocytes
1 1 1
1
Giant cells
Others"
1
1
2 3 3 2 1
0.8
2.2
0.2
alnflammatory infiltrate (lymphocytes, plasma cells).
NJ) and polyglactin 910 (Vicryl, Ethicon). The histologic reaction, formation of adhesions, and nidation index (ratio of ova ovulated to those that implanted) were determined and compared. MATERIALS AND METHODS
Twenty sexually mature New Zealand White female rabbits weighing between 2500 gm and 5000 gm were used. They were fed standard food pellets and kept at 20° C. All surgery was carried out by the same surgeon. Surgery was carried out under aseptic conditions, and general anesthesia was administered by intramuscular injection of a mixture of Fentanyl and Fluanisone (Hypnorm, Lab Uva, Paris, France), 0.7 cm/kg body weight. Surgery was carried out on the left tube. The right tube was left intact for control purposes. An oblique flank incision was used to approach the oviduct. The oviduct was withdrawn from the abdominal cavity and was placed on a small Silastic platform. Care was taken to limit handling of the tissues and to minimize trauma. A Zeiss OPMI-6 operating microscope (Carl Zeiss, Inc., New York, NY) with either a 125-mm or a 200-mm objective lens was used. The peritoneal coat was removed in the area to be transected and anastomosed. The fallopian vessels were cauterized with the use of
bipolar diathermy with jeweler's forceps. Any bleeding was controlled by using this same method. The tissues were frequently irrigated with Ringer's lactate to avoid drying. The midampullary portion of the fallopian tube was then divided by vertical incision with the use ofVannas microsurgical scissors. End-to-end anastomosis was performed with 10-0 monofilament nylon suture mounted on a 130-l-'-m needle in one group of ten rabbit oviducts and 10-0 monofilament polyglactin 910 suture mounted on a 130-l-'-m needle in the other group of ten rabbit oviducts. In all cases, the sutures were placed through the muscularis and serosa, excluding the mucosal layer. In each anastomosis, two initial sutures were placed at a 90-degree interval in the posterior wall of the oviduct, and then six to eight interrupted stitches were used. Before placing the oviduct back in its original anatomic position, care was taken to gently wash out the peritoneal cavity with saline. The wound was then closed with 3-0 and 2-0 polyglactin sutures in two layers. Two weeks after surgery the rabbits were mated with bucks of proven fertility. They were examined after mating to verify pregnancy. Those rabbits that did not become gravid at the first trial were mated again with the bucks. Laparotomy was then carried out through a midline
Table 2. Histologic Reaction at 90 Days in Ten Rabbits Nylon Histiocytes
Giant cells
Polyglactin Others"
1 2 3 4 5
1 1 1 1 1
2 1 1 1 2
4
%
1
1.4
0.4
Histiocytes
Others"
1 *b
1
Giant cells
* * *
* * * *
* * *
*
aInflammatory infiltrate (lymphocytes, plasma cells). b Asterisk indicates that no trace of suture was found. 708
Sojo et al. Microsurgery: comparison of sutures
Fertility and Sterility
=~er view of the anastomosis site 30 days after rec.o~
struction showing polyglactin suture surrounded by a mInImal infJ.a~atory reaction (hematoxylin and eosin [H & E]).
incision. The number of pregnancies in each uterine hom was verified, and any adhesions present were evaluated according to parameters previously established by Winston4 : 0, absence of adherence; 1, microscopic adherence at the level of the anastomosis; 2, macroscopic tubal adherence; 3, adherence of the fallopian tube to the uterus, bladder, intestine, or abdominal wall. . The oviducts were removed for evaluatIon at specific intervals after surgery. The first group of ten was sacrificed 30 days after surgery, including five rabbits whose left oviducts were reanastomosed with polyglactin and five rabbits whose left oviducts were reanastomosed with nylon. The second group was sacrificed at 90 days after surgery; half of the oviducts were reanastomosed with polyglactin and the other half with nylon. The oviduct was excised 1 cm above and below the anastomosis. It was fixed, sectioned, and stained for light microscopy. Semiserial sectioning was carried out in each tube of the anastomosis area. Care was taken to include mucosa, muscularis, and serosa. The histologic evaluation was carried out by the pathologist and by the surgeon. The histologic reaction to all polyglactin and nylon sutures was graded according to the parameters established by Gomel et a1. 12 : (1) degree of infiltration by mononuclear histiocytes-1, minimal infiltrate; 2, moderate infiltrate; or 3, marked infiltrate; and (2) multinucleated giant cell reaction-O, no reaction; 1, minimal infiltrate; 2, moderate infiltrate; or 3, marked infiltrate. When fibrosis, inflammatory infiltrate, or other cells were found, these were reported in each case. Vol. 39, No.5, May 1983
Figure 2 . . . High-power view of the anastomosIS SIte sutured WIth polyglactin 30 days after surgery (H & E).
RESULTS The evaluation of the histologic reactions to polyglactin versus nylon suture is summarized in Table 1 at 30 days and in Table 2 at 90 days. In agreement with the results attained by Go.m~l et a1.,12 polyglactin at 30 days shows a mInImal reaction fundamentally characterized by the presence of giant multinucleated cells (Figs. 1 and 2). At 30 days, nylon elicited a minimal reaction but characterized by the presence of histiocytes (Figs. 3 and 4). At 90 days, polyglactin sutures could not be found in 80% of the cases, indicating that it had been totally absorbed by this time. In only one case, a minimal amount of suture was found in the inner part of a giant cell suggesting any type of pericellular reaction (Fig. 5). Nylon elicited a minimal reaction, which had essentially resolved at 90 days despite suture material persistence in the inner part of giant multinucleated cells (Figs. 6 and 7). Histologic alterations in the anastomosis area were minimal in both groups. The mucosa of the anastomosis area could not be distinguished from that of the nonsutured area. In the majority of cases, a minimum scar reaction was found in the muscular layer, and no lack of continuity was found. Table 3. Nidation Index After Microsurgical End-to-End Anastomosis of the Rabbit Oviduct Nylon
(n = 10)
Not operated upon Operated upon
Polyglactin (n = 10)
79% 71%
81% 76%
aNo statistically significant differences by the Yates' X2 test (P < 0.05).
Sojo et aI. Microsurgery: comparison of sutures
709
Figure 3
Low-power view of the anastomosis site 30 days after surgery, showing nylon suture surrounded by a minimal inflammatory reaction (H & E).
The incidence of adhesions was identical in both groups (average 1). Eight of ten animals (80%) became pregnant in the operated oviduct in both groups. The nidation index in the polyglactin group was 76%, and it was 71% in the nylon group. The control oviduct indexes were 81% and 79%, respectively (Table 3). These differences between the two groups and between the oviduct operated upon and that not operated upon are not statistically significant (Yates' X2 test, P < 0.05). DISCUSSION
A large number of experiments have shown minimal reaction and excellent functional results in the oviduct of the female rabbit with the use of nylon sutures. 4 , 6, 10, 12, 13
Figure 5
High-power view of the mucosa of the anastomosis site showing a small piece of polyglactin suture (arrow), the only one found 90 days after surgery (H & E).
710
Sojo et al. Microsurgery: comparison of sutures
Figure 4 Low-power view of the anastomosis site 30 days after reconstruction, showing nylon suture in the inner part of giant cells, and minimal inflammatory reaction (H & E).
Stangel et al.,9 with five anastomoses in rabbits, obtained a 100% pregnancy rate using polyglycolic acid. In a recent study, Gomel et al. 12 found that nylon and polyethylene are less inert than polyglactin in the uterus of the female rabbit at 80 days. Riddick et al.,ll in a comparative study of polyglycolic acid and polyglactin in the uterus of the rat, found at 90 days significantly more reactions to polyglycolic acid and the persistence of a large amount of this suture. At 90 days we did not find the suture when we used polyglactin nor any cellular reaction in the anastomosis area in 80% of the cases. This would support the hypothesis on its reabsorption through hydrolysis. 12, 14 Nylon persisted in a part of the giant cells, with minimum cellular reaction and practically an absence of other inflammatory cells. In several cases, these giant cells were
Figure 6 Low-power view of the anastomosis site 90 days after reconstruction, showing epithelial glands in the submucosa and nylon suture surrounded by moderate inflammatory reaction (H&E).
Fertility and Sterility
I REFERENCES
Figure 7 High-power view of the epithelium, showing nylon suture in a giant cell immediately below it. There is no inflammatory reaction (H & E).
found immediately below the epithelium (Fig. 7). This suggests the possibility of elimination of suture toward the tubal lumen. In view of the fact that Smith,IO in a comparative study using 10-0 nylon and 8-0 Vicryl suture, as well as Craig et al.,15 using 4-0 and 2-0 polyglactin, found results that were very similar, we may assume that the tissue reaction as well as the time of absorption for polyglactin are independent of the caliber of the suture. In the present study, the percentage of pregnancies was the same in both groups. The results of the present study reveal no significant functional differences (pregnancies, nidation index) between oviducts reanastomosed with nylon versus polyglactin suture nor between oviducts operated upon and those not operated upon.
Vol. 39, No.5, May 1983
1. Swolin K: Electromicrosurgery and salpingostomy: long term results. Am J Obstet Gynecol 121:418, 1975 2. Paterson P, Wood C: The use of microsurgery in the reanastomosis of the rabbit fallopian tube. Fertil Steril 25:757, 1974 3. Eddy CA, Antonini R Jr, Pauerstein CJ: Fertility following microsurgical removal of the ampullary-isthmic junction in rabbits. Fertil Steril 28:1090, 1977 4. Winston RML: Microsurgical reanastomosis of the rabbit oviduct and its functional and pathological sequelae. Br J Obstet Gynaecol 82:513, 1975 5. Diamond E: Microsurgical reconstruction of the uterine tube in sterilized patients. Fertil Steril 28:1203, 1977 6. Gomel V: Tubal reanastomosis by microsurgery. Fertil Steril 28:59, 1977 7. Winston RML: The future of microsurgery in infertility. In Clinics in Obstetrics and Gynecology, Vol 5, No 3, Edited by DSB Inglis. London, W. B. Saunders Co., 1978, p 607 8. Khoo SK, Mackay EV: Reactions in rabbit fallopian tube after plastic reconstruction. I. Gross pathology, tubal patency, and pregnancy. Fertil Steril 23:201, 1972 9. Stangel JJ, Settles HE, Reyniak JV, Freedman WL, Stone ML: Microsurgical anastomosis of the rabbit oviduct using 9-0 monofilament polyglycolic acid suture. Fertil Steril 30:210, 1978 10. Smith DC: Presented at Microsurgery Seminar, Third International Congress of Gynecologic Endoscopy, San Francisco, December 1977. In Current Problems in Obstetrics and Gynecology, Edited by V Gomel. Chicago, Medical Publishers, 1978, p 256 11. Riddick DH, DeGrazia CT, Maenza RM: Comparison of polyglactin and polyglycolic acid sutures in reproductive tissue. Fertil Steril 28:1220, 1977 12. Gomel V, McComb P, Boer-Meisel M: Histologic reactions to polyglactin 910, polyethylene and nylon microsuture. J Reprod Med 25:56, 1980 13. Seki K, Eddy CA, Smith NK, Pauerstein CJ: Comparison of two techniques of suturing in microsurgical anastomosis of the rabbit oviduct. Fertil Steril 28:1215,1977 14. Salthouse TN, Matlaga BF: Polyglactin 910 suture absorption and role of cellular enzymes. Surg Gynecol Obstet 142:544, 1976 15. Craig PH, Williams JA, Davis KW, Mogoun AD, Levy AJ, Bogdansdy S, Jones JP: A biological comparison of polyglactin 910 and polyglycolic acid synthetic absorbable sutures. Surg Gynecol Obstet 141:1, 1975
Sojo et al. Microsurgery: comparison of sutures
711
Vol. 39, No.5, May 1983 Printed in U.SA.
Histology and fertility after microsurgical anastomosis of the rabbit fallopian tube with nylon and polyglactin sutures
Diana Sojo, M.D.*t Juan Diez Pardo, M.D.:!: Manuel Nistal, M.D., Ph.D.§ Ciudad Sanitaria La paz and Autonomous University of Madrid School of Medicine, Madrid, Spain
Polyglactin and nylon suture material were compared in microsurgical anastomosis of oviduct of rabbits with regard to the histologic reaction, adhesion formation, and nidation index. Thirty days after surgery, the tissue inflammatory response was very similar in both groups. At 90 days, polyglactin had been totally absorbed in 80% of the cases, and no inflammatory reaction persisted at the site of the suture. At this time, multinucleated giant cell reaction to nylon sutures was persistent but minimal. The results reveal no significant functional differences between oviduct reanastomosed with nylon versus polyglactin suture. No significant difference in subsequent fertility due to suture selection was demonstrated. Fertil Steril39:707, 1983
The work of Swolin1 in the 1960s and that of Paterson and Wood, 2 Eddy and collaborators, 3 Winston,4 Diamond,5 and Gomel6 introduced microsurgery to gynecology and established its value as a research tool. Certainly, one of the greatest contributions that microsurgery has made has been in the study of fallopian tube physiology. 7 The advent of this technique in gynecology has stimulated the development of very fine suture materials.
Received September 10,1982; revised and accepted November 22, 1982. *Reprint requests: Dr. Diana Sojo, Servicio de Ginecologfa, Unidad de Fertilidad, Centro Especial Ram6n y Cejal, M-34 Madrid, Spain. tDepartment of Obstetrics and Gynaecology, Ciudad Sanitaria La Paz. :t:Laboratory of Experimental Microsurgery, Ciudad Sanitaria La Paz. §Department of Morphology, Autonomous University of Madrid School of Medicine. Vol. 39, No.5, May 1983
The studies of Khoo and Mackay 8 and those of Winston4 have shown that the use of catgut suture provokes extensive tissue reaction. Histologic investigations have studied 9-0 polyglycolic acid9 and compared catgut to nylon,4 8-0 braided polyglactin to 10-0 nylon,10 and polyglactin to polyglycolic acidll in reproductive tissue. Gomel et al.,12 in a recent histologic study, compared polyethylene, nylon, and PQlyglactin 10-0 monofilament and concluded that polyglactin was less reactive than nonabsorbable sutures. Since all of these studies are basically descriptive and do not specifically compare results from a functional point of view, it was thought that a comparative study of fertility following anastomosis with sutures of equal caliber but different material could contribute some insight into the selection of sutures in microsurgery of the female genital tract. This study was therefore designed to examine the anatomic and functional results of microsurgical anastomosis of the oviduct in rabbits, using nylon (Ethilon, Ethicon Company, Somerville, Sojo et al. Microsurgery: comparison of sutures
707
Table 1. Histologic Reaction at 30 Days in Ten Rabbits Nylon Histiocytes
Polyglactin
Giant cells
Others"
1 2 3 4 5
2 1 3 2 1
3 2 0 1 0
1
%
1.8
1.2
0.4
Histiocytes
1 1 1
1
Giant cells
Others"
1
1
2 3 3 2 1
0.8
2.2
0.2
alnflammatory infiltrate (lymphocytes, plasma cells).
NJ) and polyglactin 910 (Vicryl, Ethicon). The histologic reaction, formation of adhesions, and nidation index (ratio of ova ovulated to those that implanted) were determined and compared. MATERIALS AND METHODS
Twenty sexually mature New Zealand White female rabbits weighing between 2500 gm and 5000 gm were used. They were fed standard food pellets and kept at 20° C. All surgery was carried out by the same surgeon. Surgery was carried out under aseptic conditions, and general anesthesia was administered by intramuscular injection of a mixture of Fentanyl and Fluanisone (Hypnorm, Lab Uva, Paris, France), 0.7 cm/kg body weight. Surgery was carried out on the left tube. The right tube was left intact for control purposes. An oblique flank incision was used to approach the oviduct. The oviduct was withdrawn from the abdominal cavity and was placed on a small Silastic platform. Care was taken to limit handling of the tissues and to minimize trauma. A Zeiss OPMI-6 operating microscope (Carl Zeiss, Inc., New York, NY) with either a 125-mm or a 200-mm objective lens was used. The peritoneal coat was removed in the area to be transected and anastomosed. The fallopian vessels were cauterized with the use of
bipolar diathermy with jeweler's forceps. Any bleeding was controlled by using this same method. The tissues were frequently irrigated with Ringer's lactate to avoid drying. The midampullary portion of the fallopian tube was then divided by vertical incision with the use ofVannas microsurgical scissors. End-to-end anastomosis was performed with 10-0 monofilament nylon suture mounted on a 130-l-'-m needle in one group of ten rabbit oviducts and 10-0 monofilament polyglactin 910 suture mounted on a 130-l-'-m needle in the other group of ten rabbit oviducts. In all cases, the sutures were placed through the muscularis and serosa, excluding the mucosal layer. In each anastomosis, two initial sutures were placed at a 90-degree interval in the posterior wall of the oviduct, and then six to eight interrupted stitches were used. Before placing the oviduct back in its original anatomic position, care was taken to gently wash out the peritoneal cavity with saline. The wound was then closed with 3-0 and 2-0 polyglactin sutures in two layers. Two weeks after surgery the rabbits were mated with bucks of proven fertility. They were examined after mating to verify pregnancy. Those rabbits that did not become gravid at the first trial were mated again with the bucks. Laparotomy was then carried out through a midline
Table 2. Histologic Reaction at 90 Days in Ten Rabbits Nylon Histiocytes
Giant cells
Polyglactin Others"
1 2 3 4 5
1 1 1 1 1
2 1 1 1 2
4
%
1
1.4
0.4
Histiocytes
Others"
1 *b
1
Giant cells
* * *
* * * *
* * *
*
aInflammatory infiltrate (lymphocytes, plasma cells). b Asterisk indicates that no trace of suture was found. 708
Sojo et al. Microsurgery: comparison of sutures
Fertility and Sterility
=~er view of the anastomosis site 30 days after rec.o~
struction showing polyglactin suture surrounded by a mInImal infJ.a~atory reaction (hematoxylin and eosin [H & E]).
incision. The number of pregnancies in each uterine hom was verified, and any adhesions present were evaluated according to parameters previously established by Winston4 : 0, absence of adherence; 1, microscopic adherence at the level of the anastomosis; 2, macroscopic tubal adherence; 3, adherence of the fallopian tube to the uterus, bladder, intestine, or abdominal wall. . The oviducts were removed for evaluatIon at specific intervals after surgery. The first group of ten was sacrificed 30 days after surgery, including five rabbits whose left oviducts were reanastomosed with polyglactin and five rabbits whose left oviducts were reanastomosed with nylon. The second group was sacrificed at 90 days after surgery; half of the oviducts were reanastomosed with polyglactin and the other half with nylon. The oviduct was excised 1 cm above and below the anastomosis. It was fixed, sectioned, and stained for light microscopy. Semiserial sectioning was carried out in each tube of the anastomosis area. Care was taken to include mucosa, muscularis, and serosa. The histologic evaluation was carried out by the pathologist and by the surgeon. The histologic reaction to all polyglactin and nylon sutures was graded according to the parameters established by Gomel et a1. 12 : (1) degree of infiltration by mononuclear histiocytes-1, minimal infiltrate; 2, moderate infiltrate; or 3, marked infiltrate; and (2) multinucleated giant cell reaction-O, no reaction; 1, minimal infiltrate; 2, moderate infiltrate; or 3, marked infiltrate. When fibrosis, inflammatory infiltrate, or other cells were found, these were reported in each case. Vol. 39, No.5, May 1983
Figure 2 . . . High-power view of the anastomosIS SIte sutured WIth polyglactin 30 days after surgery (H & E).
RESULTS The evaluation of the histologic reactions to polyglactin versus nylon suture is summarized in Table 1 at 30 days and in Table 2 at 90 days. In agreement with the results attained by Go.m~l et a1.,12 polyglactin at 30 days shows a mInImal reaction fundamentally characterized by the presence of giant multinucleated cells (Figs. 1 and 2). At 30 days, nylon elicited a minimal reaction but characterized by the presence of histiocytes (Figs. 3 and 4). At 90 days, polyglactin sutures could not be found in 80% of the cases, indicating that it had been totally absorbed by this time. In only one case, a minimal amount of suture was found in the inner part of a giant cell suggesting any type of pericellular reaction (Fig. 5). Nylon elicited a minimal reaction, which had essentially resolved at 90 days despite suture material persistence in the inner part of giant multinucleated cells (Figs. 6 and 7). Histologic alterations in the anastomosis area were minimal in both groups. The mucosa of the anastomosis area could not be distinguished from that of the nonsutured area. In the majority of cases, a minimum scar reaction was found in the muscular layer, and no lack of continuity was found. Table 3. Nidation Index After Microsurgical End-to-End Anastomosis of the Rabbit Oviduct Nylon
(n = 10)
Not operated upon Operated upon
Polyglactin (n = 10)
79% 71%
81% 76%
aNo statistically significant differences by the Yates' X2 test (P < 0.05).
Sojo et aI. Microsurgery: comparison of sutures
709
Figure 3
Low-power view of the anastomosis site 30 days after surgery, showing nylon suture surrounded by a minimal inflammatory reaction (H & E).
The incidence of adhesions was identical in both groups (average 1). Eight of ten animals (80%) became pregnant in the operated oviduct in both groups. The nidation index in the polyglactin group was 76%, and it was 71% in the nylon group. The control oviduct indexes were 81% and 79%, respectively (Table 3). These differences between the two groups and between the oviduct operated upon and that not operated upon are not statistically significant (Yates' X2 test, P < 0.05). DISCUSSION
A large number of experiments have shown minimal reaction and excellent functional results in the oviduct of the female rabbit with the use of nylon sutures. 4 , 6, 10, 12, 13
Figure 5
High-power view of the mucosa of the anastomosis site showing a small piece of polyglactin suture (arrow), the only one found 90 days after surgery (H & E).
710
Sojo et al. Microsurgery: comparison of sutures
Figure 4 Low-power view of the anastomosis site 30 days after reconstruction, showing nylon suture in the inner part of giant cells, and minimal inflammatory reaction (H & E).
Stangel et al.,9 with five anastomoses in rabbits, obtained a 100% pregnancy rate using polyglycolic acid. In a recent study, Gomel et al. 12 found that nylon and polyethylene are less inert than polyglactin in the uterus of the female rabbit at 80 days. Riddick et al.,ll in a comparative study of polyglycolic acid and polyglactin in the uterus of the rat, found at 90 days significantly more reactions to polyglycolic acid and the persistence of a large amount of this suture. At 90 days we did not find the suture when we used polyglactin nor any cellular reaction in the anastomosis area in 80% of the cases. This would support the hypothesis on its reabsorption through hydrolysis. 12, 14 Nylon persisted in a part of the giant cells, with minimum cellular reaction and practically an absence of other inflammatory cells. In several cases, these giant cells were
Figure 6 Low-power view of the anastomosis site 90 days after reconstruction, showing epithelial glands in the submucosa and nylon suture surrounded by moderate inflammatory reaction (H&E).
Fertility and Sterility
I REFERENCES
Figure 7 High-power view of the epithelium, showing nylon suture in a giant cell immediately below it. There is no inflammatory reaction (H & E).
found immediately below the epithelium (Fig. 7). This suggests the possibility of elimination of suture toward the tubal lumen. In view of the fact that Smith,IO in a comparative study using 10-0 nylon and 8-0 Vicryl suture, as well as Craig et al.,15 using 4-0 and 2-0 polyglactin, found results that were very similar, we may assume that the tissue reaction as well as the time of absorption for polyglactin are independent of the caliber of the suture. In the present study, the percentage of pregnancies was the same in both groups. The results of the present study reveal no significant functional differences (pregnancies, nidation index) between oviducts reanastomosed with nylon versus polyglactin suture nor between oviducts operated upon and those not operated upon.
Vol. 39, No.5, May 1983
1. Swolin K: Electromicrosurgery and salpingostomy: long term results. Am J Obstet Gynecol 121:418, 1975 2. Paterson P, Wood C: The use of microsurgery in the reanastomosis of the rabbit fallopian tube. Fertil Steril 25:757, 1974 3. Eddy CA, Antonini R Jr, Pauerstein CJ: Fertility following microsurgical removal of the ampullary-isthmic junction in rabbits. Fertil Steril 28:1090, 1977 4. Winston RML: Microsurgical reanastomosis of the rabbit oviduct and its functional and pathological sequelae. Br J Obstet Gynaecol 82:513, 1975 5. Diamond E: Microsurgical reconstruction of the uterine tube in sterilized patients. Fertil Steril 28:1203, 1977 6. Gomel V: Tubal reanastomosis by microsurgery. Fertil Steril 28:59, 1977 7. Winston RML: The future of microsurgery in infertility. In Clinics in Obstetrics and Gynecology, Vol 5, No 3, Edited by DSB Inglis. London, W. B. Saunders Co., 1978, p 607 8. Khoo SK, Mackay EV: Reactions in rabbit fallopian tube after plastic reconstruction. I. Gross pathology, tubal patency, and pregnancy. Fertil Steril 23:201, 1972 9. Stangel JJ, Settles HE, Reyniak JV, Freedman WL, Stone ML: Microsurgical anastomosis of the rabbit oviduct using 9-0 monofilament polyglycolic acid suture. Fertil Steril 30:210, 1978 10. Smith DC: Presented at Microsurgery Seminar, Third International Congress of Gynecologic Endoscopy, San Francisco, December 1977. In Current Problems in Obstetrics and Gynecology, Edited by V Gomel. Chicago, Medical Publishers, 1978, p 256 11. Riddick DH, DeGrazia CT, Maenza RM: Comparison of polyglactin and polyglycolic acid sutures in reproductive tissue. Fertil Steril 28:1220, 1977 12. Gomel V, McComb P, Boer-Meisel M: Histologic reactions to polyglactin 910, polyethylene and nylon microsuture. J Reprod Med 25:56, 1980 13. Seki K, Eddy CA, Smith NK, Pauerstein CJ: Comparison of two techniques of suturing in microsurgical anastomosis of the rabbit oviduct. Fertil Steril 28:1215,1977 14. Salthouse TN, Matlaga BF: Polyglactin 910 suture absorption and role of cellular enzymes. Surg Gynecol Obstet 142:544, 1976 15. Craig PH, Williams JA, Davis KW, Mogoun AD, Levy AJ, Bogdansdy S, Jones JP: A biological comparison of polyglactin 910 and polyglycolic acid synthetic absorbable sutures. Surg Gynecol Obstet 141:1, 1975
Sojo et al. Microsurgery: comparison of sutures
711