Download 7th Day Fixed Suture adjustment

7TH DAY FIXED SUTURE
ADJUSTMENT
ALL CHILDREN AND ADULTS
Alfred J. Cossari, MD
Port Jefferson, NY
Financial Disclosure
 I have no financial interests or
relationships to disclose.
My Objectives
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Describe the 2 stages of strabismus surgery
Briefly compare 3 basic adjustment procedures
Look at the timing of adjustments with respect to
events occurring in the healing process
Provide details of the 7th day fixed suture procedure
Encourage surgeons who have avoided hang-back
sutures to consider the 7th day procedure
Recommend that all patients be prepared by their
surgeon for a possible adjustment
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Strabismus Surgery
- requires 1 or 2 stage 
1st stage (primary surgery): procedure that executes
the type and amount of surgery determined to best
correct a specific set of sensorimotor defects
 2nd (adjustment) stage: a brief interruption of the
healing process that provides a second guess
opportunity when the primary surgery appears to
be failing
After 7-10 days, interruption of the healing process is
no longer temporary due to advancing scar formation;
revision at this stage requires a reoperation
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Suture Adjusting
- an overview  Standard hang-back suture: has been the centerpiece
for routine or selective suture adjusting within 24
hours of surgery
 Short tag noose suture: is one example of a modified
hang-back suture that eliminates the need to tie the
suture when no adjustment is required
 7th day fixed suture: is an approach that avoids using
a special suture and defers adjustment of the suture
position to the 7th day
 Reality is: there is an adjusting procedure suited to
the preferences of most strabismus surgeons
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Adjustment Procedures
- percentage adjusted  100% of patients with a standard hang-back suture
need either an early adjustment or a tie-off
 < 50% of patients with a short tag noose suture are
early adjusted; the remainder absorb without tying
 5% of all patients have an aberrant primary surgery
result requiring a 7th day fixed suture “rescue”
adjustment at day #7
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Early Adjustment
- 24 hours / early inflammatory phase  Easiest time to adjust a hang-back suture
 Minimal fibrosis of the platelet clot
 Least accurate time to perform a motility
assessment
 Pain, splinting and drowsiness are present
 Patient interaction is often part of this 2nd guess;
O.R, bedside or exam chair
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7th Day Fixed Suture Adjustment
- early proliferative phase  More accurate time for a motility assessment
(including diagnostic gaze positions)
 Pain, splinting and drowsiness are resolved
 Blunt dissection is required to replace the fixed
suture
 Fibrin/collagen have begun to fibrose the tissues
 Patient interaction is not used for this 2nd guess
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Typical Example
- supporting 7th day adjust  4 year old
 X(T) = 27, RH(T) = 5
 Recessions (LROU and RSR)
 ET = 30, LHT = 4
(day #1)
 With a hang-back suture, an early adjustment
would probably have been performed
 A hang-back was not used, so early adjustment
was not considered
 F/T alternate occlusion was prescribed with
probability of a 7th day adjustment
 ET = 10, LHT =2
(day #6)
 7th day adjustment deemed unnecessary
 Orthophoric
(week #3 – year #4)
An early adjustment would have adjusted him out
of this excellent result
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7th Day Fixed Suture
- surgeon profile  Distrusts hang-back sutures and nooses
 Distrusts early postop assessment of motility
 Distrusts bedside interactive decision-making
 Enjoys a high surgical success rate w/o early
adjusting
 Recognizes the need for an occasional “rescue”
adjustment
 Or, uses a hang-back but occasionally has need for a
7th day rescue
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7th Day Fixed Suture
- patient experience  100% of patients are prepared for the 5%
probability of an adjustment
 95% are happy when they discover an
adjustment is not needed
 5% are not surprised when an adjustment is
recommended
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7th Day Fixed Suture
- surgical issues  All 6 EOMs have been adjusted
 Adjustments are scheduled as an add-on to my weekly
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block-time
The same anesthetic technique is used (general or
regional) as the primary surgery
Tugging on muscle hooks is avoided to prevent
breaking the suture or tearing it from the muscle
Fixation and rotation of the globe are accomplished
with bridle sutures and locking Stern-Castroviejo
forceps
The new suture is secured before cutting the old
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7th Day Fixed Suture
- cost reduction issues  Reduced personnel time for up to 95% of
surgeries (surgeon, anesthesiologist, OR nurses,
RR nurses, techs, etc.)
 Fewer instrument trays and materials
 Suture adjustment submissions are reduced by up
to 95%
 No increase in reoperations due to long-term
failures compared with other adjustment
techniques
suggestions for successful
Second Guessing
 Determine your preference: hang-back or 7th day fixed
suture adjustment technique (or both)
 Prepare all patients for the 7th day fixed suture
adjustment process; an early adjustment preference
does not preclude possible need for a 7th day rescue
 Develop your second guessing skills and statistics – don’t
forget to assess motility on POD #6
 Decrease the need for 2nd guessing with better stage 1
planning
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Semantics of this 7th Day 2nd Guessing
(adjustment vs. reoperation)
 Back to OR on a different day
 Repeat anesthetic
 Same healing process with muscle position adjustment
 No excision of scar
 No new muscle operated
 Placement of a new suture in the same muscle or tendon
 Late second guess opportunity
Your choice!
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Summary
 All patients should be afforded the opportunity of
having the surgeon second guess the placement of
muscle attachments before healing occurs whenever
there is an unexpected response to surgery
 3 basic second guessing approaches:
- standard hang-back suture
- short tag noose suture
- 7th day fixed suture
 Success is largely the result of a good sensorimotor
assessment and sound surgical decisions; not a
specific adjustment technique