Dehiscence of Cruroplasty after Gastric Sleeve: Prevention Based on Proper Surgical Technique

Objective: To identify the safest and most effective knot-tying sequences for cruroplasty after gastric sleeve surgery, aiming to reduce recurrence risk. Materials and Methods: A total of 38 knot-tying sequences were tested using a dynamometer and nonabsorbable sutures. These were divided into four groups: Silk 0 (8 sequences), Silk 2/0 (12), Nylon 1 (12), and Polypropylene 2/0 (14). Each sequence was randomly selected and evaluated based on the average tensile strength of 10 tied knots. Results: For Silk 2/0, the strongest sequences were H3H2a (46.39 N) and H2H1aH1aH1aH1a (45.89 N); the weakest were SSbSb (22.28 N) and SSbSbSb (24.18 N). For Silk 0, H3H2a (72.44 N) and H3H2s (70.48 N) were most resistant, while H1H1sH1sH1sH1s (56.6 N) had the lowest strength. With Nylon 1, H2H1sH1sH1sH1sH1s and H2H1aH1aH1aH1aH1aH1a had the highest strengths; SSbSbSb (29.38 N) was weakest. Polypropylene 2/0 sequences showed consistent strength, with H2H1aH1aH1aH1a (48.91 N) being the strongest. Conclusions: For Silks 0 and 2/0, at least three half-knots (H1H1H1) are recommended. Starting with a double knot (H2) offers no added benefit. Slip knots should include a minimum of five throws. For Nylon 1, six-throw sequences are optimal; fewer than four throws are not recommended. Polypropylene 2/0 showed uniform performance across sequences. Knot symmetry did not significantly affect strength in any group. All recommended sequences exceed the 43 N threshold needed to prevent cruroplasty dehiscence under normal intra-abdominal pressures.