† Dependent on flow settings. 

1. SAGES RECOMMENDATIONS REGARDING SURGICAL RESPONSE TO COVID-19 CRISIS [https://www.sages.org/recommendations-surgical-response-covid-19/]. Accessed 3/30/2020. 

2. Wick E, Shore A, Hirose K, et al. (2011). Readmission Rates and Cost Following Colorectal Surgery. Dis Colon Rectum. 54(12):14751479. 

3. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. doi:10.1001/jamasurg.2017.0904. 

4. WHO Global Guidelines for the Prevention of Surgical Site Infection, 2016. 

5. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2016;224:59-74. 

6. US Market Share Report, October 2016. Ethicon, Inc. 

7. SURGICEL® Technical Report, 2018. Ethicon, Inc. 

8. Hong YM, Loughlin KR. The use of hemostatic agents and sealants in urology. J Urol. 2006;176(6 Pt 1):2367-2374. 

9. SURGICEL® Absorbable Hemostat. Full Prescribing Information. Ethicon, Inc. 

10. Sissener T. Suture patterns. Com Anim. 2006;11:14-19. 

11. Moran ME, Marsh C, Perrotti M. Bidirectional-barbed sutured knotless running anastomosis v classic Van Velthoven suturing in a model system. J Endourol. 2007;21(10):1175-1178. 

12. Vakil JJ, O'Reilly MP, Sutter EG, Mears SC, Belko SM, Khanuja HS. Knee arthrotomy repair with a continuous barbed suture: a biomechanical study. J Arthroplasty. 2011;26(5):710-713. 

13. Nonnenman H. 100326296: Time zero tissue holding - Competitive claims comparisons for STRATAFIX Knotless Tissue Control Devices vs various products. 2015. Ethicon, Inc. 

14. Levine BR, Ting N, Della Valle CJ. Use of a barbed suture in the closure of hip and knee arthroplasty wounds. Orthopedics. 2011;34(9):e473-e475. doi: 10.3928/01477447-20110714-35. 

15. Einarsson JI, Chavan NR, Suzuki Y, Jonsdottir G, Vellinga TT, Greenberg JA. Use of bidirectional barbed suture in laparoscopic myomectomy: evaluation of perioperative outcomes, safety, and efcacy. J Minim Invasive Gynecol. 2011;18(1):92-95. 

16. Eickmann T, Quane E. Total knee arthroplasty closure with barbed sutures. J Knee Surg. 2010;23(3):163-167. 

17. Ming X, Rothenburger S, Yang D. In vitro antibacterial efcacy of Monocryl Plus Antibacterial Suture (poliglecaprone 25 with triclosan). Surg Infect (Larchmt). 2007;8(2):201-207. 

18. Ming X, Rothenburger S, Nichols MM. In vivo and in vitro antibacterial efcacy of PDS Plus (polidioxanone with triclosan) suture. Surg Infect (Larchmt). 2008;9(4):451-457. 

19. Severson E, Singh J, Browne J, et al. Total Knee Arthroplasty in Morbidly Obese Patients Treated With Bariatric Surgery. Journal of Arthroplasty. 2012;27:1696-1700.  

20. Ethicon retrospective analysis of economic and clinical outcomes comparing the use of Echelon Powered vs. Medtronic non-powered endoscopic surgical staplers to treat patients undergoing video-assisted thoracoscopic surgery lobectomy.Review of 3,006 cases between 2012 and 2015 from the Premier Perspective® Hospital Database. Data assessed included length of stay, total hospital cost, supply cost, room & board cost, incidence of transfusion, and incidence of hemostasis-related complications; all p ≤ 0.05. 

21. ESP Award Winners: Surgical Instruments Category - 3/23/16. 

SURGICEL Essential Product Information
•    INDICATIONS
SURGICEL^® Absorbable Hemostat (oxidized regenerated cellulose) is used adjunctively in surgical procedures to assist in the control of capillary, venous, and small arterial hemorrhage when ligation or other conventional methods of control are impractical or ineffective. SURGICEL^® ORIGINAL, SURGICEL^® FIBRILLAR™, SURGICEL^® NU-KNIT^®, and SURGICEL^® SNoW™ Absorbable Hemostats can be cut to size for use in endoscopic procedures.
•    PRECAUTIONS
Use only as much SURGICEL^® Absorbable Hemostat as is necessary for hemostasis, holding it firmly in place until bleeding stops. Remove any excess before surgical closure in order to facilitate absorption and minimize the possibility of foreign body reaction.
In urological procedures, minimal amounts of SURGICEL^® Absorbable Hemostat should be used and care must be exercised to prevent plugging of the urethra, ureter, or a catheter by dislodged portions of the product. 
Since absorption of SURGICEL^® Absorbable Hemostat could be prevented in chemically cauterized areas, its use should not be preceded by application of silver nitrate or any other escharotic chemicals.
If SURGICEL^® Absorbable Hemostat is used temporarily to line the cavity of large open wounds, it should be placed so as not to overlap the skin edges. It should also be removed from open wounds by forceps or by irrigation with sterile water or saline solution after bleeding has stopped.
Precautions should be taken in otorhinolaryngologic surgery to assure that none of the material is aspirated by the patient.  (Examples: controlling hemorrhage after tonsillectomy and controlling epistaxis.)
Care should be taken not to apply SURGICEL^® Absorbable Hemostat too tightly when it is used as a wrap during vascular surgery (see Adverse Reactions section of the complete product package insert).
•    ADVERSE EVENTS 
“Encapsulation” of fluid and foreign body reactions have been reported. 
There have been reports of stenotic effect when SURGICEL^® Absorbable Hemostat has been applied as a wrap during vascular surgery. 
Paralysis and nerve damage have been reported when SURGICEL^® Absorbable Hemostat was used around, in, or in proximity to foramina in bone, areas of bony confine, the spinal cord, and/or the optic nerve and chiasm. 
Blindness has been reported in connection with surgical repair of a lacerated left frontal lobe when SURGICEL^® Absorbable Hemostat was placed in the anterior cranial fossa. 
Possible prolongation of drainage in cholecystectomies and difficulty passing urine per urethra after prostatectomy have been reported. 
For more information, please consult your doctor or for product quality and technical questions, call 1-800-795-0012.  For complete product information including indications, contraindications, warnings, precautions, and adverse reactions, please reference the individual product package inserts.  

SURGICEL^® Powder Absorbable Hemostat Essential Product Information
INDICATIONS
SURGICEL^® Powder (oxidized regenerated cellulose) is used adjunctively in surgical procedures to assist in the control of capillary, venous, and small arterial hemorrhage when ligation or other conventional methods of control are impractical or ineffective. SURGICEL^® Powder can also be applied in laparoscopic or other endoscopic procedures when used with the SURGICEL™ Endoscopic Applicator.
The SURGICEL™ Endoscopic Applicator is intended for use in delivering SURGICEL^® Powder absorbable hemostat to bleeding surgical sites through a 5 mm or larger trocar.
CONTRAINDICATIONS
• Do not inject or place SURGICEL^® Powder into an open blood vessel. Do not use to treat bleeding from large defects in arteries or veins.
• SURGICEL^® Powder should not be used to control hemorrhage from large arteries or veins.
• The SURGICEL^® Powder and the SURGICEL™ Endoscopic Applicator devices were not designed for intraluminal procedures.
• When SURGICEL^® Powder is used to help achieve hemostasis in, around, or in proximity to foramina in bone, areas of bony confine, the spinal cord, or the optic nerve and chiasm, it must always be removed after hemostasis is achieved since it will swell and could exert unwanted pressure.
• SURGICEL^® Powder should not be used for implantation in bone defects, such as fractures, since there is a possibility of interference with callus formation and a theoretical chance of cyst formation.
WARNINGS
•  SURGICEL^® Powder is not intended for use on dry (non-bleeding) surfaces or for prevention of bleeding.
• Closing with SURGICEL^® Powder in a contaminated wound without drainage may lead to complications and should be avoided.
• SURGICEL^® Powder should not be impregnated with anti-infective agents or with other materials such as buffering or hemostatic substances. 
• SURGICEL^® Powder is dry and there may be difficulties in precise delivery under certain circumstances. Unintentional device placement may result in powder scattering and device migration that may increase the risk of adhesion formation. In preclinical in vivo animal studies it was demonstrated that SURGICEL^® Powder does not increase the incidence of remote adhesions in laparoscopic procedures.
• Although SURGICEL^® Powder is bactericidal against a wide range of pathogenic microorganisms, it is not intended as a substitute for systemically administered therapeutic or prophylactic antimicrobial agents to control or to prevent postoperative infections.
•  To prevent clogging with the SURGICEL™ Endoscopic Applicator Tip, do not touch the tip to wet surface. Be careful to avoid damaging tissue with the rigid tip.
• Do not attempt to trim the applicator tip. Replace the tip if it becomes clogged.
PRECAUTIONS
•    SURGICEL^® Powder should not be used in conjunction with autologous blood salvage circuits, because its fragments may pass through the transfusion filters of blood-scavenging systems.
•    Use only as much SURGICEL^® Powder (oxidized regenerated cellulose) as is necessary and apply only where needed for hemostasis. Remove any excess before surgical closure in order to facilitate absorption and to minimize the possibility of foreign body reaction.
•    Use minimal amount of SURGICEL^® Powder required to achieve hemostasis, and remove excess powder in the area of drains to prevent clogging.  In urological procedures, minimal amounts of SURGICEL^® Powder should be used and care must be exercised to prevent plugging of the urethra, ureter, or a catheter by dislodged portions of the product.
•    Since absorption of SURGICEL^® Powder could be prevented in chemically cauterized areas, its use should not be preceded by application of silver nitrate or any other escharotic chemicals.
•    If SURGICEL^® Powder is used temporarily to line the cavity of open wounds, it should be removed by irrigation with sterile water or saline solution after bleeding has stopped.
•    Precautions should be taken in otorhinolaryngologic surgery to ensure that none of the material is aspirated by the patient (e.g., controlling hemorrhage after tonsillectomy and controlling epistaxis).
•    The applicator tip provided on the SURGICEL^® Powder device is not intended for laparoscopic or other endoscopic use. If laparoscopic or other endoscopic use is desired, remove the existing applicator tip from the SURGICEL^® Powder device, and replace with the SURGICEL™ Endoscopic Applicator tip (supplied separately). In laparoscopic or other endoscopic procedures, SURGICEL^® Powder should only be applied using the SURGICEL™ Endoscopic Applicator. Consult the SURGICEL™ Endoscopic Applicator Instructions for Use (IFU) for proper assembly and directions for use with the SURGICEL^® Powder device.
•    The SURGICEL Endoscopic Applicator is supplied with a flexible inner tip inside a rigid cannula. The rigid cannula cannot be used independently.
•    The SURGICEL Endoscopic Applicator should only be used by persons having adequate training and familiarity with endoscopic techniques.  Consult medical literature relative to techniques, complications, and hazards prior to performance of any endoscopic procedure. 
•    To prevent inadvertent device spillage, or unintended contact with tissue, organs, or blood, maintain visualization of the SURGICEL™ Endoscopic Applicator tip at all times.
•    Do not compress or excessively bend the flexible inner tip of the SURGICEL Endoscopic Applicator which could obstruct the application of the powder.  It is possible that the powder accumulated in the applicator could disperse beyond the target bleeding site upon compression of the bellows, which may require additional irrigation and aspiration.
ADVERSE EVENTS 
•    Paralysis and nerve damage have been reported when other SURGICEL^® products were used around, in, or in proximity to foramina in bone, areas of bony confine, the spinal cord, and/or the optic nerve and chiasm. 
•    Blindness has been reported in connection with surgical repair of a lacerated left frontal lobe when other SURGICEL^® products were placed in the anterior cranial fossa (see WARNINGS and PRECAUTIONS).
•    Foreign body reactions have been reported with other products from the SURGICEL^® Family of Absorbable Hemostats.
•    Burning has been reported when other SURGICEL^® products were applied after nasal polyp removal. Headache, burning, stinging, and sneezing in epistaxis and other rhinological procedures, and stinging when SURGICEL^® product was applied on surface wounds (varicose ulcerations, dermabrasions, and donor sites) have also been reported.
•    For more information and technical questions, call 1-800-795-0012.  For complete information including indications, contraindications, warnings, precautions, adverse reactions, and directions for use, consult the product package insert.

SURGIFLO^® Hemostatic Matrix Kit Essential Product Information (Made from Absorbable Gelatin Sponge, USP) with Thrombin

DESCRIPTION
SURGIFLO^® with Thrombin (SURGIFLO^® Hemostatic Matrix Kit) is intended for hemostatic use by applying to a bleeding surface.
ACTIONS
When used in appropriate amounts SURGIFLO^® is absorbed completely within 4 to 6 weeks. 

INTENDED USE/INDICATIONS
SURGIFLO^®, mixed with thrombin solution, is indicated in surgical procedures (other than ophthalmic) as an adjunct to hemostasis when control of bleeding by ligature or other conventional methods is ineffective or impractical.
CONTRAINDICATIONS
• Do not use SURGIFLO^® in intravascular compartments because of the risk of embolization.
• Do not use SURGIFLO^® in patients with known allergies to porcine gelatin.
• Do not use SURGIFLO^® in closure of skin incisions because it may interfere with the healing of skin edges. This interference is due to mechanical interposition of gelatin and is not secondary to intrinsic interference with wound healing.
WARNINGS
• SURGIFLO^® should not be used in the presence of infection and should be used with caution in contaminated areas of the body
• SURGIFLO^® should not be used in instances of pumping arterial hemorrhage. SURGIFLO^® will not act as a tampon or plug in a bleeding site.
• SURGIFLO^® should be removed from the site of application when used in, around, or in proximity to foramina in bone, areas of bony confine, the spinal cord, and/or the optic nerve and chiasm because it may swell resulting in nerve damage.
•Excess SURGIFLO^® should be removed once hemostasis has been achieved.
• The safety and effectiveness of SURGIFLO^® for use in ophthalmic procedures has not been established.
• SURGIFLO^® should not be used for controlling post-partum intrauterine bleeding or menorrhagia.
• The safety and effectiveness of SURGIFLO^® has not been established in children and pregnant women.
• The blue flexible applicator tip should not be trimmed to avoid exposing internal guidewire.
• The white straight applicator tip should be trimmed away from the surgical area. Cut a square angle to avoid creating a sharp tip. 
PRECAUTIONS
• Safe and effective use of SURGIFOAM^® Sponge has been reported in a published neurologic retrospective study involving 1700 cases in Europe. Safe and effective use in neurosurgery has not been proven through randomized, controlled clinical studies in the United States.
• SURGIFLO^® is supplied as a sterile product and cannot be resterilized.
• SURGIFLO^® should not be used for packing unless excess product that is not needed to maintain hemostasis is removed. SURGIFLO® may swell up to 20% upon contact with additional fluid.
• SURGIFLO^® should not be used in conjunction with autologous blood salvage circuits. 
• SURGIFLO^® should not be used in conjunction with methylmethacrylate adhesives.
• In urological procedures, SURGIFLO^® should not be left in the renal pelvis or ureters to eliminate the potential foci for calculus formation.
ADVERSE EVENTS
A total of 142 patients received SURGIFOAM^® Sponge during a clinical trial comparing SURGIFOAM^® Sponge to another absorbable gelatin sponge. In general, the following adverse events have been reported with the use of absorbable porcine gelatin-based hemostatic agents:
• Gelatin-based hemostatic agents may serve as a nidus for infection and abscess formation and have been reported to potentiate bacterial growth.
• Giant cell granulomas have been observed at implant sites when used in the brain.
• Compression of the brain and spinal cord resulting from the accumulation of sterile fluid have been observed.
• Multiple neurologic events were reported when absorbable gelatin-based hemostatic agents were used in laminectomy operations, including cauda equina syndrome, spinal stenosis, meningitis, arachnoiditis, headaches, paresthesias, pain, bladder and bowel dysfunction, and impotence.
• The use of absorbable gelatin-based hemostatic agents during the repair of dural defects associated with laminectomy and craniotomy operations, has been associated with fever, infection, leg paresthesias, neck and back pain, bladder and bowel incontinence, cauda equina syndrome, neurogenic bladder, impotence, and paresis.
• The use of absorbable gelatin-based hemostatic agents has been associated with paralysis, due to device migration into foramina in the bone around the spinal cord, and blindness, due to device migration in the orbit of the eye, during lobectomy, laminectomy, and repair of a frontal skull fracture and lacerated lobe.
• Foreign body reactions, “encapsulation” of fluid, and hematoma have been observed at implant sites.
• Excessive fibrosis and prolonged fixation of a tendon have been reported when absorbable gelatin-based sponges were used in severed tendon repair.
• Toxic shock syndrome was reported in association with the use of absorbable gelatin-based hemostats in nasal surgery.
• Fever, failure of absorption, and hearing loss have been observed when absorbable hemostatic agents were used during tympanoplasty.