laboratory investigation

J Neurosurg 123:153–160, 2015

Neurosurgical patties: adhesion and damage mitigation

Ashley A. Stratton-Powell, MSc,1 Ian A. Anderson, MRCS(Ed),2 Jake Timothy, MD,2
Nikil Kapur, PhD,1 and Peter Culmer, PhD1
School of Mechanical Engineering, University of Leeds; and 2Department of Neurosurgery, Leeds General Infirmary, Leeds,
1

United Kingdom

Object  Neurosurgical patties are textile pads used during most neurosurgical operations to protect tissues, manage
the fluid environment, control hemostasis, and aid tissue manipulation. Recent research has suggested that, contrary to
their aim, patties adhere to brain tissue and cause damage during removal. This study aimed to characterize and quan-
tify the degree of and consequences resulting from adhesion between neurosurgical patties and brain tissue.
Methods  Using a customized peel apparatus, the authors performed 90° peel tests on 5 patty products: Policot,
Telfa, Americot, Delicot, and Ray-Cot (n = 247) from American Surgical Company. They tested 4 conditions: wet patty on
glass (control), wet patty on wet brain peeled at 5 mm/sec (wet), dry patty on wet brain peeled at 5 mm/sec (dry), and wet
patty on wet brain peeled at 20 mm/sec (speed). The interaction between patty and tissue was analyzed using peel-force
traces and pre-peel histological analysis.
Results  Adhesion strength differed between patty products (p < 0.001) and conditions (p < 0.001). Adhesion strength
was greatest for Delicot patties under wet (2.22 mN/mm) and dry (9.88 mN/mm) conditions. For all patties, damage at
the patty-tissue interface was proportional to the degree of fiber contact. When patties were irrigated, mechanical adhe-
sion was reduced by up to 550% compared with dry usage.
Conclusions  For all patty products, mechanical (destructive) and liquid-mediated (nondestructive) adhesion caused
damage to neural tissue. The greatest adhesion occurred with Delicot patties. To mitigate patty adhesion and neural tis-
sue damage, surgeons should consider regular irrigation to be essential during neurosurgical procedures.
http://thejns.org/doi/abs/10.3171/2014.12.JNS14917
Key Words  adhesion; neurosurgical patty; irrigation; iatrogenic damage

T
he neurosurgical patty (also known as a surgical
sponge or cottonoid) is a disposable textile pad that
has a diverse range of functions (e.g., tissue protec-
tion, fluid management, hemostasis, and tissue manipula-
tion). Historically, patties were cut from cotton sheets by
operating room staff to suit the surgeon’s requirements.1
However, this practice led to iatrogenic complications
such as gossypibomas (in Latin, gossypium means cotton).
Such complications were reduced by the introduction of
the patty string, but the safety of patty use remains under
scrutiny.12 The patty market is saturated with similar prod-
ucts and with claims that lack substantiated quantitative
data, which makes it difficult for neurosurgeons to make
an evidence-based decision about the safest and most ef-
fective patty types.
Adhesions at the patty-tissue interface have been shown
to damage neural tissue when the patty is removed.12 Simi-
lar inadvertent neural trauma has been seen during lami-
nectomies, in which the size and area of the laminectomy
membrane has been directly proportional to the working
area of the surgical intervention.8 The cause of patty adhe-
sions remains speculative, but Menovsky et al.12 postulated
that the primary cause was coagulation. No reference was
made to physical adhesion mechanisms, which may also
have an effect;2 adhesion theory suggests that protrud-
ing patty fibers may break the tissue surface because of a
mismatch in material stiffness.2 Mechanical adhesion be-
tween patty fibers and tissue can ultimately lead to tissue
avulsion when the patty is removed. Although the fibrous,
sponge-like composition of patties is ideal for absorption,

Abbreviation  PBS = phosphate-buffered saline.

submitted  April 23, 2014.  accepted  December 12, 2014.
include when citing  Published online February 20, 2015; DOI: 10.3171/2014.12.JNS14917.
Disclosure  Preliminary research was supported by The Clothworkers’ Company (University of Leeds). Dr. Jake Timothy’s time was supported by the NIHR Leeds Mus-
culoskeletal Biomedical Research Unit.

©AANS, 2015 J Neurosurg  Volume 123 • July 2015 153

A. A. Stratton-Powell et al.
their antiadhesive properties are questionable. It has been
proposed that a liquid-mediated adhesion mechanism may
contribute to the overall stickiness of the patties, especial-
ly within the wet environment typically maintained in a
neurosurgical operative field.2
With this study, we aimed to quantify the adhesion
strength between neurosurgical patties and brain tissue
while identifying the method of adhesion and quantify-
ing the degree of damage, if any. The hypotheses were as
follows: 1) patties will adhere to brain tissue, 2) adhesion
strength will differ according to patty type, 3) mechanical
and liquid-mediated mechanisms will both contribute to
adhesion strength, and 4) superficial damage will occur
and will be proportional to the patty-tissue interface.
Methods
Neurosurgical Patty Samples
The American Surgical Company donated 5 types of
patty; these patty choices represented a range of materials
and thicknesses found in the wider spectrum of commer-
cially available patties. Telfa patties featured a perforated
polyethylene terephthalate antiadhesive barrier lining the
contact surface (Fig. 1). Each patty type had a radiopaque
tag and a tail on the top side, which was not in contact with
the neural tissue. The height and width of the patties were
measured by using a Trimos height gauge and a Nikon
Profile Projector V-16D (Nippon Kaggakukk) (Table 1).
Fig. 1. Close-up photographs of each patty product.  A: Policot.  B:
Telfa.  C: Ray-Cot.  D: Americot.  E: Delicot. Note the differences in
fiber length and orientation, particularly between patties shown in A, C,
and E. Telfa patties (B) have a perforated Telfa layer covering the cotton
fibers. The Ray-Cot patty (C) shows the radiopaque tag that extends the
length of the product.
154 J Neurosurg  Volume 123 • July 2015
TABLE 1. Patty brands, material, and dimensions
Mean Value (± SD) in mm
Product* Material Height Width
Policot Polyester 0.329 (0.011) 13.027 (0.133)
Telfa Cotton w/ Telfa layer 0.451 (0.016) 13.804 (0.031)
Americot Cotton 0.622 (0.025) 13.349 (0.025)
Delicot Rayon & polyester blend 0.163 (0.008) 13.352 (0.015)
Ray-Cot Rayon 0.438 (0.014) 12.796 (0.032)
*  All products from the American Surgical Company.
90° Peel Test Design
A custom peel apparatus was developed to peel pat-
ty samples perpendicular to the tissue (Fig. 2). A 10-g
GSO-10 sensor load cell (Transducer Techniques) was
calibrated and tested for repeatability before being used
to measure peel force. The rig was actuated by using a
linear stage VT-75 stepper motor (PI miCos) controlled by
a custom LabVIEW interface (National Instruments). Peel
force was recorded at 66 Hz concurrently with displace-
ment and time.
Tissue Specimen Preparation
Before the study began, ethics approval was obtained
from the University of Leeds Research Ethics Committee.
Brain from mature pigs (≈ 24 weeks of age) was chosen
as the model because of its mechanical5 and cytoarchi-
tectural similarity to adult human brain (Fig. 3).14,17 Fresh
porcine brain halves were obtained immediately postmor-
tem from the local slaughterhouse. The pigs were slaugh-
tered according to a standardized procedure, and the brain
halves were extracted as a by-product. The brain halves
were transported in an ice-cooled box during the 20-min-
ute trip to the laboratory.
The brain halves were carefully submerged in refriger-
ated (4°C) phosphate-buffered saline (PBS) solution until
required. Porcine brains have been shown to become stiff-
er as a function of time; all experiments were completed
Fig. 2. Final peel rig setup.  A: 10-g force transducer.  B: Stepper mo-
tor.  C: Patty tail.  D: Sample shield.  E: Patty.  F: Brain specimen.  G:
Pulley.  H: Sliding tray. The pulley linkage mechanism created syn-
chronous movement between the load cell (vertical movement) and the
sliding tray (horizontal movement). The patty tail was pulled taut by this
motion, and the patty peeled at a rate of 5 mm/sec or 20 mm/sec.

Fig. 3. Porcine brain halves as received (A) and after preparation (B). The cerebellum (1) and brainstem (2) were dissected (black
dashed line), and the patty was placed on the white matter within the cortex (3) (white dashed line).
within the suggested 6-hour limit.4 Similar protocols have
been used in several recent studies for the mechanical test-
ing of porcine brain tissue.7,13,15,16
The brain halves were dissected into approximately 10-
mm slices in the midsagittal plane by using an autopsy
brain knife. This technique exposed large white matter
areas, which were identified visually (Fig. 3). The brain
slices were dissected 5 at a time, irrigated with PBS, and
placed individually in petri dishes.
90° Peel Test
Before use, the patties were measured and standardized
to a length of 40 mm by using surgical scissors and a ruler.
Ten patties of each type were tested for each of the 4 con-
ditions (control, wet, dry, and speed). The order of patties
and experiments was randomized.
Specifically, the 4 conditions were as follows: 1) wet
patty on glass microscope slide (control), 2) wet patty on
wet brain (wet), 3) dry patty on wet brain (dry), and 4)
wet patty on wet brain at a higher peel rate of 20 mm/
sec (speed). For all wet conditions, the patty was soaked
in PBS and gently wrung before being placed on the tis-
sue in accordance with recommendations of the manufac-
turer and the literature.12 For all dry conditions, the patty
was not soaked in PBS before being applied to the brain
slice. Previous studies have adopted a wide range of peel
rates, from 0.04 mm/sec11 to 166.6 mm/sec.9 Without an
established standard for biomaterial-on-tissue peel tests,
we considered 5 mm/sec to be the most appropriate rate,
similar to rates used by Bundy et al.3 and Kumar et al.10
The quicker peel rate condition (speed) was 20 mm/sec
because this rate was visually quicker than rates observed
in neurosurgical practice.
Each patty was placed onto the white matter of its cor-
responding brain slice. Damaged white matter was the
only abundant tissue in this in vitro model. Menovsky et
al.12 used a human model to assess patty adhesion to in-
tact arachnoid, intact cortex, damaged white matter, and
damaged gray matter. The porcine brains had neither
Characterizing neurosurgical patty adhesion
intact meninges (dura, arachnoid, or pia maters) nor an
arachnoid-free cortex, which made testing these tissues
not possible. Because of the relatively low quantity of gray
matter in the porcine brain, isolating enough gray matter
for testing was also unattainable. Therefore, only damaged
white matter was tested in this study. Patties were left on
brain samples at room temperature (21°C ± 1°C) for 15
minutes.12 The 3 types of wet-condition samples were ir-
rigated with PBS every 5 minutes to prevent dehydration.
(Irrigation was omitted for the dry condition.) The petri
dish containing the patty–brain (wet) sample was placed
in the tissue tray and aligned precisely with the load cell
to ensure that a 90° angle was maintained during the peel
protocol. Each patty sample was manually tied by the pat-
ty tail to the load cell. The peel test program was initiated
and followed by the automated protocol (Fig. 4).
The free-swell absorptive capacity was calculated for
each patty type by using the standard EN13726–1:2002
(Test methods for primary wound dressings. Aspects of
absorbency; http://shop.bsigroup.com/ProductDetail/?pid
=000000000030013007) as a guideline. This test mea-
sured the absorptive properties of the patties in the ab-
sence of applied load and in excess test fluid. Trials were
repeated 10 times by using 10-mm2 samples. This tech-
nique normalizes the absorption capacity to patty thick-
ness, which therefore gives a good indicator of absorption
per weight.
Data Processing
For signal processing, all data files were imported into
OriginPro version 9 (OriginLab) software. Raw signal
data were smoothed by using an 8-point moving average
filter. The initial peak peel force was used to characterize
the peel force and was defined as the first significant peak
evident after the initialization of the peel protocol.3 Time
and displacement were normalized between samples by
using a peel threshold value of 5 mN as an indicator that a
peel force had been registered. This value was greater than
the signal noise but low enough to capture all peak peel
J Neurosurg  Volume 123 • July 2015 155
A. A. Stratton-Powell et al.

2125 RTS microtome was prepared with the blade set at

5° and at 5-μm section thickness. Hematoxylin and eosin
stains were used to enhance the ability to see the patty
fibers and tissue cytoarchitecture. The final slides were
scanned digitally in high definition and analyzed by a con-
sultant neuropathologist.

Statistical Analyses
To analyze adhesion strength between patty types, we
used the Statistical Package for Social Sciences (SPSS
version 20, IBM Company) to adopt a 1-way independent
analysis of variance. We used the Tukey post hoc analysis
when the homogeneity of variance was assumed; alterna-
tively, we used the Games-Howell post hoc analysis.
To compare each condition against the control, we used
a polynomial contrast with either the Tukey or the Games-
Howell post hoc analysis. The Dunnett test was used to
test for differences between the conditions for each patty
Fig. 4. Typical peel test signal tracing. The shaded sections detail the
type. The alpha level for both analyses was set at p < 0.05.
protocol subdivisions. 1 = Peel test initiates and pulls the patty string
taut. 2 = Peeling begins and a peak adhesion force (asterisk) is identi- Results
fied. 3 = Patty detaches from the tissue sample.
Peel Test Results
Adhesion (peel force > 5 mN) occurred for all patty
force measurements. Three patty samples were identified products used with brain tissue (i.e., wet, dry, speed)
as outliers caused by signal artifacts and were omitted (Table 2). Adhesion strength was defined as the peak peel
from the data processing. force divided by the patty width, allowing for a fair com-
parison between patty products. For the control condition,
Patty-Tissue Interface Analysis adhesion strength differed significantly according to patty
One patty from each product type was used for histo- product (p = 0.002) and was significantly lower for Policot
logical analysis. Each patty was cut to 20 mm to fit into patties than for all other patty products (p < 0.001).
standard histology cassettes. The patties and neural tissue Patty products differed significantly under wet (p
underwent the same preparation as did those for the peel < 0.001) and dry (p < 0.001) conditions. Under the wet
test under wet conditions. The specimens were carefully condition, adhesion strength was significantly greater for
placed in a histology cassette, labeled, and fixed in forma- Delicot patties than for Policot (p = 0.01), Americot (p =
lin (40% formaldehyde) for approximately 36 hours. 0.04), and Ray-Cot (p = 0.13) patties. Under the dry con-
An expert in histological techniques processed, sec- dition, adhesion strength was significantly less for Telfa
tioned, stained, and scanned the tissue samples. In ac- patties than for Americot (p = 0.048) and Delicot patties
cordance with standardized histological procedures, each (p = 0.002). Adhesion strength was also significantly lower
specimen was submerged in molten paraffin wax and left for Ray-Cot patties than for Delicot patties (p = 0.02). No
to solidify and harden at room temperature. A Leica RM significant differences were found between patty products
TABLE 2. Peak peel force and adhesion strength values for all patty products under each study condition
Product, Mean Value (± SD)
Condition* Policot Telfa Americot Delicot Ray-Cot
Control
  Peel force 4.45 (1.17) 13.86 (4.97) 9.16 (2.49) 19.18 (5.24) 12.78 (2.9)
  Adhesion strength 0.340 (0.08) 1.00 (0.37) 0.686 (0.19) 1.44 (0.39) 0.999 (0.22)
Wet
  Peel force 17.60 (4.73) 27.29 (8.27) 20.07 (6.08) 29.63 (11.5) 17.89 (2.98)
  Adhesion strength 1.35 (0.35) 1.98 (0.62) 1.50 (0.45) 2.22 (0.86) 1.40 (0.23)
Speed
  Peel force 21.72 (7.8) 27.99 (11.1) 25.63 (6.61) 31.13 (7.5) 22.07 (8.57)
  Adhesion strength 1.66 (0.58) 2.03 (0.79) 1.92 (0.51) 2.33 (0.57) 1.73 (0.68)
Dry
  Peel force 91.50 (36.29) 70.73 (16.87) 129.97 (52.31) 132.05 (30.24) 79.04 (28.6)
  Adhesion strength 7.04 (2.9) 5.13 (1.2) 9.71 (3.9) 9.88 (2.3) 6.18 (2.3)
*  Peel force units in mN; adhesion strength in mN/mm.

156 J Neurosurg  Volume 123 • July 2015


Fig. 5. Peak adhesion strength among patty products for each condition. Adhesion strength threshold (dashed line) is represented
by an adhesion strength of 0.5 mN/mm, equivalent to a peel force of 0.005 N and a 10-mm patty width. Note change in scale for
the dry condition. Statistics shown for a between-patty analysis (ANOVA); significance is denoted as follows: *p < 0.05; **p < 0.01;
***p < 0.001. Error bars signify standard deviations.
for the speed condition (Table 2; Fig. 5). Under the control
condition, adhesion strength was significantly less than
that under wet conditions for all patty types except Delicot
patties (p = 0.19).
Peel forces were significantly greater for all patty prod-
ucts under the dry condition than under the other condi-
tions (p < 0.001) (Fig. 6). Under the dry condition, mean
adhesion strength increases ranged from 260% (Telfa) to
550% (Americot).
The Delicot brand could absorb 18.2 times (± 10.0) its
dry weight, which was greater than the absorption capa-
bility of Telfa (15.9 times ± 10.3), Americot (12.5 times
± 3.8), Ray-Cot (6.5 times ± 1.0), and Policot patties (4.7
times ± 1.3).
Tissue-Patty Interface Histology
The area of patty contact could be identified by defor-
mation of the tissue (Fig. 7) and further verified by the
area of tissue trauma and fiber attachment at the patty-
tissue interface (Fig. 8). A visual comparison between the
patty contact area and undisturbed brain tissue showed
distinct differences in tissue surface roughness and trau-
ma (Fig. 7). For the Delicot patty, deep interlocking fibers
with the tissue were seen, whereas for the Americot patty,
superficial but traumatic fiber attachment was seen (Fig.
8). Mechanical adhesion was therefore evident from these
histology sections.
Characterizing neurosurgical patty adhesion
The unique composition of the Telfa patty yielded com-
pelling evidence for fiber–tissue interlocking and trauma.
The regular holes in the antiadhesive barrier were imprint-
ed onto the brain tissue and identified as protuberances
in the tissue (Fig. 9). The tops of the protuberances were
damaged by interlocking fibers, whereas the tissue lying
under the antiadhesive barrier was otherwise compressed
and seemingly undamaged (Fig. 10).
Discussion
Although one previous report described adhesion be-
tween patties and neural tissue, the study methods were
qualitative and the mechanisms of adhesion were not ex-
plored.12 An understanding of the origins of patty adhe-
sion may improve neurosurgical protocol and the future
design of patties. This study aimed to quantify patty adhe-
sion and tested the following hypotheses.
Hypothesis 1: Patties Will Adhere to Brain Tissue
For all patty products, adhesion was greater under the
3 study conditions than under the control condition; some
patties were 75% more adhesive under the wet condition
(Policot: control = 0.34 mN/mm, wet = 1.35 mN/mm).
These results support the findings of Menovsky et al.12 and
fundamental Hypothesis 1—that adhesion occurs at the
interface between patties and brain tissue.
J Neurosurg  Volume 123 • July 2015 157
A. A. Stratton-Powell et al.

Fig. 6. Peak adhesion strength among conditions for each patty product. Adhesion strength threshold (dashed line) represented
by an adhesion strength of 0.05 mN/mm, equivalent to a peel force of 0.5 mN and a 10-mm patty width. Statistics shown for
contrast of condition against the control condition; significance is denoted as follows: *p < 0.05; **p < 0.01; ***p < 0.001. Error bars
signify standard deviations.

Hypothesis 2: Adhesion Strength Will Differ According to
Patty Type
Adhesion strength differed among patty products. Deli-
cot patties were the most adhesive product, up to 39% more
adhesive than the other patty products under the wet con-
dition. Adhesion strengths among Policot, Americot, and
Ray-Cot patties were similar, ranging from 1.35 to 1.50
mN/mm; Telfa strength was slightly higher, at 1.98 mN/
mm. These quantitative data suggest that—in accordance
with Hypothesis 2—adhesion strength differs among patty
products.
Hypothesis 3: Mechanical and Liquid-Mediated
Mechanisms Will Both Contribute to Adhesion Strength
This study eliminated the effect of coagulation to reveal
the underlying physical mechanisms of adhesion. All patty
products except Policot exceeded the 5-mN peel threshold
under the control condition. Therefore, liquid-mediated
158 J Neurosurg  Volume 123 • July 2015
adhesion was found to be a contributing factor to adhe-
sion. The natural hydrophobicity of polyester may explain
the reduced liquid-mediated adhesion of the Policot pat-
ties. This hydrophobicity may also be reflected by its low
absorption capacity (http://www.americansurgical.com/
products/polyester/policot/).
The dry condition minimized the effect of liquid-me-
diated adhesion. For all patty products, recorded adhesion
strengths were between 260% and 550% greater under
dry than under wet conditions. When put into perspective,
adhesion under dry conditions was over 300 times less
than that of household masking tape (3.5 N/mm, 3M 200
masking tape). Irrigating the patties with PBS increased
the pliability of the fibers, which consequently reduced
their penetrability. Adhesion was therefore not exclusively
liquid mediated, and irrigation of the patties with PBS sig-
nificantly mitigated adhesion strength.
Histological analysis showed that for all patty products,

Fig. 7. Delicot patty in contact with brain tissue. Unaltered and undis-
turbed tissue shown next to the deformed area of highly damaged tissue
under the patty (black line). H & E. Figure is available in color online
only.
patty fibers were interlocked into the brain tissue across
the fiber contact surface area. Depth of fiber penetration
was difficult to determine because of the deformation of
the tissue; however, for the Delicot patty, fibers penetrated
more than 100 µm into the tissue. Telfa and Americot pat-
ties were both composed of cotton fibers, although Telfa
patties had an additional perforated polyethylene tere-
phthalate antiadhesive barrier lining the contact surface.
Not only was adhesion strength significantly reduced for
the Telfa patties compared with Americot patties under the
dry condition, but the histological analysis also revealed a
substantial reduction in fiber contact and damage because
of the antiadhesive barrier. Without liquid-mediated ef-
fects, adhesion strength seemed to be related to the area of
fiber contact and the depth of fiber penetration. Each patty
product facilitated liquid-mediated and mechanical adhe-
sion to the neural tissue, thereby supporting hypothesis 3.
Hypothesis 4: Superficial Damage Will Occur and Will Be
Proportional to the Patty-Tissue Interface
Menovsky et al.12 identified the trauma potential of each
patty by qualitatively assessing the ease of removal and by
measuring how much tissue appeared on the patty. Trauma
could not be assessed quantitatively by this study, although
the histological analysis provided a unique insight into the
potential damage caused by patty use.
Telfa patties caused the least visible trauma, yet their
peel force was greater, but not significantly, than that of
Fig. 8. Superficial interlocking fibers caused by the Americot patty (A;
arrows). A deep interlocking fiber (128.9 µm) caused by the Delicot patty
(B). H & E. Figure is available in color online only.
Characterizing neurosurgical patty adhesion
Fig. 9. Telfa patty showing areas of fiber contact (black arrows) and
compressed tissue (solid lines) under the antiadhesive barrier unique to
this patty product. Note the cotton fiber adhered to the tissue (gray ar-
row). H & E. Figure is available in color online only.
Policot, Americot, and Ray-Cot patties under the wet con-
dition. This finding suggests that adhesion strength was
not directly proportional to the damage caused under wet
conditions. Tissue damage was, however, proportional to
the area of fiber contact. For example, the tissue exposed to
the Telfa patty fibers was damaged, but the tissue protect-
ed by the antiadhesive barrier was not. If a fibrous patty
without an antiadhesive barrier was 13 mm × 60 mm in
width and length, respectively, the extent of damage would
be 780 mm2. Considering that 20 or more patties may be
used per operation, 15,600 mm2 or 1.56 m2 of superficial
brain damage could occur in 1 operation. This consider-
ation poses further questions regarding postoperative glio-
sis and whether it is proportional to patty use, similar to
the laminectomy membrane being proportional to surgical
intervention.8 These results did not strictly agree with hy-
pothesis 4 because the damage identified was specifically
fiber induced.
Limitations
Biological mechanisms and thrombogenicity of mate-
rials were omitted from this study, which may have po-
tentially exacerbated adhesion strength (e.g., coagulation).
Consequently, the results may be an underestimation of in
vivo adhesion strength and damage.
Identifying damage mechanisms other than those of
Fig. 10. Close-up of Fig. 9 and the tissue avulsion in the area of fiber
contact (arrows). Note the areas of smooth, compressed, and possibly
undamaged tissue where the Telfa antiadhesive barrier lay. H & E. Fig-
ure is available in color online only.
J Neurosurg  Volume 123 • July 2015 159
A. A. Stratton-Powell et al.
avulsed tissue was not possible in this study. With Telfa
patty use, high densities of compressed neural tissue were
found and assumed to be atraumatic. However, this as-
sumption may not be true; compression has been identified
as a potential damage mechanism.6 Similarly, it was as-
sumed that liquid-mediated adhesion was relatively atrau-
matic. The forces created by liquid-mediated adhesion
were not visibly damaging, yet diffuse strain-related dam-
age may have been caused at the tissue surface. From these
data, no specific patty product could be recommended.
Conclusions
Neurosurgical patty manufacturers claim that their pat-
ties are antiadhesive, yet recent evidence12 and the results
of this study suggest otherwise. Patties are designed to ful-
fill 4 key functions: tissue protection, fluid management,
hemostasis, and tissue manipulation. The differences in
absorption between patty types reflect the demand for
patties with a range of functions; however, patient safety
should not be compromised to achieve this. The Delicot
patty provides a case in point, providing high absorption
but also a high potential for adhesion and trauma. This
study investigated the properties of patty design; further
research could assess patty performance for each function
listed above.
The damage caused by the patties in this study was fi-
ber induced and could not be defined by adhesion strength
alone because of a range of destructive and nondestruc-
tive adhesion mechanisms. Liquid-mediated mechanisms
caused adhesion but were assumed to be nondestructive,
whereas destructive mechanical adhesion was evident for
all tissue conditions. Future patty designs should explore
antiadhesive barriers that eliminate patty fiber–brain con-
tact. Absorbent fiberless materials may also minimize
brain tissue avulsion; further research is required to test
the efficacy of new patty materials.
Irrigation reduced adhesion strength by up to 550% and
protected the tissue from more severe trauma. Regular ir-
rigation should therefore be considered essential during
neurosurgical procedures.
Acknowledgments
The authors acknowledge Miss Zahra Ehteshami (University of
Leeds) for her technical input into the peel test apparatus and Mr.
Kirijen Vengadasalam (University of Leeds) for conducting the
preliminary research.
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Author Contributions
Conception and design: all authors. Acquisition of data: Stratton-
Powell, Culmer. Analysis and interpretation of data: all authors.
Drafting the article: Stratton-Powell. Critically revising the
article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf
of all authors: Stratton-Powell. Statistical analysis: Stratton-Pow-
ell. Administrative/technical/material support: Kapur, Culmer.
Study supervision: Kapur, Culmer.
Supplemental Information
Previous Presentation
Portions of this work were presented in poster form at the 2013
meeting of the Society of British Neurological Surgeons, Rom-
ford, United Kingdom, September 25, 2013.
Correspondence
Ashley A. Stratton-Powell, Institute of Medical and Biological
Engineering, School of Mechanical Engineering, University of
Leeds, Woodhouse Ln., Leeds, West Yorkshire LS2 9JT, United
Kingdom. email: sp09aasp@leeds.ac.uk.