JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
NOVEMBER 1992
TECHNIQUES AND INNOVATIONS
A SIMPLE CUFF-SUTURE TECHNIQUE FOR Downloaded by: National University of Singapore. Copyrighted material.
MICROVASCULAR ANASTOMOSIS Ganesh R. Deshmukh, Yeng Yang, Vivian A. Tellis, and Paul H. Gerst
ABSTRACT The use of synthetic cuffs to simplify and hasten microvascular anastomoses is offered as an alternative to conventional methods. In this study, a soft, non-irritating, silicone rubber cuff was used to construct endto-end and end-to-side cuff-sutured anastomoses in rats. This technique was as rapid as other non-sutured anastomoses, required no assistant, and provoked no foreign-body reactions.
We report the technique of using a soft, nonirritating, silicone rubber cuff for anastomosis. This technique eliminates the need for an assistant and can be applied for both end-to-end and end-to-side anastomoses.
Gradual traction is applied to the sutures to evert the renal vein over the cuff and telescope it into the IVC. Vascular clamps are released and sutures tied.
RESULTS MATERIALS AND METHODS For end-to-end anastomoses, a silicone cuff, 2 mm wide and having a slightly larger diameter than the vessels, is slipped over the proximal end of one of the carotid arteries. Three 10-0 nylon sutures are placed, as shown in Figure 1, so that they trisect the cuff circumference. Gradual traction is applied to the sutures until the proximal vessel is everted over the cuff and telescoped into the lumen of the distal vessel. For end-to-side anastomoses, the renal vein is reimplanted into the inferior vena cava (IVC). An incision approximately 0.5 mm smaller in diameter than the renal vein is made in the IVC. A cuff-suture anastomosis is constructed using a silicone cuff 2.5 mm i.d. and 2 mm long. The 10-0 nylon sutures are placed, as shown in Figure 2, dividing the cuff into quadrants.
End-to-end anastomoses required an average of 6 min. The average size of the carotid artery was 1.5 mm. All 10 anastomoses were patent at necropsy. End-to-side anastomoses required an average of 7 min; the average diameter of the renal vein was 2.2 mm, and that of the IVC was 3.0 mm. One rat died during surgery as a result of bleeding from an inadvertent IVC laceration; five others survived. No animal bled from the suture line at any time, and all wounds healed well. At necropsy, all five anastomoses were patent. There were no intraluminal thrombi and no reactions to the silicone cuff (Fig. 3). Microscopic examination revealed normal morphology at all anastomotic sites, with no evidence of interstitial congestion or glomerular or tubular injury. The sites had smooth, intimal continuity, with no foreign body reaction, (see Fig. 3).
Departments of Surgery, Montefiore Medical Center and Bronx-Lebanon Hospital Center and the Transplant Program, Montefiore Medical Center, Bronx, NY Reprint requests: Dr. Tellis, Director, Transplant Program, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10567 Accepted for publication lune 22,1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
491
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
Distal Vessel
NOVEMBER 1992
Proximal Vessel
Cuff
Proximal Vessel
Renal Vein A Inferior Vena Cava
492
Figure I. End-to-end anastomosis. A, Each suture was inserted from inside to outside the cuff, from outside the proximal cut end to inside the lumen and then B, from inside to outside the distal lumen.
Figure 2. End-to-side anastomosis. A, Suture 1 was passed from inside out through the cuff, from outside in through the edge of the cut proximal end of the renal vein, and B, from inside out through the IVC, then tied. Sutures 2,3, and 4 were placed in the same manner and tied. (Figure continued on next page)
Downloaded by: National University of Singapore. Copyrighted material.
Suture
CUFF-SUTURE TECHNIQUE/DESHMUKH, YANG, TELLIS, GERST
Inferior Vena Cava
Renal Vein
Figure 2, cont.
Figure 3. Photomicrograph of end-to-side anastomosis. The silicone cuff is difficult to visualize because it remains unstained. There is no identifiable foreign-body reaction to the cuff. (H&E, X4)
DISCUSSION The performance of microvascular anastomoses is a skill that is acquired by a variable amount of practice. The small number of animals required to master the use of the silicone rubber cuff testifies to the utility of this technique. The value of sutureless, cuffed anastomoses has
been demonstrated by experimental cardiac, renal, and pancreatic transplantation in rats.1-3 Marz and Ferrero2 found that conventional suture techniques and non-sutured cuff techniques had equivalent patency rates for vessels more than 1 mm in diameter. However, the non-sutured techniques, while offering speed and ease, require an assistant, use a rigid Teflon or polyvinyl chloride cuff that causes irritation, and cannot be applied to end-to-side anastomoses.3-5 PGA 493
Downloaded by: National University of Singapore. Copyrighted material.
Suture
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
cuffs and the Unilink device produce little irritation, but also cannot be applied to end-to-side anastomoses.5'6
REFERENCES '
Nolan M, Lindsay N: Pancreatic transplantation in the rat. Transplantation 33:327, 1982 2 M a r z A F e r r e r o M . S u t u r e v e r s u s cuff t e c h n i q u e s for cardiac grafting in the rat. Transplantation 33:327, 1982 3 Kamada N: A description of cuff techniques for renal transplantation in the rat. Transplantation 39:93, 1985 4 D a n j e l RK o l d i n g M ; A n a b s o r b a b ! e anastomotic device for microvascular surgery: Experimental studies. Plast Reconstr S u r 74 329 § - - l986 5. Euler E, Wilker D, Eitel F, Mager S: Non-suture microsurgical anastomosis. J Reconstr Microsurg 4:49, 1987 6. Ragnarsson R, Berggren A, Klintenberg C, Ostrup L: Microvascu' a r a n a s t : o r n o s e s ' n irradiated vessels: A comparison between the Unilink system and sutures. Plast Reconstr Surg 85:412, 1990
Downloaded by: National University of Singapore. Copyrighted material.
The t e c h n i o u e described minimizes operating , , , ... . ., D time and can be done without assistance. Because the position of the SUtures on the CUff controls the degree Of telescoping, the technique can b e used for end-to., _, ,. ... ,, side anastomoses. The compliant silicone cuff serves as a Strut for the sutures and acts as a fluid seal. Although we cannot rule out the possibility of long, . ., I ... c i term Stenosis or occlusion With the Use Of the Silicone rubber CUff, there was no reaction to it and no evidence of fibrosis at 8 weeks after surgerv
NOVEMBER 1992
494
NOVEMBER 1992
TECHNIQUES AND INNOVATIONS
A SIMPLE CUFF-SUTURE TECHNIQUE FOR Downloaded by: National University of Singapore. Copyrighted material.
MICROVASCULAR ANASTOMOSIS Ganesh R. Deshmukh, Yeng Yang, Vivian A. Tellis, and Paul H. Gerst
ABSTRACT The use of synthetic cuffs to simplify and hasten microvascular anastomoses is offered as an alternative to conventional methods. In this study, a soft, non-irritating, silicone rubber cuff was used to construct endto-end and end-to-side cuff-sutured anastomoses in rats. This technique was as rapid as other non-sutured anastomoses, required no assistant, and provoked no foreign-body reactions.
We report the technique of using a soft, nonirritating, silicone rubber cuff for anastomosis. This technique eliminates the need for an assistant and can be applied for both end-to-end and end-to-side anastomoses.
Gradual traction is applied to the sutures to evert the renal vein over the cuff and telescope it into the IVC. Vascular clamps are released and sutures tied.
RESULTS MATERIALS AND METHODS For end-to-end anastomoses, a silicone cuff, 2 mm wide and having a slightly larger diameter than the vessels, is slipped over the proximal end of one of the carotid arteries. Three 10-0 nylon sutures are placed, as shown in Figure 1, so that they trisect the cuff circumference. Gradual traction is applied to the sutures until the proximal vessel is everted over the cuff and telescoped into the lumen of the distal vessel. For end-to-side anastomoses, the renal vein is reimplanted into the inferior vena cava (IVC). An incision approximately 0.5 mm smaller in diameter than the renal vein is made in the IVC. A cuff-suture anastomosis is constructed using a silicone cuff 2.5 mm i.d. and 2 mm long. The 10-0 nylon sutures are placed, as shown in Figure 2, dividing the cuff into quadrants.
End-to-end anastomoses required an average of 6 min. The average size of the carotid artery was 1.5 mm. All 10 anastomoses were patent at necropsy. End-to-side anastomoses required an average of 7 min; the average diameter of the renal vein was 2.2 mm, and that of the IVC was 3.0 mm. One rat died during surgery as a result of bleeding from an inadvertent IVC laceration; five others survived. No animal bled from the suture line at any time, and all wounds healed well. At necropsy, all five anastomoses were patent. There were no intraluminal thrombi and no reactions to the silicone cuff (Fig. 3). Microscopic examination revealed normal morphology at all anastomotic sites, with no evidence of interstitial congestion or glomerular or tubular injury. The sites had smooth, intimal continuity, with no foreign body reaction, (see Fig. 3).
Departments of Surgery, Montefiore Medical Center and Bronx-Lebanon Hospital Center and the Transplant Program, Montefiore Medical Center, Bronx, NY Reprint requests: Dr. Tellis, Director, Transplant Program, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10567 Accepted for publication lune 22,1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
491
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
Distal Vessel
NOVEMBER 1992
Proximal Vessel
Cuff
Proximal Vessel
Renal Vein A Inferior Vena Cava
492
Figure I. End-to-end anastomosis. A, Each suture was inserted from inside to outside the cuff, from outside the proximal cut end to inside the lumen and then B, from inside to outside the distal lumen.
Figure 2. End-to-side anastomosis. A, Suture 1 was passed from inside out through the cuff, from outside in through the edge of the cut proximal end of the renal vein, and B, from inside out through the IVC, then tied. Sutures 2,3, and 4 were placed in the same manner and tied. (Figure continued on next page)
Downloaded by: National University of Singapore. Copyrighted material.
Suture
CUFF-SUTURE TECHNIQUE/DESHMUKH, YANG, TELLIS, GERST
Inferior Vena Cava
Renal Vein
Figure 2, cont.
Figure 3. Photomicrograph of end-to-side anastomosis. The silicone cuff is difficult to visualize because it remains unstained. There is no identifiable foreign-body reaction to the cuff. (H&E, X4)
DISCUSSION The performance of microvascular anastomoses is a skill that is acquired by a variable amount of practice. The small number of animals required to master the use of the silicone rubber cuff testifies to the utility of this technique. The value of sutureless, cuffed anastomoses has
been demonstrated by experimental cardiac, renal, and pancreatic transplantation in rats.1-3 Marz and Ferrero2 found that conventional suture techniques and non-sutured cuff techniques had equivalent patency rates for vessels more than 1 mm in diameter. However, the non-sutured techniques, while offering speed and ease, require an assistant, use a rigid Teflon or polyvinyl chloride cuff that causes irritation, and cannot be applied to end-to-side anastomoses.3-5 PGA 493
Downloaded by: National University of Singapore. Copyrighted material.
Suture
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
cuffs and the Unilink device produce little irritation, but also cannot be applied to end-to-side anastomoses.5'6
REFERENCES '
Nolan M, Lindsay N: Pancreatic transplantation in the rat. Transplantation 33:327, 1982 2 M a r z A F e r r e r o M . S u t u r e v e r s u s cuff t e c h n i q u e s for cardiac grafting in the rat. Transplantation 33:327, 1982 3 Kamada N: A description of cuff techniques for renal transplantation in the rat. Transplantation 39:93, 1985 4 D a n j e l RK o l d i n g M ; A n a b s o r b a b ! e anastomotic device for microvascular surgery: Experimental studies. Plast Reconstr S u r 74 329 § - - l986 5. Euler E, Wilker D, Eitel F, Mager S: Non-suture microsurgical anastomosis. J Reconstr Microsurg 4:49, 1987 6. Ragnarsson R, Berggren A, Klintenberg C, Ostrup L: Microvascu' a r a n a s t : o r n o s e s ' n irradiated vessels: A comparison between the Unilink system and sutures. Plast Reconstr Surg 85:412, 1990
Downloaded by: National University of Singapore. Copyrighted material.
The t e c h n i o u e described minimizes operating , , , ... . ., D time and can be done without assistance. Because the position of the SUtures on the CUff controls the degree Of telescoping, the technique can b e used for end-to., _, ,. ... ,, side anastomoses. The compliant silicone cuff serves as a Strut for the sutures and acts as a fluid seal. Although we cannot rule out the possibility of long, . ., I ... c i term Stenosis or occlusion With the Use Of the Silicone rubber CUff, there was no reaction to it and no evidence of fibrosis at 8 weeks after surgerv
NOVEMBER 1992
494
