Surgical Neurology International
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Editor: James I. Ausman, MD, PhD University of California, Los Angeles, CA, USA
Technical Note
Modified method for microvascular anastomosis suturing Volodymyr O. Solomiichuk Neurosurgical Department,Yalta City Hospital,Yalta, Crimea, Ukraine E‑mail: *Volodymyr O. Solomiichuk ‑ [email protected] *Corresponding author Received: 22 February 14 Accepted: 06 March 14 Published: 19 April 14 This article may be cited as: Solomiichuk VO. Modified method for microvascular anastomosis suturing. Surg Neurol Int 2014;5:56. Available FREE in open access from: http://www.surgicalneurologyint.com/text.asp?2014/5/1/56/131107 Copyright: © 2014 Solomiichuk VO. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract Background: Suturing of microvascular anastomosis is still a time‑consuming procedure, despite the fact that different techniques and devices were designed to reduce the operation time and increase the patency rate. This paper reports a method for microvascular anastomosis suturing, using foam rubber cylindrical mandrel, which helps to solve the above‑stated problems. Methods: The principle of method is based on running suture, imposed around the foam rubber mandrel. Then the suture is divided into separate stitches. After the visual control of anastomosis lumen knots are tightened. The procedure is the same for front and back parts of anastomosis. Results: Testing of technique in the laboratory showed the possibility of using a single thread per anastomosis and reducing the time for suturing from 17.3 to 15.4 min compared with standard procedure. Conclusions: Described technique allows surgeon to control the lumen of anastomosis before tightening knots, reduces time of work, and does not increase the cost of operation.
Access this article online Website: www.surgicalneurologyint.com DOI: 10.4103/2152-7806.131107 Quick Response Code:
Key Words: Foam rubber mandrel, microsurgery, microvascular anastomosis, suturing method
INTRODUCTION Suturing of microvascular anastomosis is still a time‑consuming procedure, despite the fact that different techniques[1] and devices[2] were designed to reduce the operation time and increase the patency rate.[3] This paper reports a method for microvascular anastomosis suturing, using foam rubber cylindrical mandrel, which helps to solve the above‑stated problems.
Description of method
This method can be used for any type (end‑to‑end, end‑to‑side, or side‑to‑side) microvascular anastomosis. Auxiliary tool is a foam rubber cylindrical mandrel [Figure 1], 10 mm long and 3 mm in diameter.
For end‑to‑end and side‑to‑side anastomosis suture technique is almost the same. Primarily, two first stitches, 180° one opposite another, at the corners of the artery cut, are placed [Figure 2]. Then, running suture on the rear anastomosis part around the foam rubber mandrel is performed [Figure 3]. After that the thread is cut, splitting the suture into separate stitches, the mandrel is removed [Figure 4], and knots are tightened. Next suturing of the front anastomosis part is performed similarly. After removal of mandrel, the lumen of anastomosis is visually controlled [Figure 5] to verify the intactness of the anastomosis opposite wall, and after that knots are tightened.
Surgical Neurology International 2014, 5:56 http://www.surgicalneurologyint.com/content/5/1/56
Figure 1: Rubber foam mandrel
Figure 2: Two first stitches, 180° one opposite another are placed
Figure 3: Sutures around the foam rubber mandrel
Figure 4: The mandrel was removed
Figure 5: Visual control of the anastomosis lumen
The stacking order for the first four stitches on the end‑to‑side anastomosis at acute angle is shown in Figure 6. Then, suturing of the rear and front anastomosis parts, using foam mandrel, similarly to the method described above, is performed [Figures 7 and 8].
DISCUSSION Procedure invention and testing was carried out in the laboratory at 20 femoral arteries of chicken thighs. Ten arterial end‑to‑side anastomoses were performed in conventional way, using interrupted sutures, and 10
Figure 6: Stacking order for the first 4 stitches on the end-to-side anastomosis at acute angle
anastomoses were performed, following the above‑described method. All the anastomoses were performed by one surgeon during 5 days, 2 per day in the stack of one regular – one modified technique. Time, spent on the anastomosis, was measured from the moment of the first stitch imposition to the removal of thread excess after tightening the last knot. Rubber foam mandrel technique showed the reducing of time, required for the end‑to‑side anastomosis from 17.3 to 15.4 min [Table 1], compared with standard procedure. Also it made possible to control the lumen of
Surgical Neurology International 2014, 5:56 http://www.surgicalneurologyint.com/content/5/1/56
Figure 7: Sutures on the front part of the anastomosis
Figure 8: Lumen visual control before tightening knots
anastomosis visually at both halves of its circumference before tightening knots. Furthermore, the technique allows using just one thread per anastomosis.
Table 1: Results of in‑lab experiment
A mandrel, required for this technique, does not increase the cost of operations and allows to work in the surgical wound almost of any depth and diameter. Also the described method may be used as an exercise for microsurgical skills training.
CONCLUSION Above‑mentioned method allows surgeon to control the lumen of anastomosis before tightening knots, reduces time of work, and does not increase the cost of operation.
ACKNOWLEDGMENTS The author would like to thank Dr. Philippe Dodier, Dr. Maximilian Krawagna, and Dr. Tomas Menovsky for their advice and support for the idea.
Case number Standard procedure Stitches Time, min Modified procedure Stitches Time, min
1
2
3
4
5
6
7
8
9 10 Median
12 11 11 9 8 10 9 10 10 10 25 25 16 15 16 16 16 15 15 14
10 17.3
12 11 10 11 12 10 10 10 9 10 22 18 16 16 16 14 13 14 13 12
10.5 15.4
REFERENCES 1.
2.
3.
Demiralp CO, Serel S, Zeyrek T, Demirseren ME, Ergun H, Yormuk E. New end‑to‑end microvascular anastomosis with geometrically adaptable ends technique: An experimental study on rats. Bratisl Lek Listy 2011;112:483‑7. Ferroli P,Acerbi F,Tringali G, Polvani G, Parati E, Broggi G. Self‑closing Nitinol U‑Clips for intracranial arterial microanastomosis: A preliminary experience on seven cases. Acta Neurochir (Wien) 2009;151:969‑76. Okada Y, Shima T,Yamane K,Yamanaka C, Kagawa R. Cylindrical or T‑shaped Silicone rubber stents for microanastomosis‑Technical note. Neurol Med Chir (Tokyo) 1999;39:55‑7.
Copyright of Surgical Neurology International is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
OPEN ACCESS For entire Editorial Board visit : http://www.surgicalneurologyint.com
Editor: James I. Ausman, MD, PhD University of California, Los Angeles, CA, USA
Technical Note
Modified method for microvascular anastomosis suturing Volodymyr O. Solomiichuk Neurosurgical Department,Yalta City Hospital,Yalta, Crimea, Ukraine E‑mail: *Volodymyr O. Solomiichuk ‑ [email protected] *Corresponding author Received: 22 February 14 Accepted: 06 March 14 Published: 19 April 14 This article may be cited as: Solomiichuk VO. Modified method for microvascular anastomosis suturing. Surg Neurol Int 2014;5:56. Available FREE in open access from: http://www.surgicalneurologyint.com/text.asp?2014/5/1/56/131107 Copyright: © 2014 Solomiichuk VO. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract Background: Suturing of microvascular anastomosis is still a time‑consuming procedure, despite the fact that different techniques and devices were designed to reduce the operation time and increase the patency rate. This paper reports a method for microvascular anastomosis suturing, using foam rubber cylindrical mandrel, which helps to solve the above‑stated problems. Methods: The principle of method is based on running suture, imposed around the foam rubber mandrel. Then the suture is divided into separate stitches. After the visual control of anastomosis lumen knots are tightened. The procedure is the same for front and back parts of anastomosis. Results: Testing of technique in the laboratory showed the possibility of using a single thread per anastomosis and reducing the time for suturing from 17.3 to 15.4 min compared with standard procedure. Conclusions: Described technique allows surgeon to control the lumen of anastomosis before tightening knots, reduces time of work, and does not increase the cost of operation.
Access this article online Website: www.surgicalneurologyint.com DOI: 10.4103/2152-7806.131107 Quick Response Code:
Key Words: Foam rubber mandrel, microsurgery, microvascular anastomosis, suturing method
INTRODUCTION Suturing of microvascular anastomosis is still a time‑consuming procedure, despite the fact that different techniques[1] and devices[2] were designed to reduce the operation time and increase the patency rate.[3] This paper reports a method for microvascular anastomosis suturing, using foam rubber cylindrical mandrel, which helps to solve the above‑stated problems.
Description of method
This method can be used for any type (end‑to‑end, end‑to‑side, or side‑to‑side) microvascular anastomosis. Auxiliary tool is a foam rubber cylindrical mandrel [Figure 1], 10 mm long and 3 mm in diameter.
For end‑to‑end and side‑to‑side anastomosis suture technique is almost the same. Primarily, two first stitches, 180° one opposite another, at the corners of the artery cut, are placed [Figure 2]. Then, running suture on the rear anastomosis part around the foam rubber mandrel is performed [Figure 3]. After that the thread is cut, splitting the suture into separate stitches, the mandrel is removed [Figure 4], and knots are tightened. Next suturing of the front anastomosis part is performed similarly. After removal of mandrel, the lumen of anastomosis is visually controlled [Figure 5] to verify the intactness of the anastomosis opposite wall, and after that knots are tightened.
Surgical Neurology International 2014, 5:56 http://www.surgicalneurologyint.com/content/5/1/56
Figure 1: Rubber foam mandrel
Figure 2: Two first stitches, 180° one opposite another are placed
Figure 3: Sutures around the foam rubber mandrel
Figure 4: The mandrel was removed
Figure 5: Visual control of the anastomosis lumen
The stacking order for the first four stitches on the end‑to‑side anastomosis at acute angle is shown in Figure 6. Then, suturing of the rear and front anastomosis parts, using foam mandrel, similarly to the method described above, is performed [Figures 7 and 8].
DISCUSSION Procedure invention and testing was carried out in the laboratory at 20 femoral arteries of chicken thighs. Ten arterial end‑to‑side anastomoses were performed in conventional way, using interrupted sutures, and 10
Figure 6: Stacking order for the first 4 stitches on the end-to-side anastomosis at acute angle
anastomoses were performed, following the above‑described method. All the anastomoses were performed by one surgeon during 5 days, 2 per day in the stack of one regular – one modified technique. Time, spent on the anastomosis, was measured from the moment of the first stitch imposition to the removal of thread excess after tightening the last knot. Rubber foam mandrel technique showed the reducing of time, required for the end‑to‑side anastomosis from 17.3 to 15.4 min [Table 1], compared with standard procedure. Also it made possible to control the lumen of
Surgical Neurology International 2014, 5:56 http://www.surgicalneurologyint.com/content/5/1/56
Figure 7: Sutures on the front part of the anastomosis
Figure 8: Lumen visual control before tightening knots
anastomosis visually at both halves of its circumference before tightening knots. Furthermore, the technique allows using just one thread per anastomosis.
Table 1: Results of in‑lab experiment
A mandrel, required for this technique, does not increase the cost of operations and allows to work in the surgical wound almost of any depth and diameter. Also the described method may be used as an exercise for microsurgical skills training.
CONCLUSION Above‑mentioned method allows surgeon to control the lumen of anastomosis before tightening knots, reduces time of work, and does not increase the cost of operation.
ACKNOWLEDGMENTS The author would like to thank Dr. Philippe Dodier, Dr. Maximilian Krawagna, and Dr. Tomas Menovsky for their advice and support for the idea.
Case number Standard procedure Stitches Time, min Modified procedure Stitches Time, min
1
2
3
4
5
6
7
8
9 10 Median
12 11 11 9 8 10 9 10 10 10 25 25 16 15 16 16 16 15 15 14
10 17.3
12 11 10 11 12 10 10 10 9 10 22 18 16 16 16 14 13 14 13 12
10.5 15.4
REFERENCES 1.
2.
3.
Demiralp CO, Serel S, Zeyrek T, Demirseren ME, Ergun H, Yormuk E. New end‑to‑end microvascular anastomosis with geometrically adaptable ends technique: An experimental study on rats. Bratisl Lek Listy 2011;112:483‑7. Ferroli P,Acerbi F,Tringali G, Polvani G, Parati E, Broggi G. Self‑closing Nitinol U‑Clips for intracranial arterial microanastomosis: A preliminary experience on seven cases. Acta Neurochir (Wien) 2009;151:969‑76. Okada Y, Shima T,Yamane K,Yamanaka C, Kagawa R. Cylindrical or T‑shaped Silicone rubber stents for microanastomosis‑Technical note. Neurol Med Chir (Tokyo) 1999;39:55‑7.
Copyright of Surgical Neurology International is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
