and John E. Skandalakis1
(1)
Centers for Surgical Anatomy and Technique, Emory University School of Medicine Piedmont Hospital, Atlanta, GA, USA
Abstract
Digital replantation, free tissue transfer, vascularized bone grafting, and other procedures have become possible with the advent of microsurgery. A basic set of instruments should include microsurgical forceps (4, 5A), vessel dilating forceps, curved scissors, straight scissors, and vascular clamps (single and double for both arteries and veins). For more advanced procedures, surgical background with color contrast, microsutures, and microirrigation syringes are needed. Surgical setup and choice of sutures are explained. The advantages, disadvantages, and procedures for magnification with operating loupes and operating microscopes are detailed. Microsurgical tools require specialized handling, care, and storage conditions. The technique of end-to-end arterial and venous repair, nerve repair, and neuroentubulation is presented.
Introduction
The era of microsurgery, which followed the introduction of ultrafine, nonreactive sutures, precision surgical instrumentation, and improved optical magnification, led to digital replantation, free tissue transfer, vascularized bone grafting, and other procedures. This chapter provides basic information about microsurgical procedures, techniques, and the equipment needed to perform them.
Microsurgical Instrumentation
Because of the exacting requirements of microsurgical procedures, high-quality instrumentation is crucial. Microsurgical tools require specialized storage conditions and individual cleaning, as well as regular inspections, repair, and replacement to ensure that they are ready for use by the surgical team.
A basic set of instruments should include microsurgical forceps (4, 5A), vessel dilating forceps, curved scissors, straight scissors, and vascular clamps (single and double for both arteries and veins). For more advanced procedures, surgical background with color contrast, microsutures, and microirrigation syringes are needed. Some complex cases may be facilitated by custom instruments.
Methods of Magnification
Operating loupes—easily used and customized to each surgeon—work well for procedures in which lower levels of optical magnification (2.5–6.5×) are sufficient. The disadvantage of loupes is that magnification and depth of field are fixed.
An operating microscope is necessary for surgeries that require higher levels of magnification. This larger instrument provides exceptional image clarity and vibrant light. The operating microscope can be set up for use by a single operator or two surgeons. Newer microscopes have the capability for in-room televised display and recording of the operation. However, operating microscopes are more cumbersome to use than loupes, are expensive, and require significant maintenance.
Procedures often done with loupe magnification include:
Pediatric hernia repair
Hypospadias
Discectomy
Coronary artery bypass graft
Arterial bypass graft using reversed saphenous vein interpositional graft
Larger nerve repair
Blepharoplasty
Tendon repair
Procedures often done with use of the operating microscope include:
Replantation
Free tissue transfer
Hand aneurysm resection and repair
Smaller vessel repair (digital artery)
Smaller nerve repair (digital nerve)
Vascular repair
Psychomotor Skills Training
Like most surgical skills, precision techniques for microsurgery are best taught in a laboratory setting; standardized instruction is available in a number of centers. Typically students begin with simple methods for arterial repair. As their skills improve they advance to more difficult procedures, such as interpositional vein grafting. Because live animals are used, surgeons obtain direct feedback on the outcome. The significant learning benefit from this method is that students know their success rate for various procedures prior to taking them to a clinical setting.
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