- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Kusunoki 33-1, Toyama, 931-8533, Japan
- Department of Neurosurgery, University of Toyama, Sugitani 2630, Toyama, 930-0194, Toyama, Japan
Department of Neurosurgery, University of Toyama, Sugitani 2630, Toyama, 930-0194, Toyama, Japan
DOI:10.4103/2152-7806.76143Copyright: © 2011 Matsumura N 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.
How to cite this article: Matsumura N, Hayashi N, Kamiyama H, Kubo M, Shibata T, Okamoto S, Horie Y, Hamada H, Endo S. Microvascular anastomosis at 30-50× magnifications (super-microvascular anastomosis) in neurosurgery. Surg Neurol Int 24-Jan-2011;2:6
How to cite this URL: Matsumura N, Hayashi N, Kamiyama H, Kubo M, Shibata T, Okamoto S, Horie Y, Hamada H, Endo S. Microvascular anastomosis at 30-50× magnifications (super-microvascular anastomosis) in neurosurgery. Surg Neurol Int 24-Jan-2011;2:6. Available from: http://sni.wpengine.com/surgicalint_articles/microvascular-anastomosis-at-30-50x-magnifications-super-microvascular-anastomosis-in-neurosurgery/
Background:We report a safe and precise technique of microvascular anastomosis at higher magnifications (30 – 50 ×) in neurosurgery and evaluate our experiences to examine the utility of this method for cerebral revascularization in various situations.
Methods:A retrospective review was carried out of patients who underwent microvascular anastomosis using a high-magnified operating microscope. This method was performed in 30 patients with 35 microvascular anastomoses in various situations. This microscope has two optical systems, a standard zooming system and a newly developed high magnification system. High resolution and good depth of focus are achieved by a new lens design in the optical system, which makes the image of the object very clear at higher magnifications. In this operating microscope, the combination of a 10 × eyepiece and the 200, 250, and 300-mm objective lens enables a range of final magnifications from 2.9 × to 50.4 ×.
Results:This method enabled one to pay attention to performing atraumatic manipulations of small vessels and correct suturing, intima-to-intima, of vessel walls. Microvascular anastomoses were performed safely and precisely at higher magnifications. All anastomoses were patent.
Conclusion:It is obvious that practical final magnifications of more than 30 × in neurosurgery would be super-magnified operative views. Microvascular anastomosis at 30 – 50 × magnifications (super-microvascular anastomosis) can help neurosurgeons to improve their skills, with good visualization, and to be safe and accurate when conducting cerebral revascularization in various situations.
Keywords: Cerebral aneurysm, Cerebral revascularization, Microvascular anastomosis, Moyamoya disese, Operating microscope
Microvascular surgery has required techniques for suturing or anastomosing small vessels with diameters of less than 2.0 mm using an operating microscope. Microvascular anastomosis in neurosurgery has been an effective and essential technique in the treatment of symptomatic, hemodynamic, cerebrovascular occlusive diseases, moyamoya diseases, and complex cerebral aneurysms.[
Here, we report a safe and precise technique of microvascular anastomosis at higher magnifications (30 - 50 ×) (super-microvascular anastomosis) in neurosurgery, and evaluate our experiences to examine the utility of this method for cerebral revascularization in various situations.
Thirty patients, 21 males and 9 females aged 16 to 77 years (mean 61.1 years), were treated for symptomatic hemodynamic cerebrovascular occlusive diseases (23 cases), moyamoya diseases (three cases), and complex cerebral aneurysms (four cases), with 35 microvascular anastomoses at higher magnifications between November 2007 and August 2010. A retrospective review of these patients who underwent microvascular anastomosis was performed. The clinical characteristics of these patients are summarized in
A novel high-magnified stereoscopic operating microscope with 50 × as the maximum magnifying power [
The usual surgical procedures and instruments in microvascular anastomosis were employed. The magnification could be altered to match the requirements as necessary. Microvascular suturing and anastomosing were performed at higher magnifications in point for a particular situation. After microvascular anastomosis was completed, the patency of the anastomosis was evaluated by intraoperative direct observation at higher magnifications and with a postoperative cerebral angiogram.
In our case series, 33 STA-MCA anastomoses, one occipital artery (OA)-MCA anastomosis and one OA-posterior inferior cerebellar artery anastomosis were performed. Microvascular anastomoses, in which the recipient cortical arteries were 0.5 to 1.8 mm in diameter, were performed using 10-0 or 11-0 monofilament nylon at higher magnifications. This enabled one to pay attention to performing atraumatic manipulations of small vessels and correct suturing, intima-to-intima, of vessel walls. In microvascular anastomosis, a high magnification system was used for observing the wall of the donor artery after cutting, incising of the recipient artery with microscissors after clamping, passing of a micro-needle through the vessel wall, checking the knot and cutting the suture after knotting, and observing the patency of the anastomosis in the surface and deep surgical fields. High resolution and good depth of focus were achieved by a new lens design in the optical system, which made the image of the object very clear at higher magnifications. The working space, the size of the field of vision, and the illumination of the operative fields were also suitable for small objects at higher magnifications.
The recipient cortical artery (less than 1.0 mm in diameter), such as a larger vessel of STA-MCA anastomosis, was visualized and manipulated precisely (Case 13) [
(a) Microvascular suturing at 50 × was performed using an 11-0 nylon suture with a needle (80-μm in diameter). Micro-forceps and micro-needle holder was used, No.3 jeweler's forceps. One scale on the sheet is 1.0 mm (b) Microvascular anastomosis of a very small vessel and a fragile vessel wall could be performed safely and precisely at 50 ×. The end-to-side anastomosis was completed and patent (c) Finally, STA-MCA double anastomosis was completed
(a) Intraoperative view of a donor artery (subgaleal segment of OA) and a recipient artery (distal cortical artery of the angular artery). The recipient cortical artery was 0.5 mm in diameter. One scale on the sheet is 1.0 mm (b) Microvascular suturing at 50 × could be performed using an 11-0 nylon suture with a needle (80-μm in diameter and 3-mm in length) (c) Microvascular anastomosis was completed and patent (d) Finally, OA-MCA anastomosis was completed on the parieto-occipital lobe
Postoperative angiograms revealed good patency of all anastomoses and patients had no complications in this procedure (but there was one hyperperfusion syndrome).
The cortical artery (M4 segment) of the middle cerebral artery was often selected as the recipient cortical artery for less invasive approaches.[
These microvascular anastomoses were difficult in patients with very small, thin, fragile, and transparent recipient arteries. Moreover, the donor scalp arteries in atherosclerotic cerebrovascular occlusive diseases could also cause problems due to intimal dissection associated with atherosclerotic changes. These cortical arteries sometimes collapsed and had less than 1.0 mm diameter.
The ostium of the recipient artery and the orifice of the donor artery must be clearly visualized for the establishment of microvascular anastomosis in various situations. The visualization methods in microvascular anastomosis have also been reported.[
In hand surgery, a novel stereoscopic operating microscope with 40 × and 50 × magnifying power was developed and used in 2003, and reported in 2006.[
The 300-mm objective lens has been developed for neurosurgery in this study. This operating microscope has a weak point, in that, the objective lens has to be exchanged and fixed before an operation in neurosurgery; 200, 250, and 300 mm objective lens were used in the surface and deep surgical fields. However, microvascular anastomosis itself is usually performed on a plane field and does not need a change in various working distances intraoperatively. We have reported on this operating microscope from preliminary personal experiences.[
It is obvious that the practical final magnifications of more than 30 × in neurosurgery, would be super-magnified operative views. We think that this microvascular anastomosis at higher magnifications (super-microvascular anastomosis) can help neurosurgeons improve their skills, with good visualization, and conduct safe and accurate cerebral revascularization in various situations.
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