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.

Keywords: 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.

Figure 1

Rubber foam mandrel

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 ].

Figure 2

Two first stitches, 180° one opposite another are placed

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.

Figure 3

Sutures around the foam rubber mandrel

Figure 4

The mandrel was removed

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.

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 .

Figure 6

Stacking order for the first 4 stitches on the end-to-side anastomosis at acute angle

Then, suturing of the rear and front anastomosis parts, using foam mandrel, similarly to the method described above, is performed [Figures 7 and 8 ].

Figure 7

Sutures on the front part of the anastomosis

Figure 8

Lumen visual control before tightening knots

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 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 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

0Above-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.

References

1. 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

2. 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

3. 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