The video shows a microvascular anastomosis for reconstructive surgery of the head and neck. This series of sutures offers a number of advantages when working with limited available space, weak vessels (vessels that have been irradiated or that have atherosclerosis plaques), suturing in tension, or suturing small vessels (less than 0.8 cm diameter). It has been demonstrated through our own experience that a back-wall suture technique using a single clamp may be appropriate for vessels less than 0.8 mm in diameter or for lymphaticovenular anastomoses.
Video. Techniques useful in complex microvascular anastomosis.
A microvascular anastomosis is demonstrated in this video as an approach for reconstructive surgery of the head and neck. This series of sutures has the potential to offer many advantages in situations such as those where there is limited available working space, weak vessels (for example, vessels that have been irradiated or that have atherosclerotic plaques) or suturing in tension or with small vessels (less than 0.8 cm in diameter). A link to the video relating to this article can be found at: https://doi.org/10.24983/scitemed.imj.2021.00151
During the video, arterial anastomosis was initiated using back-wall suturing without the use of vascular double-clamps (Figure 1A-B). There has been only one vascular single clamp used to control arterial blood flow far from the work area. It allows intimal compression to be performed in relatively healthy regions of poor-quality or under-tension vessels, thus minimising endothelial damage as well as avoiding vessel turnover and stretching of the endothelium. Following that, the stitches were performed in a regular fashion on the lateral walls (Figure 1C-D). A running suture was placed in the anterior portion of the lumen in order to provide adequate visual control (Figure 1E-F). As of this point (Figure 1G-H), the arterial single vascular clamp remained in place.
Anastomosis among the vessels was then performed based on a triangulation technique, with a coupler device utilized for vessels with a diameter ranging between 0.8 and 4.0 mm (Figure 1I-J). This particular technique allows for a higher level of venous stabilization when compared to a manual suturing method without vascular double-clamps. It was of the utmost importance that we attached the vessel endothelium onto the device (and not just the media). There should be no valves located near the venous anastomosis. It was at this point that the single arterial clamp was released (Figure 1K-L) to enable the veins to be sutured together. The dark venous blood flow from the flap and its quality can be observed in this manner prior to the device being closed on itself and reinforced with a mosquito forceps. Consequently, there was no need to conduct a venous milking patency test. Vein anastomoses should be placed on top of arterial anastomoses to prevent vascular compression.
From the author's perspective, a back-wall suture technique with the use of a single clamp may lead to a satisfactory outcome for vessels under 0.8 mm in diameter or in lymphaticovenular anastomosis. A caution should be taken to avoid using a double vascular clamp during arterial suture: in the case of right-handed surgeons, the right arterial vessel can prove difficult to control, so the single clamp should be left in place as a temporary ballast.
Figure 1. (A, B) Arterial microvascular anastomosis using a back wall technique. (C, D) Arterial microvascular anastomosis with regular single stitches situated on the lateral wall. (E, F) The arterial microvascular anastomosis is performed with three to four loops of the running anterior wall technique. (G, H) A microvascular anastomosis of the arteries has been achieved. (I, J) A three-pin venous microvascular anastomosis using a triangular technique. (K, L) A venous microvascular anastomosis, which has been implanted with six pins on one side.
Received date: August 20, 2019
Accepted date: October 16, 2019
Published date: December 16, 2021
The study is in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
The video won the award for Microsurgical Videos from the International Microsurgery Club on Facebook.
The study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The author reports no financial or other conflict of interest relevant to this article, which is the intellectual property of the author.
It is pertinent to note that all opinions and statements made by the author(s) throughout this article are solely those of the author(s). They may not be representative of those of their affiliated organizations, the publishing house, editors, or other reviewers since they are the opinions and statements of the author(s) alone. The publisher does not guarantee or endorse any statements made by the manufacturer of any product mentioned in this article or the author's evaluation.
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Video 1. Techniques useful in complex microvascular anastomosis.
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I have read through the paper entitled “Useful skills for complex microvascular arterial and venous anastomosis”. This is an interesting video article that won the award of Microsurgical Videos from the International Microsurgery Club on Facebook Group. As stabilization is quite difficult, especially for veins, the backwall anastomosis with single clamp is not an easy task for beginners. Despite the fact that the technique described in the article is not a novel one, the video illustration does a good job of illustrating the idea. Grammatical mistakes and sentence framing must be corrected. It would be helpful to include more figures to explain the surgery involved. It is my opinion that this video article can then be considered for publication after a minor revision is completed.
ResponseWe have addressed all of the reviewer's questions and concerns. Additional figures have been added in order to address these issues. As a way of expressing our interest in this original work, we describe a method that we have developed to overcome the difficulties associated with anastomoses, especially those involving tension vessels or poor quality vessels (intimal flaps, radiation, atherosclerosis, etc.). We look forward to receiving a favorable response from the reviewer, and we appreciate your kind assistance and reviewing the article.
Ganry L. Techniques useful in complex microvascular anastomosis. Int Microsurg J. 2021;5(2):2. https://doi.org/10.24983/scitemed.imj.2021.00151
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