Microvascular vessel anatomosis

Considerations

• • Learning

  • 2005: Learning to Perform Microvascular Anastomosis

  • 2008: Training of microsurgical skills on nonliving models

  • 2009: A newly designed training tool for microvascular anastomosis techniques: Microvascular Practice Card

  • Technique 

  • 2008: Microsurgical anastomosis with the 'PCA' technique

  • 2011: From simple interrupted to complex spiral: a systematic review of various suture techniques for microvascular anastomoses

Preparation

• • Flush the artery and venous system with hep saline prior to (open system)

  • Inset first (Dr. Gurushanthaiah/Fong)

  • Anastomosis first (Dr. Moon)

  • Prep vessels 

    • trim the adventitia from the edge of planned anastomosis

      • triangulate the vessel by holding only the adventitia. 

    • check arterial and venous flow

Procedure

• • Artery before vein

  • Arterial

    • 9-0 nylon non traumatic needle (non cutting)

    • Vessel clamps on both sides 

    • Make sure the edges are smooth and not ragged

    • Make sure end is not near a point of arborization

    • Place vessels in the arena (not sure what it's called) with background

• • • Next, the 8, 9, 10 oclock stitches you throw but do not tie down to allow for you to look into the vessel lumens as you place the stitches. 

      • once all three are placed, then you can tie them down. 

    • Flip the vessels over 180 and repeat. 

    • As a resident, most likely you will not be doing the artery. You can assist by keeping things dry with Weck-cel sponges, irrigate with hep saline when needed, cut with straight microscissors

• • Venous 

    • Use of coupler 

      • largest coupler that will fit the smaller of the vessels.

      • size the vessel with the sizer to choose the coupler

    • Place first of two vessels through the ring of the coupler 

    • Use the angled micropickups with the gap in the middle (one in each hand) to place the edge of the vein and impale the edge over the coupler pins 

      • with the pickups closed, then place the gap within the pickups on the coupler pin and gently push down. 

        • push down very gently to avoid macerating the intima

      • want to triangulate the edges first then get then impale the rest of the edges of the vessel. 

  • Make sure the edges of the vein are everted

• • • Repeat for the other vessel

• • Once the veins are properly seated, turn the knob on the coupler applicator all the way until the coupler/vessels comes out of the applicator

  • Give the coupler a little extra squeeze with hemostat

  • Vessel clamps off

  • Irrigate the vessels with 2% lidocaine

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

Links

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - FREE TISSUE TRANSFER FLAPS IN HEAD & NECK RECONSTRUCTION: MICROVASCULAR ANASTOMOSIS TECHNIQUE

  • Iowa Protocols - Microsurgical technique - Includes videos 

• UTMB Grand Rounds - Microvascular Free Tissue Transfer

  • Microsurgical Technique for 1mm Vessel End to End Anastomosis - Article plus 40 minute video

  • YouTube (7:31) - Microsurgical arterial end-to-end anastomosis; basic technique by AboutMicrosurgery

  • YouTube (18:37) - MICROSURGERY - End To End Arterial Arterial Anastomosis by World Microsurgery

  • YouTube (20:53) - The Mechanics of Microsurgical Suturing by Columbia Orthopedics (excellent instruction)