Precise One-Suture Needle-Guided Technique for Window Creation in Supermicrosurgical End-to-Side AnastomosisFunding None.
18 August 2018 (eFirst)
We have read with great pleasure the recent article by Ooi et al entitled “Geometric three-dimensional end-to-side microvascular anastomosis: a simple and reproducible technique.” The authors' novel design of a V-shaped vesselotomy with geometrically cut end vessel affords an elegant solution to significant microsurgical considerations by reducing the thrombogenicity of high turbulence areas and creating a patch vesselplasty for patency. Nevertheless, as we congratulate the authors for achieving a success rate of 98% for free tissue transfers over a decade, we have found that the formation and management of small structures, such as triangular vessel flaps, becomes significantly more difficult as vessel diameters decrease.
Therefore, we wish to offer our own geometric technique for microsurgical vesselotomies, whose use scales especially well into the vessel diameters of supermicrosurgery. Our simple-to-apply, mathematically-based method is designed to avoid sizing issues which occur with commonly used methods of vesselotomy. Size-mismatched vesselotomies require revisions in additionally cutting or tying which may ultimately compromise the integrity of the anastomosis  and should be avoided.
For an ideal anastomosis, a surgeon must create a window of the same diameter, d, as that of the end vessel.  As the end vessel lies flat intraoperatively, our assessment is limited to its width, w ([Fig. 1]). This width, w, is approximately of the circumference, C, of the vessel. In addition, we know that C = πd. Therefore, . Solving for d, we find that , concluding that for the best size coherence of both end lumen and side window, a vesselotomy with a diameter two-thirds the width of the flat end vessel is ideal.
We apply this knowledge in practice by first comparing the flat end vessel to our suture needle, and noting the distance traced by two-thirds its width. We then place a suture at the desired anastomosis location perpendicularly across the vessel. We tie a floating square knot and cut it with a long tail. Next, we enter the vessel longitudinally along its course, and place entry and exit bites a distance apart, pulling until the needle is halfway through and centered with respect to the previously placed suture and longitudinal bite. Finally, we gently elevate the tied suture, and with curved scissors held point-up, directed perpendicularly to the vessel, cut along the curvature of the suture needle, removing all aforementioned materials from the site ([Fig. 2]). Please view our [Supplementary Video 1] (available in online version only) for a narrated demonstration of this technique.
Supplementary Video 1
This video shows a narrated demonstration of our novel mathematically-based technique for window creation in end-to-side anastomosis in a live rat model. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ejournals/html/doi/10-1055-s-0038-1667361-jrm-18-0179-v1.mp4.
With this method, we are able to consistently obtain a precise supermicrosurgical window down to 0.3 mm compared with existing Gestalt methods. We believe this to arise from the mathematical basis of our technique, the use of a floating tether for mobility, and the advantages of cutting along a firm suture needle guide. This allows for the full-thickness traversal of the vessel wall, formation of an optimal window, and removal of all support structures. Our method, in theory and practice, results in a simple, novel, and precise technique for creating an optimal window in end-to-side anastomosis and is particularly useful in supermicrosurgical situations where such precision is key.
The authors have no commercial associations or financial interests that may pose or create a conflict of interest regarding the contents of this article.
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