Improvements in microsurgery have been expeditiously achieved with advancements in
engineering and technology. In developing countries, regional reconstructive alternatives
are considered before free tissue transfer to improve the postoperative care, equipment
utilization, intraoperative time, and the cost of surgical interventions.[1] Nonetheless, the implementation of free tissue transfer is sometimes required as
no other reconstructive approach suffices the needs of complex tissue defects. Accomplishing
microsurgical reconstructions in emergent nations can be challenging as it is resource-demanding,
requires more surgical equipment, added intraoperative time, and demands careful postoperative
monitoring.[2] Therefore, the aim of this report was to provide a series of affordable and low-cost
instruments and gadgets, developed out of necessity, to improve microsurgical interventions
in developing countries ([Video 1]
[2]
[3]
[4]
[5]).
Vessel Loops from Latex Gloves
Vessel Loops from Latex Gloves
Vessel loops are disposable medical device made of an elastomer of polysiloxane (silicone
rubber) available in multiple colors.[3] The most common use of a vessel loop is the identification of arterial and venous
vessels, peripheral nerves, and tendons.[3] However, it can be used for atraumatic retraction, to deliver a nerve through a
tunnel for nerve coaptation, to temporarily close fasciotomy wounds, or can be used
as a finger tourniquet.[3] Recently, we have used the circumferential border of the proximal end of latex gloves
as vessel loops, obtaining a low-cost accessible utensil that fulfills the aforementioned
functions. Certainly, the latex from which gloves are made of provides a waterproof
vessel with almost the same friction coefficient of silicone ([Fig. 1]).[4]
Fig. 1 Blue glove used for vessel loop.
Vessel Loop from Surgical Gauze Sponges
Vessel Loop from Surgical Gauze Sponges
Surgical sponges of medium size usually contain a blue radiopaque strip that can be
detected under X-rays, which make them useful for identification if it is mistakenly
left within the surgical field after closure ([Fig. 2]). This blue strip can be detached from the sponge and used as a low-cost vessel
loop as an alternative to latex gloves and silicone loops. However, care must be taken
when handling these gauze-based loops as the friction generated from the material
can cause microtrauma to the vessel's wall and thin delicate hollow/tubular structures.
Fig. 2 Microsurgical background and gauze-based loop.
Visibility Background Material
Visibility Background Material
Background sheets are beneficial as they prevent tissue and suture thread from sticking,
and facilitate movement of the suture thread with less friction. Currently, we use
two different accessible and cost-effective alternatives as visibility background
materials during microsurgery. The first option is a small rectangular segment of
a sterile surgical glove crafted to a reasonable size after the excess powder is removed;
the second option is a small rectangular piece from sterile drapes. The later has
a suitable color and texture that avoids reflections from the theater's lights, its
texture is firmer than the surgical glove, and the pattern on the surface simulates
a grid to identify the size of structures ([Fig. 2]).[5] In comparison to modern background sheets, the gloves and drapes are radiolucent
that makes their identification with radiography not possible if they are left within
the surgical field.
Abbocath No. 18 Retractor
Abbocath No. 18 Retractor
In our hospital, we use a retractor model made with the needle of a peripheral venous
catheter (Abbocath No. 18). The venous catheter is held with the nondominant hand.
With the dominant hand, a hemostatic clamp is taken and directed toward the tip of
the needle and secured. Afterward, the tip of the needle is firmly bent until it is
molded into the desired shape and curvature ([Fig. 3]). If desired, the tip of the needle can be smoothened before bending.
Fig. 3 Abbocath No. 18 microsurgical retractor.
CholoSuck
The use of closed suction drainage has proven to be safe to prevent fluid accumulation
after reconstruction with free flaps. We have been pragmatic by creating the CholoSuck.
This drain is crafted using a 100-cc syringe ($3.33/item), a 10-cc syringe ($0.34/item),
a catheter, and surgical elastic bands ([Fig. 4]). First, the tip of the 100-cc syringe is inserted in the catheter. Then, after
pulling the plunger to generate negative pressure, a 1-cc syringe is inserted between
the plunger's flange and the barrel's flange of the 100-cc syringe to maintain the
position of the plunge, ultimately preserving the negative pressure. Finally, the
10-cc syringe is secured with the surgical elastic bands.
Fig. 4 Supplies for the CholoSuck.
Another way to preserve the negative pressure is to perforate the plunge proximal
to the barrel's flange, so a needle cap can be inserted to block the pullback of the
plunger. With the implementation of this closed system with negative pressure, we
have seen the same rate of seromas and hematomas following free tissue transfer while
reducing the cost of postoperative care ([Fig. 5]).
Fig. 5 CholoSuck generating negative pressure.
Currently, none of the microsurgeons that have used any of these innovative ideas
has come across any related complications. This preliminary report demonstrates that
this technology is reliable and beneficial, especially in developing countries. Further
studies are required to identify if the implementation of these inexpensive tools
significantly reduces the cost of hospitalization and postoperative care.
Video 1 Construction of vessel loop.
Video 2 Construction of microsurgical background.
Video 3 Construction of vessel loop.
Video 4 Construction of microsurgical retractor.
Video 5 Construction of CholoSuck.
