1

SURGICAL TECHNIQUE

TRAINING IN MICROVASCULAR SURGERY USING A

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CHICKEN WING ARTERY

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Akihiko Hino, M.D.
Department of Neurosurgery,
Saiseikai Shigaken Hospital, Shiga,
Japan
Reprint requests:
Akihiko Hino, M.D., Department
of Neurosurgery, Saiseikai
Shigaken Hospital, Ohashi 2-4-1,
Ritto, Shiga 520-30, Japan.
N6UIJoHU/fzMAptn on 03/30/2023
OBJECTIVE: Microarterial anastomosis is now seldom performed for treatment of
atherosclerotic occlusive cerebrovascular disease. However, a small but significant
number of procedures still require this technique. When a surgeon’s clinical
experience is limited, regular practice is required to maintain and improve surgical
skills. The present training system involves passage from suturing of synthetic
materials (such as Silastic tubes) to practice with experimental living animals or
cadavers. However, these methods are neither convenient nor practical for daily
exercises and rehearsals. I present a unique training exercise for microarterial

Email: hinolab@maia.eonet.ne.jp anastomosis, using a chicken wing artery.

Received, December 3, 2002.
Accepted, February 10, 2003.
METHODS: A brachial artery can be extracted from a chicken wing. The artery is
5 to 6 cm long and measures approximately 1 mm in diameter. The artery can be
used to practice end-to-end, end-to-side, or side-to-side anastomosis under the
microscope.
RESULTS: Several advantages are noted: the materials are cheap, convenient to
manage, and easy to obtain, and neither specific facilities to maintain living
animals nor anesthesia is needed. Moreover, the diameter and structure of the
material are identical to those of human cortical vessels, making the rehearsal quite
similar to the actual surgical experience.
CONCLUSION: This exercise is useful not only for young surgeons who wish to
learn microsurgical techniques but also for more experienced surgeons who need
to maintain or improve their skills.
KEY WORDS: Cerebral revascularization, Microsurgery, Training

Neurosurgery 52:1495-1498, 2003 DOI: 10.1227/01.NEU.0000065174.83840.62 www.neurosurgery-online.com

E MATERIALS AND METHODS

xtracranial-intracranial arterial anastomosis is now sel-
dom performed for treatment of atherosclerotic occlusive
cerebrovascular disease (4–6, 17, 18). However, a small
but significant number of neurosurgical procedures still re-
quire this technique (17).
When the clinical experience of surgeons is limited, they
require regular continuous practice to develop, maintain, and
improve their skills. Typical microarterial anastomosis train-
ing programs include suturing of surgical gloves and Silastic
tubes and practice with living animals (such as rats) or with a
cadaver in the laboratory (2, 3, 7–16, 19). These training meth-
ods certainly help surgeons learn basic skills for microneuro-
surgery. However, they are neither convenient nor practical
for routine exercises or rehearsals. The nonbiological materials
are quite different from human vessels, making the exercise
far from actual surgical experience, and living animals are not
necessarily easy to manage. Here I present a unique microar-
terial anastomosis exercise using a chicken wing artery.
Chicken wings can be purchased at any local supermarket.
A package usually contains more than six wings, and the price
is less than a few United States dollars. A brachial artery can
be extracted from a chicken wing with cooking scissors, in the
kitchen (Fig. 1). The skin is lifted up and dissected, starting
from the ventral side, from the shoulder to the wing tip. The
brachial artery can be identified between the biceps brachii
and the triceps brachii, along the shaft of the humerus. When
the artery is peeled away from the wing, it is 5 to 6 cm long
and measures approximately 1 mm in diameter; it is identical
to a human cortical artery. Arteries thus harvested can be kept
in the refrigerator until used.
In the practice room, surrounding fat and connective
tissue are removed from the artery under the microscope.
The divided artery is then ready for practice of end-to-end,
end-to-side, or side-to-side anastomoses (Fig. 2A). These

NEUROSURGERY VOLUME 52 | NUMBER 6 | JUNE 2003 | 1495

 HINO
three types of anastomo-
ses can be performed on
one specimen with 10-0 or
11-0 monofilament. Spe-
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cific techniques, including
the shape of the arterec-
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tomy, the type of sutures,
the use of stents, and the
incident angle of the by-
pass graft, may vary FIGURE 1. Dissection of a brachial
among surgeons. How- artery (arrows) from a chicken wing.
ever, the basic principles The artery is 5 to 6 cm long.
of microsuturing are gen-
eral; the sutures must be a precise distance from the vessel
edge, and the needle must penetrate the entire thickness of
the vessel wall without touching the intima (4, 8, 17, 18).
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The materials should be kept moist during the anastomosis
to prevent the structures from drying out. After the anas-
tomosis is completed, obstacles and failures should be eval-
uated critically and reflectively (Fig. 2B). First, water is
injected into the vessel via a 24-gauge needle and any leak
or resistance is examined. Then the artery is cut and the
intimal appearance at the anastomosis is checked under the
microscope, to search for kinking or strangulation.
DISCUSSION
The International Cooperative Study of Extracranial/
Intracranial Arterial Anastomosis (6), which was published
in 1985, brought about, despite many criticisms, a drastic
decrease in the number of microsurgical cerebral revascu-
larizations (1, 5). At the laboratory level, training in this
technique is still a good educational experience for young
surgeons who wish to learn basic microsurgical skills. Clin-
ically, however, many surgeons do not routinely perform
this procedure, and it is now recognized as a specialized
technique for a few experts who mainly treat very complex
aneurysms or cranial base tumors (17). For a planned op-
eration that requires high-flow bypass, it might be wise to
refer the case to an expert who routinely performs this type
of procedure.
However, low-flow bypasses, including end-to-side, end-
to-end, and side-to-side anastomoses, might still be helpful
FIGURE 2. A, extracted chicken wing artery, ready for end-to-side anas-
tomosis. The artery measures approximately 1 mm in diameter. B, com-
pleted end-to-side anastomosis with an interrupted suturing technique,
with 11-0 monofilament.
1496 | VOLUME 52 | NUMBER 6 | JUNE 2003
options for a small but significant number of routine or
emergency operations. Between 1995 and 2002, I performed
eight microrevascularization procedures during surgical
treatment of approximately 300 cerebral aneurysms, includ-
ing standard superficial temporal artery-middle cerebral
artery bypasses in three cases, an occipital artery-
posteroinferior cerebellar artery bypass in one case, middle
cerebral artery end-to-end anastomoses in two cases, and
direct arterial repair in two cases. I think that microsurgical
revascularization is still an important technique, sometimes
performed as an emergency measure, that should be mas-
tered by many surgeons.
The best way to maintain surgical skills and consistent
ability is to routinely perform procedures. If surgeons who are
not routinely presented with such clinical experiences want to
maintain or improve their skills, however, then the only solu-
tion is to regularly repeat correct rehearsals. Books, lectures,
videotapes, and the assistance of experienced surgeons facili-
tate the development of cognitive and perceptual skills, but
motor skills can be developed and maintained only with reg-
ular practice.
In many laboratories, the typical microsurgical training
method involves gradual passage from suturing of syn-
thetic materials, such as surgical gloves or Silastic tubes, to
practice with experimental living animals, such as rats, or
practice with cadavers (2, 3, 7–16, 19). Because such training
certainly helps surgeons develop microsurgical skills, sur-
geons should complete this training before treating their
first patients. However, these methods are neither conve-
nient nor practical for daily exercises or rehearsals. Suturing
of nonbiological materials feels quite different from sutur-
ing of human vessels, and living animals are not necessarily
easy to handle.
The exercise on chicken wing arteries described here has
several advantages; the materials are cheap, convenient to
manage, and easy to obtain, and neither a specific facility to
maintain living animals nor anesthesia is required. Moreover,
the diameter and structure of the chicken wing artery are
identical to those of human cortical vessels, making the re-
hearsal quite similar to actual surgical experiences. This prac-
tice conveys to trainees the same basic abilities in microvas-
cular surgery as does training with experimental living
animals, although the hemodynamic patency of the anastomo-
ses cannot be confirmed. I recommend that young trainees
attempt this exercise before working with living animals. I
also recommend this exercise for veteran surgeons who have
mastered the microanastomosis technique but who do not
routinely use this procedure in clinical practice. This exercise
will surely facilitate the development and maintenance of
surgical skills.
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Surgery 81:596–598, 1977.
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Side-to-side arterial anastomosis model in the rat internal and external
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Kunstliche Organe 16:178–190, 1983.
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Surg 10:331–332, 1983.
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Acknowledgments
I thank Drs. Hideki Oka, Tadashi Echigo, and Masahito Fujimoto, Saiseikai
Shigaken Hospital, for valuable support and constructive remarks.
COMMENTS
T he author has reported something truly novel, namely, a
low-cost, non-institutional review board approval-
requiring mechanism to teach microsurgical skills to neuro-
surgical residents, neurosurgical fellows, and practicing neu-
rosurgeons. As microsurgical therapy for aneurysms evolves,
more of our practice requires advanced techniques that are no
longer emphasized in many training programs. The dramatic
decrease in the number of bypass procedures being performed
has clearly threatened these skills and thus the collateral ben-
efits for other dissection techniques as core components of
neurosurgical capability. With progress in endovascular ther-
NEUROSURGERY
TRAINING IN MICROVASCULAR SURGERY
apy, aneurysms referred for surgical treatment tend to be
more complex. Bypass procedures offer an excellent way to
maintain circulation if parent artery sacrifice is required or to
provide additional collateral flow if prolonged temporary oc-
clusion is needed.
The advantages of this approach lie in its ultimate economy:
there is no need for rodent anesthesia, institutional review
board approval, laboratory technicians, or postoperative an-
giography. Furthermore, after harvest of the graft, the residual
specimen can be eaten!
H. Hunt Batjer
Chicago, Illinois
T he author presents a novel training model, involving the
artery of chicken wings, for learning microvascular anasto-
mosis techniques used by neurosurgeons mainly for extracranial-
intracranial bypass surgery. He demonstrates the feasibility of
the model for providing arteries approximately 5 to 6 cm in
length and approximately 1 mm in diameter and for allowing
different types of anastomoses. The major advantage of this new
training system is the possibility of learning to manipulate bio-
logical microvascular material that is very easily procured at low
cost. However, one main disadvantage is that the model is he-
modynamically nonfunctional, as the author mentions.
In special cases involving difficult aneurysms or cranial base
surgery, extracranial-intracranial anastomoses become neces-
sary. Because these cases are rather rare, most neurosurgeons do
not routinely use the anastomosis technique. I agree with the
author that constant training is required to hone already acquired
microvascular skills and that the model he suggests might be an
appropriate training system for neurosurgeons. However, diffi-
cult aneurysms or cranial base tumors should be treated in
specialized centers, where extracranial-intracranial bypasses are
performed on a routine basis. This model might be appropriate
to train subspecialists in the specialized centers as well.
Gabriele Schackert
Dresden, Germany
T he author describes a unique microvascular anastomosis
training method using chicken wings, which can be pur-
chased as food at any supermarket. Unfortunately, the patency of
the anastomoses cannot be confirmed, because this training
method does not use experimental living animals. Some nonbio-
logical tube materials that exhibit wall compliance similar to that
of experimental animal vessels are now available. I agree that
technical training for microvascular anastomosis is essential for
the clinical practice of neurosurgical procedures.
Nobuo Hashimoto
Kyoto, Japan
T he author introduces a nice method for practicing anasto-
mosis procedures using a chicken wing artery. The indi-
cations for microarterial anastomosis are rather limited but, as
the author mentioned, it is quite an important procedure for
vascular surgery or even tumor surgery. The author presents
VOLUME 52 | NUMBER 6 | JUNE 2003 | 1497
 HINO

a unique material, i.e., chicken wing artery, for practicing
anastomosis procedures. It is an ideal material because it is
cheap, convenient to manage, and easy to obtain; furthermore,
it is a living material. Although the hemodynamic patency of
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it is expensive and difficult to find anatomic substitutes that
reproduce the conditions for human superficial temporal
artery-to-middle cerebral artery bypass. A commonly used
model is the rat femoral or carotid artery, which requires

the anastomoses cannot be confirmed, surgical procedures can approvals and also maintenance of anesthesia. The one
be adequately practiced with this material. drawback in contrast to the rat model is that true blood flow
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Shigeaki Kobayashi cannot be reestablished to evaluate the quality of the anas-

Kazuhiro Hongo tomosis. Cannulating the arteries and establishing flow
Matsumoto, Japan with saline or substitute blood solutions would be a good
alternative.

T he author describes the use of an artery found on easily

available chicken wings for surgical training in micro-
vascular anastomosis techniques. As the author points out,
David W. Newell
Seattle, Washington
N6UIJoHU/fzMAptn on 03/30/2023

Left, sagittal drawing depicting the path of the steel orbitoclast used in the transorbital lobotomy of Freeman and Watts (from, Freeman W, Watts JW:
Psychosurgery: In the Treatment of Mental Disorders and Intractable Pain. Springfield, Charles C Thomas, 1950, ed 2, p 52). Right, the leuko-
tomes and the orbitoclasts in the case that Freeman carried in his suit jacket pocket (from, Valenstein ES: Great and Desperate Cures: The Rise and
Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York, Basic Books, Inc., Publishers, 1986).

1498 | VOLUME 52 | NUMBER 6 | JUNE 2003 www.neurosurgery-online.com