D R G AV I N A S H R A O

FELLOW IN HAND &

M I C R O S U R G E RY
SKIMS, SRINAGAR

PRINCIPLES OF
 Microsurgery
 Definition
 Surgery utilizing
magnification and
small, handheld
instruments and
sutures to correct
defects in small
&/or delicate tissues
 INTRODUCTION

  Two main purposes of microsurgery are to transplant tissue from one

part of the body to another and to reattach amputated parts.

 It is incorrect to state that microsugery is simply a general term for

surgery requiring an operating microscope

 It is based on the fact that the human hand, by appropriate training, is

capable of performing finer movements than the naked eye is able to see.

 Magnification is a tool to lessen the effects of compromise in treatment

modalities

 The term MICROVASCULAR SURGERY was coined by JACOBSON

Microsurgical techniques include nerve and blood vessel repairs
and grafts, free tissue transfers, limb replantation, and composite
tissue allotransplantation.

Technical expertise, Preoperative planning and Post-Operative

monitoring are also critical in achieving a successful microsurgical
reconstruction.
 HISTORY
► 1590- Invention of compound microscope by Zacharia
Janseen
► 1889- First successful end-to-end arterial anastomosis by
Jassinowski  in sheep.
► 1897- First vascular anastomosis by J.B.Murphy in
humans
► 1902- End to end anastomosis by 3-stay suture technique by
Alexis Carrel.
► 1965- First digital replantation by Tamai
► 1968- First successful toe to thumb transfer by Cobbett
► Guthrie and Carrel - inclusion of the INTIMA in repair laid the
foundations for standardization of anastomotic techniques.
► 1912 - Carrel – (Nobel Prize in Medicine and Physiology), First
described the technique of placing triangulating sutures to
ensure equal traction on the blood vessels being anastomosed.
► 1968- First free flap in Bombay,India by Antia and Buch (Use of
dermatolipomatous groin flap to fill a facial defect).

► 1970- First completely successful free flap operation in

Oakland,California by Mclean and Buncke.

► 1973- First composite flap (groin flap) by Daniel.

 PRINCIPLES OF MICROSURGERY

 As a treatment philosophy, microsurgery incorporates three

important principles:

1.Improvement of motor skills, thereby enhancing surgical ability.

2.An emphasis on passive wound closure with exact primary

apposition of the wound edge.

3.The application of microsurgical instrumentation and suturing to

reduce tissue trauma.
MICROSURGICAL TRIAD
To do a job….you need the right tools
 Microsurgery
 Differs from traditional surgery
in:
 Surgeon position

 Magnification

 Specialized
instrumentation
 Suture and needle size
 EQUIPMENT FOR MICROSURGERY

 Good quality instruments – prefer own instruments

 Old wornout, battered instruments – not even suitable for

Lab training.
 Spring tension – appropriate.

Weak – closes early – hold the instrument gently with tips 1-

2mm apart and pronate forearm such that instrument is
upside down – falls down.
Firm – fatigue of thumb muscles – hold the instrument gently
closed for 10 min.
Jewellers forceps
 Straight pointed no.3 – non dominant hand for tissue
handling and suture tying.
 Tip precision – 1/1000 = diameter of 10.0 Nylon.
 Jaws should meet over 3mm (not only at tip)– easy
thread pickup
Angled jewellers forceps
 Reaching under vessel, tying knots, doing patency
test.
 Rest same as straight jewellers.
 Needle holder
 Round handled, fine, fully curved jaws with a lock.
 Look for open gap at the at the point jaws closes
completely – thread traps.
 Vessel dilator
 Modified jewellers forceps
 Slender, smoothly polished, non-tapering tip.
 Used for dilating vessel, counter pressure for suturing.
 Dissecting scissors
 Spring handled with gently curved blades, lightly round at
the tips.
 Rounded tips are important – enable to dissect closely
along a vessel with out perforating it,
 Adventitia scissors
 Trimming adventitia off the vessel end.
 A pair of Fine straight, sharp pointed tip microscissors.
 Vessel clamps

 Collection of clamps required.

 One comparatively large sliding approximator clamp with built in

suture holding frame.

 A smaller plain approximator clamp

 Two small single clamps – small gentle jaws.

Larger – 11mm – harmless on vessels between 1.5 and 0.7 mm diameter

Smaller – 8mm – less closing force for vessels between 1.0 and 0.4mm.
 Clamp applicator forceps.
Closing pressure (gms), area of vessel wall compressed by clamp (mm2)

 Good clamp – Recommended closing pressure – 5-10gm/mm2 – large

vessels and 15-20 gm/mm2 on smaller vessels.
 For every vessel there will be two suitable clamp sizes – smaller clamp is
recommended to use.
12 5gm/mm2
10
8 10gm/mm
2
6
4 15gm/mm
2 2
0
B1 B2 B3 HD RD
 Non microsurgical instruments.
 Autoclavable Instrument case.
 Hemolytic emzyme solution – contact time of 30 min - best to clean

microinstruments.
 Small fine flat jawed pliers – minor adjustments tip of jewellers.

 Instrument demagnetizer – simple hollow electric coil connected to

the regular AC supply – place instrument inside – swith on current –

slowly withdraw till it is 60cm away- then swit
 Sutures – flat bodied microvascular needles on 10.0 nylon. ch off

current.
100 microns needle – basic exercise.
75 microns needle for advanced exercise.
AVOID round bodied needles – difficult to control.
 Magnification

 OPERATING MICROSCOPE

 MAGNIFICATION LOUPES-
 Microscope
 Zeiss – Good Optics.
 Best focal length for objective lens is 200mm for normal
height, 300mm for very tall persons for better working
position
 Best eyepiece magnification is 12.5X.
 200mm + 12.5X gives magnification range between 4 to 20.
 Full floor column, adjustable supprt arm, foot controls,
inclinable eyepiece – in newer scopes – required.
 Floor mounted / Ceiling mounted / Table mounted / Portable
 Care of microscope
 Clean outer glass surface of eyepiece and objective lens
each time – with lens tissue.
 Cover after use.
 Careful handling while moving.
Optical head has
 Primary surgeon
 Beam splitter
 Assistant surgeon
 Video attachment
OPERATING MICROSCOPE - Features

 Coaxial illumination.
 variable magnification
 motorized continuous zoom
 motorized focus
 motorized X-Y axis
 Foot controls adjust light, magnification, zoom, focus and X-Y
axis
 Allow multiple surgeons
 Floor, table or ceiling mount
 Additional attachments
 Operating Microscope
 magnification from 5-40x
 magnification of 5-20x is generally
sufficient.
 Increased cost and maintenance
 longer surgical setup time
 less intraoperative positioning flexibility
 less portability
 Prior to surgery

 Center the X-Y axis

 Lowest magnification, Zero the fine focus.
 Adjust the gross focus manually
 Adjust the interpupillary distance
 Adjust the chair and table height
 Ensure the surgeons view and the video view are both in focus Verify at the
highest magnification to be used.
 Position all foot pedals where they can be reached
 Microscope pedal goes to the non- dominant foot

 Know Where All The Foot Pedal Controls Are Before Starting Surgery
 When seated, adjust gross focus by hand, not foot pedal.
 AT THE START OF SURGERY

 Surgeon is seated comfortably

 Feet reach the pedals
 Back is straight
 Arms at 90 degrees
 Lean slightly forward
 Arms on armrests
 Hands positioned and supported
 Rest on the ball of the hand or extend 5th finger for support
 Turn off room light and on microscope light
 PREOP CHECK LIST

Adjust table height

Adjust chair height
 Adjust microscope height
Adjust chair arm rest position
Set microscope fine focus to neutral Center X-Y axis
Adjust microscope tilt
Adjust interpupillary distance
Set microscope to highest magnification to be used
Adjust focus of oculars
Ensure video and assistant images are also in focus
Return microscope to low magnification Place foot pedals to be comfortably accessible
 Surgeon Position
 Surgical Position
 Seated
 Specialized chairs with
armrests
 Arms resting on armrest
 Essential for fine motor control
 Surgical Position
 Seated
 Specialized chairs with
armrests
 Arms resting on table
or armrest
 Essential for fine motor
control
 Able to adjust height
Positioning of hand
 Arm - Rested, Elbow, Wrist, Ulnar border of hand
on table, forearm supinated a little.
 Three digit grip – IF, THUMB, MF.
 MF – rest firmly on the working surface either
directly or via RF.

PULP TO PULP PINCH

 Instrument Handling
 Delicate, precise
movements
 Finger movements only
 Pencil grip
 Arms on arm rests
 Elbows and wrists
locked
Simple Loupes

 one pair of positive meniscus lenses

 limited by spherical aberration and color fringing
 plastic construction
 fixed interpupillary distance
 very short working distance
 poor surgeon body and arm position
 strain on the surgeon’s neck and back.
 POOR CHOICE
 Galilean Loupes
 up to 2.5x magnification
 multiple lenses to offer magnification
and are generally lightweight and less
expensive
 adjustable interpupillary distance
 working distance varies
 Prismatic Loupes

 up to 8.0x magnification
 ≥5.0x a microscope is preferred
 highest optical quality
 series of lenses and prisms to magnify the subject
 similar in principle to low-power telescopes
 greater magnification As magnification increases
 they become long and
 sharp resolution heavy
 Shallow depth of field
 greater depth of field
 Head movements
 heavier and more expensive make use difficult
(>5X)
 Magnification – purpose:

 Provide an improved view of the tissues

of concern

Will vary by tissue of interest

 Allow a comfortable working distance
for the surgeon

Back straight, arms at 90 degrees

 Facilitate adjustment of the
interpupillary distance to suit the
surgeon
 Permit a wide field of view
AS MAGNIFICATION INCREASES
 The field of view and depth of field decrease
 At 3.5X - field of view is 50mm and depth of field is
2.6mm
 At 20X - field of view is 10mm and depth of field is
0.4mm
 Magnification
 Beginning surgeons should
start with magnification
early as part of their basic
training
 Will improve their tissue
handling and appreciation
for tissue trauma and wound
apposition
FIRST THING FIRST – PRECONDITIONS FOR
SUCCESS
 Uninteruppted Surgical training.
 Adequate sleep.
 Diengage from Clock and Telephone.
 NO MAGIC for success – dedicated Practice – as Margin of
error is measured in thousandths of an inch.
 If Some thing is wrong – Donot Struggle ON – Figureout
First and then Proceed.
 Avoid Cigarette Smoking, Coffee before Surgery, Strenous
manual exertion like weight lifting / playing tennis etc
(Causes tremors).
 Take a Break – When the advise is given – not to resist it.
 Surgeons must have a plan to achieve the goal, But must also
be adaptable and familiar with more than one technique, so that
obstacles encountered during the surgical procedure may be
overcome.
 Not all surgeries proceed according to the plan.
 We may all travel a different route and method.
 We get there in various ways, BUT…..we all get to the SAME

DESTINATION
 Regardless of our individual variations, we must all follow the BASIC RULES:

 To Use Appropriate Magnification And Instrumentation

 To Be Efficient And Precise
 To Ensure Minimal Tissue Trauma
 To Minimize Surgical Time
 To Obtain Excellent Tissue Wound Apposition With The
Smallest And Most Appropriate Suture Materials
 To Achieve A Successful, Comfortable, Cosmetic Outcome
EXIT PUPIL – OPTICAL AXIS
 Exit pupil
 Lies in mid air at short distance of 15mm from eye piece.
 Diameter of exit pupil is 2mm and pupil in normal light condition is
3mm.
 The exit pupil must sit right in the middle of the hole in iris, that is
pupil – for circular field of vision.
 Movements even by a millimeter changes circular field to eclipse.
 Position eyepiece at 500 angle to the horizontal for better longterm
comfort. (very tall near to 60, very small near to 40)
 Handling needle holder and suture
 Lift thread with forceps in left hand till the needle dangles and
just rest on surface – rotate thread accordingly to position
needle direction.
 Needle is to be setup at 900 to the needle holder tip.
 Needle tip should point horizontally not up / not down – hold at
the middle of needle.
 Needle holder is held with tip pointing away – towards left for
right handed.
 Passing Needle through the tissue
 Needle should pass perpendicular to tissue surface.
 Evert tissue edge before passing needle – place forceps
underneath, near to the needle placement and evert tissue –
never grab full thickness.
 Needle should come out of the other side perpendicularly –
counter press to the needle is given from outside side with
forceps near the exit point.
 Width of bite from tissue edge – 3 times the thickness of
needle.
 Pull thread in straight line, drop the needle.
 Short end of thread should be at least 3mm.
 Knot tying
 Pick the long thread with left hand forceps.
 Turning it into loop over needle holder.
 Now Picking up short end.
 Completing first half knot
 Then second half knot
 Use third extra half knot also for safety.
 Cut short end first and discard it.
 Then hold long end and cut it after needle come in view.
 Surgeons knot with a double throw – overcomes natural
elastic retraction of tissue (Tension free repair).
 MICROVASCULAR
SURGERY
1. Gentle handling of
tissues
*Avoid grasping the ends of
the vessels to be
anastomosed
*Grasp only a small
quantity of loose
periadventitia
 2. ADEQUATE DEBRIDEMENT

► Inspect under high

power for signs of
damage
► Debride until no signs of
vessel damage
► Strong pulsatile flow of blood
after adequate debridement
 3.SPASM

► Trauma is blamed for the reason of spasm

► Two main factors for spasm
- cold
- contact of outside wall of vessel with freshly shed blood
 RELIEF OF SPASM

► Mechanical dilatation

► Hydrodistention of the vein graft

► Moist gauge soaked in warm saline

► 1% lignocaine spray – contact time 3 min – after dilation wash

 4. SIMILAR DIAMETER OF
VESSELS
Vessels with dissimilar
diameter of upto 50%
can be anastamosed
satisfactorily
► Small vessel is dilated
and divided obliquely
(not >300 to give
adequate symmetry

► When the size

discrepancy is much
greater, an
interposing vein graft
is used
 5. TENSION-FREE
ANASTOMOSIS
► Apply an adjustable approximating clamp to bring the vessel
end together for convenient suturing

► Never apply clamp with excess tension

► Avoid any kinking or twisting of the vessels distal to the

anastomosis

► Avoid inverting cut end of vessel wall during anastamosis -

THROMBOGENIC
 6. CORRECT SUTURE TENSION
► Not too tight or too loose sutures

► Too tight sutures

Avoided by a
small “suture
circle” at the end
of three ties.
7. APPROPRIATE SUTURE SPACING:

-Goal is to achieve an ultimately leak - free

anastomosis with as few sutures as possible

8. RECHEK OF ANASTOMOSIS:

-All anastomosis are rechecked prior to the final skin

closure
 8 CHOICE OF RECIPIENT
VESSELS
► Use of healthy vessel of reasonable size with good outflow is
the key for success

► Pre-operative assessment - caliber and injury during dissection.

► Mobilisation of vessels – for tension free repair.

 DISSECTION TECHNIQUES
► Hemostasis – must
*Torniquet
*Vascular clips
*Bipolar coagulator

► Avoid perivascular hematoma

► Irrigation – moisten tissue every few minutes with RL, mop

excess with sponge.
 Avoid damage – on dissection
 DONOT - work in a field obscured by blood.

- work out of focus.

- cut when you cant see.

- hold scissors at wrong angle.

- grab full thickness of vessel wall.

 Grab vessel with its outer layer – adventitia

 Divide adhesions b/w adventitia and vessel wall – tease the adventitia
before cutting with round microscissors – to see cut end of tunica media.

 Cauterize any branching of vessel with bipolar at a distance away from main
Preparing the vessel ends
 Get the blood out – RL Flushes
 Remove the adventitia – to see media.
 Dilate vessel ends – relieve spasm. And to handle

easily during repair.

This will determine the quality of anastamosis to a

larger extent
Background –
1mm Grid Lines - Provides an accurate measuring tool for the
surgeon
Available in Blue, Green or Yellow - Best contrast
Non-Reflective Surface - Eliminates glare from OR lighting
Radiopaque Silicone Material - Can be seen under X-Ray if
needed
 TECHNIQUE OF ANASTOMOSIS
1.Resection to normal
-
vessels:
Resect proximal to areas with
microscopic signs of
vessel damage with fine,
straight, sharp scissors in
a single motion
Demonstration of forward pulsatile flow prior to clamping
2. Clamping of vessels:
- With double approximating
clamp leaving generous length
of vessel end for ease of
working
- Tips of the jaws should project
just beyond the vessel for
maximal grip
Incorrect vertical position
Incorrect horizontal position
3. Positioning: -Correct position of the clamp is
horizontal and parallel to the operator
 4. Final Preparation of vessel ends:
► Resect sufficient periadventitia,
flush with the underlying vessel
nd
to expose 2-3 mm of the vessel
wall for suturing
► If the lumen is small
or in spasm, gently
dilate it with vessel
dilator

dr sumer yadav (mch nd nstructive

► Irrigate the lumen with
solution of heparinized
saline (1000 units per 100
ml).
 5. SUTURING
► End to end / End to side - depending on type of anastamosis
► Full thickness of wall
► Size of the suture material – 10.0 Nylon
► Number of sutures – 8 stiches for 0.7 – 2 mm vessel diameter
sufficient
► Distance between sutures – equidistant – good enough to
prevent leak.
► Arteries- more sutures than veins
► Pass the needle at right angles to the wall at a distance from
the margin slightly greater( 1-2 times for arteries, 2-3 times
for veins) than the thickness of the vessel wall
► Make sure that the posterior wall is not accidentally cought
► For last 2-3 sutures: Modified Harashina technique
► For thick walled arteries
and large diameter
collapsible veins- use
180 degree halving
method ( first suture at
150 degree position and
second suture at -30
degree
For thin walled vessels,
use 120 degree
triangulating method for
key sutures (First suture
at 150 degree position
and second suture at
+30 degree position)
 6.RELEASE OF CLAMPS
► The distal clamp is released first

► If any major leak, reapply the clamp, irrigate and insert

additional superficial thickness sutures

► Now release both the clamps- usually small amount of blood

leaks from anastomosis, but stops after a few min. with the
application of sponges
 VENOUS ANASTOMOSIS
► Veins are thinner, flatter and more difficult to anastomose
► Use ringer’s solution to float or irrigate the vessel
► Deeper bites
► More sutures
 ALTERNATIVE ANASTOMOSIS
TECHNIQUES
1. BACK-WALL FIRST (ONE-
WAY UP) TECHNIQUE

-This technique is safest

because the entire inside of
the anastomosis can be
visualized until the very last
few sutures are placed
 2. FLIPPING TECHNIQUE

When free flap, digit or vein graft is fixed fo mobile vessel, it can
be flipped to expose the back-wall for repair, as rotation is not
possible
 3. CONTINUOUS SUTURING
► Acceptable patency rates ( 92% for arteries, 84% for veins)
comparable with interrupted sutures
► Advantages: Quicker and more hemostatic
► Disadvantages:
* Potential for creating purse-string constriction at the site of
anastomosis
* Entrapment of the suture material in the clamp
* Breakage of the suture

► So less favourable
 4. SLEEVE ANASTOMOSIS

► Microanastomosis of
vessels in 1 mm external
diameter range can be
accomplished by means of
invaginating technique
with fewer sutures than the
end to end method of
closure
► Advantages:
- Quicker
- Less intraluminal suture exposure
- Less vessel trauma owing to fewer sutures

► Disadvantages:
-Patency rate is significantly less than that
achieved by the conventional end to end method, so it
is not superior in clinical situations
 END TO SIDE ANASTOMOSIS
► Indications:
*To preserve patency of the recipient vessel in lower
limb,esp. in elderly patients, where sacrifice of a major
vessel can have a serious effect on the distal blood flow
*Considerable size or wall thickness, mismatch between
the vessels
Steps of end to side anastomosis
► Advantages:
-Search for recipient arteries is simplified
-No. of possible sites to which free flaps can be transferred
is greatly increased
 Signs of Patency

 Expansile pulsations – increase and decrease in diameter of

vessel distally with each pulsation – patent
 Wriggling – change in curvature of vessel distally with each beat
– patent
 Longitudinal pulsations – conentrared over particular point –
along long axis – hammering against a partial / complete block
 False wriggling can be seen with longitudinal pulsations – lift
anastamotic site with suture thread.
 PATENCY
► Return of colour

► Capillary oozing and venous bleeding from the

revascularized tissue

► Direct inspection under the microscope

► Uplift test & Empty and Refill test

Uplift test
 Empty & Refill
test
► This is traumatic and is performed as gently and infrequently as
possible
 Modified Uplift test – Vein patency

 Curved forceps beneath vein distal to anastamosis – lift it up till

occluded – move it along proximal in downstream direction –
going past anastamotic site.

 Patent – vessel fills up behind moving instrument.

 Blocked – distally dilated with negative filling test & with time
blood in vein becomes dark.
 Practical points on blood.
 Undamaged vessel wall secretes anticoagulants – so uncontaminated
blood in undamaged vessel remain liquid for several hours.
 Blood inside a vessel will not clot unless – the vessel is damaged /
blood contaminated with thromboplastins
 Blood that is in open contact with the wound should never be allowed
to stand still in a vessel unless heparinized irrigation fluid is present.
 Wise to leave the vessel alone and run for 20 min – after dissection &
20 min after anastamosis.
 ANASTOMOTIC FAILURE
A) TECHNICAL ERRORS:
1. Tearing
2. Leaking
3. Narrowing
4. Through-stitching
5. Inclusion of adventitia

B) Poor flow from proximal vessel due to undetected damage

more proximally or vasospasm
C) A clot or thrombus at the anastomotic site or in an area where
a clamp was applied

Damage to endothelium from

+ Excessive clamp pressure

+ Poor technique or
-
+ Contamination
 Prevention:

+ Flushing of the suture line with heparinized solution

+ Systemic heparin (40 u/kg before completion of anastomosis
and release of clamps)
 REVISION OF THE FAILED
ANASTOMOSIS
► If the patency test reveals slow filling of the distal vessel,
revise the anastomosis, carefully keeping original
problem in mind

► Insert a vein graft, if the vessel length is insufficient

*Poor proximal flow that does not respond to local vasodilator
and warming may require:
Proximal exploration of the vessel

Dilatation along a proximal length of vessel sufficient to relieve

vasospasm
 FACTORS INFLUENCING
FAILURE OF
ANASTOMOSIS
A. TECHNICAL:
► Both walls sutured together
► Traumatic vessel handling
► Apposition of vessel edges
► Disproportional vessel size
► Tension at suture line
► Excessive clamp pressure
► Kinking of vessels
B. REPERFUSION FAILURE:

► Blood turbulence

► Spasm

► Hypercoagulability

► Acidosis

► Cold

► Hypovolemia

► Vasoconstrictors
C. POSTOPERATIVE CARE:
► Infection
► Acidosis
► Cold
► Limb position
► Environmental factors
POST-OPERATIVE MEASURES
► Oxygen administation

► Bed rest or limited movements for 3 to 5 days

► Warm room

► Limb elevation to decrease the venous congestion

► Fluid administration

► Pharmaotherapy – anticoagulants
► Adequate analgesia

► Limitation of visitors and telephone calls to decrease the

emotional stress

► Prohibition of smoking, caffeine and chocolate

because they may cause vasoconstriction