Principle of
Microsurgery
Dr. Nyein Chan Aung
Supervised by Prof: Dr U Soe Naing
Presentation outline
Introduction
Instruments and their principles
Critical points in suturing in microsurgery
Take Home message and Summary
INTRODUCTION
• The term microsurgery was coined in a paper on experimental anastomosis
of 1- to 2-mm vessels at the American College of Surgeons meeting in 1960
by Jacobson and Suarez.
• Microsurgery today cannot rightly be called a separate specialty, because the
techniques it involves cross the boundaries of many surgical specialties —
from obstetrics to otolaryngology.
• In fact, anyone with reasonable technical ability can perform
microsurgery, given three prerequisites:
(1) suitable magnification
(2) appropriately sized instruments and suture material
(3) initial training and subsequent practice
- to establish the hand-eye coordination and
- to handle delicate tissues, instruments
Loupes
• the usual working distance is about 16
inches (to avoid neck pain)
• magnification of 2.5× is widely used
• suture placement is more precise with
the higher magnification
• Higher-power (3.5× to 4.5×) loupes are
much heavier than the lower-power
ones and are usually much more comfortable
mounted on a padded headband rather than
eyeglasses.
Arm, Table, and Chair Positioning
• The most important factors in avoiding
fatigue, frustration, and tremor are
positioning and comfort. (Acland)
• feet flat on the floor and
• the hips and knees at approximately right
angles.
• Chairs with armrests and backs are available,
and in protracted procedures (multiple digital
replantations) these can decrease fatigue.
The level of tremor increases as the level of
lack of support increases up the arm.
An unsupported hand will lead to a relatively
small tremor, whereas unsupported forearms
will lead to a rather gross tremor.
FIGURE 44-4 Incorrect position rapidly leads to
fatigue, poor coordination, and poor results.
A, the chair is too high, causing back and arm strain
B, the seat is too low and the arms are unsupported.
Microsurgical Instruments
- Essential features in all microsurgical
instruments include
- fine tips to spread, hold, or cut
delicate tissue and suture;
- a non-reflective surface; and
- comfortable handles that close
easily to prevent fatigue.
- Most micro-surgeons learn with No. 3 and
No. 5 jeweler's forceps and short scissors and
needle holders.
• Many modern instruments are longer (16 to 18 cm) than in
the past and counterbalanced.
• easier to use than older, short instruments
• rest in the first web space and their increased weight is equalized
by the counterbalancing.
• Likewise, many older instruments are flat, whereas many
modern instruments have rounded handles.
• allows much more precise and easy manipulation of the
instruments with the fingers, which are essential and frequent
motions in microsurgery.
Forceps
1. Adventitia forceps having a small-toothed end are useful during the initial dissection of
small vessels and nerves and for repair of tendons under loupe magnification.
2. Smooth-tipped forceps are used the most in microsurgery and can range from a 1-mm
wide tip to very fine tips for vessel dilation.
3. Tying forceps have a broader grasping area and blunter tips than jeweler's forceps. These
types of forceps are the most popular in use today.
Scissors
• Straight and curved scissors are available, both with blunt or sharp
tips.
1. Blunt, curved designs are most useful for dissection of vessels and nerves.
2. Straight scissors are used for circumcision of adventitia and freshening the
ends of vessels and nerves.
Clamps
• the correct clamp is important to minimize damage to the vessel wall
In general, clamps are divided into use on veins or arteries.
• Venous clamps require less closing pressure because of veins' thin walls,
whereas arteries require slightly more force.
• The venous clamp has a flat jaw all the way to the end.
• The arterial clamp has a very small lip at its tip, which keeps the clamp from
crushing the vessel wall
Background
• Thin sheets of plastic background material (available in several colors) are
used by some surgeons to enhance the surgeon's view of the vessel and
sutures and to isolate the vessel from the surrounding tissue and blood.
• Models with a mechanism for suction incorporated into the sheets have
been introduced.
Irrigations
• For irrigation of the vessel, lidocaine or other pharmacologic substances
are used to decrease spasm.
• Once the vascular anastomoses are complete, warming the digit or flap
can be helpful.
• Warm solution should never be placed on tissue without blood flow (an
amputated digit or flap), because warmth increases metabolic demand and
can decrease the tolerance to ischemia.
Sutures
Take Home Message!
Thank you!!!
