This document provides an overview of microvascular surgery principles including:
- Preoperative evaluation of patient medical status and vascular supply
- Microvascular surgery equipment such as microscopes, instruments, and sutures
- Recipient vessel analysis and preparation techniques
- Various anastomosis techniques including end-to-end, end-to-side, and sleeve methods
- Suturing techniques like interrupted, continuous, and mattress styles
- Anastomotic devices that can be used instead of sutures such as rings, pins, clips, and tubes.
flaps in surgery slideshare
plastic surgery
cosmetic surgery
African experience
NIGERIAN SURGERY
HISTORY OF FLAPS
medicine
medical school
burrows triangle
rotational flaps
transpositional flaps
Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
flaps in surgery slideshare
plastic surgery
cosmetic surgery
African experience
NIGERIAN SURGERY
HISTORY OF FLAPS
medicine
medical school
burrows triangle
rotational flaps
transpositional flaps
Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
What is MIS?
A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these struct uresIncludes laparoscopic, endoscopic, and other approaches.
Why MIS?
Decreased patient pain
Decreased patient recovery period
Possible decrease in inflammatory response in the patient which may prove to have a better outcome in oncologic operations.
Distant future
In the distant future, there will be a para- digm shift with the development of non-inva- sive surgical techniques in combination with nanotechnologies and a new era in the devel- opment of surgery, and subsequently in surgi- cal techniques, will be opened.
Nanotechnology is an umbrella term for materials and devices that operate at the nanoskill (1 billionth of a meter). In terms of scale, a nanometer is approximately one 1/8000 of a human hair or 10 times the diam- eter of a hydrogen atom. The size of the device can vary but starts from a ten thou- sand-logic element system that will occupy a cube of no more than one hundred nanome- ters. This is a volume slightly larger than 0.001 cubic microns. This would be sufficient to hold a small computer. For example, if red blood cells are approximately eight microns in diameter, the 100 nanomicroprocessor will be 80 times smaller than a red blood cell. Devices this size could easily fit into the circulatory system and could even conceivably enter indi- vidual cells.
It has not changed the nature of disease
The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise
If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.
We actually do not know what is there stored for us, but we believe that laparoscopy is trending towards advancement and nano and robotic technology is going to replace in future.
3D cameras have come into existence and various newer technologies are being invented.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
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Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
A Strategic Approach: GenAI in EducationPeter Windle
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This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
How to Make a Field invisible in Odoo 17Celine George
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Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Macroeconomics- Movie Location
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Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
3. DEFINITIONSMICROSURGERY:
In 1979, DANIEL RK = any surgery
performed under magnification. Further
includes: - microvascular
microneural
microlymphatic
microtubular
3
5. 5
HISTORY
• Pare in 1552 = described possibility of vascular repair.
• J. B. Murphy, 1897 = first described the vascular anastomosis.
• Alexis Carrel, 1902 = performed the first anastomosis.
Plastic Surgery. McCarthy 2nd ed vol I.
6. 6
• Antia & Buch performed the first free flap transfer for facial
defect in BOMBAY, INDIA.
• But the first report for a free flap transfer in human was
published in 1970 by Mclean & Buncke.
Plastic Surgery. McCarthy 2nd ed vol I.
8. VASCULAR
STATUS Factors to be assessed carefully –
1. deep vein thrombosis
2. varicose veins
3. previous trauma or fractures
4. peripheral circulation
5. peripheral vascular disease
8
9. 9
Investigations may include –
• Allen test (in RFFF)
• Pulse oximetry
• Color-flow Doppler
• MRI angiography
If there is any major concern about vascular supply then an
alternative donor site should be considered.
10. Patient’s Medical status
Patient age,
Smoking
Alcohol consumption
Prior radiation therapy &
operative procedures
10
Risk factors for free flap failure: a retrospective analysis of 881 free flaps for head and neck defect reconstruction
Int. J. Oral Maxillofac. Surg. 2017; 46: 941–945
12. Operating room setup
Use a 2 team approach
Create working space around the head and neck.
Use 2 electrocautery systems
Warming blanket covers the torso and the
opposite limb
Proper height of the table/chair while raising the
flap
12
14. SURGICAL MICROSCOPES
YEAR 1800 – CARL ZEISS(German
Machinist)
YEAR 1920 – CURL NYLEN
( SWEDISH OTOLOGIST) – designed first
surgical microscope.
YEAR 1950 – ZACHARIAS JANSSEN –
developed Compound microscope
14
Plastic Surgery. McCarthy 2nd ed vol I.
15. 15
MICROSCOPE(greek) = mikros(small) + skopien(to view)
ADVANTAGES:
1. 40x zoom
2. Easily adjustable
3. Same field view
4. Can be videotaped
DISADVANTAGES:
1. Big and clumsy
2. Limit surgeon’s choice of position
3. Expensive
17. Body position:
Seat Legs Head & upper body
Forearms Do not lean on elbow
Hand position:
use 3 point stabilization – Elbow, Wrist, Finger
Microscope position
Eyeglasses
ONLY FINGERTIPS MOVE IN A WRITING POSITION
17
SETTINGUPA MICROSCOPE
Microsurgery essentials: preparation. Plastic Surgery, Stanford Medicine
18. 18
MAGNIFYING LOUPES
First time - German physician Saemisch in 1876
TYPES:
1. COMPOUND(Galilean) 2. PRISMATIC(Wide Angle)
Plastic Surgery. McCarthy 2nd ed vol I.
20. TIPS FOR USE:
DISSECTION OF FLAPS – 2.5X
ANASTOMOSIS – 3.5X or 4.5X
WORKING LENGTH – 12-20inches
20
Plastic Surgery. McCarthy 2nd ed vol I.
21. MICROSURGICAL
INSTRUMENTS
21
1. weight must not exceed 15 to 20 g
2. must be at least 10 cm long.
3. closing pressure should lie between 50 and 60 g
4. vascular clamps must exert an evenly distributed pressure The
jaws must lie parallel with each other.
Peterson’s Principle of oral and maxillofacial surgery. 2nd & 3rd ed.
22. 22
SCISSORS NEEDLE HOLDERS
Spring loaded
DISSECTING SCISSORS: have
rounded tip and curved blade
ADVENTITIA SCISSORS: have sharp
tip and straight blades
Spring loaded
should be held like a pencil with
pulp to pulp pinch.
End of the instrument is supported
by thenar web.
23. FORCEPS
JEWELER’S FORCEPS – designed by
SWISS DULMONT FACTORY
Have flat handle, sharp narrow tips
Mainly used in non dominant hand
Types: no 2, no. 5, no. 7
23
24. CLAMPS JACOBSON – 1st use of bulldog clamps
ACLAND IN 1974 – developed a device
with 2 clamps incorporated with a
sliding bar
24
27. MICROVASCULAR ANAESTHESIA
to provide adequate perfusion of
transplanted tissue
minimize any morbidity associated with
prolonged surgery/anesthesia
27
BASIC TARGETS
PERIOPERATIVE
ANAESTHESIA
28. WARMING
Maintain normothermia with active
warming(solution heaters, blanket with
forced hot air)
Central and peripheral temperature must
be monitored
the room temperature must be increased
to 22°-24°C
28Alexander’s Care of the patient in Surgery 15th ed
29. POSITIONING
prevent hypothermia
eyes should be protected
thromboembolic prophylaxis
pneumatic compression stockings is
recommended
or if possible
passive mobilization of the limbs several times
during surgery
29
30. meticulous attention to possible pressure points
to avoid –
Pressure sores
Neuropathy
30
Alexander’s Care of the patient in Surgery 15th ed
31. Access and
monitoring
1. Catheterization
2. Invasive arterial pressure(AP) monitoring -
recommended (always with free flap)
3. Central venous pressure monitoring can be used but
not recommended routinely
4. Central temperature monitoring is essential.
5. Peripheral temperature must also be measured
6. Urine output =1 to 2 mL/kg peri- and postoperative
periods
7. Gastric tube should be placed
31
32. TECHNIQUE
1.Use a balanced technique with adequate
analgesia
2.Use of nitrous oxide should be avoided.
Sevoflurane and desflurane are possible
choices.
3.Achieve normocapnia as
hypocapnia – decreases cardiac output
hyperoxia – causes vasoconstriction
32
33. 4. When using microscope, decrease the tidal
volume and increase the respiratory rate.
5. Controlled hypotension is indicated.
33
34. FLUID
THERAPY
1.Hyperdynamic circulation is required
2.Adequate blood pressure with vasodilatation
3.Normovolemic or hypervolemic hemodilution
should be maintained.
4.Fluid administration should be cautious and
guided by signs of ischemia and
hypoperfusion.
34
35. Combination of crystalloid and colloids is
generally appropriated, guided by urinary
output of at least 0.5 mL/kg/hr.
1. Try limit the use of crystalloids
2. Synthetic colloids can be used
3. Try avoiding gelatins
4. Dextrans as plasma substitutes
5. Hydroxyethyl starches
6. Hypertonic saline solutions
7. Blood transfusion
35
38. 38
RECEPIENT VESSEL ANALYSIS
In general, for defects located in the –
Upper third of the head - superficial temporal artery(1.9-2.2) and
vein
Mid and lower third of the face - the facial artery & vein(1.1-3.7;
1.8-5.8) as well as superior
thyroid artery and vein
Neck - the carotid and jugular vessels & their various branches.
40. 40
1. Vessels - grasped only by periadventitial tissue
2. Visualize - the interior of the vessel
3. Relieve - vessel end spasm if present
4. Vessel end - should be approximated
5. Stumps - irrigate to remove blood clots.
6. Adventitia is then trimmed from the stumps
7. Non adherent sheet is placed as a background
SURGICALTECHNIQUE
41. MICROANASTOMOSIS
Ideally the perfect microvascular
anastomotic technique would be –
1. easy to both perform
2. minimize ischemia time,
3. avoid vessel wall trauma, and
4. provide the best short- and long-term
patency rates.
41
ANASTOMOSING
TECHNIQUES
42. ENDTO ENDANASTOMOSIS
employed for vessels of similar diameter.
Vessels ends are brought together just short of
touching.
Full thickness stay sutures are placed –
2-stay suture technique – sutures at
180degree (12 & 6 O’ clock position)
3–stay suture technique – sutures at
120degrees (10, 2 & 6 O’clock position)
42
43. 43
ENDS OFTHEVESSELS SHOULD NEVER BE GRASPED
BasicTechniques in Microvascular Anastomosis. Facial plastic surgery Volume 12, Number 1 January 1996
44. ENDTO SIDE
ANASTOMOSIS
Utilized mainly – Size discrepancy
IJV is the only vessel
It requires creating a hole in the recipient
vessel. An ellipse is removed matching the
size of the donor vessel
Two stay sutures are placed 180" apart. The
posterior wall is generally repaired first.
44
BasicTechniques in Microvascular Anastomosis. Facial plastic surgery Volume 12, Number 1 January 1996
45. SLEEVEANASTOMOSIS
45
First described by Lauritzen (1984)
Can only be utilized in vessels mismatch
cases
BasicTechniques in Microvascular Anastomosis. Facial plastic surgery Volume 12, Number 1 January 1996
46. SUTURINGTECHNIQUES
1. Posterior-wall-first suture
2. Standard interrupted suture
3. Continuous suture
4. Locking continuous suture
5. Interrupted horizontal mattress suture
6. Continuous horizontal mattress suture
7. Spiral Suture technique
46
BasicTechniques in Microvascular Anastomosis. Facial plastic surgery Volume 12, Number 1 January 1996
47. Posterior-Wall-
First
first described
by Harris and Buncke
47
BasicTechniques in Microvascular Anastomosis. Facial plastic surgery Volume 12, Number 1 January 1996
52. ANASTOMOTIC
MICROVASCULAR
DEVICE
Payr in 1900, introduced an extraluminal
magnesium prosthesis.
the proximal vessel end was passed
through a ring and everted over it.
The proximal vessel end and ring was
then pulled into the dilated distal vessel
end and secured with a circumferential
ligature
52Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
53. In 1960, Holt and Lewis first
described the use of paired
anastomotic rings
ring had six evenly spaced pinholes
and interposed between the holes
were six pins
53Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
54. Nakayama 1962 – presented a ring-pin device
with instrumentation.
device consisted of two metallic rings with
pinholes and pins.
Used for vessels ranging 1.5 – 4mm in outer
diameter and remained in situ
54
55. 55
In 1984, Daniel and Olding described the use of a polyglactin coupler.
In 1999, a Japanese group of investigators published about a pin-ring
coupler with absorbable rings that consisted of L-lactic acid and
glycolic acid
Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
56. Advantages –
ease with handling of friable veins
elimination of any chances of placing
sutures through the back wall
speed of anastomosis
56
57. Staples and
clips
Between 1945 and 1950, inverted U-shaped
tantalum clips with pointed ends were used to
perform end-to-end anastomoses in vessels
ranging from 1・3 to 20 mm in diameter.
1st clinical report came in 1956 from Androsov
57Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
58. Tubes and
stents
first described in 1894 by Robert Abbe
In 1897, Nitze used small ivory tubes for
anastomosis.The vessel ends were slipped over
a small ivory cylinder, after which a ligature was
used to hold them in place.
Later, Blakemore and associates bridged arterial
defects by joining two vessel ends over a tube of
vitallium.
58Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
59. 59
Swenson and Gross, used absorbable fibrin tubes in 1947.
In 1965, Ota and colleagues, used a soluble gelatin stent.
Weiss and Lam usedTantalum stents.
Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
60. OTHER
OPTIONS
1. Adhesives:
fibrin glues: in 1977 by Matras et al
cyanoacrylate(methyl-, ethyl- and butyl
cyanoacrylates, 2-octyl-cyanoacrylate)
2. Welding:
Thermal
laser: introduced in 1979 by Jain and Gorisch
60Non-suture methods of vascular anastomosis. BritishJournal of Surgery 2003; 90: 261–271
61. POSTOPERATIVE
PERIOD
Extubation
It is desirable to have an awake and
cooperative patient
Avoid large pressure variations associated
with cough and agitation
Recovery of consciousness should be painless.
NSAIDs should be avoided at an early stage
61
62. 62
POSTOPERATIVE CARE
Normothermia, Prevent postop shivering
Hyper dynamic circulation.
Normal systolic blood pressure (> 100 mm Hg).
Hematocrit 30% (monitoring in the first 24 h qid).
Urine output >1mL/kg/h
SpO2 > 94% (O2 in the first 24 h).
Effective analgesia.
Periodic flap monitoring
Nutritional support
64. 68
NON INVASIVE METHODS
1. Clinical monitoring (color, capillary return, temperature)
2. Surface Doppler monitoring (using low-frequency
continuous-wave ultrasound
3. Colour Doppler sonography
4. Laser Doppler flowmeter
5. Microlightguide Spectrophotometry
Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques—Part I. Non-invasive
techniques .BritishJournal of Oral and Maxillofacial Surgery 47 (2009) 351–355
65. 69
INVASIVE METHODS
1. Implantable Doppler monitoring (using high-frequency pulsed
ultrasound)
2. The Cook venous Doppler monitoring system
3. Tissue pH
4. Oxygen tension/oxygen partial pressure monitoring
5. Microdialysis
Postoperative monitoring of microsurgical free-tissue transfers for head and neck reconstruction: a systematic
review of current techniques—Part II. Invasive techniques. BritishJournal of Oral and Maxillofacial Surgery 47 (2009) 438–442
71. CONCLUSION
Microvascular surgery is a highly successful
and reliable method for the reconstruction
of large head and neck defects, associated
with a low incidence of free flap failure,
promoting primary wound healing.
75
72. REFERENCES
1. Plastic Surgery. McCarthy 2nd ed vol I.
2. Peterson’s Principle of oral and maxillofacial surgery. 2nd & 3rd ed.
3. Flaps and reconstructive surgery 2nd ed
4. Facial Plastic, Reconstructive andTrauma Surgery – Robert Dolan
5. Atlas of Microvascular Surgery: Anatomy and Operative Approaches 2nd ed
6. Microsurgery essentials: preparation. Plastic Surgery, Stanford Medicine
7. Alexander’s Care of the patient in Surgery 15th ed
8. Cummings Otolaryngology 6th ed.
9. RecipientVesselAnalysis for Microvascular Reconstruction of the Head
and Neck. Annals of PlasticSurgery •Volume 52, Number 2, February
2004.
10. Recipient vessels in head and neck microsurgery: radiation effect and
vessel access. Plast Reconstr Surg. 1993;92:628–632.
11. Microvascular reconstruction after previous neck dissection. Arch
Otolaryngol Head Neck Surg. 2002;128:328–331.
76
73. 77
10.Techniques for management of size discrepancies in microvascular anastomosis. Microsurgery.2000;20:162–
166.
11. Comparison of end-to-end and end-to-side venous anastomosis in free-tissue transfer following resection of
head and neck tumors. Microsurgery. 1996;17:146–149.
12. Interposition vein grafting in head and neck reconstructive microsurgery. J Reconstr Microsurg.
1993;9:245–252.
13. From simple interrupted to complex spiral: a systematic review of various suture techniques for
microvascular anastomoses. Microsurgery, 2011;31:72–80.
14. Systematic review: Anastomotic microvascular device. J Plast Reconstru Aesth Surg (2014) 67, 752-755.
15. Anesthesia and Surgical Microvascular Flaps. Rev Bras Anestesiol 2012; 62: 4: 563-579.
16. BasicTechniques in MicrovascularAnastomosis. Facial plastic surgeryVolume 12, Number 1 January 1996.
17. Microvascular surgery in plastic surgery:free-tissue transfer. JOURNAL OF MICROSURGERY, 1979; 223-230.
18. Free tissue transfer flaps in head & neck reconstruction: microvascular anastomosis technique.
19. The use of color Doppler ultrasound in the assessment of vessels for facial transplantation.Ann Plast Surg,
2007;59:82-6.
20. Free flap reexploration: indications, treatment and outcomes in 1193 free flaps. Plast Reconstr Surg
2007;119(7):2092-2100.
74. 78
21. Risk factors for free flap failure: a retrospective analysis of 881 free flaps for head and neck defect reconstruction
Int. J. Oral Maxillofac. Surg. 2017; 46: 941–945.
22. Salvage of failed free flaps used in head and neck reconstruction. Head & Neck Oncology 2009, 1:33
23. Horizontal mattress technique for anastomosis of size-mismatched vessels. Plast Surg 2015;23(2):100-102
Editor's Notes
The development of microvascular surgery has resulted in the advancement in two impressive methods : reimplantation and transplantation
Head and neck reconstructive surgery represents a major challenge facing the need to achieve a good cosmetic and functional outcome.
Free flaps became popular in the head and neck region, they increased the choices of tissue availability in the quest to achieve an ideal reconstruction and a functional rehabilitation of the patient.
1st experimental free flap was performed on a dog in 1965.
Antia and Buch in 1965 used a groin flap to fill the facial defect
Preoperative evaluation is important in order to select the most suitable flap, and to select patients and to optimize their medical status and comorbid conditions
4. Poor digit perfusion can be further exacerbated by donor vessel sacrifice, yielding cold intolerance or even digit necrosis
5. extremity vessels are known for a tendency toward advanced atherosclerotic disease in patients with peripheral vascular disease
Assess the patient’s fitness to undergo major surgery
1. Chronologic age itself does not seem to contraindicate surgery, although the incidence of medical complications is higher after treatment
3.perioperative withdrawal prophylaxis and nutritional supplementation, because acute withdrawal after surgery is associated with a higher rate of complications and flap loss
with vasculitis are at a relatively high risk for microvascular pedicle compromise, = relative contraindication
extensive inadvertent preoperative use of anticoagulating medicines can also compromise microvascular success., are predisposed to compressive neck hematomas that can lead to significant blood loss, airway compromise, or flap pedicle compression.
3. hematologic disorders —should also be strongly considered for nonmicrovascular reconstructions because of the difficulties in maintaining healthy patent anastomoses associated with prothrombotic and coagulopathic states
4. patients treated with steroids can experience poor healing or increased infectious complications
Resect the primary tumour and elevate the flap simultaneously as a 2-team approach to reduce surgical time as it has benefit
Create working space around the head and neck region by placing the anaesthetic machinery at the foot of the bed with extensions for intravenous lines and anaes-thetic tubings both for the patient and for flap survival
Produced the high quality microscope that became an integral part of lab research soon.
But the first surgical microscope was developed by curl.
Body position:
Seat should be comfortable
Legs apart and flat on floor & should be directly under the table
Head & upper body should remain motionless
Forearms must lie passively on table
Do not lean on elbow to maintain position
Elbow: on table/folded towels
Wrist: ulnar side should rest on table/folded towels
Finger: middle, ring and little finger rest on table forming a stage for index finger and thumb to work
Compound loupes : consist of 2magnifying lenses separated by air. But image quality tends to get distorted around magnification above 2.5x
Prismatic loupes : provide higher optical quality. They have a Schmidt prism which lengthens the path of light inside the loupe. Provide wider field of view and longer depth but are 30-40times heavier and expensive
Titanium instruments usually have less
So that they lie loosely in the hand weight
Tremor increases with higher closing pressure
over the whole length of the jaw of the clamp.
Scissors are spring loaded to allow for finer movements
Dissecting scissors when held close can be used as dissecting probe
These can also be used for cutting microsutures less thn 8-0
microscissors should have an opening of less than 4 mm.
It should be held like a pencil with pulp to pulp pinch. End of the instrument is supported by thenar web.
Movement comes from the finger tips, the hand should remain still
They are further classified based on the – width of the contact surface, narrowness and overall configuration.
No. 2 = have wide jaws and can be used as needle holders
No. 5 = have fine tips and are suitable for tissue handling and microsurgery
No. 7 = have curved jaws
It should be held like a pencil with pulp to pulp pinch. End of the instrument is supported by thenar web.
Movement comes from the finger tips, the hand should remain still
Light bulldog clamp has got pinch action to open and close. Blades have got fine transverse serrations which permits a secure grip of the vessel
Bipolar produces heat effect in a very small area flows from one tine (or prong or blade) of the bipolar instrument to the other tine as it passes through the tissue
located between the tines between the pointed instrument tips.
Anesthesia may be an important and determining factor in success of any surgery due to its role in hemodynamic stability and regional blood flow.
1. to prevent increased viscosity and vasoconstriction
2. As large areas exposed for prolonged periods, associated with fluid and blood loss. Furthermore, anesthesia changes the thermoregulatory mechanisms
3. a temperature that reduces heat loss from the patient and is not uncomfortable for the surgical team
Preoperative preparation and patient positioning can be time consuming and it is important to prevent hypothermia during this phase of exposure
meticulous attention to possible pressure points - to avoid problems, such as neuropathy (damage to peripheral nerves, The mechanisms for nerve injuries include compression (pressure), stretch, direct trauma, laceration, ischemia, and metabolic derangement. Prolonged stretching from hyperabduction of an extremity or compression from pressure results in ischemia, which can progress to necrosis) & pressure ulcers. Gel pads are particularly useful for areas of greatest risk
catheterization is essential for good venous access (possibly large caliber)
invasive arterial pressure(AP) monitoring - recommended (always with free flap) serial blood gases and hematocrit calculation
Central venous pressure monitoring can be used but not recommended routinely
Central temperature monitoring (via nasopharyngeal or rectal/bladder tube) is essential.
Peripheral temperature must also be measured as a decrease in skin temperature may reflect hypovolemia and vasoconstriction
Urine output is another indicator of vascular filling - should be kept from 1 to 2 mL.kg-1 peri- and postoperative periods
Gastric tube should be placed
1. to reduce the stress response and catecholamine release.
2. especially in long surgeries because it is associated with gastric distension, nausea and vomiting after surgery.
sevoflurane, may have beneficial effects on microcirculation, reducing plasma leakage into interstitial space and, therefore, decreasing the edema
3. increase in PaO2 is followed by a decrease in tissue perfusion as a result of vasoconstriction, leading to poor distribution of microcirculation infusion
When the microscope is used for preparation of anastomosis in chest or abdomen, the tidal volume should be reduced to minimize movements. The respiratory rate must be increased to maintain the minute volume
1. hyperdynamic circulation is required with high cardiac output, and peripheral vasodilation. For appropriated maintenance of perfusion pressure in transplanted flap
2. adequate blood pressure with vasodilatation promotes good flap perfusion by increasing the regional blood flow
3.
4. The free flaps are subject to interstitial edema, as they do not have lymphatic drainage and, thus, excessive fluid administration can be deleterious. Moreover patients with documented ischemic heart disease or ventricular dysfunction may not tolerate a volume overload. Fluid administration should be cautious and guided by signs of ischemia and hypoperfusion - (decreased urine output, increased serum lactate,) difference between central and peripheral temperature)
1. limit the use of crystalloids only to the replacement of maintenance needs 7, noting that excessive use can cause flap edema.
2. Synthetic colloids have the advantage of being readily available, stable, relatively inexpensive, and with no risk of transmitting infectious diseases
have a short half-life and may lead to postoperative hypovolemia
3. Gelatins as they have a short half lie and may cause hypovolemia
4. Dextrans as plasma substitutes seem to have beneficial effects on microcirculation bcz of Its antithrombotic effects by reducing platelet adhesion and depression of factor VIII activity represent an advantage in terms of thromboprophylaxis, but limit the amount administered during a major loss of blood
5. Good plasma expanders with low incidence of anaphylactic reactions and may reduce reperfusion injury
6. Good plasma expanders
7. Blood transfusion is recommended if hemoglobin falls to values below 7-8 g/dl
during dissection to improve surgical conditions and reduce blood loss
Beta-blockers can cause peripheral vasoconstriction and therefore its use (especially taking advantage of its potential cardiac benefit) must take into account the risk/benefit
1. subcutaneous heparin - vessel lumen is usually irrigated with heparinized solution (5,000 U: 500 ml NS).
3. Thrombolytic agents (such as streptokinase and urokinase) are administered directly into the thrombosed vessels
The selection of recipient vessels is an important component affecting patency. healthy vessels of reasonable size with good outflow should be selected.
The decision is usually based on the location of the defect and the proximity of a recipient artery and vein..
The vessel wall consist of 3 principal layers.
The innermost tunica intima is formed by a single layer of endothelium resting on a basal lamina.
This layer is separated by tunica madia by subendothelial layer consisting of connective tissue.
2. Tunica media consists mainly of smooth muscle cells and is the thickest layer of arterial wall.
3. Outermost layer of vessel wall is tunica adventitia.
The properties of elasticity and distensibility
enable arteries to compensate for changes in blood pressure
and volume. Because of the thicker muscle layer, severed
arteries are capable of contracting and constricting enough to stop
hemorrhage. In contrast, veins are more fragile than arteries
2. for intimal tears which expose thrombogenic subendothelium
3. Spasm of a vessel may be secondary to cool temperature, traumatic handling, and /or dryness of the tissue careful insertion and opening with a jewelers forceps can relieve the spasm.
4. Too much tension can cause intimal tears which can lead to thrombosis formation
6. Adventitia is removed from the vessel ends to improve visualization of the vessel walls and to ensure accurate suture placement. It should not be peeled away with microforceps as rough manipulation can result in vasospasm
7. Usually a pliable non adherent sheet is placed as a background to separate the vessels from underlying field of similar color.
microvascular anastomoses is undoubtedly one of the most critical steps in performing free tissue transfer, limb replantation, and/or composite tissue allotransplantation.
Usually 8 sutures
Needle is passed at a right angle to the vessel wall
The vessel may be grasped by gently bunching the periadventitia or careful insertion of the jewelers forceps into the lumen
Needle is then passed through the corresponding vessel again at right angles.
The sleeve anastomosis technique begins with gentle dilatation of the proximal (feeding) vessel end. This is followed by partial thickness bites (without entering the vessel lumen) placed at a distance approximately one and half times the vessel diameter from the vessel end. these sutures (most often a total of two to three depending on the vessel size) are passed through the inner side of the distal vessel end in an inside-out fashion and then tied. The proximal folded vessel is then gently tucked inside the distal vessel with another forceps taking care to avoid gripping the end of the proximal vessel
Multiple techniques have been described in the literature Overall, the simple interrupted suture technique is often
considered by many to be the gold standard in endto-
end microsurgical anastomoses.
the suture is passed full thickness from the outside-in direction of one vessel end into the lumen and then from the inside-out through the other vessel end. An average of eight sutures is needed to achieve an anastomotic strength comparable with the native vessel wall. The vessel ends can be bisected with two stay sutures placed at (12 o’clock and 6 o’clock positions) and then three interrupted sutures are placed in between on each side, or triangulated with three stay sutures placed at (10 o’clock, 2 o’clock, and 6 o’clock positions) using two
sutures in between all three
After the first knot is tied (A), a short remnant is left on one end and the other end is ran continuously to suture closed the posterior wall. The suture is then pulled snug with each pass instead of keeping the edges separated until the end. After the posterior wall is complete, the suture is cut leaving behind a short remnant (B). A second knot is tied (1808 to the first knot) using a second suture, and the remnant is tied to the second knot (C). The suture is then ran along the anterior wall (D) and tied to the first suture remnant completing the anastomosis (
The spiral-interrupted technique is a unique modification that involves placing a loose running suture to form a decrescendo spiral (loops) on the surface of the anastomosis. This suture then becomes interrupted following tangential cuts made through the loops. All suture segments are then tied individually as similar to the common interrupted technique
The history of vascular anastomosing rings goes back to
Absorption of themagnesium resulted in
a perivascular inflammatory mass that eventually occluded
the vessel. To avoid this inflammation, othermaterials have
been introduced, such as caramel1, silver8, polyethylene9
and tantalum
The arteries were slipped through the rings and their edges everted and fixated to the pins in each, after which the rings were approximated. Two fixating sutures on the outside joined the two rings
To solve the problems associated with permanent rigid
rings, absorbable anastomotic couplers were introduced
who did not use the device for anastomosis but for the repair of various vessel injuries and traumatic aneurysms
stents may be applied in two ways, one as the sole means for vascular anastomosis, the other was as an aid to facilitate handsewn anastomosis
Fibrin glue consists of two components and imitates the final step of blood coagulation
Most patients can be extubated at the end of surgery despite the long duration. In cases of head and neck tumor, where edema may be a problem, a period of mechanical ventilation after elective surgery can be considered if possible, given the risk of perioperative bleeding and hematoma formation.
Postoperative shivering should be prevented and promptly treated, as it more than doubles the O2 consumption, increases the circulating catecholamines, and causes peripheral vasoconstriction. It has also been shown to cause a marked reduction in flap BF. Treatment should be made with external heating associated
with small intravenous doses of meperidine (10-20 mg).nRecently, one study demonstrated that tramadol could be even more effective 44. Other drugs such as chlorpromazine (2.5-5 mg) or clonidine (100-150 μg) have been also used.
The microvascular technique of free flap and its artery and vein transfer and its anastomosis to the receiver site has several stages harvesting the flap and clamping vessel, primary ischemia as soon as BF stops and intracellular anaerobic metabolism starts (dependent on surgical time 60- 90 minutes);
2) reperfusion as soon as arterial and venous anastomosis are complete and after declamping;
3) Secondary ischemia, a result of flap hypoperfusion (minimized with appropriate anesthetic approach)
With minor injuries, the flap recovers and normal metabolism is restored if some flap factors are unfavorable, namely, prolonged periods of ischemia or inadequate perfusion pressure. In this case, reperfusion injury occurs when BF allows the influx of inflammatory substances that may ultimately destroy the flap
Secondary ischemia occurs after flap transfer and reperfusion. This period is more harmful to the flap than primary ischemia. The flaps affected by secondary ischemia present with massive intravascular thrombosis and significant interstitialbedema
3.
4. Blood flow can also be measured by using the Doppler shift of laser light. Measures the flow within a volume of 1mm3 of tissue, 1.5mm below the surface of the skin.
This can be achieved by using light of uniform wavelength
from a helium neon laser.
5. white light from a xenon lamp is irradiated into the tissue through a light transmitting fibre. The transmitter fibre is closely surrounded by six receiver fibres, so that light is emitted and received through one cable of fibres. The irradiated light is partly absorbed by
the skin, partly reflected, and partly backscattered; the spectrum of backscattered light lies in the wave length range of 502–630 nm and depends on its absorption by intracapillary
haemoglobin. Oxygenated and deoxygenated haemoglobinhave different spectral absorption patterns. Vascular occlusions led
to immediate and massive decreases in haemoglobin oxygenation
End-to-side anastomosis can overcome this problem, although it creates turbulence and increases flap failure rates (3,7). Interpositional vein grafting is another option, although it involves two anastomoses, which increases the risk for thrombosis (8). Other techniques have been described (9) including fish-mouth incision, oblique section, differential suture bites, wedge excision of the larger vessel and vessel invagination
Venous anastomotic thrombosis results in increased flap turgor, rapid capillary refill with brisk bleeding of darker blood, and, finally, darkening and mottling of the skin paddle
Arterial insufficiency manifests as a profound paleness and coolness, loss of flap turgor, and absence of any capillary refill or bleeding to pinprick
surgical methods should be the first choice as it offers significantly
higher salvage rates non-surgical procedures should only be used if surgical revision is not feasible or fails
