Microvascular Surgery"

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1 PROGHESS IN CARDIOVASC( ILAH Sl irg ERY T Microvascular Surgery" JULIUS H. JACOBSON II, M.D., AND ERNESTO L. SUAREZ, M.D. H E GREAT PROGRESS IN VASCULAR surgery during the last decade is most remarkable in surgery of large vessels. It is less striking in the intermediate sizes, and virtually stops in small vessels. This communication briefly describes a new technique, called microvascular surgery, which promises the same success with small vessel surgery as that obtained in large vessels. Experimental verification is largely complete,'''' but true clinical evaluation awaits the ultimate test, long-term improvement of the patient. The techniques evolved have additional appplication in reconstruction of many small body structures, i.e., nerves, ureters: vas deferens, and Fallopian tubes. In fact, they apply in any situation where the surgeon finds his ability hampered by the smallness of structures involved. This is particularly true in pediatric surgery. *From the Department of Surgery, Division of Surgical Research, University of Vermont, College of Medicine. Burlington, Vermont In analyzing the poor results in reconstruction of small vascular structures, it was reasoned that surgical technique was at fault. Thus, a I mm. error in suture placement, of no significance in an aortic anastomosis, accounts for some of the failues in vessels measuring 5 to 10 mm. in diameter, e.g., the superficial femoral and popliteal arteries, and outright failures in vessels below 5 mm., e.g., tibial and dorsalis pedis arteries. The mathematic relationship expressed in Poiseuille's law of fluid dynamics, although not wholly applicable to blood flow, is fundamental to the understanding of this concept: the flow of blood through a vessel varies as the fourth power of its diameter. In such a geometric relationship, where the effect of change in diameter is multiplied to the fourth power, the significance of small errors is tremendously magnified. It has been demonstrated amply by work done thus far that technical difficulties have FIGURE I : At left is a 30 mm. arterial anastomosis done with conventional suturing technique. On the right is another segment of the same vessel using the microvascular technique. 220

2 Volume 41. No.2 February MICROVASCULAR SURGERY 221 FIGL'RE 2 : Single binocular microscope. Note the arm device for holding the vascular clamps. See text. been in the ability of the eye to see, rather than the hand to do (Fig. 1). This problem has been solved by the use of a dissecting microscope. Initial experience may be Iikened to the first view of the moon through a powerful telescope; a whole new magnitude of detail is appreciated. Blood clots, intimal tears and adventitia insinuated into FIGURE 3 : Inner aspect of endarterectomy suture Ii ne three months following surgery. Note 62 stitches in a 1.9 em. incision.

3 222 JACOBSON AND SUAREZ Diseases of the Chest the suture line become glaringly apparent. The microscope is pictured in Fig. 2. In use, focusing is carried out through a sterile drape. A new double binocular microscope ( Diploscope ) allowing both the surgeon and assistant to view the operative field simultaneously should be available soon. Adequate working distance in even the deepest cavities is little problem with the choice of lenses available. In vascular anastomoses, clamps are held in an adjustable arm device which prevents respiratory and cardiac movement from being transmitted to the operative field. Magnifications of 10 to 16X are used for removal of adventitia and placement of initial stay sutures. Actual suture placement is carried out under 25 to 40 magnifications. As in machine shop practice, dissection and suture placement are carried out with the instruments stabilized with a "rest." At times, this is a bar placed near the point of surgery, but more often is a finger of the other hand or convenient part of the operative field. An average 3 mm. diameter arterial anastomosis takes 10 to 15 minutes to carry out. Twenty-five to 30 stitches are taken. The large number are necessary for hemostasis because the usual eversion, inversion and bunching up of the suture line, which account for hemostasis between sutures with conventional methods, are no longer present. Figure 3 shows an endarterectomy suture line having 62 stitches in a distance measuring somewhat less than 2 em. in length. Work is in progress on the use of a vascular glue for hemostatic purposes. A minimal number of stitches may then be placed, with hemostasis achieved by use of FIGURE 4 : 1.2 mm. arterial anastomosis performed with ultra-fine nylon suture material. Site or anastomosis is difficult to see with the naked eye.

4 Volume 41, No.2 February, 1962 MICROVASCULAR SURGERY 223 FIGURE 5 : Splenorenal venous anastomosis in a four-week-old puppy. No. 7-0 silk was used. A No. 20 hypodermic needle is placed at the lower portion of the field. FIGURE 6 : End-to-end anastomosis of canine groin lymphatic to a small twig of the femoral ve.n.

5 224 JACOBSON AND SUAREZ Diseases of the Chest the glue between stitches. This is, of course, important in applications where interruption of blood flow for more than four or five minutes is a problem. In endarterectomy' of vessels in the 2 to 4 mm. range, it has been found extremely important to obtain an absolutely smooth medial surface. 'fags of adventitia or plaques not visible to the naked eye may cause eventual thrombosis. Early clinical experience is promising. Principles of vascular reconstruction remain unchanged. The technique merely allows Halstedian principles of fine stitching and gentle manipulation of tissues to be applied to finer structures. The microsurgical technique offers virtually assured patency of small vessels where pioneering attempts in the past have shown poor results. It is likely that acute arterial occlusive disease of the brain' and heart will be treated as surgical emergencies in the future, as is the aortic saddle embolus today. The heart will be revascularized by endarterectomy or systemic-tocoronary artery shunts'" rather than the various cardiopexy procedures now in vogue. Correction of arterial insufficiency of the lower extremities, which now stops at the knee, can be extended to the most peripheral arteries in the foot (Fig. 4). In renal hypertension, a better technical result is obtained on the main renal artery and major segmental arterial obstructions can also be relieved. Reconstruction of both large and small veins becomes possible. The splenorenal and superior mesenteric-to-vena caval shunts can be carried out without regard to the size vessels involved (Fig. 5). The subclavian-to-pulmonary artery shunt can be done successfully in the youngest infant rather than the pulmonary artery-to-aortic shunt with its attendant complications of performance and eventual take-down.' The blood supply of intestinal segments used in esophageal replacement can be shifted. Revascularization of transplanted organs will be no problem when the homograft rejection phenomenon is solved." Early experimental work (Fig. 6) indicates that lymphedema of the arm and leg may be correctible by anastomosis of terminal blocked lymphatics to neighboring venules. SUMMARY Techniques of microvascular surgery are briefly described. Arteries, veins, and possibly lymphatics, measuring down to fractions of a millimeter can be reconstructed. Clinical application for improvement of existing vascular surgical procedures and future new areas opened up by the technique are described. The technique may be readily used by anyone competent in vascular surgery. BIBLIOGRAPHY 1 JACOBSON, J. H., AND SUAREZ, E. L.: "Microsurgery in Anastomosis of Small Vessels," Surge Forum, 11: 243, JACOBSON, J. H., AND SUAREZ, E. L.: "Microsurgery - Application to Organ Transplantation," Trans. Am. Soc. Arti], Int. Organs, 7: 301, JACOBSON, J. H., AND SUAREZ, E. L.: "Microvascular Surgery-Instrumentation and Technique," l- Card. Surg., In Press. 4 SUAREZ, E. L., AND JACOBSON, J. H.: "Results of Small Artery Endarterectomy-Microsurgical Technique," Surge Forum, 12: 256, KOSSE, K-H., SUAREZ, E. L., FAGAN, W. T., POWELL, P. R., AND JACOBSON, J. H.: "Microsurgery in Ureteral Reconstruction," l- Urol., In Press. 6 JACOBSON, J. H., WALLMAN, L. J., SCHUMACH ER, G. A., FLANAGAN, M., SUAREZ, E. L., AND DONAGHY, R. M. P.: "Microsurgery as an Aid to Middle Cerebral Endarterectomy," [. Neurosurg., In Press. 7 JACOBSON, J. H., MILLER, D. B., AND SUAREZ, E. L.: "Microvascular Surgery: ANew Horizon in Coronary Artery Surgery," Circulation, 22: 767, JACOBSON, J. H.: "Discussion Regarding Anastomosis of the Coronary Arteries" in Prosthetic Valves for Cardiac Surgery, C. C Thomas, Springfield, Ill. 9 JACOBSON, J. H., SUAREZ, E. L., TABAKIN, B. S., HANSON, J. S., AND CALDWELL, E. J.: "Reassessment of the Blalock vs. Potts Operation : Obervations on Anmal Growth in the Presence of an Artificial Patent Ductus Arteriosus," Circulation, 24:965, 1961.

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