LETTER TO THE EDITOR
MICROSURGERY 34:333–334 (2014)
A BASIC EXPERIMENTAL MODEL FOR END-TO-END ANASTOMOSIS OF VESSELS WITH DIAMETER DISCREPANCY Dear Editor,
A competent knowledge of various microsurgical techniques is essential in various surgical specialities1,2 and a microsurgical training program simulating basic technical maneuvers and difficult clinical situations is incorporated into regular residency training.3 The end-to-end anastomosis of vessels with different luminal diameters is one of the most frequently faced technical problems in clinical microvascular surgery which is unexpectedly not considered in standard microsurgical training programs. In this letter, a new training model facing this important technical difficulty is presented which may be a useful addition to the basic microsurgical training program. The basis of the new training model for vessel size discrepancy is end-to-end anastomosis of rat femoral artery to the femoral vein by dividing them through different levels. Two different ratios of discrepancy (Moderate lumen discrepancy ratio 5 1:1.3–1.5 and Severe lumen discrepancy ratio 5 1:1.8–2) can be achieved in this model. The mean diameter of the vessels at a level cranial to the epigastric branches is 0.8–0.9 mm for the artery and 1.3–1.4 mm for the vein. Dividing the femoral artery and femoral vein at a level between the deep branches and the epigastric vessels creates a moderate lumen discrepancy of 1:1.3–1.5 ratio for practicing endto-end anastomosis (Fig. 1). The oblique cut or spatulation of the smaller vessel end combined with closer placement of the sutures can be exercised in this situa lu, M.D., Gu € mu €s¸pınar Mahallesi Filiz *Correspondence to: Hakan S¸irinog _ Sokak, Demirlipark Sitesi B/19, Yakacık, Kartal, Istanbul, Turkey. E-mail: [email protected] Received 10 November 2013; Revision accepted 19 December 2013; Accepted 24 January 2014 Published online 5 February 2014 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22233 Ó 2014 Wiley Periodicals, Inc.
tion. Saphenous artery is the continuation of the femoral artery after the epigastric branch and its most proximal part has a diameter of 0.7–0.8 mm. In contrast, the diameter of the femoral vein at the level between the inguinal ligament and the deep branches is about 1.4–1.5 mm. Dividing the proximal saphenous artery and cranial femoral vein and rotating the proximal cut edge of the saphenous artery cranially until reaching the proximal cut edge of the femoral vein for end-to-end anastomosis gives a severe discrepancy model with the mismatch ratio of 1:1.8–2 (Fig. 1). End-toend anastomosis after fishmouth incision4 to the arterial end is exercised at this degree of discrepancy. The presented training model offers a standard and necessary exercise to overcome the problem of vessel diameter discrepancy faced in microsurgical end-to-end anastomosis in a range of 1:1.2 to 1:2. Vessel diameter discrepancy is an important clinical problem commonly faced in free tissue transfer and in our opinion, the addition of this easy and feasible model to the basic microsurgical training program may be helpful for the trainees by dealing with this important clinical problem. MEHMET BAYRAMIC¸LI Department of Plastic, Reconstructive and Aesthetic Surgery Marmara University School of Medicine _ Istanbul, Turkey HAKAN S¸IRINOGLU, M.D.* Department of Plastic, Reconstructive and Aesthetic Surgery € Kırdar Training and Research Hospital Kartal Dr. Lutfi _ Istanbul, Turkey ¸ YALC¸IN, M.D. DOGUS Department of Plastic, Reconstructive and Aesthetic Surgery Marmara University School of Medicine _ Istanbul, Turkey
334
Letter to the Editor
Figure 1. (1) Femoral artery and femoral vein of the rat are divided between the deep branches and superficial epigastric vessels and a moderate lumen discrepancy of 1:1.3–1.5 ratio is achieved. The oblique cut or spatulation of the smaller vessel end is suitable for exercise. (2) Most proximal part of the saphenous artery is divided after the ligation of all side branches and rotated cranially until reaching the femoral vein and anastomosed to the femoral vein which is divided at the level between the inguinal ligament and the deep branches. On this severe discrepancy model, which has a mismatch ratio of 1:1.8–2, fishmouth incision to the arterial end or tapering the vein into a smaller diameter can be exercised on this model. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
REFERENCES 1. Goosens DP, Gruel SM, Rao VK. A survey of microsurgery training in the United States. Microsurgery 1990;11:2–4. 2. Bayramic¸li M, G€ur€unl€uoglu R, Numanoglu A. Slide framework model to practice microsurgery. Plast Reconstr Surg 2001;107:296.
Microsurgery DOI 10.1002/micr
3. Acland RD. Practice Manuel for Microvascular Surgery. St. Louis: C.V. Mosby Co.; 1989. pp 105–108. 4. Harashina T, Irigaray A. Expansion of smaller vessel diameter by fish-mouth incision in microvascular anastomosis with marked size discrepancy. Plast Reconstr Surg 1980;65:502–503.
MICROSURGERY 34:333–334 (2014)
A BASIC EXPERIMENTAL MODEL FOR END-TO-END ANASTOMOSIS OF VESSELS WITH DIAMETER DISCREPANCY Dear Editor,
A competent knowledge of various microsurgical techniques is essential in various surgical specialities1,2 and a microsurgical training program simulating basic technical maneuvers and difficult clinical situations is incorporated into regular residency training.3 The end-to-end anastomosis of vessels with different luminal diameters is one of the most frequently faced technical problems in clinical microvascular surgery which is unexpectedly not considered in standard microsurgical training programs. In this letter, a new training model facing this important technical difficulty is presented which may be a useful addition to the basic microsurgical training program. The basis of the new training model for vessel size discrepancy is end-to-end anastomosis of rat femoral artery to the femoral vein by dividing them through different levels. Two different ratios of discrepancy (Moderate lumen discrepancy ratio 5 1:1.3–1.5 and Severe lumen discrepancy ratio 5 1:1.8–2) can be achieved in this model. The mean diameter of the vessels at a level cranial to the epigastric branches is 0.8–0.9 mm for the artery and 1.3–1.4 mm for the vein. Dividing the femoral artery and femoral vein at a level between the deep branches and the epigastric vessels creates a moderate lumen discrepancy of 1:1.3–1.5 ratio for practicing endto-end anastomosis (Fig. 1). The oblique cut or spatulation of the smaller vessel end combined with closer placement of the sutures can be exercised in this situa lu, M.D., Gu € mu €s¸pınar Mahallesi Filiz *Correspondence to: Hakan S¸irinog _ Sokak, Demirlipark Sitesi B/19, Yakacık, Kartal, Istanbul, Turkey. E-mail: [email protected] Received 10 November 2013; Revision accepted 19 December 2013; Accepted 24 January 2014 Published online 5 February 2014 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22233 Ó 2014 Wiley Periodicals, Inc.
tion. Saphenous artery is the continuation of the femoral artery after the epigastric branch and its most proximal part has a diameter of 0.7–0.8 mm. In contrast, the diameter of the femoral vein at the level between the inguinal ligament and the deep branches is about 1.4–1.5 mm. Dividing the proximal saphenous artery and cranial femoral vein and rotating the proximal cut edge of the saphenous artery cranially until reaching the proximal cut edge of the femoral vein for end-to-end anastomosis gives a severe discrepancy model with the mismatch ratio of 1:1.8–2 (Fig. 1). End-toend anastomosis after fishmouth incision4 to the arterial end is exercised at this degree of discrepancy. The presented training model offers a standard and necessary exercise to overcome the problem of vessel diameter discrepancy faced in microsurgical end-to-end anastomosis in a range of 1:1.2 to 1:2. Vessel diameter discrepancy is an important clinical problem commonly faced in free tissue transfer and in our opinion, the addition of this easy and feasible model to the basic microsurgical training program may be helpful for the trainees by dealing with this important clinical problem. MEHMET BAYRAMIC¸LI Department of Plastic, Reconstructive and Aesthetic Surgery Marmara University School of Medicine _ Istanbul, Turkey HAKAN S¸IRINOGLU, M.D.* Department of Plastic, Reconstructive and Aesthetic Surgery € Kırdar Training and Research Hospital Kartal Dr. Lutfi _ Istanbul, Turkey ¸ YALC¸IN, M.D. DOGUS Department of Plastic, Reconstructive and Aesthetic Surgery Marmara University School of Medicine _ Istanbul, Turkey
334
Letter to the Editor
Figure 1. (1) Femoral artery and femoral vein of the rat are divided between the deep branches and superficial epigastric vessels and a moderate lumen discrepancy of 1:1.3–1.5 ratio is achieved. The oblique cut or spatulation of the smaller vessel end is suitable for exercise. (2) Most proximal part of the saphenous artery is divided after the ligation of all side branches and rotated cranially until reaching the femoral vein and anastomosed to the femoral vein which is divided at the level between the inguinal ligament and the deep branches. On this severe discrepancy model, which has a mismatch ratio of 1:1.8–2, fishmouth incision to the arterial end or tapering the vein into a smaller diameter can be exercised on this model. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
REFERENCES 1. Goosens DP, Gruel SM, Rao VK. A survey of microsurgery training in the United States. Microsurgery 1990;11:2–4. 2. Bayramic¸li M, G€ur€unl€uoglu R, Numanoglu A. Slide framework model to practice microsurgery. Plast Reconstr Surg 2001;107:296.
Microsurgery DOI 10.1002/micr
3. Acland RD. Practice Manuel for Microvascular Surgery. St. Louis: C.V. Mosby Co.; 1989. pp 105–108. 4. Harashina T, Irigaray A. Expansion of smaller vessel diameter by fish-mouth incision in microvascular anastomosis with marked size discrepancy. Plast Reconstr Surg 1980;65:502–503.
