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Day 3. Wet-Laboratory Microsurgical Training
solution to prevent tissues from drying out under the light of
the microscope. Small gauze tissues or cotton rounds and sticks
are used to remove blood and excess fluid. Papaverine solution
can be applied locally to prevent vasospasm. When the vessels
have been dissected free from the surrounding tissue, they are
ready to be used in the exercises.
4.8.2 Approach to the Neck Vessels
Depending on the goal of the experiment, either a linear incision or a curved cutaneous incision can be performed. A linear
incision should be chosen for survival experiments, whereas a
large cutaneous flap can be used for termination experiments,
as it allows more working space, easy access to the anatomy,
and fewer hairs near the anastomosis. The main steps of carotid
exposure are presented in ▶ Fig. 4.6. One should pay attention
while dissecting the cervical fascia, as it contains many veins
and small arteries, including the jugular vein, which may look
like avascular tissue when it is surgically put under tension during dissection. A careless tear or cut in this vessel could create
significant bleeding. After exposing the neck muscles, the sternocleidomastoid muscle, which runs obliquely, should be
retracted laterally. If mobilization of this muscle is needed for
adequate exposure, care should be taken to coagulate or ligate
its feeding vascular bundle. After retraction of the sternocleidomastoid and midline muscles apart, the last thin muscle covering the carotid artery is exposed. This muscle may be retracted
laterally or cut after its vascular supply has been identified and
ligated or coagulated.
The carotid artery can be seen as a pulsating vessel contained in
the white bundle of the vagus nerve. Care should be taken to dissect
the artery proximally and distally, to prevent injury to the vagus
nerve, as injuring the vagusnervemay affect animal survival.
4.8.3 Midline Laparotomy
Midline laparotomy is an extensive invasive approach and
should preferably be performed last if multiple approaches are
undertaken. This approach is relatively straightforward. The
major steps of midline laparotomy are presented in ▶ Fig. 4.7.
Special caution and aseptic conditions are required for survival
experiments, while for termination procedures, less care is necessary. The exposed content of the abdominal cavity should be
continuously moistened to prevent it from drying out. The animal’s intestines are usually taken out, retracted to the right and
kept in moistened surgical gauze. The aorta and vena cava are
Fig. 4.7 Midline laparotomy. The rostral direction is to the right. (a) After the surgical field is shaved, (b) the skin is incised at the midline. (c) The
peritoneum is then opened with scissors beginning near the xyphoid process and proceeding caudally, and (d) the wound edges are retracted to the
sides with stay sutures. (e) The surgical field is draped. (f) The intestines are then moved aside and covered with moistened surgical gauze, exposing
the right kidney, pulsating aorta, and inferior vena cava. The liver may also be retracted upwards with wet cottonoids. (g) The left kidney is exposed,
and the renal vein is visible at the center of the exposure.
63
Day 3. Wet-Laboratory Microsurgical Training
frequently hidden beneath a layer of adipose tissue, but can be
easily recognized by its pulsation. The aorta lies to the left and
behind the vena cava, and it is significantly smaller and brighter
than the vena cava.
Knowledge of the rat anatomy and experimentation with
various approaches allows safe and fast access in order to save
time for the actual anastomosis training. However, training in
gentle tissue handling during dissection of delicate animal tissues as a preparatory step should not be underestimated. Preparation of a bloodless, clean, hydrated (not dried out!), and
unobstructed operative field is one of the key factors for
successful anastomosis.
References
[1] Russell WMS, Burch RL. The Principles of Humane Experimental Technique.
London: Methuen; 1959
[2] Carstens E, Moberg GP. Recognizing pain and distress in laboratory animals.
ILAR J; 41(2):62–71
[3] Flecknell PA. Laboratory Animal Anesthesia. 3rd ed. London: Academic Press;
2009
[4] Boston University Research Support. Compliance. Available at: http://www
.bu.edu/researchsupport/compliance/. Accessed March 23, 2018
[5] University of California, San Diego, Animal Care Program. Tranquilizers, anal-
gesics and anesthetics for use in rodents & lagomorphs. 2013. Available at:
http://blink.ucsd.edu/_files/sponsor-tab/iacuc/Rodent_Rabbit_Anesthesia.pdf
. Accessed December 3, 2019
[6] West Virginia University Institutional Care and Use Committee. WVU IACUC
Approved Guidelines: Anesthesia and Analgesia in Rats. SOP no. 11–012:
West Virginia University; 2011
[7] Fish RE, Brown MJ, Danneman PJ, Karas AZ. Anesthesia and Analgesia in Labo-
ratory Animals. 2nd ed. New York, NY: Academic Press; 2008
[8] Carpenter JW. Exotic Animal Formulary. 3rd ed. St. Louis, MO: Elsevier Saun-
ders; 2005
[9] Hillyer EV, Quesenberr y KE. Ferrets, Rabbits, and Rodents: Clinical Medicine
and Surgery. 1st ed. New York, NY: W.B. Saunders; 1997
[10] Diehl KH, Hull R, Morton D, et al. European Federation of Pharmaceutical
Industries Association and European Centre for the Validation of Alternative
Methods. A good practice guide to the administration of substances and
removal of blood, including routes and volumes. J Appl Toxicol; 21(1):15–23
[11] American Veterinary Medical Association. AVMA Guidelines for the Euthana-
sia of Animals: 2013 Edition. 2013. Available at: https://www.avma.org/KB
/Policies/Documents/euthanasia.pdf. Accessed December 3, 2019
[12] Ryuhei K, Ken-ichiro K. Off-the-job Neurosurgical training System at Univer-
sity of Fukui: lifelong education for neurosurgeons. Jpn J Neurosurg.; 19(5):
388–394
64
Day 4: Exercise Set 1: Basic Arterial Anastomoses
5 Day 4: Exercise Set 1: Basic Arterial Anastomoses
Evgenii Belykh and Nikolay L. Martirosyan
Abstract
In this chapter, we describe techniques for suturing basic vascular microanastomoses on biological tissues and introduce principles of microvascular suturing. We describe continuous and
interrupted sutures in end-to-side anastomosis, end-to-end
anastomosis, and side-to-side anastomosis.
Keywords: carotid artery, end-to-end anastomosis, end-to-side
anastomosis, femoral artery, laboratory animals, rat, side-toside anastomosis
5.1 Vascular Suturing
The walls of small arteries consist of three layers: the intima,
which faces the lumen; the media; and the adventitia, which is
the outermost layer. The intima consists of a monolayer of
endothelial cells and internal elastic lamina. Smooth muscle cell
proliferation and atheromatous plaques are usually observed in
intima of aged patients. The media occupies up to 80% of the
thickness of the vascular wall and, depending on the order of
segments of arteries, includes varied layers of smooth muscle
cells, a small amount of elastic fibers, and a collagen framework.
In small terminal branches of cerebral vessels, the elastic fibers
of the media are usually absent, and the media consists mostly
of reticulin fibers and smooth muscle cells. Of the three layers,
the media provides the most strength for the vascular suture
because of its pronounced collagen network.
has the highest thrombogenic proper ties.
There are several basic requirements for microvascular
sutures. Correctly placed sutures will:
●
Permit no major leakage from the vessel
●
Allow precise coaptation of the intima
●
Be durable
●
Cause no narrowing of the lumen
●
Leave no sutures or adventitia in the lumen
The main requirement for a vascular suture is that it is tight
enough to prevent leaks. The choice of appropriate needles and
sutures is one of the most important factors for successful vascular suturing. Most microsurgical needles are curved, although
straight needles are sometimes used for end-to-end microanastomosis. Inexpensive, nonsterile sutures can be chosen for
training; however, only special vascular needles should be used
for surgery. The following sizes of sutures are usually used: 11–
0 for a vessel diameter of less than 1 mm, 10–0 for a vessel
diameter of 1 mm, 9–0 for a vessel diameter of 2 mm, and 8–0
and larger for a vessel diameter of more than 2 mm. The carotid
artery is sutured with 6–0 sutures.
In anastomosis of two vessels of unequal sizes, approximation of the vessel walls should be performed only within their
natural elasticity by slight stretching. Overstretching of the vessel wall can damage the intima or the entire wall and can result
in bleeding or thrombosis during or after the surgery.
1
The adventitia
Weakness of the vascular wall at the anastomosis may also
result in aneurysm formation.
The suturing must be precise, and the connection of intimal
layers is very important in vascular suturing. The muscular
membrane or the adventitial cover must not get into the lumen
of sutured vessels; otherwise, they may cause thrombosis and
failure of the anastomosis.
When all the knots on one side have been formed, the vessels
should be turned to check the quality of the sutures from
inside. The common mistakes are shown in ▶ Fig. 5.1.
5.2 Exercise: End-to-End Anastomosis on Rat Carotid Arteries
This exercise simulates rare neurosurgical situations where
end-to-end anastomosis is needed, primarily for in situ intracranial reconstructions. Performing end-to-end anastomosis is
a relatively straightforward task (▶ Fig. 5.2, Video 5.1). However,
there are several critical nuances that can make suturing either
easy and successful or difficult and unsuccessful.
To begin, you should prepare and dissect a clean and wide
operative field with sufficient length of vessel available. Next,
apply the clip approximator in either of the two ways. The first
and most common method is to place it horizontally for the
front wall exposure and then to rotate it 180 degrees for the
back wall exposure. This procedure can be used if the vessel
length allows for this degree of axial rotation. The second
method is to apply the clip approximator vertically, then rotate
it 90 degrees in one direction for front wall exposure, and then
90 degrees in the other direction for back wall exposure. This
method can be used for short vessels that do not allow much
axial rotation. If no rotation is possible, which is relatively common, then the back wall can be sutured from the inside, like in
a side-to-side anastomosis, or you can use a single stay suture
technique.
Adventitia should be cleaned from the vessel ends for a distance that allows for safe and convenient vessel end approximation and for choice of the needle puncture site, usually about
half the diameter of the vessel. Arteries will be in a contracted
state at this step, so you may want to dilate them with a dilator
or forceps, which will help you to make even spaces between
the sutures later. Stay sutures are commonly used in microsurgical practice for end-to-end anastomosis because they help to
hold the vessel lumen open. When used, stay sutures are placed
in the free ends of the arteries and are secured in slits of a silicon dam or on an approximator. However, in neurosurgery,
arteries are usually not as small, so this step can be omitted. In
addition, an approximator does not always fit in the space available in operative approaches within the brain, so they are less
likely to be used in actual surgery.
There are three common strategies for beginning interrupted
vascular suturing with stay sutures: two stay sutures may be
65
Day 4: Exercise Set 1: Basic Arterial Anastomoses
Fig. 5.1 Possible defects in performing
anastomosis. (a) Loose knots (the sutures are in
the lumen of the vessel). (b) Peeled off intima. (c)
Vessel wall cut by the sutures and with the intima
peeled off. (d) The adventitia is in the lumen of
the vessel.
placed 180 degrees apart2; two stay sutures may be placed 120
degrees apart
wall and suturing continued from both sides.
While suturing, gently grab the vessel wall by the remaining
adventitia with forceps and avoid applying pressure to the
media and intima. Use the counter-press technique for passing
the needle. For end-to-end anastomosis on a rat carotid artery,
eight sutures are usually enough, but additional stitches should
be applied if needed. Do not hesitate to check the lumen from
inside, as it is better to know whether the back wall is captured
before all sutures are tightened. Usually in small vessels, walls
are semitransparent, so if the needle can be seen through the
wall, it means the needle is usually under only one layer, but if
it is not seen, it is usually under two layers, meaning that the
opposite wall of the vessel has been inadvertently captured by
the needle and trapped into the knot, which should be avoided.
When the anastomosis is finished, check for bleeding, achieve
hemostasis as necessary, and check the blood flow through
anastomosis.
You can perform multiple end-to-end anastomoses on different vessels from the same animal and combine these anastomoses with other types of anastomoses. We advise trying three
different techniques for placing the stay sutures and different
vessel orientations to bring variety and interest to your training
sessions.
3
; or one stay suture may be placed in the back
4
Sidebar
The vessel wall must be held only by the adventitia or by using
the counter-press method. When the vessel wall is squeezed
by the forceps, the endothelium can be damaged, leading to
thrombosis.
5.3 Exercise: End-to-Side
Anastomosis on Rat Carotid
Arteries—Continuous Suture
This exercise simulates the technique needed to create a superficial temporal artery-to-middle cerebral artery anastomosis in
the end-to-side fashion. The carotid arteries are preferred over
the femoral arteries for this simulation because femoral vessels
are considerably smaller than the middle cerebral arteries. This
exercise can be completed twice on one animal. Because rats
usually have a well-developed circle of Willis, they can easily
tolerate occlusion in one carotid artery, when a survival experiment is planned.
The approach to the carotid arteries is described in Chapter 4.
After the arteries are dissected free from the periadventitial tissues, one artery is chosen as a donor and another as a recipient
(▶ Fig. 5.3). A stepwise description of the end-to-side anastomosis technique on rat carotid arteries is presented in
▶ Fig. 5.4. The donor artery is clipped proximally and distally,
then cut at the distal end and rotated across the midline to the
contralateral side. The path depends on the available length of
the transferring carotid artery. A long artery can be moved
across the midline in front of the trachea, while a shorter vascular pedicle can be passed behind the trachea. The distal end of
the donor artery is ligated.
Linear arteriotomy on the recipient vessel is begun using an
unused 27-gauge needle and continued with microscissors. The
techniques for tailoring the donor vessel optimally and end-toside anastomosis are described in Chapter 3 (▶ Fig. 3.31,
▶ Fig. 3.32). Trainees can practice classic fish-mouth tailoring
first to understand how much of a toe is required to achieve an
optimal angle for enlargement of the anastomosis. Heparinized
66
Day 4: Exercise Set 1: Basic Arterial Anastomoses
Fig. 5.2 End-to-end anastomosis on rat carotid arteries (Video 5.1). (a) Dissected carotid artery. Inset shows location of the approach and orientation
of the operative field. (b) A latex background is placed under the artery. (c) A clip approximator is applied. (d) The vessel is cut at the middle and (e) is
washed with heparinized saline. (f) The adventitia is gently removed from the ends of the joining vessels. (g) The cleaned ends are then moved closer
to each other by moving one clip of the approximator. (h) The first two sutures are placed opposite to each other. (i) The clip approximator is rotated
180 degrees to show the other side of the vessels. (j) The back wall is sutured with separate sutures first. (k) The vessel lumen is checked from inside
for any mistakes. (l) Sutures are placed on the front wall of anastomosis. (m) The clips are removed, and a small amount of bleeding is usually
observed. (n) Bleeding from the needle puncture sites usually stops by itself with gentle pressure within a few minutes.
67
Day 4: Exercise Set 1: Basic Arterial Anastomoses
Fig. 5.3 Training on the neck vessels of a rat. (a) Location of the carotid artery and jugular vein in the neck. (b) The sternohyoid muscle is retracted
medially and the sternomastoid muscle laterally. The omohyoid muscle crosses the surgical field. (c) The omohyoid muscle is retracted superolaterally
to expose the carotid artery and vagus nerve. (d) End-to-side anastomosis of the distal end of the right carotid artery to the left carotid artery is
shown. The proximal end of the carotid artery may also be used instead of the distal for this exercise.
saline should be used to keep the tissues moist. ▶ Fig. 5.4 and
Video 5.2 show the creation of an anastomosis with continuous
suture. After placing the toe and heel stay sutures, suture the
back wall first and proceed with the easier front wall last.
Before tying the last knot, temporarily release the distal clip to
wash out possible thrombus and air.
5.4 Exercise: Double End-to-Side
Sidebar
After finishing the anastomosis exercise, the recipient vessel
should be incised in the back wall opposite the anastomosis
and the site of anastomosis inspected from the inside. Only the
intima layer should be visible inside at the area of contact be-
tween the anastomosing vessels. The lumen must have a large
enough diameter with no stenosis. The distance between each
suture must be equal.
Anastomosis on Carotid Arteries—
Arterial Loop
In this training exercise, you will create an arterial loop by performing a double end-to-side anastomosis on the carotid
arteries. After completing a single end-to-side anastomosis
between the left and right carotid arteries, ligate and cut the
same carotid artery again, but now at its caudal end. This free
end of the artery is then anastomosed to the recipient carotid
artery on the opposite side, distally or proximally to the first
anastomosis. After the second end-to-side anastomosis is completed, a pulsatile arterial loop is formed (▶ Fig. 5.5).
5.5 Exercise: End-to-Side
Anastomosis Between Carotid
Artery and Jugular Vein—
Interrupted Suture
This procedure is a more complex variant of an end-to-side
anastomosis, mainly because it involves the dissection and handling of veins, which are more fragile than arteries. The jugular
veins lie more superficially than the carotid arteries and require
68
Day 4: Exercise Set 1: Basic Arterial Anastomoses
Fig. 5.4 End-to-side anastomosis on rat carotid arteries (Video 5.2). (a) View of animal positioning and approach to carotid arteries. Inset shows
location of the approach and orientation of the operative field. (b) The carotid arteries are dissected on both sides; the right carotid artery is ligated
proximally, translocated over the muscles on the left side, and aligned with the contralateral carotid artery. (c) After finishing the continuous suturing
on the back wall, the lumen is checked from the inside. (d) The continuous sutures are tightened and secured. (Continued)
meticulous dissection and ligation of side branches. A stepwise
description of this technique is presented in ▶ Fig. 5.6 and
Video 5.3. The key points are the same as for any end-to-side
anastomosis; however, in this anastomosis, it is usually difficult
to estimate the final size of the vein because arterial flow will
distend it, which makes it harder to prepare the appropriate
side opening on the carotid artery. After the toe and heel
sutures are placed, the front and back sides of the anastomosis
are sutured. As can be seen in ▶ Fig. 5.6m, we used interrupted
sutures. Each suture was placed and tied individually, except for
the last two, which were placed without tightening, so there
was enough space to place the instruments for the counterpressure technique for the last suture. Once the last suture had been
placed, the knots were made.
The adventitia of veins is very thin and attaches to the fine
media and intima without a clear border, so it cannot be
removed as efficiently as it can from arteries. Because of this
quality, removing adventitia from a vein requires more precise
microdissection.
Continuous suture with loose loops makes suturing easier at
the final steps. This method is especially helpful when suturing
veins with their thin walls. The running suture suspends the
vessel open, preventing the collapse of walls and enlarging the
opening between the two vessels. The infusion of isotonic saline
can also help to prevent the vein wall from collapsing. To save
time, experienced surgeons sometimes make the running
suture by piercing both vessel walls with one movement of the
needle. During suturing of the vessel wall, the filament should
be seen through the vessel wall, which indicates the adequate
coaptation of vessels with no folding of the intima.
The sutures are cut after the knots are tied, leaving 0.2-mm
to 0.3-mm ends. One end can be made longer than the other, so
it will be easier to grasp it with forceps when needed.
5.6 Exercise: Side-to-Side
Anastomosis on a Femoral Artery
and Vein—Continuous Suture
The basic technique of side-to-side anastomosis is described in
Chapter 3, Section 3.8.5 Side-to-Side Anastomosis. Training of a
side-to-side anastomosis requires two parallel vessels. In a biological model, you can use a naturally encountered parallel
artery and vein or you can dissect an arterial graft separately on
the contralateral side. For the example of this exercise, we performed side-to-side anastomosis on a rat femoral artery and
vein (▶ Fig. 5.7, Video 5.4). Because of the small vessel size, we
did not place a second stay suture for this anastomosis.
69
Day 4: Exercise Set 1: Basic Arterial Anastomoses
Fig. 5.4 (Continued) (e) Continuous sutures are placed on the front wall in a right-to-left direction. (f) The front wall sutures are tightened. (g) The back
and front wall sutures are tightened. (h) View after removing the temporary clips and achieving hemostasis.
5.7 Tests for Patency of the Anastomosis
After completion, the anastomosis should be assessed visually
under medium magnification of the microscope. There are several simple tests to assess patency of anastomosis. The first
method is purely observational and relies on determination of
one of the three types of pulsation.
ent, the distal artery should pulsate and slightly enlarge with
every systole, that is, expansile pulsation, or it should have a
“wriggling” pulsation. Pulsatile movement of the anastomosis
toward the direction of flow with elongation of artery, “longitudinal pulsation” usually means that the blood flow is
obstructed. Pulsation of the vessel proximal to anastomosis
should never be used as a sign of patency.
The “lift test” is more sensitive. The vessel is lifted from
underneath with closed forceps until the blood flow stops. The
artery above the forceps becomes pale. Then the forceps are
moved distally to the anastomosis with the same lifting force. If
the anastomosis is patent, the vessel should rapidly become
filled with blood.
The “milking” test (also known as Acland’s test or the double
occlusion test) requires two forceps. Gently squeeze the artery
6
5
If the anastomosis is pat-
5
distal to the anastomosis with two forceps placed close to each
other. While the forceps are closed, spread them to the sides
(“milking” movement), creating a bloodless segment of the
artery. Then release the proximal forceps: if the arterial segment swiftly fills with the blood, then the anastomosis is patent; if it does not, there is a proximal obstr uction.
Squeezing the artery with the forceps may be traumatic, so the
same milking test can instead be reproduced using a single angulated-tip forceps. The closed forceps are introduced underneath
the vessel and used to lift the vessel until the blood flow stops.
Then the forceps are opened, creating a bloodless arterial segment
between the tips. Then the forceps are rotated to the side, releasing the pressure to the vessel from the proximal forceps’ tip. If the
vessel segment is filled with the blood, the anastomosis is patent.
Additionally, when the vessel is lifted by the forceps, one can
observe the pulsation of the arterial blood, which breaks
through the compressing lifting pressure of the forceps with
each systole. This test relies on the flickering of arterial blood
and works only on the thin-walled translucent vessels.
Finally, the patency of the anastomosis can be conf irmed by
ultrasound or by injecting dyes while watching for a change in
color distal to the anastomosis. Nonfluorescent dyes (e.g., methylene blue) as well as fluorescent dyes (e.g., fluorescein sodium
5
70
Day 4: Exercise Set 1: Basic Arterial Anastomoses
Fig. 5.5 Double end-to-side anastomosis on
carotid arteries of a rat (arterial loop). (a)
Photograph showing location of the approach
and orientation of the operative field (left) and
intraoperative photograph (right) of surgical
exposure: the left carotid artery is prepared for
harvesting, and the right carotid artery is
exposed on a background. (b) Illustrations
showing the first anastomosis created between
distal end of the left carotid artery and proximal
right carotid (left, black arrow) and the second
anastomosis between proximal end of the left
carotid and distal portion of the right carotid
(right, white arrow). (c) Final result after
completion of suturing of both anastomoses and
formation of vascular loop. (d) Blood flow
through the vessels shows the patency of both
anastomoses.
and indocyanine green) can be used with the appropriate light
filters on the microscope. Radiographic angiography is unnecessary in training settings; however, it can be used in chronic
experiments to assess long-term patency of the anastomosis.
5.8 Hemostasis
Hemostasis can be difficult to achieve, and the anastomosis
may seem leaky at first. Slight bleeding from the needle puncture sites is unavoidable and stops with time on its own. However, bleeding will persist in some cases, especially with
generous use of heparin wash. Points of copious stream-like
bleeding most often occur in places of unequal coaptation of
the vessel edges and triangular tissue protrusions (so-called
dog ears). Very few sut ures are actually needed to join the vessels without significant bleeding because blood pressure pushes
the walls outward, which closes the gaps between the sutures
in the same way as leaflets of the heart valves obstruct the
backflow.
When bleeding occurs right after the clips are opened, the
clips can be closed for a while and then opened again. While
the clips are closed, one can finish tightening the final knot.
This method allows the blood flow to stagnate and small clots
to appear that close the small holes from the needle punctures.
If oozing continues after removing the clip, apply gentle pressure with a cotton pad and wait several minutes for clot formation. If bleeding still continues, use a small piece of smashed
muscle or fat to wrap around the anastomosis (▶ Fig. 5.8).
71
Day 4: Exercise Set 1: Basic Arterial Anastomoses
72
Fig. 5.6 Carotid–jugular fistula: Technique of end-to-side anastomosis of carotid and jugular vessels with interrupted suture (Video 5.3). (a) The
carotid artery is dissected from its connective tissue. Inset shows the location of the approach and orientation of the operative field. (b) The right
carotid artery is exposed. (c) A latex background is placed behind the exposed artery. (d) The jugular vein is carefully dissected out, coagulating side
branches. (e) The jugular vein is coagulated and cut distally and (f) is washed with a heparinized solution. (g) The vessels are aligned to mark the sites
of the planned anastomosis. (h) The adventitia is removed from the joining vessels, the vein is trimmed in a fish-mouth fashion, and the carotid artery
is incised. (i) The vein is fixed with two stay sutures on toe and heel. (j) One side of the anastomosis is completed with interrupted sutures. (k) The
back side of the sutured wall is checked from inside the vessel. (l) Image showing puncturing of both vessel walls with a single needle pass. (m) The
front wall is finished with interrupted sutures. (n) Blood flow is restored when clips are removed. (o) The vein has become distended and bright red,
showing patency of the anastomosis.