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1 Microsurgery Essentials: Preconditions, Instrumentation, andSetup
7
commonly used. Nylon has these characteristics, its strength
and handling during knotting are adequate, and it is usually
black, which makes it clearly visible under the microscope.
Polypropylene monolament and polyester monolament
are also inert sutures that retain their strength well in the tissue, and the material is softer than nylon; however, their light
color makes them more difcult to see under the microscope,
and special care is necessary when handling them to not to
damage them.
All these materials are available in different sizes: 8/0 (0.4
metric), 9/0 (0.3 metric), 10/0 (0.2 metric), and 11/0 (0.1
metric). The 11/0 sutures have an average diameter of 18μm,
those of 10/0 of 25μm, those of 9/0 of 35μm, and those of
8/0 of 45 μm. Nowadays, 12/0 and 13/0 sutures are also
available for supramicrosurgery.
Regarding the needle, the monolament material is usually inserted into a 3/8 circle needle end. Different characteristics are important to take into account when selecting the
best needle for each situation: needle length (size of the
needle in mm), needle prole (curved and usually 3/8, but
half circle needles are occasionally used), needle diameter
(measured in microns and dependent on the needs, until very
recently, 130μm needles were the nest available, but diam-
eters as ne as 30μm are now manufactured), and cross section (the vast majority of needles used in microsurgery have
an atraumatic tip and a round body).
1.4 Microsurgical Training
Microsurgical techniques have historically been learned
through observation and practice in the operating room and
also through courses developed in multiple laboratories
around the world. Microsurgery has a steep learning curve;
therefore, following a proper training program and deliberate repetitive practice are essential to obtain the necessary
skills.
1.4.1 Formal Microsurgery Training
Curriculum
tubes to simulate blood vessels, but there are also some laboratories that work with cryopreserved arteries [15].
For the practice of microdissection and vascular anastomoses, various inert organic models are used. The main
organic models are the chicken wing [16] and the chicken
thigh [17] that allow the practice in vessels of optimal size
for teaching microsurgery and supermicrosurgical techniques. Furthermore, these models can be used to practice
aps, such as the chicken thigh adductor profundus free muscle ap [18].
The highest delity simulator for clinical microsurgery is
the rat, which remains as an indispensable live animal model
for many training courses worldwide. It allows interaction
with bleeding, spasm, thrombosis, and a real anatomy [19].
Despite the new simulation models for supermicrosurgery
[20], the rat continues to be the best preparation model for
achieving high standards of competency. Different submillimetric vessels in the rat have been described for performing
supermicrosurgical anastomoses [21], vascularized lymph
node transfers [22], and lymphovenous anastomoses [23].
In addition, and despite the anatomical variations, the pig
has proven to be a great translational model for teaching free
and perforator aps [24–27]. But the cost and the requirements to work with this animal restrict its use to specic surgical training centers with a highly specialized team of
veterinarians.
Due to the great disparity of training programs, the
International Society for Experimental Microsurgery (ISEM)
published some recommendations [28]. In addition, the
International Microsurgery Simulation Society (IMSS)
reached an international consensus of experts in which the
minimum standards for a basic microsurgery course and the
minimum thresholds for training were established [29] and
suggested the use of microsurgical anastomosis global rating
scales [30] to assess learning.
Recently, the pandemic situation of Covid-19 signicantly affected medical education and made face-to-face
microsurgical teaching adapt to the new times [31]; also
mass online forums emerged to help learning in times of
social isolation [32, 33]. We are perhaps facing nowadays a
paradigm shift that will lead to new evolutions in the learning of reconstructive microsurgery.
Educational programs for microsurgery include the use of
surgical microscopes, the handling of specic microsurgical
instruments, and practice with small sutures. Basic techniques of suturing and anastomosis are also taught. Increasing
restrictions on the use of live animals for surgical training
courses have led to the development of synthetic, inert
organic, and virtual simulation for learning surgical skills.
Most of the courses begin with basic suturing exercises
either on surgical gloves, gauzes, or microsuture cards [14].
Many programs continue with different silicone elastomer
1.4.2 Home Microsurgical Training Setup
Following a well-established curricular program and receiving training from experts is the best form of learning microsurgery. Then, to strengthen knowledge and rene skills,
repetitive individual practice is needed. However, the lack
of time and access to microscopy and instruments are
impediments in this regard. The ideal situation would be to
have several periodical weeks of practice in a microsurgery
8
A. Ballestín and S. Shurey
laboratory, although this optimal form of training is not
always possible. One way to complement the formal training would be to establish a home setup for microsurgery
training and then to follow online teaching contents made
by experts for the correct review and practice of microsurgical techniques [34].
The most expensive required materials are the microscope
and instruments. However, nowadays a cheap tabletop
microscope with an ×5–40 magnication can be purchased
online [35]; it is important that focal distance allows practice.
Basic suture practice can even be performed using a smartphone [36] although magnication, working distance, and
quality vary greatly with respect to clinical practice.
Training can be performed with a basic set of instruments
(needle holder, straight and angled forceps, and microsurgical scissors), vascular clamps, and microsutures. All these
materials can be found online at cheap prices, although without the quality standards required for clinical practice.
Furthermore, simulation methods described previously can
be used (surgical gloves, gauzes, silastic tubes, chicken
thighs and wings) which are inexpensive and easily available. This training method will not replace formal courses
but is a useful complement for continued practice.
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chicken thigh adductor profundus free muscle ap: a novel validated non-living microsurgery simulation training model. Arch
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19. Shurey S, Akelina Y, Legagneux J, Malzone G, Jiga L, Ghanem
AM.The rat model in microsurgery education: classical exercises
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D, Ghanem AM, etal. Evolution of an evidence-based supermicrosurgery simulation training curriculum: a systematic review. J Plast
Reconstr Aesthet Surg. 2018;71(7):976–88.
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Garcia-Iza L, Thomas I, et al. Porcine experimental model for
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S, etal. International microsurgery simulation society (IMSS) consensus statement on the minimum standards for a basic microsurgery course, requirements for a microsurgical anastomosis
global rating scale and minimum thresholds for training. Injury.
2020;51(Suppl 4):S126–S30.
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etal. Microsurgery training during COVID-19 pandemic: practical
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Basic andAdvanced Microvascular
Anastomotic Techniques
AlbertoBallestín andYelenaAkelina
2
2.1 Introduction
Reconstructive microsurgery is a surgical technique that has
been practiced since the 1960s, when Jacobson and Suárez
performed vascular anastomoses in 1mm vessels with the
use of a surgical microscope, specic instruments, and
microsutures [1]. However, the rst vascular anastomosis
techniques were previously described on large-caliber vessels by Carrel and Guthrie at the beginning of the twentieth
century [2]. Due to those technical advances that changed
surgery forever, Carrel was awarded the Nobel Prize in
Physiology or Medicine in 1912 “in recognition of his work
on vascular sutures and the transplantation of blood vessels
and organs.”
The development of surgical microscopes, the renement
of instruments, and the manufacture of microsutures made
possible to describe several microsurgical anastomosis techniques. Success on small vessel and nerve anastomoses have
allowed the surgical replantation of severed parts and the
performance of a wide variety of free tissue transfers in
patients. Therefore, innumerable surgical approaches have
changed for reconstructing patients suffering from highintensity trauma or burn injuries or after receiving resective
cancer surgeries. This chapter describes, step-by-step, each
of the main microvascular anastomosis techniques as well as
indicates essential handling tips for a proper dissection of the
tissues involved in these surgeries.
A. Ballestín (*)
Tumor Microenvironment Laboratory, UMR3347 CNRS/U1021
INSERM, Institut Curie, Paris, France
Y. Akelina
Microsurgery Research and Training Laboratory, Columbia
University, New York, NY, USA
2.2 Tissue Handling
Microvascular anastomoses are common techniques in
reconstructive surgery; they are the essence of free tissue
transfers. Fundamental to its successful performance are the
execution of careful tissue dissections, the understanding of
anatomical differences between arteries and veins, and the
appropriate vessel pedicle preparation.
Gentle tissue dissections are required prior to perform
anastomoses. Accordingly, smooth harmonic movements
should be performed, applying a very small amount of forces
while dissecting, most of which are below the surgeons’ tactile sensory threshold.
Respect innate anatomy of vessel pedicle is a prerequisite
to accomplish success. Blood vessels must be handled with
great care, parallel dissection of perivascular tissues is recommended to avoid damaging, but if necessary, vessels can
be gently manipulated by holding the tunica adventitia, its
outermost layer.
Arteries and veins have three layers (tunica intima, tunica
media, and tunica adventitia) that are formed and have different characteristics among them. Veins have an anatomy
that makes the free edges to be anastomosed more collapsible and easy to damage. This is due to the fact that they
have less collagen bers compared to arteries. Thus, it is
necessary to be especially delicate when manipulating veins
to avoid damage, as well as working with irrigation to visualize the vascular lumen during the microsurgical
procedure.
Vascular damage during dissection would lead to specic
injuries at the tunica intima, media, and/or adventitia. It
would cause vessel spasm that would make it difcult to perform the anastomotic technique. And furthermore, it would
stimulate platelet aggregation and, consequently, the development of thrombus that would lead to failure.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_2
11
12
A. Ballestín and Y. Akelina
The main cause of spasm is improper vessel handling and
dissection. In addition, the loss of temperature in the surgical
eld may lead to spasm too. This can be favored by a low
external temperature or by the lack of proper tempered irrigation. Therefore, adequate warm moistening of the vessels
is required to prevent vascular drying and smooth ber contraction. If spasm occurs despite taking these precautions,
vasodilators can be applied locally.
Regarding thrombosis and besides vessel injury, other
factors can also contribute to its development which usually occurs in the rst 24h after surgery. Poor microsurgical technique, torsion of the vascular pedicle when
performing ap insetting, or a prolonged ischemic time [3]
will favor the development of thrombus and the failure of
surgery [4].
Once the blood vessels to be anastomosed are clamped
and exposed under the microscope, local irrigation with heparinized serum is necessary to avoid having any blood inside
the lumen as well as to keep vessels in a hydrated and correct
elasticity state.
Next, adventitiectomy of vessel ends must be performed
to prevent adventitia from entering in the lumen. Adventitia
may disturb correct laminar blood ow after anastomosis
and even act as a thrombogenic attractant that will lead to
anastomotic failure.
Finally, to facilitate the microsurgical anastomosis technique, blunt-tipped vasodilator forceps can be used to widen
vessel lumen and help in size matching of the vessel ends to
be anastomosed. It has to be a delicate maneuver, since overdilation can damage vascular endothelium.
2.3 Microvascular End-to-End
Anastomotic Techniques
2.3.1 End-to-End Anastomosis Using
Biangulation Technique
1. Perform blunt dissection to expose the vessels to be
anastomosed.
2. Isolate arteries from veins.
3. Ligate small vessel branches if needed, or use a bipolar
cautery.
4. Once vessels are exposed and cut, use heparinized saline
solution to wash out both vessel lumens and their edges.
5. Place a double clamp to approach both vessel ends and
locate a contrast background to enhance visualization
(Fig.2.1a).
6. Prepare vessel edges by trimming adventitia using ne
forceps and microsurgical scissors (Fig.2.1b).
7. Dilate vessel ends using a polished blunt-tipped vessel
dilator.
8. Place two interrupted stay sutures at 180° (12 o’clock
and 6 o’clock positions). If using a clamp with frame, x
the ends of each stay suture to the frame (Fig.2.1c).
9. Place three more interrupted sutures starting at 3 o’clock,
then 1 o’clock, and 4 o’clock positions. Middle stitch
may be left longer for vessel handling to avoid catching
the back wall while suturing (Fig.2.2a).
10. Flip the double clamp 180° to expose the posterior wall,
check the lumen by irrigating heparinized saline solution, and complete the anastomosis in the same manner
as anterior wall (Fig.2.2b).
ab c
Fig. 2.1 First steps of an end-to-end arterial microsurgical anastomosis using biangulation technique. (a) Microscopic view of an artery
after clamping and washing out using heparinized serum saline. (b)
Excess of adventitia removal. (c) Placement of two stay sutures 180°
apart one from each other
2 Basic andAdvanced Microvascular Anastomotic Techniques
13
a
c
b
d
Fig. 2.2 End-to-end arterial microsurgical anastomosis using biangulation technique. (a) Placement of microsurgical stitches on the anterior
wall. (b) Placement of microsurgical stitches on the posterior wall after
11. After completion, release the stay sutures and remove
the clamp (Fig.2.2c).
12. Place some adipose tissue and a surgical gauze over the
anastomosis site for a few minutes for hemostasis [5]
before evaluating patency.
13. Check vessel after completing the anastomosis
(Fig.2.2d).
14. If bleeding occurs, repair the anastomosis with additional stitches using the partial occlusion techniques [6]
to avoid thrombus development (Fig.2.3).
2.3.2 End-to-End Anastomosis Using One-
Way- Up Technique
1. Prepare the vessel as previously described for end-to-end
biangulation anastomosis technique.
2. Place and secure the rst stay suture at 12 o’clock
position.
having turned the microvascular clamp 180°. (c) Microvascular clamp
removal. (d) Patent end-to-end arterial anastomosis
Fig. 2.3 Partial occlusion technique to perform anastomosis repair
without clamps [6] to avoid thrombus development
14
ab
Fig. 2.4 End-to-end anastomosis using one-way-up technique. (a) Backhand technique for placing posterior wall stitches, rst pass outside in in
the left side. (b) Microscopic view of the anterior wall after the placement of the rst two stitches of an anastomosis using one-way-up technique
A. Ballestín and Y. Akelina
3. For the all posterior wall stitches, make the rst pass out-
side in using a backhand technique and the second pass
sists of three steps: preparation of the donor vessel, prepara-
tion of the recipient vessel, and the microsuture technique.
inside out with the forehand technique for having the knot
outside of the lumen (Fig.2.4a, b).
4. Fix the 6 o’clock stay stitch once midpoint of the anasto-
2.4.1 Preparing Donor Vessel (Vessel End)
mosis is reached.
5. Proceed closing the anterior wall in the normal, single
pass forehand manner.
6. Upon completion of the vessel sutures, release the stay
suture and the vessel clamp.
1. Perform careful blunt dissection of the vessel under high
magnication. If needed, ligate or coagulate small vessel
branches.
2. Place a single clamp on the proximal end of the vessel
and ligate distally.
3. Transect the vessel close to the ligature and ush with
2.4 Microvascular End-to-Side
Anastomotic Technique
heparinized saline.
4. Trim the excess of adventitia at the vessel edge and dilate
its lumen by using vessel dilators.
The most common technique in vascular microsurgery is the
end-to-end anastomosis, which is performed between vessels of the same or similar caliber. When end-to-end cannot
2.4.2 Preparing Recipient Vessel (Vessel Side)
be done because it is necessary to preserve the blood ow of
a vessel, or when there are size discrepancies greater than 2:1
between the vessels to be anastomosed, end-to-side anastomosis is performed [7].
Size discrepancy is a common issue in reconstructive
microsurgery, because vessel caliber change can cause turbulent blood ow and, therefore, predisposes to platelet aggregation. Small size discrepancies can be resolved by
mechanical expansion with vasodilator forceps. Other option
if the size of the donor vessel is small is to enlarge lumen
diameter by cutting the end of the vessel obliquely. However,
in the event of large discrepancies, other techniques such as
sleeve anastomosis could be considered [8].
Clinically, end-to-side anastomoses are commonly performed in tissue revascularizations and organ transplants and
during free tissue transfers. The end-to-side technique con-
1. Place two single clamps on both the proximal and distal
end of the recipient vessel.
2. Position the donor vessel next to the recipient vessel to
help visualize the space required for the size of the arteriotomy or venotomy (depending on the type of vessel
being used).
3. Before creating the side cut, remove completely adventitia over an area twice as large as the arteriotomy or venotomy size.
4. Plan the lateral arteriotomy/venotomy in an area that will
help to avoid tension during the anastomosis. To avoid
tension more dissection may be performed or mobilizing
the tissues involved may be needed. Do not place the lateral arteriotomy/venotomy directly over any marginal
branch.
ab
cd
2 Basic andAdvanced Microvascular Anastomotic Techniques
15
5. Gently lift the vessel wall with straight forceps or by
using a microsuture stitch to pull the vessel. Make a small
“v-shaped” cut underneath the forceps or suture
(Fig.2.5a). To do so, position your scissors longitudinally
along the vessel at a 45° angle, and make a small nick in
the vessel. Flush through the newly made cut with heparinized saline. And then, dilate the cut opening using a
vessel dilator to a size that is approximately 20% larger
than the diameter of the donor vessel that is going to be
anastomosed to the recipient vessel.
e f
Fig. 2.5 End-to-side anastomosis. (a) Cut of an oval-shaped opening
that is similar in size to the vessel to be approximated. (b) Placement of
two stitches at 180° to connect the donor and recipient vessels together.
(c) Back-wall sutures of the end-to-side anastomosis. (d) Inspection of
the vessel lumen after posterior wall suture. (e) Front wall sutures of the
end-to-side anastomosis. (f) Patent end-to-side anastomoses
16
A. Ballestín and Y. Akelina
2.4.3 Microsuture Technique forEnd-to-Side
Anastomosis
1. Connect the end of the donor vessel with the side of the
recipient vessel with the rst stitch that should be placed
closest to the proximal end of the donor vessel at the longitudinal aspect of the elliptical arteriotomy/venotomy (9
o’clock position). The second stitch should be placed
180° opposite the rst stitch (3 o’clock position). Make
sure the stitches are made “outside in, inside out” to let
the knot outside the anastomosis lumen (Fig.2.5b).
2. After this, complete circumferential stitches on the wall
that is opposite the surgeon; complete the back wall rst
(Fig.2.5c). This will help prevent inadvertent back-wall
stitches throughout the procedure. Make sure the middle
stitch is placed straight and the two others radially. Pay
attention to the spacing between the stitches. Be sure to
make small bites when throwing stitches (between 1 and
2 needle widths from the suture line).
Note: In case the vessel cannot be mobilized, or it is
very difcult to interrupt suturing of the back wall, interrupted stitches can be placed “outside in, inside out” in a
similar way to the one-way-up technique, or even a continuous hemisuture can be made on the back wall.
3. After completing the back wall, irrigate with heparin
solution to remove any blood residue remaining in the
lumen and to inspect for back-walling stitches (Fig.2.5d).
4. Perform suturing of the front wall (Fig.2.5e). In order to
avoid the back-wall stitches, we suggest keeping the middle stitch open while also placing two radial stitches.
Then, close both radial stitches before closing the middle
stitch. Again, place all stitches in the same “outside in,
inside out” manner.
5. Once the procedure is completed, examine the anastomosis for gaps before clamps are removed. The order of
clamp release should follow the lowest blood pressure to
highest blood pressure.
6. Finally, check for patency to ensure re-establishment of
blood ow through the anastomosis (Fig.2.5f).
grafting can also be used to help in difcult anastomoses
with short vessel stumps, to avoid bifurcations, or to place
the anastomoses away from infected, radiated, atherosclerotic, or otherwise altered vessels [11].
Interpositional microvascular vein grafting consists of
three steps: preparation of the artery, preparation of vein
graft, and the microsuture technique.
2.5.1 Preparation oftheArtery
1. Clamp and wash out the artery with heparinized saline.
2. Trim the adventitia from the edge and insert the vasodilator
forceps into the arterial ends to slightly enlarge the lumen.
3. Using the small ruler, measure the length of the gap
between the edges of the artery to determine the exact
length of the graft needed to cover that defect (Fig.2.6a).
2.5.2 Preparation ofVein Graft
1. Place marking stiches in the vein adventitia so that you
can align the graft in the proper orientation of the valves
and blood ow. This means that the graft will need to be
reversed when inserted into the artery such that the distal
end of the vein is sutured to the proximal end of the artery.
Leave one marking stitch longer to facilitate keeping
track of the proximal end.
2. Ligate both ends of the vein, ensuring you have at least
1mm more length than the artery defect on each end.
3. Excise the distal end of the vein rst, irrigate with hepa-
rinized saline, and trim the adventitia before excising the
other end, as it is easier to ush and trim with one end still
attached. Then, excise the proximal end of the vein and
bring it to the arterial defect to start suturing (Fig.2.6b).
2.5.3 Microsuture Technique
forInterpositional Vein Graft Technique
2.5 Interpositional Venous Grafting
Interpositional vein grafts have become a standard procedure
for bridging segmental vascular defects in reconstructive
microsurgery [9].
In the past, in replantation surgery, the bones and soft tissues were shortened to achieve direct anastomosis.
Nowadays, vein grafts are essential to face defects in which
vascular tissue has been lost due to trauma, after debridement or resection surgery. But grafts can also be considered
when there is a signicant size discrepancy between the
recipient vessels and the ap pedicle [10]. In addition vein
1. Place the rst stay suture at 12 o’clock through the proximal end of the artery to the distal end of the vein. Then
place the second stay suture at the 12 o’clock in the distal
end of the artery to the proximal end of the vein, using the
marking stitches to ensure proper alignment with no
twisting of the vein.
Note: When working with medium- or large-sized
vessels, there are greater gaps, so it may be needed to
use a double clamp to approximate the artery and vein
rst on the proximal anastomosis and then on the
distal.
2. Then place the third and fourth stay sutures at 6 o’clock
on both sides. Leave some length on each stay suture for
easier manipulation of the vessels.
ab
cd
2 Basic andAdvanced Microvascular Anastomotic Techniques
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17
Fig. 2.6 Interpositional vein graft. (a) Artery defect requiring a vein
graft. (b) Vein graft positioned in the eld. Its size is larger than the
existing arterial defect, although it may not seem like it because after its
Note: In case of a large-sized discrepancy, oblique cuts
can be made to spatulate the edges of the artery and
harvesting the vessel is naturally retracted. (c) Anastomosed vein graft.
(d) Patent microvascular vein graft
2.6 Supermicrosurgery andFuture
Perspectives
reduce the diameter differences.
3. Complete the anterior walls on both anastomoses with
three middle evenly spaced stitches.
Note: Make sure that the marking stitches are aligned
to ensure that there is no twisting of the vein.
4. Flip microvascular clamps to complete suturing of posterior walls.
5. Upon completion of both anastomoses, examine the
suture lines for any gaps and place extra sutures if needed
(Fig.2.6c).
6. Release the distal clamp rst and let the retrograde ow
open the lumen to show any defects. Then open the proximal clamp (Fig.2.6d).
7. Finally, check the patency distally from the distal
anastomosis.
Supermicrosurgery is the part of microsurgery that includes
the dissection and anastomosis of vessels smaller than
0.8 mm [12]. Thanks to the use of 11/0, 12/0, and 13/0
sutures, this technique allows anastomosing of very small
arterial, venous, and lymphatic vessels that were previously
inaccessible.
It is a technique that enabled to rene multiple soft tissue reconstruction techniques such as nger-tip replantation, toe tip transfers for ngertip loss, and free
perforator-to- perforator aps. Furthermore, it has had a
paramount impact in the surgical treatment of lymphedema,
allowing to perform vascularized lymph node transfers [13,
14] and lymphaticovenular [15] and lymphatico-lymphatic
anastomoses [16].
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