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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3743_Библиотеки_им_академика_М_И_Перельмана
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100
A manual of basic microsurgical techniques
Figure 11.7 Completing anastomosis.
Figure 11.8 Completed anastomosis.
Anastomosis with single clamps
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End-to-end venous anastomosis
This uses the same 120° or triangulaon technique as for the artery.
● Apply single clamps to the vein distal end rst.
● Place as proximally and distally as possible.
● Transect, ush and remove any obvious connecve ssue.
● Place the rst 120° stch with a double throw and gently bring the edges together,
ensuring there are no tears in the wall.
● Complete the stch with two single throws and leave the proximal end of the stch long.
● Place the second 120° stch in the same way as the rst, leaving the proximal end long.
● Apply single clamps to the long ends – these act as ‘weights’ to help add horizontal
tension.
● Place a third stch with two single throws in the middle of the anterior wall, leaving
the proximal end of the suture long.
● On the anterior wall, place another stch on either side of the central stch, using
the central stch to give some tension (Figure 11.9).
101
Figure 11.9 Anterior wall anastomosis.
102
A manual of basic microsurgical techniques
● Remove the single clamp weights. Pass one stay suture under and one over to
reveal the posterior wall.
● Replace the single clamp weights onto the long ends and place a central stch, leav-
ing the proximal end long.
● Remove the right single clamp weight onto the central stch to give tension.
● Place another central stch into the vein poron, leaving the proximal end long,
and add another stch on either side.
● Move the weight clamp over to the le and place another central stch to the
vein poron, leaving the proximal end long, and add another stch on either side
(Figure 11.10).
Figure 11.10 Posterior wall anastomosis.
Anastomosis with single clamps
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● Irrigate vein, remove the proximal clamp, wait for oozing to stop and then remove
the distal clamp (Figure 11.11).
103
Figure 11.11 Completed venous anastomosis.
When using the double clamp, only ve stches are placed into the venous posterior
wall; because of dicules in alignment with the single clamp method, more may be
needed. Take care to take very small stch bites (1.5× the thickness of the vessel wall)
to avoid narrowing at the anastomosis.
12
Continuous suturing
techniques
In this module, the femoral artery and vein in the rat are dissected and anastomosed with
a connuous suturing technique. The same exercises can be carried out in the chicken.
The anterior wall can be anastomosed rst if there is room to ip the double clamp. If
not, the posterior wall can be completed through the anterior wall.
Advantages
● Quick technique.
● Less likely to bleed on clamp removal.
● If clamp space is ght, the posterior wall can be sutured through the front.
● Very good for anastomosing friable vessels.
Disadvantages
● Need to be accurate with suture placement and bite size.
● Correct horizontal tension is needed to avoid the ‘purse-string’ eect, parcularly
with veins.
● Have to be sure not to stch in opposing wall.
● Not advisable without a double clamp.
It is advisable not to aempt this technique unl you are experienced in interrupted
suturing.
The anastomosis
Connuous sutures of 10/0 monolament polyamide or monolament polypropylene
are used in all these exercises on rat femoral vessels (8/0 or 9/0 can be used for the
chicken vessels).
Working on the anterior wall rst is easier using the standard triangulaon method,
but if space is ght for ipping the clamp, then the posterior wall is anastomosed rst
through the anterior wall using the reverse triangulaon technique.
DOI: 10.1201/9781003413080-12
Continuous suturing techniques
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The method shown throughout is the reverse triangulaon to enhance the exercise
diculty (normal 120° triangulaon technique suture placement can be used if vessel
access is not a problem).
The idea is to place the rst two stay sutures at 120° onto the posterior wall and apply
horizontal tension. This aens and stabilises the posterior wall so that the anterior
240° falls away from the posterior. With the correct tension, the anterior wall opens as
a ‘mouth’ through which the posterior wall can be anastomosed (Figure 12.1).
Reverse triangulation technique
Figure 12.1 Placement of 120° stay sutures on posterior wall.
Femoral artery continuous anastomosis
105
● Clamp and prepare the artery (see Chapter 7) using the double clamps.
● Place the rst stay suture (one double and two single throws) into the 120° point
on the proximal and distal posterior wall on the le side. Leave the short end of the
suture aached (Figure 12.2).
Figure 12.2 Placement of rst stay suture.
106
A manual of basic microsurgical techniques
● Place a second stay suture on the right hand side into the 120° point on the proximal
and distal posterior wall.
● Leave the ‘short’ end long enough to x to the right-hand cleat; the ‘long’ end has
the needle aached (Figure 12.3).
Figure 12.3 Placement of second stay suture.
● Place enough horizontal tension to straighten the posterior wall and open the ante-
rior wall into a ‘mouth’ (Figure 12.4).
Figure 12.4 Anterior ‘mouth’.
Continuous suturing techniques
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● Place the next stitch into the posterior wall as close to the stay suture as
possible.
● Go from outside in on the proximal wall then direct the needle back out, then
from outside in on the distal side (the needle should now be on the inside of the
posterior wall) (Figure 12.5). This manoeuvre ensures the stch is placed as close
to the stay suture as possible and ensures a gap is not le in the distal posterior
wall that could bleed.
● Gradually work along the posterior wall, taking ‘arterial-size’ bites, one needle-
thickness apart.
● Adjust tension as you go but do not ‘purse string’.
● Finish the last stch as close to the le stay suture as possible. Tie with a double
loop to the short end of the stay suture and keep the needle aached.
If the needle is kept to the le and the suture to the right, this minimises the risk of
the suture tangling.
● Bring the needle through to the anterior wall and work along to the right-hand stay
suture.
107
Figure 12.5 Needle on inside of anastomosis.
108
A manual of basic microsurgical techniques
If the needle is kept to the right and the suture to the le this minimises the risk of the
suture tangling on the posterior wall.
● Detach the stay suture from the cleat and e with a double and two single throws
(Figure 12.6).
Figure 12.6 Detachment of the rst stay suture.
Ensure you use a double throw; a single throw will not lock, and the artery will
narrow.
● Remove the other stay suture.
● Remove the double clamp distal end rst (Figure 12.7).
● Check ow with the ‘milk’ test.
Continuous suturing techniques
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109
Figure 12.7 Clamp removal.
Femoral vein continuous anastomosis
This is performed in the same manner as the femoral artery.
● Clamp and prepare the vein (see Chapter 7) using the double clamps.
● Place the rst stay suture (one double and two single throws) into the 120° point on
the proximal and distal posterior wall on the le side.
● Aach the long end of the suture (with the needle) to the cleat and then cut.
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