Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3743_Библиотеки_им_академика_М_И_Перельмана
.pdf
130
A manual of basic microsurgical techniques
using the angle of incision, the size and grouping of the fascicles and the epineural
vascular topography as visual guides to matching.
The epineurium should not be stripped from the nerve segments, as this is important
to the vascular supply of the anastomosed nerve.
● Grasp the epifascicular epineurium with forceps working under 6–10× magnicaon
and pass a 9/0 or 10/0 suture at the 120° posion. Take 1 mm bites out of the
epineurium and pass the needle so that it lies parallel with the surface just beneath
the epineurium, not into the perineurium, and taking care not to transx any of the
fascicles.
● Secure with a double and two single throws, leaving the proximal end long. Repeat
at the opposite 120° point (Figure 14.5).
Figure 14.5 Stay suture placement.
● Place the third and fourth sutures between the two stays, tying a simple square
knot and cung both ends short. All subsequent sutures should be simple square
knots (Figure 14.6).
● The nerve is now rotated about its longitudinal axis using the stay sutures, the long
ends of which are aached to single Acland clamps to hold the nerve in posion
(Figure 14.7).
Before suturing the posterior wall, aenon must be paid to the axoplasm. Unlike
human nerves, the axoplasm is exuded connuously from the proximal nerve stump
and can make the anastomosis dicult to complete. To alleviate this, a few millimetres
of the proximal and distal axoplasm are resected, creang an empty epineural ‘pocket’
in which to place the exuding proximal axoplasm. This is not necessary in humans, as
the axoplasm does not protrude.
Peripheral nerve repair
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
131
Figure 14.6 Anterior wall.
Figure 14.7 Posterior wall.
Care should be taken when tying subsequent sutures that the epineural walls are
brought together without involving the neuroplasm. This should be gently ‘tucked’
into the distal pocket as the stches are brought together.
132
A manual of basic microsurgical techniques
● The h suture is placed at the midpoint posion and the proximal end le long.
● The single clamp is removed and placed onto this midpoint suture to ensure ten-
sion; this rotates the nerve and allows placement of the sixth and seventh sutures
(Figure 14.8).
● The Acland clamp is then moved to the le, sll aached to the midpoint suture;
this then rotates the nerve to the le and allows placement of the eighth and ninth
sutures (Figure 14.9).
Figure 14.8 Clamp repositioned.
Figure 14.9 Nerve rotated.
Peripheral nerve repair
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Once the anastomosis is complete, the Acland clamps are removed and the nerve
rotated to its original posion. The stay sutures are then cut short, the background
material removed and the area irrigated (Figure 14.10).
133
Figure 14.10 Completed nerve anastomosis.
Interpositional nerve grafts
To mimic the clinical situaon in which interposional nerve gras are used to join
damaged nerves without undue tension, the rat sciac nerve is removed from one leg
via the standard surgical approach and graed onto the opposite limb.
It is possible to harvest between 1.0 and 1.2 cm of donor nerve. With the chicken
nerve, 1 cm can be removed, reversed and then anastomosed into the gap.
● Excise 0.5 cm of nerve from the recipient side. The nerve stumps will spring back
and create a gap to be bridged of at least 1.0 cm.
● The gra is then sutured in posion using the standard epineural anastomosis
described earlier (Figure 14.11).
134
A manual of basic microsurgical techniques
Figure 14.11 Nerve graft.
Interfasicular repair
This repair is no longer used in the clinical situaon due to excessive brosis occurring within the nerve; however, it is a useful exercise for dissecon and anastomoc
purposes, parcularly when wanng to repair nerves at the supramicrosurgical level.
This exercise can also be performed using the chicken nerve.
● The sciac nerve is exposed and dissected clear for a sucient length to allow tran-
secon 5 mm proximal to its division into bial, sural and peroneal nerves.
● Using the microscope at 10× magnicaon, dissect and roll back the peripheral epi-
neurium for a distance of about 1 mm, then separate each fascicle gently, teasing
apart the interfascicular epineurium.
● Transect each fascicle.
It is possible to place two sutures 180° apart in the two smaller fascicles, passing the
needle (9/0 or 10/0) through the perineurium only. In the larger fascicle, it may be
possible to place three sutures (Figure 14.12).
Figure 14.12 Fascicular anastomosis.
15
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
This exercise ulises rat testes and the vas anastomosed end to end using a two-layer
technique. The same exercise could be carried out on abaoir specimens obtainable
from farm animals if available.
Vasovasostomy can be performed in rats as a model for training and research, although
the rat vas lacks the thick musculature characteriscs of the human vas.
In man, the vasovasostomy can also be completed either by a single layer of interrupted sutures through the whole wall of the vas or by two layers of sutures, one joining mucosa to mucosa and the other seromusculature to seromusculature.
The suture used throughout is a 10/0 nylon for the rat and in man 9/0 nylon on a
micropoint needle.
The method described is the modied two-layer technique, though other techniques
are described in the literature.
Rat vasovasostomy
Vasovasostomy clamps
When aempng a vasovasostomy, it is best to use specially designed double
clamps; these will make the operaon that much easier but are expensive to purchase (Figure 15.1).
Figure 15.1 Vasovasostomy clamps.
DOI: 10.1201/9781003413080-15
136
A manual of basic microsurgical techniques
Advantages:
● Reduces operang me
● Ends clamp slippage with the use of at-pped, non-penetrang steel spikes
● Gentle to mucosa
● Two-direconal fold that facilitates anterior and posterior wall anastomosis
● Adjustable and lockable
● Easily stabilised by aaching a haemostat
The vasovasostomy described in the rat utilises two single clamps instead
of the approximator clamp, as some units may not have them due to availability
or cost.
Rat dissection
A vercal incision over the scrotum is carefully deepened unl the tess, epididymis and straight poron of the vas are revealed. The whole structure is elevated and
placed onto a damp swab to hold it in posion (Figure 15.2).
Figure 15.2 Vas dissection.
Rat vasovasostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Exposing the whole length of the vas gives room for pracsing mulple anastomoses
(Figure 15.3).
Anatomy
137
Figure 15.3 Anatomy.
Vasovasostomy: Two-layer method
There are a few dierent techniques described in the literature; the most common
is the two-layer or modied two-layer method. Either method can be used for pracce; the method used here for training purposes is the modied two layer. This diers
from the standard two layer, as the rst two or three stches are placed through the
full thickness of the vas deferens, not just the mucosal layer.
Vasovasostomy modied two-layer method
With this method, four (in the rat) to six (in man) sutures are placed through the full
thickness of the vas. These sutures ensure that the lumens on both sides of the vas
are correctly aligned.
Stches are then placed in the outer layer of the two ends to prevent sperm leakage
and potenal scarring or breakdown.
The thick walls of the vas can prevent adequate alignment if anastomosed by the seromuscular layer alone.
138
A manual of basic microsurgical techniques
Vasovasostomy preparation
It is important that the area is kept irrigated throughout the procedure to alleviate
dehiscence and to prevent later adhesions.
● The advena is gently freed from around the vas (Figure 15.4).
Figure 15.4 Adventitia removal.
● The main vessel (artery of the vas deferens) underlying the vas is carefully dissected
free and preserved (Figure 15.5).
Figure 15.5 Preservation of the artery of the vas deferens.
Rat vasovasostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
It is important that before the vas is divided any possible bleeding is controlled, as
any oozing will obscure the transected end of the vas and make anastomosis more
dicult.
● The smaller vessel can also be dissected free and preserved (in man) or be ligated
or cauterised in the rat model.
● Once the possibility of any bleeding is alleviated, the vas can be placed over a piece
of background material and then divided.
● The rst suture is placed at the 10 o’clock posion through the seromuscular layer
and into the lumen on both sides, leaving the stch uned unl the 2 o’clock suture
is in posion (Figure 15.6).
139
Figure 15.6 First stitch placement.
● Once in posion, the stches are ed and cut.
● Due to the thickness of the vas wall, the stches should consist of a double throw
followed by two single throws.
● The ends of the vas are again aligned with two 10/0 sutures, this me through the
seromuscular layer at 180°. These are secured, leaving one end of the stch long
in each case. These help to manipulate the vessel and place subsequent sutures.
Соседние файлы в папке Библиотека им академика М.И. Перельмана