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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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140
A manual of basic microsurgical techniques
● The next stch is placed equidistant to these two on the anterior wall and the gaps
between lled with two to three more stches (Figure 15.7).
Figure 15.7 Completed anterior wall.
● On compleon of the anterior wall, the vas is ipped over (this is easy if a double
clamp is used), or alternavely, if this clamp is not available, single clamps can be
applied to the long suture ends. These act as weights and help to keep the vas in
place for the posterior anastomosis (Figure 15.8).
● As before, two sutures are placed at 10 o’clock and 2 o’clock into the vas lumen and
not ed unl both are in place.
Figure 15.8 Posterior wall exposure.
Rat vasovasostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
● The next stch is placed in the middle of the posterior wall into the seromuscular
layer, leaving one end long. Another one to two sutures are placed alongside this.
● To reach the last quadrant, a single clamp can be removed and placed onto the cen-
tral posterior stch. This rotates the vas and makes it easier to place the last one to
two sutures (Figure 15.9).
Figure 15.9 Rotating to stitch the last quadrant.
141
● On completion, make sure the vas is not twisted and remove the background
material (Figure 15.10).
Figure 15.10 Completed vasovasostomy.
16
The inial dissecon is the same as the for the vasovasostomy. The suture used
throughout is 10/0 nylon for the rat and 9/0 for man on a micropoint needle.
Double-armed needles are available that make the anastomosis much easier but are
expensive, so for pracce purposes and as some units do not have access to them,
single needles are ulised.
In this module the exercise ulises rat testes and the vas is anastomosed using an
intussuscepon two-suture transverse technique (modied for pracce in the rat).
Rat epididymovasostomy
Epididymovasostomy clamps
When aempng an epididymovasostomy, it is best to use specially designed double
clamps; as menoned, these will make the operaon that much easier but are expensive to purchase (Figure 16.1).
Figure 16.1 Epididymovasostomy clamp example.
Advantages:
● Reduces operang me
● Ends clamp slippage with the use of at-pped, non-penetrang steel spikes
● Gentle to mucosa
DOI: 10.1201/9781003413080-16
Rat epididymovasostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
● Two-direconal fold that facilitates anterior and posterior wall anastomosis
● Adjustable and lockable
● Easily stabilised by aaching a haemostat
The epididymovasostomy described here in the rat does not use these clamps, as
some units may not have them due to availability or cost.
Various methods are described in the literature, and any of these could be used
for training purposes. The method utilised for this exercise is an intussusception
two-suture transverse technique. The transverse technique has been chosen, as
the epididymis transection is easier to perform on the rat than with a longitudinal
incision.
Epididymovasostomy dissection
Normally in man the caput epididymis is used, but in the rat exercise, the cauda is
ulised, as the caput is too fragile (Figure 16.2).
143
Figure 16.2 Anatomy.
144
A manual of basic microsurgical techniques
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 16.3).
Figure 16.3 Adventitia removal.
● The main vessel underlying the vas can be carefully dissected free, doubly ligated
and cut (Figure 16.4).
Figure 16.4 Dividing the artery of the vas deferens.
● 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.
Rat epididymovasostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
The vas is then transected, leaving a longer ‘stump’ on the vas side (Figure 16.5).
Figure 16.5 Dividing the vas.
145
● The vas is then placed adjacent to the cauda.
● With scissors, an incision is made in the caudal sac equal to the outside diameter
of the vas (Figure 16.6).
Figure 16.6 Incising the caudal sac.
146
A manual of basic microsurgical techniques
● The epididymis tubule is gently freed by blunt dissecon (in man, sharp dissecon
is needed, as the ssue is much tougher) (Figure 16.7).
● Two 8/0 monolament nylon sutures are placed on either side of the vas lumen and
ed to secure the vas in place, ensuring there is no tension (Figure 16.8).
Figure 16.7 Exposing the tubule. Figure 16.8 Securing with 8/0.
● The end of the vas is then resected to healthy, vascularised ssue and the vas lumen
exposed (Figure 16.9).
Figure 16.9 Exposing the vas lumen.
Rat epididymovasostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
● Insert one 10/0 suture ~3 mm from the vas end from outside of the vas to the
inside. Bring the needle through to the external vas opening and then transversely
into the tubule. Leave the suture uned. Repeat for the other side (Figure 16.10).
Figure 16.10 Insertion of rst two sutures.
● Transversely, incise the tubule between the sutures with Vannas scissors, making
the smallest cut possible (Figure 16.11).
147
1
Figure 16.11 Incising the tubule transversely.
● Take the needles back into the vas and exit at the original entrance point. Double-e
each stch, ensuring the tubule is invaginated into the vas (Figure 16.12).
Figure 16.12 Invaginating the tubule.
148
A manual of basic microsurgical techniques
● With 10/0 sutures placed into the vas muscularis, secure the vas to the caudal sac
along the anterior wall (Figure 16.13).
Figure 16.13 Securing the vas muscularis on the anterior wall.
● Complete the posterior wall with 10/0 interrupted sutures to secure the vas to the
caudal sac.
● Posion the vas so there is no tension present (Figure 16.14).
Figure 16.14 Completed epididymovasostomy.
Note
1 In man, the suture is normally placed into tubule rst and then out through the vas. This
puts unnecessary strain on a rat tubule, so the preference is to do it the other way a round.
17
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Key points:
● Properly maintained instruments are crical to success.
● Microvascular transfer has major surgical stress to the paent. Perioperave assess-
ment is important.
● High blood ow into and out of the free ssue transfer is the key to success. Vessel
selecon is crical in ensuring success. When possible, use large-calibre vessels.
● Seng up the posion of the microscope and the ergonomics of the chair are
important.
● Postoperave support for blood pressure, intravascular volume and cardiac support
is important in maintaining good ow through the free ssue transfer.
● The rate of successful salvage is inversely proporonal to the elapsed me between
the onset of ischaemia and clinical recognion. Postoperave monitoring is an
essenal element of microsurgery.
Clinical practice
Preoperative
Free ssue transfer is a major surgical procedure, with signicant surgical stress.
Fluid loss, hypothermia and length of procedure all have signicant eects on success. Paents must be crically assessed for cardiac, pulmonary and renal status and
opmised.
Microsurgical instruments
Operating microscope
The operang microscope should have good opcs, a wide eld of view with a good
depth and a strong light source. Other desirable features include binocular tube
assemblies with an adjustable angle of inclinaon, an X-Y unit with a wide range of
movement in both planes and independent focus and zoom controls for the surgeon
and the assistant. An addional useful feature is an aached video camera that allows
the scrub nurses and other surgical team members to view the anastomoses for teaching and training.
DOI: 10.1201/9781003413080-17
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