Practical Points in the Operating Room
- Set your chair height so your feet are flat on the floor
- Set your microscope height so your eyes are looking straight ahead
- Set the OR table height so your hands and wrists are comfortable
- Put folded towels under your elbows/forearms until they are comfortable.
- If the table will not go low enough to position your forearms horizontally, or if your wrists are hyperflexed to get into a hole, then you should stand up to do the microsurgery.
- Pre-op: don’t smoke, usual amount of caffeine, avoid exercise 24 hours prior, get a good night of sleep.
- 3 point stability of elbows, wrists, and fingers
- Knot tying: stabilize forceps with needle holder when grasping short suture
- Suture cutting: stabilize scissors with forceps when cutting sutures.
- Patient movement:
- Have anesthesia paralyze patient to eliminate deep spontaneous breathing
- Ask anesthesia to give smaller tidal volumes
- If needed, have anesthesia stop ventilation during suture placement
Avoid Working in a Hole
- Extend your incision
- Further mobilize your recipient vessels more proximally
- Platform vessels: put multiple raytec sponges and cottonoids to bring vessels that are in a hole out to the surface
- Reposition self-retaining retractors to give wider exposure.
Keep Visual Field Dry
A bloody visual field makes every part of microsurgery more difficult, wastes time suctioning, results in more blood loss, and increases risk of thrombosis (by activating clotting cascades and platelet aggregation).
- Vessel dissection: bipolar before you cut, not after.
- Use heparinized saline dampened raytec sponges in depth of wound under vessels to soak up blood.
- Place heparinized saline dampened 1” cottonoids on top of raytec sponges to give a level surface for background material.
- Put background material on top of cottonoids and keep surface of background dry, using wec spheres.
Instruments and Supplies
- Confirm with the OR that they have all the equipment before starting the case.
- Equipment to include:
- Radial forearm flap: sterile tourniquet, dermatome
- Fibula flap: sterile tourniquet, oscillating saw, elevates, drill/bits, dermatome, mandible plating system.
- Internal mammary vessels: ronguers, elevators
- Gluteal flap: IM vessel exposure equipment, large hemoclips
- Make sure instruments are demagnetized
- If instrument tips are bent, discard them
- Keep micro instruments away from macro instruments
- Handle micro instruments individually. Never “grab” a bunch of them at once
- Make a “basket” for micro instruments lined with heparinized saline gauze
- Position vessels (or your hands) so that vessels are perpendicular to your needle holder held in your hand with the wrist in neutral position.
- Platform vessels as far out of the hole as possible
- Hold free flap in the air and let vascular pedicle dangle to unwind twists
- Wrap the flap in ice cold saline soaked lap sponge to keep fat and muscle out of microscopic visual field
- Keep flap cold throughout ischemia time by topically irrigating wrapped flap with ice cold saline during microvascular surgery
- Rapidly rewarm with warm saline (> 37 degrees C)
- Topically irrigate adventitia with papavarine
- If bleeding occurs around vascular pedicle, be patient and don’t panic
- Look for unligated/cut side branches on artery and vein
- Long side branch: use small hemoclip or cauterize with bipolar
- Short side branch: Suture tie or suture ligature
- Look for bleeding from 2nd outflow vein from flap
- If bleeding from anastomosis
- Needle hole bleeding?: leave alone
- Gap?: Add another suture
Spasm is common in both the artery and vein after reperfusion.
- Warm flap and pedicle with warm saline
- Topically apply papavarine (full strength if ½ strength not working)
- Stretch adventitia at point of narrowing
- Cut adventitia at point of narrowing
- Persistent spasm:
- Suspect damaged vessel.
- Excise damaged segment and re-do anastomosis with or without vein graft.