Surgery Spotlight: Microvascular Breast Reconstruction Vessel Anastomosis-Surgery Spotlight: Microvascular Breast Reconstruction Vessel Anastomosis

Surgery Spotlight: Microvascular Breast Reconstruction Vessel Anastomosis

Video Transcription

This video shows the view through the operating microscope. The internal mammary artery and vein have been dissected and prepared for microsurgical anastomosis.  The artery is seen lateral, and the vein is medial. The cut portion of the rib is seen at the sternal junction medially, and the patient's  head is towards the top right of the screen. The breast flap pedicle is seen along the lateral aspect of the screen. There is one artery and one vein.  The deep artery may have a curve if the dissection was carried far along the pedicle during harvest.  The pedicle itself has a large occluder clamp on it to prevent efflux of blood onto the field. A microsurgical occluder clamp is placed on the proximal part of the vein.  Clips are then placed on the distal part of the vein, and it is divided.  With the vein cut, we are able to measure the diameter to select the appropriately sized coupler. Using the measuring device, we can determine that a 2.5mm coupler is best.  Sometimes, the entire venous anastomosis is performed before the artery is occluded. However, in this case, the artery is now also occluded using an occluder clamp.  The distal portion of the artery is then clipped.  The adventitia is carefully dissected off the distal aspect of the cut artery to avoid debris sliding into the lumen during the anastomosis.  The vessel size match is good.  A single arterial and venous anastomosis will be performed to the internal mammary vessels.  At this point, the venous anastomosis is performed with the coupler device. The anastomosis can be hand sewn as well.  When using the coupler device, it is usually ideal to fix the more mobile vessel first, which is usually from the flat pedicle.  The vessel ends are first attached by triangulating the vein over the prongs.  After this is done, the vein is then placed over the remaining prongs.  Once the mobile vessel is attached to the coupler device, the device is delivered towards the vessel that is more fixed, which in this case is the internal memory vane.  The coupler application is then performed to complete the venous anastomosis.  Sometimes a hemostat is used to confirm that the ends of the coupler are fixed.  Once the coupler device is detached, a hemostat is then used again to make sure the ends of the coupler device are approximated.  Next, we turn our attention to the arterial anastomosis. This is typically done with 9-ohm microsurgical nylon suture.  Prior to anastomosis, the vessels are cut to length to avoid redundancy. There is good size match between the donor and recipient arteries. The vessels  are then dilated and prepared for anastomosis.  The arterial anastomosis is shown from start to finish. Typically, we start on the back wall and work around to the front wall of the vessel with interrupted suture.  Each suture is tied down with three square knots.  We pay special attention to approximate the vessels rather than strangulate.  The back wall is now completed and we begin the anastomosis of the front side.  These sutures can be done in one or two passes, depending on the approximation of the vessels and the comfort of the surgeon.  The occluder clamps are removed and any anastomotic leaks are inspected.  Repairs are done similarly with 9-0 Nylon Suture.  The occluder clamps of the vein and artery are then finally removed.  A pinch test can then be done in the vein to confirm flow.  The arterial and venous anastomosis are then placed in a favorable position to avoid kinking.  Strong arterial pulsations should be observed in the pedicle.  Finally, we like to place implantable Doppler probes to allow for direct vessel monitoring. The Doppler probes are particularly helpful as the flap is inset and changes in flow can  be immediately appreciated and corrected. These devices are wrapped around the vessel and then clipped for security with the excess removed using scissors.  The Doppler probe is then adjusted to be on the proximal side of the anastomosis.  There is usually several centimeters of extra Doppler wire that is kept underneath the flap to allow for accidental pulling and other changes.  A piece of surgical is then placed over the final construct to help secure the vessel configuration.  The vessel anastomoses are now complete and it is time for final flap inset.

Video Summary

The video details a microsurgical procedure involving the internal mammary artery and vein. Both vessels are prepared for anastomosis using couplers and nylon sutures. After dissecting the vessels, they are clamped, cut, and measured for matching size. A 2.5mm coupler is used for venous anastomosis, while the arterial anastomosis is done using 9-0 nylon suture. Both occluder clamps are removed, confirming flow and avoiding vessel kinking. Doppler probes are attached for vessel monitoring, ensuring optimal positioning and flow assessment. The procedure concludes with the successful completion of vessel anastomoses and flap inset.

Asset Caption

This video shows the view through the operating microscope, as vessels that have already been dissected are prepared for anastamosis.

Surgeon Scott Hollenbeck, MD; Brett Phillips, MD, MBA

Source Duke University Duke Plastic, Maxillofacial and Oral Surgery 2016

Disclosure This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Breast

Scott Hollenbeck MD

Brett Phillips MD MBA; Memben

microsurgical procedure

internal mammary artery

venous anastomosis

Doppler probes

nylon sutures