How to Deal with an Intraoperative Thrombosis of Microvascular Anastomosis

Background: Intraoperative thrombosis during microvascular surgery is a nasty complication. Most intraoperative thromboses occur at the proximity of the anastomosis and microsurgical salvage techniques are needed to correct the complication. The aim of this article is to provide an overview of basic clinical patency testing and microsurgical salvage techniques. Methods: A search of the literature up to November 2020 was performed, using PubMed and Web of Science databases. Articles reporting on clinical intraoperative patency testing and/or salvage techniques in microvascular surgery were included. Results: Comprehensive illustrations of intraoperative clinical patency testing include: pulsation pattern, flicker test and milking test. The following surgical salvage techniques for both end-to-end and end-to-side intraoperative microvascular occlusion management are described: suture-line thrombectomy, thrombectomy through arteriotomy, anastomotic resection with complete re-anastomosis and, balloon extraction. Conclusion: Decision making in surgical salvage techniques for microvascular thrombosis depends on localization of the thrombus and the surgeon’s experience and preference. In case of any doubt, it is better to reopen a few sutures and have a clear inspection of the anastomosis in order to prevent redo surgeries. This paper serves as a guide for especially the starting microsurgeon to clinically and surgically identify and handle an intraoperative microvascular anastomosis thrombosis and occlusion.

New Hemostatic Powder (GelitaCel Ca Powder^TM) and Its Application in Cranial Neurosurgery

Background: Intraoperative hemostasis during intracranial surgery is one of the most important aspects of the surgical procedure. One of the most widely practiced methods to prevent postoperative hemorrhage is to cover the cerebral wound bed with cellulose. Objective: We report on the use of a new powder form of regenerated oxidized cellulose enriched with calcium (GelitaCel Ca PowderTM, Gelita Medical, Eberbach, Germany) for hemostasis purposes in intracranial surgery. Methods: In 107 patients operated for intracranial mass lesions, the resection cavity was covered with a small layer of cellulose powder for hemostatic purposes. All patients had a postoperative CT or MRI scanning within 24 hours after surgery to detect any surgical complications and to detect the presence of blood within the surgical cavity. Results: Of the 107 operated patients, 96 (90%) had no or minimal blood in the intracranial resection field on postoperative imaging with CT or MRI. Of those 96, 69 patients had no blood at all and 27 patients had a small trace. In the remaining 11 patients, 8 patients (7.5%) had blood filling the resection cavity. In three patients (2.8%), the blood accumulation resulted in mass effect. All these three patients were re-operated due to neurological deterioration. Conclusion: We suggest that cellulose powder is an easy and safe product for hemostasis and prevention of postoperative hemorrhage in intracranial surgery. The main advantage of the powder form over regular oxidized cellulose is the no-touch technique of application and leaves no excess hemostatic material behind which could possibly cause compression.

“Ski”-Shaped Microneedle Facilitates Suturing in a Deep Narrow Surgical Field

Background: Microsurgical suturing requires high level of dexterity and practice. Suturing in a deep and narrow operative field poses additional difficulties mainly due to the long microsurgical instruments and the difficulty of manipulating a curved needle. Objective: In this technical note, we describe a simple modification of a classical curved suture needle into a “ski”-shaped needle. Methods: A classical curved needle is stretched using a needle holder. Only the tip of the needle is left slightly bent, imitating a ski. Once the needle is bent into the ski shape, it can be grasped virtually in any position with the needle holder. Results: We have used the ski needle technique suturing in several patients in which the operative field was deep and limited such as dura repair in spinal surgery in obese patients, facial nerve grafting in the internal acoustic meatus and posterior inferior cerebellar artery suturing between the caudal cranial nerves. Conclusion: This modification facilitates free positioning of the needle in the needle holder and as a consequence results in easy and faster microsuturing in a deep and narrow operative field. The ski needle technique was felt to be superior to the classical curved needle technique.