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New Technique for Ligation of Branches in Microsurgery

Nasir, Serdar M.D.; Krokowicz, Lukasz M.D.; Sonmez, Erhan M.D.; Bozkurt, Mehmet M.D.; Grykien, Christopher M.D.; Siemionow, Maria M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 45e-47e
doi: 10.1097/PRS.0b013e3181905712
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Sir:

Although microsurgical operations require teamwork, some operations, such as digital replantation, may be accomplished successfully by one microsurgeon. Branch ligation is performed more easily than other steps, such as microanastomosis. Two ties are placed at the junction of the branch and main vessel and at some distance from first knot; then the branch is cut between the two stitches. However, the surgeon may encounter some problems with branch ligation during clinical or experimental procedures if the branches are mistakenly cut before ligation during vessel dissection.

If it is long, the branch stump may be located easily and can be ligated after occlusion of blood flow with a single clamp in the main vessel. In a narrow surgical space, such as the finger, extra tissue dissection is needed to place a clamp on the main vessel. Another method is to catch the stump with forceps to occlude blood flow and then place a stitch at the junction of the branch and main vessel. In this technique, two stitches are placed and cross each other at a 90-degree angle. The first stitch is passed at the junction of the branch and main vessel, and the thread is neither knotted nor cut. The second stitch, using the same thread, is passed under a 90-degree angle in conjunction with the previous one, and the two stitches are tied using the same thread. Furthermore, the branch is obliterated by cross-traction of the vessel wall. A short branch stump, however, causes difficult manipulation during stitch placement and may easily slip out of the forceps tips. Using two stitches in branch ligation is more traumatic to the vessel wall than the previous method. We have described a new method for branch ligation in microsurgery practice.

In our method, we do not use clamp placement or stitches to occlude blood flow to ligate the branch. The nondominant hand holds the branch until placement of the first knot, while the dominant hand is used for all manipulation. After the branch is occluded with forceps tips, thread is passed behind the branch using the other hand. A loop is made with the surgeon's free (dominant) hand. A single clamp is placed at the end of the thread to provide contra-traction during tying. Subsequently, traction is applied to the thread at any region between the loop and microsurgical needle. In this technique, the loop encounters contra-traction by single clamp due to its weight. It is decreased gradually and the first knot is placed at the branch–main vessel junction. Now the nondominant hand, which was holding the branch stump, can be released safely and the clamp can be removed from the end of threat. A second knot is placed in the classic manner using two hands, and the ends of the thread are cut with scissors (Fig. 1).

Fig. 1.
Fig. 1.:
(Above, left) Occlude the branch stump with the forceps tips, and pass the thread behind the branch. (Above, right) Make a loop around the branch stump. (Center, left) Catch the end of the thread and pull it to the opposite side from the inside loop. (Center, right) Place a single clamp at end of the thread and decrease the loop diameter by pulling the thread to the opposite of the single clamp. (Below, left) Place the first tie. (Below, right) Complete the branch ligation.

Many modifications have been published relating to microsurgical difficulties, such as vessel diameter discrepancy.1–3 As far as we know, there are no published reports of modification of branch ligation in the literature. We suggest that by using our method, branches and branch stumps can be ligated easily without the need for assistance. Furthermore, ligation of short branch stumps using our technique causes the least amount of trauma to the vessel wall in comparison to other methods.

Serdar Nasir, M.D.

Lukasz Krokowicz, M.D.

Erhan Sonmez, M.D.

Mehmet Bozkurt, M.D.

Christopher Grykien, M.D.

Maria Siemionow, M.D.

Cleveland Clinic Foundation

Plastic Surgery

Cleveland, Ohio

REFERENCES

1. Siemionow M. Evaluation of long-term patency rates of different techniques of arterial anastomosis in rabbits. Microsurgery 1987;8:25–29.
2. Ozkan O, Ozgentas HE. Open guide suture technique for safe microvascular anastomosis. Ann Plast Surg. 2005;55:289–291.
3. Siemionow M. Histopathology of microarterial anastomoses: End-to-end versus end-in-end (sleeve) technique. J Hand Surg (Am). 1990;15:619–625.

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