Microvascular free flap surgery is widely used in head and reconstruction. When choosing a recipient vein in the head and neck, many options are available, including the external jugular vein, internal jugular vein, anterior cervical vein, and facial and lingual veins. Among these veins, use of the internal jugular vein for end-to-side anastomosis has become the preferred procedure after verifying the superiority of end-to-side anastomosis in head and neck reconstruction.1
Although selection of the internal jugular vein as a recipient vein has various advantages, anastomosis is sometimes difficult because of the narrow surgical field and poor clamp handling. Especially with the internal jugular vein, classic transverse clamping is sometimes impossible because of difficulty achieving complete vessel exposure. This led us to search for an alternative method, and we herein introduce an unconventional clamping technique using two bulldog clamps to provide an easy and simple environment for end-to-side anastomosis. We investigated the patients’ characteristics and surgical details, including which flap and recipient vessel were used (Table 1).
The internal jugular vein was dissected for at least 1.5 cm in preparation for end-to-side anastomosis. Before placement of the clamp, the exact anastomosis site was marked on the internal jugular vein because the anastomosis site tends to shift laterally. The internal jugular vein was grasped longitudinally with two bulldog clamps (Aesculap FB353R 20/48mm, B. Braun, Melsungen, Germany) proximally and distally (Fig. 1). The flap vessels were shifted and cut perpendicularly. We checked for leaks after performing elliptical vesselotomy or slit incision and then carried out end-to-side anastomosis with interrupted sutures. When the operative field was limited or an insufficient vessel length was available, the posterior wall was sutured first. When two or more veins were included in the flap, we tried to anastomose all of them to the internal jugular vein. All 18 flaps survived without complications (e.g., hematoma formation, thrombus formation, and insufficiency).
The internal jugular vein’s diameter is very large, and it has many branches that must be handled with clamps, making it difficult to secure a sufficient visual field. Vessel preparation using conventional transverse clamping may therefore be difficult. Studies of vessel preparation methods such as clamping are lacking. Therefore, we considered an alternative clamping technique to resolve these issues. Two bulldog clamps do not take up much space. In addition, the longitudinally handled internal jugular vein affords an increased width and depth of this vessel in the microscopic visual field (Fig. 2). When using these devices, only minimal dissection of the internal jugular vein is needed, decreasing the possibility of vessel spasm or injury.
Of course, each microsurgeon has his or her own technique of easily performing end-to-side anastomosis. Although the method suggested herein is also a supportive method for end-to-side anastomosis, similar to that in many previous studies,2–4 it may provide significant surgical assistance especially to beginners in microsurgery. In conclusion, our internal jugular vein clamping method using two bulldog clamps is a valuable method that provides an easy, simple, and stable environment for end-to-side anastomosis in head and neck reconstruction.
The authors have no financial information or conflicts of interest to declare in relation to the products or devices mentioned in this article.
Jin Yong Shin, M.D.Department of Plastic and Reconstructive SurgeryMedical School of Chonbuk National University, and Research Institute of Clinical Medicine of ChonbukNational University-Biomedical Research Institute of Chonbuk National University HospitalJeonju, Republic of Korea
Gyun Roh, M.D.Department of Plastic and Reconstructive SurgeryMedical School of Chonbuk National University, and Research Institute of Clinical Medicine of ChonbukNational University-Biomedical Research Institute of Chonbuk National University HospitalJeonju, Republic of KoreaDivision of Plastic SurgeryDepartment of SurgeryMayo ClinicRochester, Minn.
Suk Choo Chang, M.D.Nae-Ho Lee, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryMedical School of Chonbuk National University, and Research Institute of Clinical Medicine of ChonbukNational University-Biomedical Research Institute of Chonbuk National University HospitalJeonju, Republic of Korea
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