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Microsuture-tying forceps with attached scissors for bypass surgery
Technology
Microsuture-Tying Forceps with Attached Scissors for Bypass Surgery Michihiro Kohno, M.D., Ph.D.,* Hiromu Segawa, M.D.,* Hirofumi Nakatomi, M.D.,* Keiji Sano, M.D., Ph.D., F.A.C.S.,* Toyohisa Akitaya,† and Toshiaki Takahashi† *Department of Neurosurgery, Fuji Brain Institute & Hospital, Fujinomiya city, Shizuoka prefecture, Japan; †Fujita Medical Instruments Co., Ltd., Tokyo, Japan
Kohno M, Segawa H, Nakatomi H, Sano K, Akitaya T, Takahashi T. Microsuture-tying forceps with attached scissors for bypass surgery. Surg Neurol 2003;60:463– 6. BACKGROUND
Bypass surgery requires the shortest temporary occlusion time of a recipient artery during anastomosis. For this purpose, we have devised a microforceps with attached scissors that makes it possible to perform the multiple steps involved in anastomosis without exchanging instruments. This microforceps avoids having to exchange instruments twice in one suturing, such as that between a microsuture-tying forceps or a microneedle holder and microscissors in conventional methods. METHODS
The instrument is made of stainless steel and is 15.5 cm long. Using this microforceps with scissors, we can suture, tie, and cut a ligature fluently for consecutive sutures without exchanging instruments. The mean time during one suturing was compared between two patient groups treated by conventional method and with use of this instrument.
uring bypass surgery, it is crucial that the time during which the recipient artery is temporarily occluded is as short as possible to minimize complications. It is necessary, therefore, to practice anastomosis techniques diligently and to devise efficient instruments and methods. A popular method of vessel anastomosis involves a right-handed surgeon holding a needle with a needle holder or forceps in his right hand, suturing and tying a ligature with the instrument, exchanging this for microscissors to cut the ligature, and then exchanging the instruments again to start another suture (2). The only way to decrease the time taken to perform the anastomosis is to omit the exchange of instruments. Therefore, we have devised an instrument that combines a microforceps with scissors. This instrument was found to be highly practical and efficient.
D
RESULTS
This instrument was used for 34 patients with ischemic cerebrovascular disease (including three who needed deep-site anastomoses) and allowed us to perform superficial temporal artery-middle cerebral artery (STA-MCA) anastomoses uneventfully. This instrument saved 15.2 s in the mean time during one suturing. CONCLUSIONS
Although it is of paramount importance to practice tying sutures well, this new instrument removes the need to exchange conventional instruments, and we believe it will save time and, therefore, decrease complications during bypass surgery. © 2003 Elsevier Inc. All rights reserved. KEY WORDS
Anastomosis, bypass surgery, instrument, microscissors, suture-tying forceps.
Address reprint requests to: Michihiro Kohno, M.D., Ph.D., Department of Neurosurgery, Fuji Brain Institute & Hospital, 270-12, Sugita, Fujinomiya City, Shizuoka Prefecture, 418-0021, Japan. Received March 11, 2003; accepted April 29, 2003. © 2003 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Instrument and Method The instrument is made of 420J-2 stainless steel and is 15.5 cm long (Fujita Medical Instruments Co., Ltd., Tokyo, Japan). The platform is located at the tip, and the scissors are 5 mm long and located proximally to the platform (Figure 1). The platform is 2 mm long and 0.2 mm wide and has a friction device that makes it easy to hold a needle or a suture, and it is bent upward about 15 degrees so as not to put strain on the anastomosed vessels while cutting a tied suture with the scissors (Figure 2C). Using this microforceps, the surgeon avoids having to exchange instruments twice for each suture. Thus, it is possible to suture, tie and cut a ligature, and perform the next suture fluently without exchanging instruments (Figure 2). This instrument 0090-3019/03/$–see front matter doi:10.1016/S0090-3019(03)00432-4
464 Surg Neurol 2003;60:463– 6
Kohno et al
Photographs of the microsuture-tying forceps with scissors. Front (left) and lateral (center) view of the whole instrument. Front (right upper) and lateral (right lower) view of the instrument tip, which is bent upward about 15 degrees to avoid strain on the anastomosed vessels while cutting a tied suture with the scissors (Figure 2C). (多): platform, (*): scissors part.
1
also makes it possible for the surgeon to maintain continuous microscopic observation of the site. This instrument was used for 34 patients with ischemic cerebrovascular disease (including three who needed deep-site anastomoses). The mean time that was taken during one suturing was compared by using Student’s t test between two groups of patients who were treated with conventional method and with this new method. All the patients studied were operated by the same surgeon (M.K.), and included eight patients treated conventionally and 31 patients with new method. Three patients who needed deep-site anastomosis using this instrument were excluded because they had a condition different from the other patients who underwent superficial anastomosis. The time for each suturing was measured on the intraoperative video tape in all patients, and the time of stay suturing varied and was unstable in these cases, so the time for stay suturing was excluded from calculation of the mean time per one suturing.
Results In all 34 patients treated with this instrument, we performed bypass surgery uneventfully, and we confirmed the usefulness of this instrument, which avoided exchanging instruments during the procedures in the anastomosis. The mean time during one suturing was significantly shorter in the patient group operated using this instrument (82.4 ⫾ 1.2 s) than in the patient group treated with conventional method (97.6 ⫾ 1.4 s) (p ⬍ 0.0001, Figure 3). The mean occlusion time of the recipient artery was also significantly shorter in the former group (18.39 ⫾ 0.85 minutes: mean number of sutures: 12.1) than in the latter group (22.25 ⫾ 1.36 minutes: mean number of sutures: 11.6) (p ⬍ 0.0001, Figure 4). In summary, this instrument saved 15.2 s in the mean time during one suturing, and this result indicates that this instrument can save more than 3 minutes if a surgeon sutures 12 times in a bypass surgery.
Instrument for Bypass Surgery
Surg Neurol 465 2003;60:463– 6
Schemas showing how to use the microsuture-tying forceps with scissors. (A) Suturing with a needle held by the platform. (B) Tying the ligature using the platform of the instrument in the right hand and the other microforceps in the left hand. (C) Cutting the tied ligature using the scissors part of this instrument. Note the usefulness of the upward-bent platform that avoids the application of pressure to the anastomosed vessels. (D) Picking up the needle smoothly for the next suture without exchanging instruments.
2
Discussion After extracranial-intracranial (EC-IC) bypass was first introduced by Donaghy and Yasargil [10], it became very popular until the publication of the Cooperative Study on EC-IC Bypass in 1985 [1], which maintained that EC-IC arterial bypass failed to reduce the risk of ischemic stroke. The number of bypass procedures then declined sharply. Re-
cently, however, there have been some moves to re-evaluate the usefulness of EC-IC bypass [5]. In addition, surgical bypass procedures are getting necessary for troublesome, difficult conditions such as giant or intracavernous aneurysms [6,7,9] and skull base tumors [3,6]. In bypass surgery, which is used primarily for
The mean occlusion time of the recipient artery was significantly shorter in the patient group (N, n ⫽ 31) operated using this new instrument (mean number of sutures: 12.1) than in the patient group (C, n ⫽ 8) treated with conventional method (mean number of sutures: 11.6) (p ⬍ 0.0001).
4
The mean time during one suturing was significantly shorter in the patient group (N, n ⫽ 31) operated using this new instrument than in the patient group (C, n ⫽ 8) treated with conventional method (p ⬍ 0.0001).
3
466 Surg Neurol 2003;60:463– 6
Kohno et al
preventing ischemia, complications must be avoided. The time for recipient artery occlusion needs to be as short as possible to reduce the possibility of cerebral infarct, which is one of the complications of this type of surgery. Recently, a method using a new device [4] and a technique involving no recipient artery occlusion [8] have been reported, but they have not yet been widely adopted. Using our new method, there is no need for investment in new equipment other than this instrument that can be used to perform even a deep-site anastomosis without any difficulty. Any stiffness in the scissors part of this instrument can be corrected by lubrication with machine oil followed by sterilization with gas. Although it is of paramount importance to practice tying sutures well, this instrument removes the need to exchange conventional instruments, and we believe it will save time and, therefore, reduce complications during bypass surgery.
4. 5.
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7.
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9.
REFERENCES 1. EC/IC Bypass Study Group. Failure of extracranialintracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial. N Engl J Med 1985;313:1191–200. 2. Eguchi T. Superficial temporal artery-middle cerebral artery anastomosis. No-Shinkei-Geka 1983;11:575–80 (Jpn). 3. Miyazaki S, Fukushima T, Fujimaki T. Resection of high-cervical paraganglioma with cervical-to-petrous
10.
internal carotid artery saphenous vein bypass: report of two cases. J Neurosurg 1990;73:141–6. Newell DW, Dailey AT, Skirboll SL. Intracranial vascular anastomosis using the microanastomotic system: technical note. J Neurosurg 1998;89:676 –81. Nussbaum ES, Erickson DL. Extracranial-intracranial bypass for ischemic cerebrovascular disease refractory to maximal medical therapy. Neurosurgery 2000; 46:37–43. Sekhar LN, Bucur SD, Bank WO, Wright DC. Venous and arterial bypass graft for difficult tumors, aneurysms, and occlusive vascular lesions: evolution of surgical treatment and improved graft results. Neurosurgery 1999;44:1207–24. Spetzler RF, Fukushima T, Martin N, Zabramski J. Petrous carotid-to-intradural carotid saphenous vein graft for intracavernous giant aneurysm, tumor, and occlusive cerebrovascular disease. J Neurosurg 1990; 73:496 –501. Tulleken CAF, Zwan AVD, Rooij WJV, Ramos LMP. High-flow bypass using nonocclusive excimer laserassisted end-to-side anastomosis of the external carotid artery to the P1 segment of the posterior cerebral artery via the sylvian route: technical note. J Neurosurg 1998;89:925–7. Weill A, Cognard C, Levy D, Robert G, Moret J. Giant aneurysms of the middle cerebral artery trifurcation treated with extracranial-intracranial arterial bypass and endovascular occlusion: report of two cases. J Neurosurg 1998;89:474 –8. Yasargil MG. Anastomosis between the superficial temporal artery and a branch of the middle cerebral artery. In: Yasargil MG, ed. Microsurgery Applied to Neurosurgery. Stuttgart: Georg Thieme Verlag, 1969: 105–15.
hen a cat cries over a rat, it’s a case of false compassion.
W
—Chinese proverb
Microsuture-Tying Forceps with Attached Scissors for Bypass Surgery Michihiro Kohno, M.D., Ph.D.,* Hiromu Segawa, M.D.,* Hirofumi Nakatomi, M.D.,* Keiji Sano, M.D., Ph.D., F.A.C.S.,* Toyohisa Akitaya,† and Toshiaki Takahashi† *Department of Neurosurgery, Fuji Brain Institute & Hospital, Fujinomiya city, Shizuoka prefecture, Japan; †Fujita Medical Instruments Co., Ltd., Tokyo, Japan
Kohno M, Segawa H, Nakatomi H, Sano K, Akitaya T, Takahashi T. Microsuture-tying forceps with attached scissors for bypass surgery. Surg Neurol 2003;60:463– 6. BACKGROUND
Bypass surgery requires the shortest temporary occlusion time of a recipient artery during anastomosis. For this purpose, we have devised a microforceps with attached scissors that makes it possible to perform the multiple steps involved in anastomosis without exchanging instruments. This microforceps avoids having to exchange instruments twice in one suturing, such as that between a microsuture-tying forceps or a microneedle holder and microscissors in conventional methods. METHODS
The instrument is made of stainless steel and is 15.5 cm long. Using this microforceps with scissors, we can suture, tie, and cut a ligature fluently for consecutive sutures without exchanging instruments. The mean time during one suturing was compared between two patient groups treated by conventional method and with use of this instrument.
uring bypass surgery, it is crucial that the time during which the recipient artery is temporarily occluded is as short as possible to minimize complications. It is necessary, therefore, to practice anastomosis techniques diligently and to devise efficient instruments and methods. A popular method of vessel anastomosis involves a right-handed surgeon holding a needle with a needle holder or forceps in his right hand, suturing and tying a ligature with the instrument, exchanging this for microscissors to cut the ligature, and then exchanging the instruments again to start another suture (2). The only way to decrease the time taken to perform the anastomosis is to omit the exchange of instruments. Therefore, we have devised an instrument that combines a microforceps with scissors. This instrument was found to be highly practical and efficient.
D
RESULTS
This instrument was used for 34 patients with ischemic cerebrovascular disease (including three who needed deep-site anastomoses) and allowed us to perform superficial temporal artery-middle cerebral artery (STA-MCA) anastomoses uneventfully. This instrument saved 15.2 s in the mean time during one suturing. CONCLUSIONS
Although it is of paramount importance to practice tying sutures well, this new instrument removes the need to exchange conventional instruments, and we believe it will save time and, therefore, decrease complications during bypass surgery. © 2003 Elsevier Inc. All rights reserved. KEY WORDS
Anastomosis, bypass surgery, instrument, microscissors, suture-tying forceps.
Address reprint requests to: Michihiro Kohno, M.D., Ph.D., Department of Neurosurgery, Fuji Brain Institute & Hospital, 270-12, Sugita, Fujinomiya City, Shizuoka Prefecture, 418-0021, Japan. Received March 11, 2003; accepted April 29, 2003. © 2003 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Instrument and Method The instrument is made of 420J-2 stainless steel and is 15.5 cm long (Fujita Medical Instruments Co., Ltd., Tokyo, Japan). The platform is located at the tip, and the scissors are 5 mm long and located proximally to the platform (Figure 1). The platform is 2 mm long and 0.2 mm wide and has a friction device that makes it easy to hold a needle or a suture, and it is bent upward about 15 degrees so as not to put strain on the anastomosed vessels while cutting a tied suture with the scissors (Figure 2C). Using this microforceps, the surgeon avoids having to exchange instruments twice for each suture. Thus, it is possible to suture, tie and cut a ligature, and perform the next suture fluently without exchanging instruments (Figure 2). This instrument 0090-3019/03/$–see front matter doi:10.1016/S0090-3019(03)00432-4
464 Surg Neurol 2003;60:463– 6
Kohno et al
Photographs of the microsuture-tying forceps with scissors. Front (left) and lateral (center) view of the whole instrument. Front (right upper) and lateral (right lower) view of the instrument tip, which is bent upward about 15 degrees to avoid strain on the anastomosed vessels while cutting a tied suture with the scissors (Figure 2C). (多): platform, (*): scissors part.
1
also makes it possible for the surgeon to maintain continuous microscopic observation of the site. This instrument was used for 34 patients with ischemic cerebrovascular disease (including three who needed deep-site anastomoses). The mean time that was taken during one suturing was compared by using Student’s t test between two groups of patients who were treated with conventional method and with this new method. All the patients studied were operated by the same surgeon (M.K.), and included eight patients treated conventionally and 31 patients with new method. Three patients who needed deep-site anastomosis using this instrument were excluded because they had a condition different from the other patients who underwent superficial anastomosis. The time for each suturing was measured on the intraoperative video tape in all patients, and the time of stay suturing varied and was unstable in these cases, so the time for stay suturing was excluded from calculation of the mean time per one suturing.
Results In all 34 patients treated with this instrument, we performed bypass surgery uneventfully, and we confirmed the usefulness of this instrument, which avoided exchanging instruments during the procedures in the anastomosis. The mean time during one suturing was significantly shorter in the patient group operated using this instrument (82.4 ⫾ 1.2 s) than in the patient group treated with conventional method (97.6 ⫾ 1.4 s) (p ⬍ 0.0001, Figure 3). The mean occlusion time of the recipient artery was also significantly shorter in the former group (18.39 ⫾ 0.85 minutes: mean number of sutures: 12.1) than in the latter group (22.25 ⫾ 1.36 minutes: mean number of sutures: 11.6) (p ⬍ 0.0001, Figure 4). In summary, this instrument saved 15.2 s in the mean time during one suturing, and this result indicates that this instrument can save more than 3 minutes if a surgeon sutures 12 times in a bypass surgery.
Instrument for Bypass Surgery
Surg Neurol 465 2003;60:463– 6
Schemas showing how to use the microsuture-tying forceps with scissors. (A) Suturing with a needle held by the platform. (B) Tying the ligature using the platform of the instrument in the right hand and the other microforceps in the left hand. (C) Cutting the tied ligature using the scissors part of this instrument. Note the usefulness of the upward-bent platform that avoids the application of pressure to the anastomosed vessels. (D) Picking up the needle smoothly for the next suture without exchanging instruments.
2
Discussion After extracranial-intracranial (EC-IC) bypass was first introduced by Donaghy and Yasargil [10], it became very popular until the publication of the Cooperative Study on EC-IC Bypass in 1985 [1], which maintained that EC-IC arterial bypass failed to reduce the risk of ischemic stroke. The number of bypass procedures then declined sharply. Re-
cently, however, there have been some moves to re-evaluate the usefulness of EC-IC bypass [5]. In addition, surgical bypass procedures are getting necessary for troublesome, difficult conditions such as giant or intracavernous aneurysms [6,7,9] and skull base tumors [3,6]. In bypass surgery, which is used primarily for
The mean occlusion time of the recipient artery was significantly shorter in the patient group (N, n ⫽ 31) operated using this new instrument (mean number of sutures: 12.1) than in the patient group (C, n ⫽ 8) treated with conventional method (mean number of sutures: 11.6) (p ⬍ 0.0001).
4
The mean time during one suturing was significantly shorter in the patient group (N, n ⫽ 31) operated using this new instrument than in the patient group (C, n ⫽ 8) treated with conventional method (p ⬍ 0.0001).
3
466 Surg Neurol 2003;60:463– 6
Kohno et al
preventing ischemia, complications must be avoided. The time for recipient artery occlusion needs to be as short as possible to reduce the possibility of cerebral infarct, which is one of the complications of this type of surgery. Recently, a method using a new device [4] and a technique involving no recipient artery occlusion [8] have been reported, but they have not yet been widely adopted. Using our new method, there is no need for investment in new equipment other than this instrument that can be used to perform even a deep-site anastomosis without any difficulty. Any stiffness in the scissors part of this instrument can be corrected by lubrication with machine oil followed by sterilization with gas. Although it is of paramount importance to practice tying sutures well, this instrument removes the need to exchange conventional instruments, and we believe it will save time and, therefore, reduce complications during bypass surgery.
4. 5.
6.
7.
8.
9.
REFERENCES 1. EC/IC Bypass Study Group. Failure of extracranialintracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial. N Engl J Med 1985;313:1191–200. 2. Eguchi T. Superficial temporal artery-middle cerebral artery anastomosis. No-Shinkei-Geka 1983;11:575–80 (Jpn). 3. Miyazaki S, Fukushima T, Fujimaki T. Resection of high-cervical paraganglioma with cervical-to-petrous
10.
internal carotid artery saphenous vein bypass: report of two cases. J Neurosurg 1990;73:141–6. Newell DW, Dailey AT, Skirboll SL. Intracranial vascular anastomosis using the microanastomotic system: technical note. J Neurosurg 1998;89:676 –81. Nussbaum ES, Erickson DL. Extracranial-intracranial bypass for ischemic cerebrovascular disease refractory to maximal medical therapy. Neurosurgery 2000; 46:37–43. Sekhar LN, Bucur SD, Bank WO, Wright DC. Venous and arterial bypass graft for difficult tumors, aneurysms, and occlusive vascular lesions: evolution of surgical treatment and improved graft results. Neurosurgery 1999;44:1207–24. Spetzler RF, Fukushima T, Martin N, Zabramski J. Petrous carotid-to-intradural carotid saphenous vein graft for intracavernous giant aneurysm, tumor, and occlusive cerebrovascular disease. J Neurosurg 1990; 73:496 –501. Tulleken CAF, Zwan AVD, Rooij WJV, Ramos LMP. High-flow bypass using nonocclusive excimer laserassisted end-to-side anastomosis of the external carotid artery to the P1 segment of the posterior cerebral artery via the sylvian route: technical note. J Neurosurg 1998;89:925–7. Weill A, Cognard C, Levy D, Robert G, Moret J. Giant aneurysms of the middle cerebral artery trifurcation treated with extracranial-intracranial arterial bypass and endovascular occlusion: report of two cases. J Neurosurg 1998;89:474 –8. Yasargil MG. Anastomosis between the superficial temporal artery and a branch of the middle cerebral artery. In: Yasargil MG, ed. Microsurgery Applied to Neurosurgery. Stuttgart: Georg Thieme Verlag, 1969: 105–15.
hen a cat cries over a rat, it’s a case of false compassion.
W
—Chinese proverb