Mechanical Anastomotic Coupling Device versus Hand-sewn Venous Anastomosis in Head and Neck Reconstruction-An Analysis of 1694 Venous Anastomoses

Abstract

Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon's skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group ( p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes ( p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss ( p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon's strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

Keywords: free flaps; free tissue transfer; head and neck reconstruction; microsurgery; microvascular anastomosis; microvascular coupling device; technique; venous anastomosis.

Fig. 1

Image showing mechanical anastomotic coupling device (MACD) ( A ) Coupler forceps, double-ended vessel measuring gauge, reusable anastomotic instrument. ( B-D ) Loading of coupler device on to the anastomotic instrument, ( E ) Coupler device ready for use.

Fig. 2

Image showing steps of mechanical anastomotic coupling device (MACD) application ( A ) Measuring the diameter of vein ( B ) Eversion of donor vein wall onto the coupler device rings ( C ) Completion of impingement of both donor and recipient vein wall edges on to the coupler device pins ( D ) Closure of the jaws of coupler device ( E ) Ensuring the approximation of both jaws with a hemostat ( F ) Disengagement of the anastomotic instrument and completion of the end to end anastomosis ( G ) An image of end-to-side anastomosis performed similarly (the head end is at the superior aspect of the image).