Assisting in Microsurgery: Operative and Technical Considerations

Abstract

Microsurgery is technically challenging, typically requiring a primary surgeon and an assistant to complete several key operative steps. These may include manipulation of fine structures, such as nerves or vessels in preparation for anastomosis; stabilization of the structures; and needle driving. Even seemingly mundane tasks of suture cutting and knot tying require fine coordination between the primary surgeon and assistant in the microsurgical environment. Although prior literature discusses the implementation of microsurgical training centers at academic institutions and residency programs, there is a paucity of work describing the role of the assistant surgeon in a microsurgery operation. In this surgical technique article, the authors discuss the role of the assisting surgeon in microsurgery, with recommendations for trainees and attendings alike.

Keywords: Assistant; Assisting in surgery; Hand surgery; Microsurgery; Plastic surgery; Reconstructive surgery.

Figure 1

A number of key steps are critical for the microsurgeon and microsurgical assistant for successful surgical outcomes.

Figure 2

Image demonstrating proper sterile draping of the operative microscope using sterile gloves to drape the handles alone.

Figure 3

Image depicting (from left to right) the micro forceps, micro needle holder, curved micro scissor, straight micro scissors, and Acland single and double approximator micro vessel clamps. The micro forceps are used for grasping and manipulating tissues and sutures. The micro needle holder is used to drive the needle. Micro scissors are used for micro tissue dissection and suture cutting. The Acland micro vessel clamps are used to occlude and approximate vessels for anastomoses.

Figure 4

Example of optimal posture and positioning of the microsurgical assistant.

Figure 5

Schematic and clinical image depicting nerve transection under the microscope with circumferential support to keep the nerve tubular, avoiding compression or flattening.

Figure 6

Schematic and clinical image depicting suture cutting under the microscope. (A) holding the suture straight up makes it difficult for the assistant to assess where the suture should be cut. (B) The surgeon optimizes visualization by holding the suture at an angle to the optical path, allowing the assistant to gauge where to place the cut.

Figure 7

Schematic and clinical image depicting the use of long suture ends to rotate and position vessel ends for suture passing. During suture knot tying, the free end of the suture should be kept in air and at a convenient location for easy grasping.