Assisting in Microsurgery: Operative and Technical Considerations

摘要

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. 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. The first microsurgical procedure was performed by Carl Olof Nylén, a Swedish otorhinolaryngologist, who also developed the first surgical microscope.1Dohlman G.F. Carl Olof Nylen and the birth of the otomicroscope and microsurgery.Arch Otolaryngol. 1969; 90: 813-817Crossref PubMed Scopus (35) Google Scholar In the subsequent century, microsurgical techniques became mainstay practice for several surgical specialties, including plastic surgery, orthopedic surgery, and otolaryngology. Microsurgery requires the use of an operating microscope (or surgical loupes) and microsurgical instruments to anastomose vessels and coapt nerves often smaller than a few millimeters in diameter. It is a technically challenging surgical discipline, often requiring years of training to develop proficiency.2Elliott R.M. Baldwin K.D. Foroohar A. Levin L.S. The impact of residency and fellowship training on the practice of microsurgery by members of the American Society for Surgery of the Hand.Ann Plast Surg. 2012; 69: 451-458Crossref PubMed Scopus (32) Google Scholar Within hand surgery, microsurgical techniques enable the anastomosis of vessels and coaptation of nerves for complex reconstructions and free tissue transfers. Assistant surgeons can aid with several key steps, including manipulation of fine structures, such as nerves or vessels, in preparation for anastomosis; stabilization of the structures; and needle driving, thereby increasing surgical efficiency and reducing operative time. Seemingly mundane tasks of suture cutting and knot tying require coordination between the primary surgeon and assistant in the microsurgical environment. Often, trainees are expected to fulfill the assistant position in a microsurgical setting before extensive exposure to microsurgery, to the detriment of the trainee’ experience. Most published literature on microsurgical education focuses on the skill set of the primary surgeon or the development of microsurgical curricula; however, less has been discussed regarding the optimal role of the assistant surgeon, which can be critical for successful surgical and clinical outcomes (Fig. 1).3Niveditha M. Sharma R. Suri A. Microsurgical suturing assessment scores: a systematic review.Neurosurg Rev. 2022; 45: 119-124Crossre