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Tuesday, August 21, 2007

Doing the anastomosis


Anybody can suture point A to point B, and doing just that is usually sufficient for the majority of surgical procedures. But vasectomy reversals require precision matched only by coronary bypass surgery to be effective. Please forgive me as I don't mean to belittle the life saving work that CT surgeons do by comparing them to me, namely a guy that performs vasectomy reversals, but good technique is good technique. Here are some key elements:
  • High Power Microscopic Surgery: if you can't see the mucosa, you can't line it up properly
  • Mucosa to Mucosa Apposition: the mucosa of one end of the vas, which is the lining of the tube, must be sutured to the mucosa of the other end of the vas. Suturing the mucosa to the muscular layer, which surrounds the mucosa, will look good to the nursing staff in the OR, but won't result in a patent anastomosis.
  • Water Tight: the anastomosis must be water tight, or free of any leakage at all. This is distinct from a vascular anastomosis since the vascular system has platelets and other compounds that will "tighten the seal" automatically. The vas deferens relies on the surgeon to do all the work.
  • Tension free: this is a basic tenet of surgery and certainly applies to vasectomy reversals as well. Any tension at all will cause a failed anastomosis.
  • Perpendicular Cuts: prior to performing the anastomosis, the microsurgeon needs to "prepare" the 2 ends of the vas deferens by cutting them to create perfect ovals. I use a nerve clamp that enables me to cut the vas with a perfect perpendicular cut.
  • Fine Suture: Anything larger than 9-0 for the mucosa is too big. As a general rule, if you can see the suture with your naked eye, it is too large for a vas deferens.
  • Atraumatic: the vas deferens must be grasped, sutures must be placed, and the anastomosis must be stabilized in an atraumatic way. To facilitate this, I use special vasal approximators and jewelers forceps and I "line-up" the mucosa so my first throw--suture placement attempt--is my only suture placement attempt. Repeated attempts will cause edema and likely lead to ultimate failure.

Thanks for listening and I hope you enjoyed the post.

The IU.