3.1 Techniques and Manual Skills

The mastery of microsurgical techniques requires time, special physical skills, motivation, patience, devotion, and a specially equipped workplace. Even experienced surgeons cannot perform microsurgical operations without specialized preparatory training.

Speed—not haste—must be part of the skill set of the neurosurgeon, because the duration of the surgical intervention necessary to create anastomoses is significant: the extent of ischemic and reperfusion injuries increases with the passage of time. Therefore, a neurosurgeon must not only have a suitable skill level in terms of precision and accuracy but also possess and cultivate operative speed. Idiosyncrasies such as impatience, insufficient coordination of movements, and tremor weigh heavily on the neurosurgeon’s ability to perform microneurosurgery. Laboratory training can be used to correct these problems through practice and adaptation or, in some cases, by convincing a trainee that a clinical focus on the practice of microsurgery is not the best career choice.

Furthermore, the work of the neurosurgeon must combine laboratory exercises with clinical practice to perfect practical skills and to learn new technologies. This chapter covers the fundamental background information that is necessary to master microsurgical techniques effectively and quickly.

3.2 Mental Concentration

Microsurgical training sessions should have scheduled breaks. Trainees should not overwork during this training, because being tired significantly decreases the educational value of the training, and it becomes a waste of time. If you feel tired after 1 or 2 hours of training, you should get up and walk away from the table for a few minutes to cleanse your mind and reduce muscle fatigue. You should return to practice only when you feel refreshed and can approach the exercises with a positive attitude toward mastering the skills.

Since the microsurgical world represents a completely different experience for even the experienced surgeon, numerous difficulties and obstacles are inevitable during training. Thus, you should learn how to avoid feeling frustrated. Difficulties with the exercises often lead to frustration and despair. In a desperate state, problems only get worse: sutures become tangled, the needle bends, and the tissue ruptures. By stopping and thinking about what creates such difficulties, you can identify the reason for your frustration, which may be a very simple obstacle, such as bad hand position, bad hemostasis, or maladjustment of the microscope. Eventually, the surgeon should develop a mental checklist of preparatory actions that can be effectively deployed during pauses taken to think through each difficulty and the reasons for it.

A quiet atmosphere in the operating room, which promotes tranquility and emotional stability in the operating surgeon are also important requirements for microneurosurgery. Leading neurosurgeons of the United States, Japan, and Europe recommend playing quiet classical music or having complete silence in the operating room.

3.3 Position of the Operator

Special attention should be paid to the position and height of the operating table and chair, the position of the operative microscope, the location of the necessary equipment and tools, and the choice of the method for hemostasis. The microsurgical training (the same as the microsurgical stage of the operation) is performed in the sitting position, with the forearms, wrists, and fingers on elbow rests or on the table in a physiologically natural position. Surgeons sometimes pride themselves on their ability to battle against fatigue and discomfort, but during microsurgery is not the time to exercise this fortitude, as it will be needed for the work itself. Comfort is not a luxury during microneurosurgery but instead is an absolute requirement. A comfortable position is defined as a position with the minimum number of muscles working. The arms must be in a relaxed position that can be maintained as long as necessary. The stance of the surgeon should be completely comfortable, without any tension. The back and neck should be straight, the forearms should be placed horizontally, and the feet should be resting comfortably on the floor or on a footrest; this position creates three points of support, which significantly decreases the work of back muscles that support stability. This position may require small but important adjustments of the surgical chair or table, which some nurses may find picky. This attitude should not deter the resident or young neurosurgeon, because a comfortable position is one of the essential components for success. The need for a more comfortable position should not arise during the operation or training, but instead should be foreseen and obtained as an essential preparatory step. Shoulders, forearms, and hands must be relaxed. This is only possible when the center of gravity of the forearm is located on the table. We maintain that a microneurosurgical operation cannot be performed optimally without elbow rests. Nevertheless, some well-known neurosurgeons (e.g., Dr. Juha Hernesniemi [Helsinki University Hospital, Helsinki, Finland] and Dr. Alexander Konovalov [Burdenko Neurosurgical Institute, Moscow, Russia]) perform the microsurgical stages of the operation without elbow rests. If the use of elbow rests is impossible, the forearms may be stabilized with the help of a standing armrest or a wrist rest affixed to the head holder.

To avoid eye fatigue caused by the changes in focal distance, you should avoid taking your eyes off the microscope oculars. Microneurosurgeons should have good vision and a good line of sight, and they should be able to use instruments dexterously with both hands. Neurosurgeons who usually wear eyeglasses should also wear them while working with the microscope.

3.4 Managing Tremor

Under normal circumstances, everyone has some degree of tremor. Whether the use of tobacco or alcohol increases tremor in surgeons performing microsurgery has not been confirmed, but their use should be discouraged. ¹ Caffeinated coffee is known to affect tremor but only when consumed in larger quantities than is normal for the individual, with no effects on tremor by a habitual coffee drinker when consumption is moderate. Hard manual exercises may affect tremor by increasing resting muscular tone, so heavy muscular strengthening workouts should be avoided for at least 1 day before surgery. Annoyance is another factor that may increase the likelihood of tremor. Neurosurgeons should therefore learn how to avoid becoming irritated. Having a mental checklist, knowing what to prepare, and determining how to deal with difficulties are key to achieving calmness and reducing annoyance.

In some instances, beta-blockers are used to decrease both anxiety and tremor in the arms. Beta-blockers are also used for the same purpose by marksmen. (Beta blockers are on the World Anti-Doping Agency’s list of prohibited substances for archery, shooting, and other sports. ² ) Several studies ^{3 ,​ 4 ,​ 5} that have shown a decrease in tremor with beta-blockers (propranolol 10–40 mg) found no effect on the quality of the anastomosis or improvement in the overall surgical results. We believe that the use of beta-blockers is acceptable if it really helps a trainee but that the primary victory over tremor emanates from other important factors. The first key factor is a comfortable position that decreases stiffness and fatigue. A comfortable position helps to fight essential tremor, which is found in everyone to some degree and which increases with exhaustion. Short intervals of rest can also be useful in minimizing essential tremor. Another key factor is appropriate hand position with the entire forearm and wrist resting on the table surface (or support stand) to minimize muscle strain (Fig. 3.1). All these factors (i.e., the skill in manipulating the instruments, the inner calmness, and the ability to suppress nervousness) can be learned through frequent training.

3.5 Techniques for Holding Microsurgical Instruments

The trainee must study how to hold and manipulate different microsurgical instruments. Holding instruments as one holds a pen or chopsticks is considered optimal. The finger pads must be placed one-third of the way from the tip of the instrument. Manipulating the shaft of the instrument as one does chopsticks is the key movement for the use of microsurgery instruments ( Fig. 3.2 ). One shaft of the microsurgery instrument, as in using chopsticks, is held with three bearing points (two fingers and the cusp of the hand), which keeps it well-fixed. The other shaft of the instrument is held and moved with the other fingers. This technique allows full control of the movement of the instrument’s tips.

The spring tension of the springy instruments, such as forceps, scissors, and needle holders, is also important. If the tension is too weak, keeping the instrument stable will be difficult. If the tension is too strong, the sensitivity and the ability to perform microscopic movements will erode, leading to tiredness and tremor.

To test for the right tension and to select the appropriate instrument, one should hold the springy instrument and close it partially. Then, fixed in this position, one should rotate the hand. If the tips of the instrument cannot be easily maintained at a fixed distance, the tension is inappropriate. Obtaining the appropriate tension is difficult at first and requires both practice in general and familiarity with the specific instrument being used. The degree of hand fatigue after a period of long training is the best indicator of proper tension. The longer a surgeon can hold the instrument partially closed, the longer he or she will be able to use the instrument during the operation without fatigue compromising microsurgical effectiveness.

3.5.1 Techniques for Holding Short Microforceps

“Reverse holding” technique (Fig. 3.3a): In the reverse holding technique, one arm of the forceps is held in a fixed position by the pads of the forefinger and middle finger. The instrument is directed toward the surgeon, its proximal part against the forefinger. The thumb is opposed to the middle and index fingers and presses down on the second arm of the instrument.

“Index push” technique (Fig. 3.3b): In the index push technique, the lower arm of the instrument is held in a fixed position by the pads of the thumb and middle finger. The instrument is directed away from the surgeon, and the tips are placed one over the other. The proximal part is rested on the first dorsal interosseous muscle near the joint at the base of the forefinger. The index finger presses down on the second arm.

“Traditional” technique (Fig. 3.3c): In the traditional technique, one arm of the instrument is held in a fixed position by the pads of the index and middle fingers. The proximal part rests near the joint at the base of the forefinger. The thumb is opposed to the index and middle fingers, so that a triangular shape can be seen from the top of the instrument (Fig. 3.3d). Grasping occurs by pressing down with the thumb. Working in this position for an extended period of time can increase essential tremor in the thumb. The trick for reducing this tremor is to position the thumb so that its tip touches and rests on the index finger, while instrument closure is made by further squeezing these three fingers.

3.5.2 Techniques for Holding Short Straight Microscissors

“Reverse holding” technique (Fig. 3.4a): In the reverse holding technique, the lower shaft is held in a fixed position by the pads of the index and middle fingers. The instrument is directed back toward the surgeon, its proximal part lying along the distal half of the index finger. The thumb is opposed to the middle and index fingers, and the thumb presses down on the second shaft of the instrument. This technique allows the right-handed surgeon to dissect in a right-to-left direction and toward the surgeon.

“Index push” technique (Fig. 3.4b): In the index push technique, one shaft of the instrument is held in a fixed position by the pads of the thumb and middle finger and stabilized along its length by the side of the forefinger base joint. The microscissors are directed straight forward or to the side from oneself while the jaws of the scissors are oriented vertically one over the other. The forefinger presses down on the second shaft to effect closure. This technique allows you to perform right-handed dissection away from yourself in a wide range toward the left.

“Traditional” technique (Fig. 3.4c): In the traditional technique, one shaft of the instrument is held in a fixed position by the pads and length of the forefinger and middle fingers. The other shaft is situated on the main pad of the phalangeal part of the thumb, and movement of this shaft is effected by opposing pressure of the thumb.

3.5.3 Techniques for Holding Long Bayonet Microscissors

Most neurosurgical scissors have a bayonet shape and are considered as the primary tool for sharp arachnoid dissection in cerebrovascular surgery. Rigid tremor-free grasping of the bayonet scissors and delicate dissection are possible using the traditional holding technique. However, familiarity with other holding techniques may not only improve maneuverability and increase confidence in performing dissection from different positions and approaches but also provide the advantage of incorporating smooth instrument tip movements in the various planes and directions. ⁶ Fig. 3.5, Fig. 3.6, Fig. 3.7, Fig. 3.8 illustrate different holding techniques for long microscissors (traditional, reverse holding, index push, and “chopsticks” holding techniques). The traditional way of holding bayonet microscissors may require wrist bending in several positions, which is not physiologically optimal, especially when working on the surface of the brain. A set of bayoneted microscissors of varying blade length is usually used during surgery in order to retain proper handling and measurability. Instruments are changed to the longer blades as the dissection progresses deeper.

3.5.4 Stable Hand Positioning

To stabilize the instrument position and to decrease hand tension and fatigue, you can use hand contact techniques: one or more fingers carry out the function of support (Fig. 3.9). This technique is helpful for laboratory use but is not always acceptable under operating conditions. Depending on the situation, a light touch against the patient may be maintained by the hypothenar eminence or the tips of the fingers to assist in stability.

3.6 Mastering Dissection with Bayonet Scissors

Effective manipulations with microscissors in a deep operating field demand very precise control of their tips. A glove placed into an empty box (the box the gloves came in is ideal for this exercise) is the first simple model designed to perfect the skills of holding and working with the bayonet scissors. ⁷ To perform this exercise, you first draw various lines on a glove with a pen and then try to cut the glove within the width of the line (Fig. 3.10). You must practice changing the position of the instrument, depending on the direction of the cut, and you must also work with both hands. This exercise will help you to develop a firm and steady scissors-holding technique for dissection in any direction. Mastery of the different individual holding techniques (Fig. 3.6, Fig. 3.7, Fig. 3.8) allows the neurosurgeon to perform sharp dissection in almost all possible directions (Fig. 3.11).

3.7 Warm-up Exercises

After mastering the instrument-holding techniques, you should begin training on the dry models. Do not hesitate to go back and check different instrument-holding techniques. Holding techniques that initially seemed to be inconvenient may later be advantageous for prolonged work under the microscope, or else they can provide additional maneuverability and steadiness.

The following exercises are initially performed during a 3-hour dry-training practice. Each of these exercises is described more fully below.

1. 
   

   Knot tying on gauze or on a latex glove: practice all three techniques (i.e., intermittent suture grasping, constant hold of one suture, and constant holding of one suture and pulling in same direction) until you can do each one well (see Sections 3.7.3 through 3.7.5 [p. 37-38]).

   
   
2. 
   

   Untying a knot: practice untying surgical knots (see Section 3.7.8 [p. 40]).

   
   
3. 
   

   End-to-end anastomosis: practice on silicone microtube.

   
   
4. 
   

   End-to-side anastomosis: practice on silicone microtube.

   
   
5. 
   

   Side-to-side anastomosis: practice on silicone microtube.

Perform each of the dry-training exercises first. After that, use a personal set of dry-training exercises to focus on refining specific skills such as tremor control and fast knot tying. For continuous training in your free time, we recommend the following set of exercises (about 10 minutes of total performance time). Each of these exercises is described more fully below.

1. 
   

   Suturing in different directions (creating a cross or snowflake pattern) (see Section 3.7.7).

   
   
2. 
   

   Untying a knot (see Section 3.7.8).

   
   
3. 
   

   Pushing the end of the suture using the needle tip (see Section 3.7.9).

For the anastomosis training, we recommend routine laboratory practice on tissue models rather than on silicone microtubes. The latter can be used during your initial training while you are memorizing the basic anastomosis principles and sequence of surgical steps. However, silicone has completely different tactile feedback and using it is just a waste of time when tissue models are available instead. When artificial materials are used, microtubes made from new materials have improved elasticity and surface friction compared with silicone, making them more similar to a real cerebral artery and therefore more appropriate for anastomosis training. ^{8 ,​ 9}

3.7.1 Knot Tying on Gauze

Tying knots on gauze is one of the first fundamental exercises (Fig. 3.12). Continuous repetition of this exercise is essential for obtaining needle- and suture-handling skills. Even the experienced neurosurgeon may need to refresh and maintain this skill. ¹⁰

To master suturing, you must be able to suture in all directions with both hands. In clinical situations, the tissues must be oriented, as much as possible, so that the manipulations can be maximally productive and convenient.

In most cases, a sailor’s knot is tied, which is more secure than a “granny knot.” A surgical knot, which is made by forming two unilateral loops, is used as a first knot when it is necessary to keep the sutured tissues under tension without the suture coming undone while preparing the second throw. A sailor’s knot made up of three throws of the suture is usually enough for making a single complete tie when suturing microscale vessels.

In the beginning stage, it is easier to grasp a needle with forceps using the technique depicted in Fig. 3.13.

Knots can be tied using any of the various techniques. The technique that enables you to maintain constant hold of one suture end is the quickest and is applied in clinical practice more often than other techniques. Naturally, the quickest and most effective surgery is achieved by avoiding unnecessary and nonproductive movements.

Related posts:

1 The Philosophy of Microsurgical Practice: Four Founding Principles Inherited from the Great Thinkers 2 Day 1: The Organization of the Microsurgical Laboratory: Necessary Tools and Equipment 8 Day 7: Models for Microneurosurgical Training and Schedules for Training 7 Day 6: Exercises: Kidney Autotransplantation, Supermicrosurgery, and Aneurysm Clipping 9 Possible Bypass Errors 10 Translation of Laboratory Skills: Indications for Bypass in Neurosurgery

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