The double stitch everting technique in end‐to‐side vascular anastomoses

Abstract

A wealth of modifications of the original end-to-side technique 1 are described in the literature, but so far no human randomized study has shown the superiority of one technique over another. 2 To answer the needs of reduced time and increased efficiency, we devised the "double stitch everting technique." Leaving the needle in situ in the vessel wall in order to help with the tying of the final two knots, also known as the "modified Harashina procedure" has already been described. 3 For this technique, the two corner sutures are placed first. The needle is then inserted in order to perform the third knot and instead of deploying it on a surgical patty in the area of the anastomosis, as common in our practice, the needle is then reinserted parallel to the third knot, which is not yet tied and left in place (Fig. 1A).The knot is then tied in usual microsurgical fashion keeping in mind the eversion of the edges and intima-tointima contact. Care should be taken not to entangle the needle in the knot. The needle can be picked up and reinserted without difficulty in an optimal position inside the needle holder (Fig. 1B). We find that performing the sutures from left to right for right-handed people poses an advantage (Fig. 1C). The technique works just as well for fish-mouthed and nonfish-mouthed donor vessels.The double stitch everting seeks to accomplish several other objectives: shortening the time spent manipulating the needle, while ensuring wall eversion especially in venous anatomoses and improving symmetrical spacing and proper bite size.Further studies and validation in the rat femoral model are underway and are the subject of a large validation project. The double stitch everting technique Figure 1. The needle is inserted parallel to the previous stitch, for at least two-thirds of its length in order to reinforce the eversion of the vessel wall and aid in intima-to-intima contact (A). The anterior wall can be easily sutured (B) with regard to bite size and symmetrical placing of knots (C). Euromex StereoBlue Trino ZoomV C microscope at 15x magnification; 9-0 suture Ethilon, Ethicon, Johnson and JohnsonV C ; Muaranaka Medical Instruments Co., Ltd., Tokyo, Japan V C silicone elastic vessel 1.5 mm.

The Double Stitch Everting Technique in the End-to-Side Microvascular Anastomosis: Validation of the Technique Using a Randomized N-of-1 Trial

“…The DSE technique was described in our group's previous publication. 11 Our research revealed that most time was lost when performing a microvascular anastomosis in-between suture tying, during needle loading and unloading. We evolved the modified Harashina procedure by proposing that before each knot is tied, the needle is ran through the vessel wall and left in place.…”

“…Notice the improvement of suture symmetry. Source: Reproduced with permission from Volovici et al 11 significant (p < 0.001, logistic regression) when adjusted for the level of experience (►Fig. 2B).…”

Comment on “A modified ‘interrupted’ method with resting of the suture needle on the vessel wall for microvascular anastomosis”

“…the journal. Our enthusiasm was somewhat dampened, nonetheless, when we realized that the technique they describe had already been published by us in the same journal in 2016 (Volovici et al, 2017). We coined this technique the double stitch everting, because it implies a double throw of the needle which, positioned and left in place inside the vessel wall, helps ensure proper wall eversion.…”