Care and Handling of Instruments
Microsurgical instruments are highly refined to permit accurate and precise use, and are very fragile and prone to damage. Storage trays for microsurgical instruments are lined with rubber pads with finger‐like projections that softly and securely grip instruments for safe placement and storage or are equipped with slots for each instrument. Storage trays are sterilizable. Be sure to return instruments to the protective pad of the storage tray even during surgery when they are not in immediate use. Use microsurgical instruments appropriately and as indicated and not for grasping or cutting thick or tough tissues, needles, or suture larger than 5‐0 USP.
When cleaning instruments, pick up microsurgical instruments one at a time. Rinse instruments with distilled water or according to manufacturer’s instructions, and gently remove organic debris with a microsurgical brush. Place instruments in a single layer in an ultrasonic cleaner with enzymatic detergent after each use. Never allow instruments to soak overnight in water or the ultrasonic cleaner. Always remove them promptly after the cycle is finished and allow them to air‐dry on an absorbent drying pad in an open position to prevent rusting of the joints and box‐lock mechanisms. Once the instruments are dry, carefully return them to the storage tray. Wrap the tray for steam sterilization in an autoclave. Most manufacturers do not recommend sterilization in a plasma sterilizer.
Assess instruments for damage before each use. Check with magnification to be certain the tips of needle holders and forceps and blades of scissors meet exactly. Never attempt to operate with a misshapen or damaged instrument. Return broken instruments to the manufacturer or to a service professional for repair or discard them. Use caution and care when using instruments as dropping a microsurgical instrument on its tip from a height as little as 2–3 cm can damage the instrument irrevocably and result in costly losses. Although microsurgical instruments can be expensive, proper care and use will ensure these instruments are an integral part of your exotic animal surgical equipment for many years.
Microsuture
The ideal suture for delicate surgery in small exotic animals should have excellent knot‐holding capability and ease of handling, and should elicit a minimal inflammatory reaction (Phillips and Aronson 2012). Microsuture is swaged onto a 1/2 or 3/8 circle needle with a round taper‐point or micropoint spatula‐shaped needle tip. Surgical Specialties Corporation (Wyomissing, PA) uses specialized needle geometry in the manufacture of Sharppoint™ microsutures to flatten the middle ⅓ of the needle for secure grasping while maintaining a pointed microsurgical needle tip.
Sizes of suture for microsurgical procedures range from 4‐0 to 11‐0, progressing from less to more delicate work. Although monofilament sutures such as nylon, polypropylene, or polydioxanone are preferred for strength, durability, and inciting minimal inflammation, multifilament sutures have excellent knot‐holding ability. When passed though bone wax, braided multifilament sutures have improved handling and less drag through tissues. Multifilament sutures should be used with caution in infected tissues as the braided configuration may provide a nidus for bacterial growth and proliferation (Phillips and Aronson 2012).
Principles of Microsurgical Techniques
Magnification surgery requires concentration, patience, and physical and mental endurance. To accurately and efficiently perform microsurgery, the surgeon must be properly prepared. Thorough preparation of the operating arena, magnification aids, instruments and suture as described in this chapter will help to ensure smooth flow of microsurgical operations and prevent physical and mental disruptions during a procedure. However, the surgeon should attend to his or her own physical and mental needs prior to a procedure.
Posture
Instructions and guidelines regarding the organization of the operating arena and customization and adjustment of magnification aids are offered elsewhere in this chapter. It is important to note here that maintaining ergonomic and appropriate posture is an extremely important principle of microsurgery that permits the performance of lengthy and difficult procedures with minimal fatigue and tremor.
Preparation and Mindset
Learning and mastering any new skill can be frustrating and test patience and resolve. The merits of developing microsurgical skills are numerous and efforts spent mastering magnification surgery are worthwhile.
Be certain to approach procedures and practice time well rested and free of any significant physical, mental, or emotional burden. Ensuring the operating arena is equipped; the surgical table and stools are properly adjusted; and the operating microscope or surgical loupes are properly functioning, ergonomic, and customized will help to limit physical burden during surgery. Avoid strenuous exercise, including isometric exercises and lifting heavy objects prior to performing or practicing microsurgical procedures. Strenuous exercise, especially of the forearms, brachial area, and shoulders, predisposes to exaggerated physiologic tremor. If possible, avoid alcoholic beverages and the excessive use of stimulants including nicotine and caffeine the day before a procedure. It is important to consider what the surgeon's normal intake of stimulants such as caffeine is and to limit intake to only the amount normally consumed – no more or less – as withdrawal from caffeine and other stimulants can also predispose to tremor.
To prevent mental burden, deal with telephone calls, messages, e‐mails, and other correspondence prior to the procedure as much as possible, and assign personnel to limit interruptions in the operating arena to only those that are most emergent.
Hand Position
Proper hand position is critical to placement of microsutures and accurate use of microsurgical instruments in small spaces and helps to limit fatigue and tremor during procedures.
Hands should be placed properly relative to the surgeon's ideal OHP as discussed earlier. This position is relaxed and balanced during the operative procedure. The OHP may be used to adjust the table height and stool height when using an operating microscope and to determine the ideal working distance when using surgical loupes.
Hands should be positioned properly relative to the surgical table. The surgeon's elbows and forearms should rest on the surgical table at an approximate angle of 90° from the shoulders. This can prove difficult when the patient is placed on the table and a sterile drape is applied to the patient but is critical for ergonomics and endurance. Tremor can persist if the surgeon's hands remain elevated from the table. An elevated hand position induces contraction of antebrachial musculature and eventual muscle fatigue and tremor despite a resting antebrachial and elbow position. To achieve the greatest stability and reduction of tremor, the surgeon's wrists and fifth digits of each hand should also rest on the surgical table or patient, and the fingers should be stacked on top of each other or splayed (Figures 3.12 and 3.14). If it is not possible for the wrists and fifth digits to rest on the table or patient, sterilizable hand rests may permit resting the entire hand.
Figure 3.14 Alternate stable hand position with fingers splayed instead of stacked on one another.
