Novel Technical Variations and Increased Adhesive Strength in the “Birdlime” Transposition Technique for Microvascular Decompression

Abstract

Vessel transposition is the standard procedure in microvascular decompression (MVD), which necessitates more complex and difficult surgical techniques, including suturing in the deep operative field. We recently reported the usefulness of TachoSil tissue sealing sheets soaked with fibrin glue for vessel transposition in MVD, known as the "birdlime" technique. Here we describe various technical variations and improved adhesive strength of this material for safe and optimal vessel transposition without complications. We retrospectively reviewed the operative findings of 31 consecutive patients who underwent MVD with the transposition procedure using TachoSil tissue sealing sheet soaked with fibrin glue between January 2012 and June 2017. The adhesive strength of TachoSil soaked with fibrin glue was measured using porcine dura mater. A single piece of this material was required in 13 patients, a single piece for multiple lesions was required in 5 patients, multiple pieces for a long segment were required in 12 patients, mainly with the offending vertebral artery in 9 patients, stacked pieces in 2 patients, and direct adhesion of vessels in 6 patients. All patients except 1 had total remission of symptoms immediately after the procedure. There were no severecomplications, recurrences, adhesions, or cranial nerve dysfunction in any patient. TachoSil soaked with fibrin glue showed significantly higher adhesive tensile strength compared with fibrin glue or Teflon felt with fibrin glue. Modifications of the birdlime technique and reinforcement of the adhesive strength provide an easy and adjustable way to perform MVD safely and effectively to reduce the risk of intraoperative neurovascular injury.