Potential Advantages of Using Three-Dimensional Exoscope for Microvascular Anastomosis in Free Flap Transfer.

Abstract

Sir: The technological advancements in microsurgical devices and instruments allow microsurgeons to perform any type of microsurgery in a feasible and safe manner. Specifically, the operating microscope has been improved upon in many aspects, including resolution of the visual field and even a three-dimensional monitoring system.1 Despite such advances in operating microscopes, a few concerns remain, such as their large and heavy build, limited visual field through the ocular lens (resulting in neck stiffness for the surgeons), and the physical discomfort for the assistant, since this completely depends on the physical position taken by the principal surgeons. The three-dimensional exoscope was first introduced in the field of neurosurgery. Oertel and Burkhardt2 described their consecutive cases of five cranial and 11 spinal procedures using the Vitom-3D exoscope (Karl Storz, GmbH, Tuttlingen, Germany), without any adverse events. Recently, the first successful case of microvascular anastomosis with the Vitom-3D exoscope, in a free deep inferior epigastric perforator flap for breast reconstruction, was reported by Piatkowski et al.3 However, their article provides only snapshot images, which make it difficult to understand how a three-dimensional exoscope seems useful. We tested the Vitom-3D exoscope in two cases for head and neck reconstruction with a free anterolateral thigh flap transfer. (Use of the Vitom-3D exoscope for the first case on August 8, 2018, was approved by the Institutional Review Board of Juntendo University Hospital.) In the first case, a 69-year-old woman who had previously undergone posterior craniotomy experienced delayed wound infection and subsequent cranial exposure. After débridement and dissection of the ipsilateral facial artery and vein under the exoscope, the descending branch of the lateral femoral circumflex artery and vein were anastomosed to the recipient vessels in an end-to-end fashion (Fig. 1). In the second case, a 71-year-old man who had undergone mesopharyngectomy due to mesopharyngeal cancer subsequently underwent reconstruction with a free anterolateral thigh flap. The superior thyroid artery and internal jugular vein were selected as recipient vessels and anastomosed with the descending branch of the lateral femoral circumflex artery and vein in an end-to-end and end-to-side fashion, respectively (Fig. 2). [See Video 1 (online), which shows a demonstration of the overview of the Vitom-3D exoscope. See Video 2 (online), which demonstrates an end-to-side venous anastomosis.] Neither of these cases had complications, including vascular thrombosis and flap necrosis. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"Overview of the vascular preparation for microvascular anastomosis using the three-dimensional exoscope. In this video, the principal surgeon makes a vascular window to the internal jugular vein as a recipient vein for end-to-side anastomosis.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_y428epmn"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"Monitor view of the end-to-side venous anastomosis. The comitant vein of the descending branch of the lateral circumflex femoral artery and internal jugular vein are anastomosed with 9-0 nylon in an end-to-side fashion.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_64vgfest"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: Overview of the Vitom-3D exoscope. Compared with the standard surgical microscope, the body is light and easy to set up. In addition, the three-dimensional wide-view monitor with 4K resolution provides a clear surgical field.Fig. 2.: Overview of microvascular anastomosis under the three-dimensional exoscope. The principal operator and assistant surgeon are sitting in an oblique, face-to-face position (approximately 150 degrees to each other).The Vitom-3D exoscope has several advantages compared to the standard surgical microscope. First, the three-dimensional wide view with 4K resolution can be obtained during the microsurgery, which allows any surgeon to deal with tiny vessels precisely and less traumatically. Second, the principal operator and assistant surgeon can be independent and not interfere with one another during the surgery, since they can watch the monitor independently. Finally, the exoscope helps to further the learning curve for residents in terms of training in microsurgery, as well as in recent reports of virtual reality.4 The trainer, trainees, and even observers can watch the same monitor simultaneously during microsurgical training and easily share technical skills and valuable tips. [See Figure, Supplemental Digital Content 1, demonstrating an overview of microsurgery training using the three-dimensional exoscope. The trainee practices microvascular anastomosis using an artificial microvessel under the guidance of the trainer, while both trainer and trainee watch the same monitor side-by-side. (Left) Anterior view; (right) posterior view, https://links.lww.com/PRS/D725.] In conclusion, the three-dimensional exoscope may be a promising device in the field of reconstructive microsurgery. DISCLOSURE The authors have no financial disclosures to report. Yuichi Ichikawa, M.D.Daiki Senda, M.D.Yoshiaki Shingyochi, M.D., Ph.D.Hiroshi Mizuno, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryJuntendo University School of MedicineTokyo, Japan