Despite the steep rise in the number of microsurgical procedures, several authors keep identifying higher rates of microsurgical errors in trainees such as back-walling (21.7 percent) and incomplete bites (19.6 percent).1,2 Usually, these errors are attributed to poor visibility of the needle within the vessel lumen.2 Application of a novel three-jaw adventitia-holding microvascular clamps (Shira MedTech, Gujarat, India) (Fig. 1) is demonstrated in this study following the hypothesis that an adventitia-holding microvascular clamp keeps the vessel wall everted for easy visualization of the lumen. The effectiveness and frequency of errors during microvascular anastomosis is compared between the adventitia-holding microvascular clamp and the Acland microvascular clamp.Fig. 1.: Construct of the three-jaw adventitia-holding microclamp and its function.This study included 10 plastic surgery trainees with 6 to 24 months of training in microsurgery. The trainees performed the second venous anastomosis in free flaps and arterial repair in zone 4 and 5 flexor tendon injuries. [See Video (online), which demostrates the application of the adventitia-holding microvascular clamps.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video demonstrates the application of the adventitia-holding microvascular clamp.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_hayw5uaz"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Outcomes using the adventitia-holding microvascular clamp were evaluated and compared to Acland microvascular clamps in terms of ease of use (Likert scale), time for vessel preparation and clamp application, time for anastomosis (excluding vessel preparation and clamp application), incidence of improper bites or back-walling, need for assistance, and suitability for space-constrained microvascular anastomosis (determined by avoiding clamp flipping and reapplication rate). Jamovi 1.2.27.0 (Jamovi, Sydney, Australia) was used to conduct an unpaired t test or Fisher’s exact test when pertinent. Twenty-five vascular anastomoses were performed, 12 using the adventitia-holding microvascular clamps and 12 using the Acland clamps. The average time for vessel preparation and clamp application was significantly shorter using the adventitia-holding microvascular clamp (p = 0.007). The average anastomosis time was significantly shorter using the adventitia-holding microvascular clamp (p = 0.007). No back-wall catches or need for flipping the clamp were noted using the adventitia-holding microvascular clamp, whereas 30.8 percent and 38.5 percent of cases in the Acland clamp group had improper bites/back-wall catch and the need for flipping the clamp, respectively. When using the Acland clamp, a higher need for assistance in comparison to the adventitia-holding microvascular clamp was noted (p < 0.001). The need for clamp adjustment was higher in the Acland clamp group in comparison to the cases using the adventitia-holding microvascular clamps (Table 1). Table 1. - Results Characteristic AHM (%) Control (%)* p No. of cases 12 13 Free flap venous anastomosis 9 7 Zone 4/5 arterial injury repair 3 6 Mean anastomosis time ± SD, min 20.8 ± 4.9 32.3 ± 5.4 <0.001 Mean vessel preparation and clamp application time ± SD, min 5.11 ± 1.3 7.45 ± 2.5 0.007 No. of instances of improper bites/back-wall catch 0 (0) 4 (30.8) 0.096 No. of instances when assistance was required 2 (16.7) 13 (100) <0.001 No. of instances of clamp flipping 0 (0) 13 (100) <0.001 No. of instances when clamps were readjusted 2 (16.7) 5 (38.5) 0.378 Ease of use (on Likert scale) Average (score 3/5) 3 6 Good (score 4/5) 5 5 Excellent (score 5/5) 4 2 Mean 4.08 3.69 0.21 AHM, adventitia-holding microclamp.*Control (Acland clamps). Currently, the flap failure rate associated with free tissue transfer is between less than 1 percent and 10 percent.1 The most common cause of this phenomenon is thrombus formation at the venous anastomosis site and ultimately venous congestion.1 Poor placement of microsurgical sutures, excessive manipulation, and obstreperous handling have been acknowledged to cause venous thrombosis in several reports.1 Therefore, the adventitia-holding microclamp allows for careful manipulation and a facile anastomosis, as it everts the vessel ends, prevents back-wall suturing as seen in our study, eliminates the need to flip clamps (which makes the procedure more convenient in space-constrained surgical sites), and reduces the requirement for assistance. In cases where no adventitia is present, the microvascular clamp can be used without the third jaw. The adventitia-holding microclamp is a versatile instrument during microsurgery, as it eliminates the need to flip the clamp, prevents back-wall sutures, and requires minimal assistance. Further studies are required for its systematic implementation.3,4 DISCLOSURE The authors have no potential conflicts of interest with respect to the research, authorship, and publication of this article. None of the authors received any funds or has any financial interests to disclose for the research, authorship, and publication of this article.