Commentary In the 50-plus years of replantation surgery, the “strip test” has been the universal, manual observational test of vessel patency. All other downstream evaluations with pulse oximetry, ultrasonic flow metering, laser Doppler scanning, and/or capillary refill testing are preceded by, and predicated on, a successful strip test of the vessel. A successful test denotes appropriate directional flow through the repair. Patency of the repair is the near-term outcome sought by the surgeon who creates a microvascular anastomosis with the operating microscope. Modern dual-head, binocular operating microscopes are equipped with electronic controls for 2-axis motion, focus, light intensity, and video monitoring with high-definition video cameras that can grab single freeze-frames of images. Experienced surgeons can look at a microsurgical anastomosis of either vein or artery and evaluate the quality and dimension of the repair. Once happy with the coaptation of vessel walls, the spacing of the sutures, and the parallel nature of the lumens both upstream and downstream, they are then ready for the next functional test. The strip test is that functional test and requires an experienced eye to judge the speed and volume of blood with which the deflated vessel fills. The surgeon’s overall perception or gestalt of the repair can be tempered or even impaired by unseen biases that shape the surgical experience. The number of times the repair was revised, the hour of the night, the third digit being replanted rather than the first, or the level of expertise of the assistant or the surgical technician can alter the overall judgment of the quality of the test. In the 2003 book Moneyball: The Art of Winning an Unfair Game, Michael Lewis described new analytical methods used in baseball to quantify what experienced scouts, coaches, and pundits were subjectively observing1. Zhu and colleagues have applied a similar quantifiable approach to the strip test to predict outcome. They used an off-the-shelf, consumer-grade, high-speed digital camera with close-up lenses to concurrently capture their observations. In real time, they applied a numeric value to what was previously the subjective judgment of the surgeon in declaring a vessel suitable for adequate flow to keep the replant viable. The strip test is not without its risk. The applied pressure can damage the intima of the vessel and should be kept to a minimum. The authors’ method of evaluation took me <1 hour to prepare following their text. I used the same camera, which I already possessed and was familiar with. I tested the method using a microscope and a fluid-filled tube. They developed the idea and set out to use it in a busy clinical practice of replantation. They created a model that gave some prediction as to whether or not they and their patient would enjoy a good result. Once a certain threshold during collection in the repaired vessels had been reached in the strip test, they could stop repairing and move to the next phase of the surgery. With replants there is much to accomplish. Being sure of the quality of the strip test is time well spent. Microscopic robotics have yet to be proven of value in the mainstream of replantation procedures. However, we now have a reliable microscopic, visual assessment tool to measure our work in a consistent fashion. Better patient outcomes will hopefully prevail, as the universally applied strip test has a quantifiable and visually measurable result in digit replantation. This evaluation paves the way for a more standard comparison of surgeons and their repairs. Late at night and far into the case, it is a reasonable end point to achieve. Electronically assisted microsurgery is starting with a high-speed digital video assessment of surgical repair.
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