Microsurgery has become an indispensable part of the armamentarium for plastic, hand, lymphatic, maxillofacial, and neurosurgeons. It is used in primary repair and reconstruction as well when other options of the reconstructive ladder are not adequate.

In 1960 Jacobson and Suarez described the first vascular microanastomosis.[1] Since that time, lots of advancements emerged both in microsurgical techniques and the instruments and devices used in the whole procedure. One of those was the introduction of microvascular anastomotic venous couplers to accelerate and simplify this tedious step. Mechanical coupler devices demonstrated an increasing popularity over the past decades and are now routinely used for performing venous anastomoses in free-flap surgery.[2] [3]

Microvascular anastomotic venous couplers are an integral component of our free-flap procedures, including flaps with small caliber vessels, enabling us to achieve faster and more secure venous anastomoses. Based on our experience we have oftentimes noticed that pulling the vessel through the coupler's ring, especially in the cases of smaller coupler sizes (i.e., 1.0 mm in diameter), can be cumbersome. This is because the straight jeweler's forceps or even the coupler forceps used to pass through the ring and handle the vessels are too big for this step in these cases. Herein, we would like to share our technique that facilitates the passage of the vein through the coupler's ring.

We utilize a commonly used setup in microsurgical procedures, that of an intravenous (hereafter IV) catheter that is connected to the suction tube through a 5-mL syringe ([Fig. 1]). The IV catheter used ranges in thickness from 20 to 26 gauge depending on the actual vessel's size, thus, in the cases of very fine vessels we use higher-gauze IV catheters. The catheter's tip is cut and reduced in length to 1 to 2 cm, not only to be stable but also resilient, resulting in a safe handling of the vessel. After the selection of the appropriate-sized coupler, the donor vessel is attached first to its coupling component. Initially, the suction power is set at 10 to 20 mm Hg, and the catheter's tip is passed through the inner side of the coupler's ring to approximate the adventitia of the venous stoma as depicted in [Fig. 1]. The low suction pressure allows a hassle-free pull of the vein through the opposing ring of the coupler. When the vessel passes the ring, it is securely stabilized in that position, ready to be everted and impaled onto the coupler's pins ([Fig. 2]). In some cases, when a larger suction catheter is used (e.g., 20 gauge), the opening of the tip of the catheter can be directly used as a coupler forceps to impale the intima of the vessel onto the pin.[4] The rest of the anastomosis procedure is followed as usual.

It is our belief that this technique will help other surgeons toward an easier, safer, and faster vessel microanastomoses, hence has the potential to be incorporated to the microsurgery training programs, such as the Fundamentals of Microsurgery (FMS) curriculum that has recently been validated.[5] The FMS program, which uses a competency-based approach, has been shown to effectively improve trainees' proficiency in basic microsurgical skills, reduce mental workload and performance anxiety, and improve intraoperative clinical proficiency. Our technique, which facilitates the anastomosis process and reduces the complexity of microsurgery, aligns well with the goals of the FMS curriculum, as well as other microsurgery curricula, and could be a valuable addition to the tasks progression for trainees to acquire the necessary skills to perform microsurgery.

Accepted Manuscript online:
16 March 2023

Article published online:
26 April 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA