All right. Good afternoon. We're going to get started. So, sorry to disappoint you, but our colleagues from Japan are not here. So, but they did send their videos. And so, we'll be watching a lot of their recorded videos. And I'm sure there are a lot of you that are excellent microsurgeons. So, this is a, please, if you have questions, stop, especially if it's a video, my video or Dr. D's video. If you have any questions or comments, you know, I think this, we can make this pretty informal to make it more engaging. And if you have comments, if you do something a little bit differently, please, feel free to come up to the microphone. And then, the last video, Dr. Koshimo's video, of course, he's not here, but his colleague from the hospital in Japan, Hirofumi, is here and will be presenting his video. So, I'm Jacques Hochbord. I'm from NYU. And the first video that we'll be starting with is enticide anastomosis with vessels around one millimeter in size. And Okay, we'll probably skip that video for now, I apologize. Sorry, this has been happening in pretty much every room. I'm sure you've seen it, too So we're just gonna quickly pivot towards a USB. Okay, while we do that, so endocyte anesthesmosis With vessels around one millimeter the video that I was gonna show is the scenario where you cannot flip up the vessel You can't do the back wall flip the vessel do the back wall and flip it back down and do the front wall And so when it's a vessel of around a millimeter in size, that's difficult. So that with the clinical scenario. Oh, here we go The clinical scenario would be something like, you know, you have a replant where it is the Anesthesia is just distal to the arch and so you have to do an endocyte unto the arch and you can't flip Of course, you can't bring the finger over and do the back wall and bring to the front wall Does that does that make sense? So it's a clinical scenario. That's Not common, but when it occurs, it's very difficult So this is just a technique of how how to do it What to focus on and of course, this is one way of doing it And so if you have a better way of doing it, or if you found something else, please Please share it with us and share with the group so The first part is creating the arteriotomy and the arteriotomy is can be challenging What I do is I place a suture into the wall and Tie that suture and then pull that now the next part is Cutting cutting the wall. I think it's very important here. My assistant is cutting with his dominant hand Because you can even see it's my assistant. So This is a little bit of a tremor You really want to do this with a dominant hand if you and then I'm coming with my dominant hand I'll just pause it there if you just the orientation of how this was is I couldn't come across and do with my left hand So my assistant do it with his dominant hand but if it's if the if the vessel is in line with you then always start with your non-dominant hand and Then end with your dominant hand because you can fix a bad cut the second time But if you start with your dominant hand and then you cut with your non-dominant hand You always have a little bit less control. You have more of a tremor and then you can You can't fix How do I explain it you want to start with a bad hand first, does that make sense? Okay All right, so you create your arteriotomy? We'll see this later, but the arteriotomy is a little bit too big What I do is I place my far corner suture first and I work towards myself or I work From my left to my right. I'm right-handed. So either towards myself if the vessel is running away from me or from left to right Yeah, so that my my dominant hand is always Unobstructed by suture that's already been placed. So we place that corner suture And now we're going to after this then we work along the back wall towards me I Think it's important to be working towards you and to be working towards your dominant hand depending on the orientation of the vessel So, with this vessel of around a millimeter in size, two or three sutures in the back wall should be sufficient. I don't know if the quality isn't great, but you'll see later the arteriotomy is a little big, and that's because the scissors were not ideal and the cut was just, we were struggling and so then we erred on too large of an arteriotomy, then you have to correct that. So, of course you really don't want to be in a scenario where you're fixing the arteriotomy. If you're in a scenario where you're fixing the arteriotomy, then you really want to excise it as much as possible. But what we did here was just a suture across it to close that down. So then we do the front wall. Once again, for the front wall, we're working towards, I'm working towards myself, or if the vessel's the other way, once again I'm working from left to right. Now that's surgeon more specific. What I do here is, because it's such a small vessel, I don't tie as I go. I throw the sutures and then I tie them sequentially. So here I threw three sutures and then I tie them as I go. And that's very important so that you can see the needle every time because if you tie and then you move to the next one, it's very difficult, especially for the last suture or the last two sutures, to see, to make sure that you haven't back walled. So throw the three and tie them as you go. Sorry, don't tie them as you go, tie them at the end. And when the vessel is oriented differently, I like to work from left to right, but some people like to work from right to left as they tie them, once they've thrown them all. All right, so that's an end-to-side any comments from anyone about how they like to do an end-to-side on a micro Vessel around a millimeter and once again, this is the scenario where you're suturing just off of the arch And you can't flip up Do the back wall and then flip it down and do the front wall any any thoughts or comments or any other techniques that you've? Seen or you've done that have worked well Any yes Even with a vessel this size, okay Yes Yes So then with with a back wall, do you you do a continuous like a running a running suture? Running suture both sides, but then but you you run and then you tie each one. Okay, okay Okay, so similar what I did on the front wall, but you do that on the back wall as well And then do you do the corner sutures separate? corner suture separate and Then do you do the corner sutures and then run the back wall and then you run the front wall? Okay, do you find it difficult to run the back wall if you've already done the corner suture? the corner suture either to the left That's your Okay, great, thank you any any other thoughts or comments Okay, all right, then we'll go to the the next one We also have a case that we can present. I have a couple of cases that we can present and discuss as well if we're running into more technical difficulties. Dr. Yoshizu Tamae has trained many Japanese micro-surgeons. My mentor, Dr. Takaya Yoshizu, was trained by Professor Tamae about 50 years ago. Dr. Yoshizu devised a novel micro-vascular arrest motion technique based on teaching only. All right, so as Jacques explained, so the organizer of the course unfortunately could not travel due to COVID, and we found that out kind of at the last minute. So we're going to try to make his videos work. I was asked to give a talk on nerve repair, so I'm happy to do that. I know that this may, for those of you that are in this room, these may be some very basic principles, but hopefully they'll be something that we could discuss, because I know there's some areas of controversy. So my name is Christopher Adee, I'm from Washington University in St. Louis. So I think everybody in this room is familiar with these general concepts, but our job when we're repairing a nerve is to provide the best possible environment for neural repair. There are three key components affecting functional recovery. Time to repair, alignment of healthy axons, and atraumatic tensionless approximation. Largely the last two are what's in our control, but not necessarily the first one. Time to repair, the rule of 18 months, that principle from the time from injury and the expected time for regeneration is key. If you are going to be outside and exceeding that window of 18 months, you are unlikely to win this game. Early diagnosis, prompt referral, and early treatment. We've worked hard at our place to make sure that our residents at least recognize these injuries, but we also know that our catchment area is quite broad, and we're relying on a lot of people from elsewhere to come in and help us out. So here's an example of... Okay. I mean, you can keep talking. Okay. Got it. Yeah, because we're trying to play the videos from the other... Okay. Yeah, I'm just trying to see if everything's hooked up so I can figure out the problem. Sure. Okay. So here's an example of a median nerve, obviously just proximal to the wrist crease. You know, inspecting this is very difficult. I don't know, how would this group evaluate this neuroma in continuity? So by show of hands, who would just go on feel alone? Right, feeling the nerve physically with your hands. Yeah. What do you do? I don't know. Do you leave this alone? It is kind of ugly looking. It's hard to accept. So this is a patient who had a... This patient had an injury, a stab wound, or something stabbing to the wrist. Sensation is out. Motor function is out. Everything's out. Easy decision then, right? But I think that, you know, for us, it unfortunately still in 2022, the best thing we have is to inspect in the way that we described, go off of your examination and make a decision. Who cuts the nerve with something like this? Who just uses a knife? Like the Neurotome? Okay. All right. I like this. It does make pretty pictures. And then you get back to bread loafing and you're supposed to bread loaf back to healthy fascicles. How do you determine healthy fascicles in the room? What do you use? So, do you end up resecting back? Yeah, I think they look different, definitely different than the proximal one. I think that's partially because of the blood nerve barrier being disrupted, especially with delirium degeneration. But I still think this is the best thing that we have, unfortunately. You know, so you don't want to cut back more than you have to. Yes? A couple of things, I couldn't see that they were all the way around, but sometimes these nerves can be easily partial. Can be what? Partial. So nerve-to-nerve, nerve-to-nerve across, you know, say the neuroma to start, and then would you then do an internal neurolysis and try to get individual healthy fascicles and then conduct across those? Right, of course. I've, you know, I have found at least in our facility the nerve-to-nerve action potentials to not be very reliable. You know, I know the way that the Mayo team sets it up, and I've seen the way that the LSU team with David Klein sets it up. I just have not found that to be reliable at our facility, so I've stopped using them. Because I don't, there are times where some of it's availability, it's kind of difficult to get them all the time, and that's probably on our end. But the results that I've seen from all of the work of doing all the, you know, the interphysical dissection and doing, stimulating those individual fascicles, if I can resect and know that I'm back to healthy and I've got a reasonable gap, I feel better about that personally. But I recognize what you're saying. I think that's a very valid point. So when is it okay to accept a little bit of tension? There is a little bit of physiologic tension in that nerve, but excessive tension, as we all know from many years and decades of prior work, will inhibit Schwann cell activation and axonal regeneration, and that will lead to scarring and a failed repair. So physiologic level of strain is probably less than 5%. Once you start getting over 8%, then you start to get temporary ischemia. And as you exceed 12 to 15%, you get irreversible ischemia and a conduction block. It's tempting to accept a little tension on your repair, though, to avoid grafting and to avoid another coaptation. You know, so this is work that demonstrates the axon counts, and there's a big drop-off once you get to higher tension, and it is a very fine line to walk. So there are ways to alleviate tension and hopefully try to close your gap, and if you can close it entirely, fantastic. You mobilize your nerve ends with neurolysis, and then who here will, is known to flex the wrist to get a little bit? Okay. How much do you flex, and what are you willing to accept, and how do you assess that at the end of the day? Single 9-0? A single 9-0? Yeah. And then do you protect it at all afterwards in terms of, you know, say you flex the wrist, and then you put it into neutral, kind of laying it on the hand table. Will you then protect them in a special kind of splint afterwards to prevent any extension? I get that. Anybody else have any other different philosophies? Back row and then we'll go here. Right, right. Why two weeks? And nobody's ever going to do that study, but that's what we all use, right? And you had a comment up here? Right, absolutely. So, a show of hands. Allograft for a major mixed nerve at this level? Okay. Autographed? this is a challenge and figure out the question that Jacques has proposed. So if you're below this tension threshold, grafting may be unnecessary. It is high-risk, high-reward, the scenario that Dr. Hackeboer described. Primary pair versus an intercalary graft. Primary pair theoretically avoids axon loss at the additional coaptation, but a ruptured repair is catastrophic. So we think, at least we're taught, dogma-wise, that you lose 30 to 50 percent of axon loss at each coaptation. That's why you try to avoid a graft, right? Laboratory study of an additional suture line shows no significant loss. So here's a study that Amy Moore did when she was back at our place, and you look at adding an additional suture line did not lead to any loss in axon counts. Now, again, you could say this is a rat study, so they're going to heal everything, but at least this is something that may be worth looking at in the future, but I think many of us would still buy that you're going to lose axons at each coaptation. It's just a matter of how many. So we talked about, many of us have talked about the 8-0 nylon test, or doing a couple of 9-0s. Now, ideally, you want to use a suture that fails by 5 percent strain on average. Remember, we talked about that's the threshold for normal blood flow. A maximum of 8 percent strain. So if this thing is going to fail, you want to know in the OR, okay? You don't want to find out later. So you don't want a suture that's going to be stronger than what happens, that's going to be stronger than the forces that are going to be on this after you leave the OR. And you'd rather have a suture that fails by breaking in the middle of the suture as opposed to pulling out of the epineurium because the suture itself is strong. So the dogma that we all talk about is, you know, if it comes together with an 8-0 nylon, is that enough? So this was a nice study done by the group out of Indiana. So they looked at various suture types, you know, 6-0, 7-0, 8-0, and 9-0. Now, you can see the thresholds here. We talked about this 8 percent being a temporary ischemia and 5 percent. Now, you ideally want a suture that's going to break earlier than the 8 percent, okay? And it looks like that's 9-0 nylon based on this because sometimes that 8-0 nylon can exceed, 8-0 can exceed that threshold and you will get a little more strain than you want. And then 9-0 nylon tended to fail by breakage rather than pullout. So for me, this study was practice changing because I went from using 8-0 to check these things to using 9-0. So 8-0 nylon is probably okay and I think if you're doing that, you're probably okay. A 9-0 nylon meets all ideal characteristics. I still have partners that use 8-0 and swear by it. These are digital nerves, digital cadaveric nerves. So nerve glue, who uses nerve glue for their repairs as, so who, does anybody show of hands, does anybody only use glue? No sutures? Okay. Who will put their sutures in, like their alignment? I like to use a glue to help get my cables together to act as a little bit of an epineurium. I think that's what you're talking about, right? So just for full disclosure, this is off-label use for nerve repair, at least in the U.S. with the FDA. You've got fibrinogen and humanthrombin and a synthetic at proatenin. So that's an anti-fibrinolytic. This acts as an adhesive cylinder. It maintains its structural integrity for about three weeks. Regeneration can occur across this. And some people say that, you know, it'll avoid fascicular extrusion, but it doesn't. You can still have fascicles that escape, so it's still critical that you have those fascicles aligned properly without anything extruding. So looking at the various studies, suture versus glue alone, equivalent results in animal studies. The glue repair dehiscence rate was 10% in the first three days in a rat sciatic nerve. When you're adding to a suture repair, it does increase your resistance to gapping, but it does not make it stronger in terms of if it pulls apart. It can still fail. So my practice, I use suture for 9-0-nylon for these smaller nerves, and it augmented with fibrin glue. I tend to use 9-0-nylon for most of mine. Just remember, the more sutures you put in, though, the more potential scarring you're causing. Each of those little sutures is going to cause a little granuloma, so you don't want to go completely bonkers on putting sutures in. Now, we tend to all protect our repairs for probably somewhere between two to four weeks. Again, that is based purely on what everybody has said over time, and nobody's really looked at that, and that'd be a tough study to do. I tend to protect mine at least 10 days. Usually it's about three weeks. The largest gain in tensile stress, at least in a rat sciatic, is in that first seven days. So I want to make sure my repair is protected during that time while that strength is accruing across the nerve. Controversial area here. I don't think we're ever going to come to agreement, at least in this room, for another few years about what to do about gaps. This is my algorithm. If I have a short gap in a sensory-only nerve, I would consider using some kind of conduit or a graft. I have some concerns based on the work that my partner, David Bergen, has done about inflammatory response after using a conduit, but I know that many will do that. If there's a gap over two centimeters and it's a sensory nerve, you could consider using an allograft or an autograft. That's what I would do in my practice, probably an allograft for a sensory-only nerve. For me, I don't use allograft for a mixed or a motor nerve of any gap, although I know that some looking at the ranger data would be compelled to do so, and there are obvious advantages to doing so. I still have some hesitations after looking at the data, and I encourage everybody to read the literature and make a decision for yourself. Now, if you get to the point where you have an excessive distance to target for a motor nerve, and sometimes even a sensory nerve, consider a nerve transfer if that option is available. It's not always available to you. So the conduits, we talked about this just briefly, but a hollow tube of varying material can be a blood vessel, can be a vein, collagen, or the older PGA ones. The goal of a conduit is to isolate and protect that fibrin clot between the nerve ends. You're essentially having the nerve grow within this protected barrier. And then you can bridge smaller gaps, very reliable for less than two centimeters. If you really look into the tables of those papers, as you get over two centimeters, the results are a little dicier. Nerve grafting we can talk about separately as just general principles. You want to match the diameter, optimize vesicular density, plus minus reversing polarity. There are studies and meta-analyses showing it doesn't matter. But it costs nothing. You're there. I just tend to do it. Your nutrition depends on inhibition. So you do need a healthy tissue bed. And as you get larger and larger with your nerve grafts, you are at risk for ischemia in the central portion of that graft. And that's where if you want to call a friend like Jacques who can give you a nice vascularized nerve flap. Principles that we talked about before about nerve repair, you want to try to get there as fast as you can, align the axons. Yeah, so in looking at the data, and you really parse it apart, first off, there are no data that are provided, at least the series that I've seen, that are outside of the industry-sponsored data. So there's that. In looking at the mixed and motor nerves, the results, I think, are too inconsistent for me to change my practice. So if it's a mixed or a motor nerve for me, and if it's an injury I have, I would rather you take my SERL, because I don't see the consistent results. A little bit of micro vascular, and last motion, take it. I will present Dr. Yoshi's tying technique under the microscope. All microsurgical instruments are held using a pencil grip because this stabilizes the wrist and small finger. After needle passage, the microsurgical forceps is placed near the anastomosis site. The suture material is pulled toward the surgeon using the forceps as a pulley. The thread is grasped by the forceps at right angle while straining the thread. The needle holder catches the thread from above when the thread is grasped by the forceps. After release of the suture material, the forceps is placed at the anastomosis site and the needle holder moved toward the anastomosis site. This automatically loops the thread. The forceps is passed through the loop and grabs an end of the suture material. The forceps and the needle holder are pulling against each other. However, the surgeon moves principally the right hand. The forceps is again placed at the anastomosis site. Only the right hand is moved toward the site. This automatically loops the thread. The loop is rolled around the tip of the forceps and the end of the thread grabs by the forceps. The suture knot is made by pulling the thread with both hands. The forceps is again placed at the anastomosis site. Only the right hand is moved to automatically loop the thread. This maneuver can be repeated. Here, I will show the video presentation of his turning technique under the microscope. The needle holder catches the thread from above, like this. This is one of important points of his technique. And only the right hand is moved to automatically loop the thread. This is also one of important points of his technique. Next, I will show the video presentation of end-to-end anastomosis of micro-vessels of the same outer diameter using his tiny technique. The vessel lumen is gently expanded. A small adventure is rejected. The lumen is rinsed with a heparin solution. The microsurgical forceps is placed into the vessel lumen to use as a counter support. When the needle passes through the full thickness of the vessel wall, after passage of thread through the opposite end of the vessel, the suture is lightly tightened by his technique. A second stage suture is placed at the side nearest the surgeon. The third tie is made between the two stage sutures. After the anterior half is anastomosed, the double clamp is rotated for inspection of the suture side from the inside. As the lumen is narrowed, it is re-expanded using the forceps. The first tie of the posterior wall is made between the two stage sutures, and the posterior ties are made sequentially. In sclerotic arteries with thick intima, cutting of both walls of the artery stand at the same time can tear the intima from the wall of vessel. Do not do this. Instead, trim the artery wall via spiral cut. This effectively removes a sclerotic wall without tearing the intima. In end-to-end anastomosis of micro-vessels with different outer diameters, the smaller vessel stump is cut obliquely to match the diameter of the opposing vessel. If this is not sufficient, a slight longitudinal incision is created to increase the diameter. In addition, cutting of the vessel end in a fish-mouth manner and vessel bifurcation usefully increase the diameter. If the diameter difference is too much, end-to-side anastomosis should be performed. At first, we suture the posterior wall using a running suture. Then, the artery wall is also repaired using interrupted sutures. As with Professor Tamai, Dr. Yoshizu also taught his technique to many young Japanese micro-surgeons throughout a one-week course in the laboratory of our hospital. Now, I follow this fine tradition. This is all I have to introduce to you. Thank you for your attention. We would like to talk about technical tips and tricks of microvascular anastomosis. We have nothing to disclose. In this presentation, we will present our views and insights based on the most recent literature with a focus on the technical aspects of microvascular anastomosis. If the most important point in microvascular anastomotic techniques could be summed up in one word for all situations, it would be to align the walls of vessels perfectly so that there is no difference in the level of the vascular intima. For vessels of varying diameters and wall thickness, the underlying principles for end-to-end anastomosis and end-to-side anastomosis are the same. In vascular anastomosis, the most fatal technical error is back wall biting. However, various methods to prevent this have been published to date. Now, we are showing several methods of end-to-end anastomosis with movies and pictures, and they are the ways to prevent back wall biting. Back wall fast technique. This is primarily used when the vessel cannot be rotated during anastomosis. The needle holder is manipulated as though making a tennis backhand. Gripping the needle holder so that it is getting closer to perpendicular to the surface makes it easier to apply force and operate when passing a stitch through the blood vessel. Furthermore, move the suture on the far side following the first stitch suture insertion. Passing a stitch as close to the stitch suture insertion as possible minimizes leakage after suturing. Open guide suture technique. This method allows constant visualization of the vascular lumen. The first stitch is tied. However, for the second stitch, the thread is passed at 180 degrees on the opposite side, and it's not tied. By passing the suture thread without tying it between the first and second stitches, erroneous back wall sutures can be prevented. However, it is not recommended when the visual field is limited because the thread can easily tangle. Untied stay suture technique. This method was first reported in 1988. Various versions of this method have since been published. The suture method employs double-armed needles. Because the stitch is passed from within the vascular lumen outwards, there is little chance of stitching the posterior wall. Furthermore, by not tying the first and second stitches, manipulations can be performed while confirming the vascular lumen until suture completion. IVAS technique. This method was published in 2008. In the event of anastomosis of vessels that are 0.5 mm or less in diameter, end-to-end anastomosis is performed with a nylon thread inserted into the vessel to avoid stitching the posterior wall. Next, we are showing the methods of end-to-side anastomosis. Arteriotomy includes slit arteriotomy and excision arteriotomy. Slit arteriotomy is making a longitudinal slit in the vessel. Excision arteriotomy is making a partial excision of the vessel. Excision arteriotomy should be performed with caution because intima detachment can occur in cases of severe arteriosclerosis and vascular injury caused by trauma. When performing end-to-side suturing, the appropriate suture angle ranges from 55 to 90 degrees and is designed based on the circumstances. We prefer a suture angle of 60 to 80 degrees. If the suture angle is 90 degrees, slit or excision arteriotomy of 1.2 times of the diameter of the host vessel is performed. If the suture angle is 60 to 80 degrees, slit or excision arteriotomy of 1.5 to 3 times diameter of the host vessel is performed. End-to-side anastomosis Stage sutures, like all other suture insertion techniques, are critical. Stage sutures are usually placed 180 degrees apart in the host vessel's heel and toe. The decision to start suturing from the far or near side is determined by the surgeon's ease of suturing, and suturing is generally started from the side that is difficult to suture. If the surgeon is right-handed, the range from 9 o'clock to 12 o'clock in terms of o'clock phase is difficult to suture. Sutures are made in this range using the backhand technique. The surgeon's movement with the needle holder is similar to that of a tennis or table tennis player holding a racket. While this type of movement is relaxed and comfortable, it is also precise and efficient. The needle tip is gentle on the vessel wall and passes through it with pinpoint accuracy. This is the normal way. We call this the forehand technique. The orientation of the needle tip is upwards, and if you turn the needle holder, you can switch the needle tip to downwards. This is the backhand technique, turning the needle 180 degrees from the forehand position, and hand movement is also opposite. Moreover, in cases where the working space is particularly limited, the needle is held like a spear to pierce the vessel wall in a straight line to make sutures. The orientation of the needle tip and whether to use the forehand or backhand must be adjusted according to the circumstances. That's all. Thank you for your attention. I attended this meeting on behalf of Dr. Kasai, Dr. Moriya, and Dr. Kojima. Since Japanese people are very sensitive to being infected by COVID-19, they were prohibited to attend this meeting by the hospital. However, I was permitted because I am young and healthy, maybe. I have the opportunity to stand here, so thank you for having me. I would like to talk about robotic and size surgery. The speakers have no relevant financial relationship. The outline is lymph bypass, less than 0.2 millimeter, finger-tip implantation, perforator to perforator flap, nerve flap, nerve bypass, concepts of oligoflap, and robotic surgery. We usually use 12 out of 15 microneedle during super micro surgery, which is the smallest in this picture. First of all, I would like to show the super micro anastomosis using 12 out of 15 microneedle during 0.2 millimeter lymphatic anastomosis. This technique is different from conservative micro anastomosis. The most different point is we cannot insert the forceps into the intima. I am starting the video. Diameter of lymphatic channel and small vein was 0.2 millimeter. We usually use 12 out of 15 microneedle. Direct threading strains the adventitious of lymphatic channel to opposite side of threading. Pass the needle through a spacer to ensure that the tip of needle does not catch the buckle. Oh, no, it's my anastomosis. Yeah, yeah. The lumen of small vessel. Pass the needle carefully to avoid passing the needles through the back wall. magnification about 12 to 15. Pass the needle through the wall with one hand. This technique is useful in small pieces and small sets. Hold up the needle to ensure that the tip of the needle does not catch the back wall. Thread the vein by the forceps and confirm the lumen using the tip of the needle and pass through the wall. Pass the needle through the wall with one hand. Hold up the needle to ensure that the tip of the needle does not catch the back wall. Check the anastomosis status with a venous workflow. In this case, three sutures are enough for 0.2 mm anastomosis. However, even a 12 or 15 micron needle seems bigger than an anastomosis of 0.2 mm. So recently we developed the super micro needle to thinner 12 or 13 micron needle. We call it nano micro. Here we show the 12 or 14 micron anastomosis. The thread is transparent due to the thinness of itself. The craftsman made this manually. I was surprised to hear that. The craftsman said this thread is too thin to dye a color. This needle is more difficult to manipulate than 12 or 15 micron needle. However, we can anastomose more precisely in the tiny anastomosis. This is an anastomosis by Dr. Koshima. He used a custom-made forceps and needle folder for the super micro surgery. This is the first case of LBA from our team. For the treatment of left upper extremity lymphedema, we performed six LBA. The result was excellent, even after long duration follow-up. The circumference in the left forearm was gradually decreased, as well as right forearm. This is a lymphatic channel biopsy from the patient observed by transmission electron microscope. Lymphatic channel has three layers, consisting from tunica adventura, tunica media, including smooth muscle cell, and tunica intima, including epithelial cell. Lymphatic smooth muscle cell is degenerated, along with severity of lymphedema. But in this patient, intact lymphatic smooth muscle cells were existed. Hence, LBA effectively worked to the patient. This is a case of fingertip replantation. The amputation occurred at the level of arterial arch. We could anathemose artery directly, however, the vein lost the length. Hence, we used this redundant artery as a artery water graft to anathemose vein. In this level, the diameter of B cell is 0.3 millimeter. It requires super microsurgical technique, and this is the result. Fingertip was survived. Other option for the treatment of finger soft tissue defect is digital artery perforator flap. This flap is based on the perforator of digital artery, and has the features of less invasiveness. Perforator-to-perforator flap is less invasive surgery of free flap, avoiding to injure main artery. The recipient B cells were detected preoperatively by ultrasound. Over 20 centimeter per second, highest peak systolic flow velocity in recipient artery is reliable to detect during exposure. We prefer the skip flap for perforator-to-perforator flap. Usually, the diameter of deep branch of skip flap and recipient perforator are less than 0.8 millimeter. Next topic is NAP flap. This is a cross-section of NAP observed by transmission electron microscope. The axon has neurofilament, microtube, and action filament called cytoskeleton. The cytoskeleton transfer in the axon toward proximal and distal interactively. This movement of cytoskeleton is important to consider NAP regeneration. And NAP has a vascular system of itself. The preservation of the vascular system is also important for NAP regeneration. Vascularized NAP flap preserves the vascular system and is distinguished from free NAP graft. To establish the effectiveness of vascularized NAP flap, we had the experiments using a lot of sciatic NAP. First, sciatic NAP and femoral artery vein was exposure. Next, the sciatic NAP was cut, and then unsutured. Third, in the group of vascularized NAP graft, the femoral artery and vein were preserved, while in the group of free NAP graft, the femoral artery and vein were cut. Also, we wrapped the sutured sciatic NAP by the plastic silicone chip to obstruct the regeneration from surrounding tissues. As you can see, the vascularized NAP graft has an intact thickness. In contrast, free NAP graft was absorbed. Through the pathological findings, vascularized NAP graft has a rich number of sick axons in the NAP compared to free NAP graft. In this case, the patient suffered from anesthesia and left sound due to the digital NAP injury. Out of the glass finding in the surgery, there was a two centimeter defect in digital NAP. Using a super nanomicro surgery, we split the digital NAP to single vascular and turn over both proximal and distal stump and suture. So we considered this side of vascular system was preserved. Tinnitus like sign was extended towards the tip of the thumb. Four months after from surgery, SUPIDI and SEMISWEINSTEIN test demonstrated five millimeter and 3.71, respectively. This is a case, 36 years old male suffered from severe pain in lateral form after blood collection. During the microsurgical dissection, we found the small lateral cutaneous neuroma. After the resection of microneuroma, I elevated the lateral femoral cutaneous nerve with deep branch of SCIA and anastomosis with a NAB and a recipient perforator. All of these anastomosis requires a super nanomicrosurgical technique. After the surgery, severe pain disappeared and sensory was recovered gradually. Next, we established the new concept of free flap called Orochi flap. Chimera flap is well known, which includes several tissue transfer based on one donor artery. Orochi flap means additional perforator flap on flap. This is a case of 10 years old female who had a floating thumb. The thumb had only one digital artery. First, the proximal thumb was skeletonized to be transferred to a more accurate anatomical position. The surgery is a little complicated. Combined thumb flap and vascularized scapula were elevated. The small portion of latissimus muscle was included in the flap as functional tissue transfer for a thinner muscle reconstruction. Also, the split motor nerve, the vascular of the strochoidal nerve was included. The scapula bone was included in this flap. However, the angular vessel of the scapula was too short to reach the metacarpal defect, so it was transacted to be free from the trochodorsal artery. The latissimus muscle here, this, was fixed to the flexor tendon of the distal floating thumb and the proximal carpal ligament with tension. A fascicle of the trochodorsal nerve, here, was sutured to the ulnar nerve at the level of the wrist. The bone was manipulated, here, into the gap between the proximal phalanx of the thumb and the base of the index finger metacarpal. Trochodorsal artery anathemas to ulnar artery for flow through. And angular vessel of the scapula was anathemas to opposite side of the trochodorsal artery. This free flap, on flap, is Orochi flap. After the surgery, some adduction was possible. And full-thickness skin grafting from the left pedal region was performed as well as the working of the flap. The results was excellent. This case was a 63-year-old female with severe pain of right axillary due to the radiation of ulcer. Bladder artery was obstructed at the level of mid-upper arm. After resection of the ulcer and exposure of bladder artery, rectus femoris muscle combined aortic flap was elevated. First, saphenous vein was transferred to be reconstruct the bladder artery and free ALT flap was bypassed the artery. The flap survived and the patient got relief from the surgery, from severe pain. Bladder artery was reconstructed and ALT bypass artery was also observed. In this session, we talked about lymphobipath less than 0.2 millimeter, fingertip replantation, perforator-to-perforator flap, nerve flap, Orochi flap. All these surgery require super-to-nanomicro surgery. The quality of super-micro surgery depends on the surgeon's dexterity and precision. To overcome to this difficulty, micro-associate, robot-assisted micro-anastomosis is developed. This is the last. Dr. Koshima organized many associations. Nowadays, we started up the Next Generation Super-Micro Surgery Consortium. The meeting is held online, both Japanese and English. If you have interest, please contact me. Thank you. All right, thank you very much. That's pretty impressive. I hope you learned some things or saw some things that make us think of how we can improve perforator-to-perforator, especially that floating thumb. I don't think anyone here would have thought about doing that. But yeah, also thank you very much for putting up with some of our technical difficulties. Any comments or questions, especially for Hirofumi about using 12-0 30-micron needle to suture a 0.2-millimeter vessel? I have to say, he's pretty good. Doesn't have much of a tremor at all. All right, thank you very much.

microsurgery techniques

anastomosis techniques

nerve repair techniques

functional recovery

super microsurgery techniques

lymph bypass

fingertip replantation

perforator-to-perforator flap

robotic surgery

Next Generation Super Microsurgery Consortium