“Quadrupod” Grip for Handling Supermicrosurgical Instruments

With the advent of supermicrosurgery, manipulating vessels smaller than 0.5 mm became practical,[1] and there have been several training models reported for supermicrosurgery.[2] [3] The tips of supermicrosurgical needle holders and forceps are usually smaller than 0.2 mm to handle 11–0 and 12–0 sutures. However, this requires more demanding technique than microsurgery. Acland and Sabapathy described microsurgery as a battle against unwanted movement. An emphasis on the avoidance of tremor in microsurgery with a well-supported hand position enabling movement of fingertips only was advocated.[4] In the “writing” position, the index and middle fingers control one side of the instrument against the thumb. Most microsurgeons mainly use the three-digit tripod grip in holding the instruments. Lin and Lee modified the writing position.[5] Although conventional microsurgical techniques can provide stability and precision to some degree, manipulation of vessels in supermicrosurgery is still challenging. To meet the needs of supermicrosurgical techniques, a novel method in which the instrument is handled with four fingers is described.

In this technique, the four fingers are used with the index, middle, and ring fingers placed on one side of the needle holder or forceps and thumb on the other side ([Fig. 1]). Thus, placing the instrument on both the ring and middle fingers offers more stable movement. In microsurgical suture, the ring finger mainly moves accompanied by the rest of the three fingers. Since the distance between the tip of the instrument and a point of contact of the ring finger is short, delicate movement is accomplished. This can diminish motion tremor, leading to less damage to vessels and accurate anastomosis.

Fig. 1 In quadrupod technique, the instrument is placed in the four fingers. Since the distance between the tip and the ring finger (double-headed arrow) is short, precise movement can be achieved. A microscopic view shows ring finger–assisted handling of a supermicrosurgical needle holder (above left).

This “quadrupod” grip offers balanced movement of all the supermicrosurgical instruments—needle holder, forceps, and scissors. In our experience, by using this technique, difficulty in manipulating small vessels is alleviated in supermicrosurgery.

• References

• 1 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
• 2 Yamashita S, Sugiyama N, Hasegawa K, Namba Y, Kimata Y. A novel model for supermicrosurgery training: the superficial inferior epigastric artery flap in rats. J Reconstr Microsurg 2008; 24 (08) 537-543
• 3 Bas CE, Cwykiel J, Siemionow M. A new supermicrosurgery training model of saphenous artery and great saphenous vein anastomosis for development of advanced microsurgical skills. J Reconstr Microsurg 2017; 33 (06) 426-434
• 4 Acland RD, Sabapathy SR. Acland’s Practice Manual for Microvascular Surgery. 3rd ed. India: The Indian Society for Surgery of the Hand (ISSH); 2008
• 5 Lin SJ, Lee BT. The intrinsic tying platform in microsurgery. Plast Reconstr Surg 2009; 123 (06) 223e-224e