Male Infertility Microsurgical Training

Fig. 1.1

Zeiss OPMI/S3/S4 Surgical Microscope Systems (a, b) with motorized zoom and focus and Zeiss OPMI-1 binocular diploscope (c) with manually controlled zoom and focus are used for male infertility microsurgery training. Microsurgical bench table (d)

Microsurgical table. The bench table should be solid and stable, with a height around 30 in. to allow for comfortable placement of the operators’ knees below the table (Fig. 1.1d). Workspace dimensions of at least 30–35 in. in length and 24 in. in width will provide ample working space.

Microsurgical instruments. There are only a few instruments required to perform virtually all urologic microsurgical procedures (Fig. 1.2):

Fig. 1.2

Basic microsurgical instrument set for male infertility microsurgery

Basic Microsurgical Set

(a)

A straight fine-tip forceps (Solomon’s forceps) with and without a suture platform (10–13.5 cm long with flat or round handle).

(b)

A non-locking needle holder with a rounded, fine curved tip (13.5 or 15 cm long).

(c)

A curved-blunt tip dissecting scissor.

(d)

A sharp iris scissor.

(e)

A vessel dilator with a slender and tapered tip.

(f)

A small straight approximator double vascular/tubal clamps (ASSI, #ST-ATCC-22) or Goldstein Microspike approximator clamp for vasovasostomy (Fig. 1.3).

Fig. 1.3

Goldstein Microspike approximator

(g)

Microsurgical bipolar cautery with fine-tipped forceps.

Non-microsurgical set and microsuture materials

(a)

A basic set of surgical instruments for small animal surgery (e.g., small needle holder, small smooth and toothed forceps, small suture scissors, small curved or blunt dissecting scissors, and clip applier).

(b)

Operating board, 35 × 35 cm².

(c)

Microsurgical suture (Sharpoint Laboratory Pack/Non-sterile, double-armed or single-armed 10-0 sutures, #AK-0100, #AK-0101) and Microsurgical Suturing Practice Cards (Sharpoint #AK-9000), soft silicone tubing (Fig. 1.4).

Fig. 1.4

(d)

Tape for fixing practice objects to the board.

(e)

10 cc irrigating syringe (with heparin or saline solution) attended to a blunt rounded 27 1/2 gauge needle.

(f)

Background material: Deep blue is the most satisfactory background color.

(g)

Silicone tubing or segments of vas deferens.

(h)

Spasmolytics—such as 1 or 2% lidocaine hydrochloride (20 mg/ml), papaverine heparinized (100–150 units/ml) solution, Ringer’s lactate solution, or saline.

Microsurgical instrument maintenance. Good performance requires properly maintained microsurgical instruments. Working with damaged instruments can be laborious and frustrating for beginners as well as experienced microsurgeons [5]. When not in use, microsurgical instruments should be stored in an instrument case with their fine tips fully protected by plastic covers or segments of silicone tubing (Fig. 1.5). Grasping more than one instrument at a time increases the chances of damage to the tips. Each instrument should be examined under the microscope prior to use and repaired as needed. Simple repairs can be accomplished by sharpening the instrument tips with Arkansas white stone, emery paper, and nail file. Microsurgical instruments are often damaged during cleaning; therefore, great care must be taken during the cleaning process. Instruments should be soaked and cleaned immediately after use in a hemolytic enzyme solution such as Haemo-Sol (Haemo-Sol, Inc., Baltimore, MD). After soaking, the instruments should be rinsed in tap water and placed on paper towels to dry. Instruments must be dry prior to storage. Covering the tips of the instruments not only avoids damage to the fine instruments but also prevents magnetization from coming in contact with each other.

Fig. 1.5

Microsurgical instruments should be protected by plastic covers in a microsurgical instrument case

Basic Preparation for Microsurgery Training

Learning male infertility microsurgery requires extensive practice and patience. Laboratory training allows for acquisition of basic skills such as microscope adjustment, instrument handling, and knot tying prior to clinical application. The following suggestions may help to structure the laboratory training routine:

Set up flexible but sufficient practice time. As a resident, fellow, or practicing surgeon, time is valuable and limited. However, the minimum practice time should be at least twice a week for 1–2 h per session until basic skills are mastered.

Minimize mental stress. Try to get adequate sleep the night before a practice session.

Accept that mastery of microsurgery cannot be achieved overnight. The process involves many steps with intricate details, each of which requires attention and concentration. Frustration is common especially during the first week of training, but do not be discouraged.

Find a comfortable sitting position and eliminate outside distractions. Your arms should be bent at a 90° angle at the elbows. Your wrists and hands should be in a relaxed anterior position. Use supportive objects, such as towels or soft material like foam to support your hands and forearms. Adjust your stance to allow yourself easy access to the controls of the operating microscope.

Use appropriate magnification and sharp focus with maximum illumination. High magnification is only needed to prepare the ends of the vas deferens or the epididymal tubule and to pass the needle through the lumen of the vas deferens or the epididymal tubule. Low magnification is used to dissect tissue and to manipulate the needle to the correct position in the needle holder. The surgeon’s knot is best tied under low power.

Learning to Use the Operating Microscope

No matter what kind of operating microscope you have, you should completely understand how to operate it before learning microsurgery.

Adjust your seat level until you have a comfortable position. Having the level too high or low can result in a sore neck or back. Your head should sit straight on your neck, and your eyes should look straight ahead, perpendicular to your spine.

Adjust the interocular distance of the eyepieces until the two images fuse together.

Maximize the light source to provide adequate light for the entire field. However, follow the instructions on the microscope and your own common sense about light intensity and the distance between the light source and the specimen to avoid burn injury.

Choose a correct focal length or working distance. A working distance of 200 mm is optimal for male infertility microsurgery.

Focus each eyepiece with the microscope at the highest magnification. Start with the eyepiece at the “0” position and adjust until a sharp image is obtained for each eye. Focus at the highest magnification should ensure focus at all lower magnifications.

Learning to Handle Microsurgical Instruments

Holding the instruments: Although many surgeons have developed their own way of holding the forceps and needle holder, the pencil-holding position with the instrument resting in the index and thumb web space is recommended (Fig. 1.6).

Fig. 1.6

Pencil-holding position (a) is demonstrated with a needle holder. The tips of the needle holder are parallel to the surface with the needle at a 30° angle. A needle is held by the tips of the needle holder using gentle pressure between thumb and index finger (b). To control hand or finger tremor, a folded surgical towel is placed to support the hand and forearm (c)

Most microsurgical skills, including suturing and knot tying, require only a slight movement of the fingers. The rest of the hand must be perfectly still. The thumb, index, and middle fingers must support each other precisely. Moreover, the weight of the hand must rest on its base to maintain stability. The thumb and index finger must hold the instrument so that its weight is transmitted through the middle finger to the work surface below. Holding the needle or cutting a suture is precisely controlled by a slight motion between the thumb and index finger (Fig. 1.6b).

Controlling hand tremor. It is extremely difficult even for surgeons with considerable microsurgical experience to coordinate hand and instrument movement and to prevent tremors without proper hand support. Therefore fingers must support each other during micromanipulation. We prefer to use folded surgical towels to support the hand and forearm (Fig. 1.6c).

“Light touch”: Microsurgical needles and sutures are easily damaged if held too firmly. A “light or gentle touch” is needed to accurately control the instrument with minimal hand pressure. One distinction of a good microsurgeon is the ability to preserve the original shape and condition of the needle throughout the operation. Once the needle is grasped between the fine tips of the needle holder, fine adjustments to the angle of the needle can be made by gently touching the needle with the tips of the forceps (Fig. 1.7a). The best way to stabilize the needle is to hold it at a point roughly one-half to two-thirds of the way back from the tip of the needle. The needle will wobble if held too close to the suture end (Fig. 1.7b) or too near the tip (Fig. 1.7c). Keeping the needle pointing in the right direction can take practice.

Fig. 1.7

Learn how to control the needle; and how to position the needle with the needle holder and forceps. Use the tips of the forceps to adjust the position of the needle in the needle holder (a). The needle will be unstable if held too close to the suture end (b) or too near the tip (c)

Forehand or backhand: How the needle is loaded on the needle holder depends on the direction of the needle stroke to be made. For right-handed surgeons, a needle stroke from right to left or towards the surgeon is made with the needle in the forehand position (Fig. 1.8a). A needle stroke from left to right or away from the surgeon requires the needle in the backhand position (Fig. 1.8b). Most microsurgeons are better able to control the needle using a forehand hold. Unless one is ambidextrous, both forehand and backhand holds are important to learn. One must learn to rotate the needle in various directions.

Fig. 1.8

Needle holding positions for forehand (a) and backhand (b) suturing require only a slight rotational movement of the fingers

Preparation of Microsurgical Sutures

Currently, we use only 10-0 microsurgical sutures for male infertility microsurgical anastomoses of the vas deferens or epididymis in our lab. There are a variety of needle shapes for different anastomoses. We commonly use non-sterile 10-0 laboratory pack (Fig. 1.9), 100 micron, nonabsorbable black nylon with double-armed (Sharpoint #AK-0101) or single-armed needles (Sharpoint #AK-0100). Animal studies suggested that nylon microsutures may be less reactive than polypropylene [6].

Fig. 1.9

Preparation of Microsuturing Practice Card

Passing the needle through tissue—A practice microsuturing card (e.g., Sharpoint Latex card, #AK-9000) is a simple and effective tool for developing suturing skills under the operating microscope.

A small incision is made on the card with a scalpel. It is important to visualize the entrance and exit points before passing the needle through the card. The entrance should be made at a point two times the wall thickness of the tissue. The needle should be perpendicular to the tissue at its entry point. Forceps provide counter-pressure to help the needle pass through the tissue edge between the tips of the forceps (Fig. 1.10a). Under low power magnification, the needle is passed perpendicular to the tissue plane through the left tissue edge from the inside, between the tips of the forceps, with a bite equal to that on right edge (Fig. 1.10b). The movement of the hand must follow the curvature of the needle (Fig. 1.10c). The needle should never be pulled through the tissue in one straight movement. One rough, straight pull can bend the needle and weaken the edge of the tissue by enlarging the needle hole. The needle holder keeps the suture end parallel to the exit hole as the needle is guided out of the tissue. Stop pulling the suture when a 1–2 cm length of the suture tail remains. Pull the needle and redundant length of suture away from the suture site before tying the knot (Fig. 1.10d).