27-Gauge Vitrectomy

Abstract

Ten years or more have passed since the current concept of 25-gauge transconjunctival sutureless vitrectomy with a trocar-cannula system emerged. There is no doubt that current microincision vitrectomy surgery with 25- or 23-gauge instrumentation has simplified the vitrectomy procedure and has provided numerous potential advantages over traditional 20-gauge surgery. The established theory regarding surgical wounds is that 'much smaller is better'. Along with the development of new-generation vitrectomy machines with ergonomic instruments, surgeons have been shifting dramatically from 20-gauge systems to 23- and 25-gauge systems over the last years. Thanks to recent innovations and improvements in high-end multifunctional vitrectomy machines and ultrahigh-speed cutters, the development of powerful light sources, and wide-angle viewing systems, several new techniques have also encouraged us to launch the development of a 27-gauge vitrectomy system over the past several years. Similar to the recent evolution in 23- and 25-gauge systems, further development and refinement of the functionality of instruments with a gauge of 27 or more are under way and will continue over the coming years, which in the future will allow us to establish this system for ultra-minimally invasive surgery for the full spectrum of vitreoretinal pathologies.

Vitreoretinal instruments: vitrectomy cutters, endoillumination and wide-angle viewing systems

“…Smaller vitrectomy probes allowed the transition to the microincision vitrectomy system (MIVS), introduced in 2002 by Fujii et al, using 25-gauge instruments and followed by Eckardt in 2005, with 23-gauge cutters [4–6]. Subsequent years have shown that the modern MIVS have numerous advantages over 20-gauge vitrectomy and are associated with better patient comfort, less conjunctival scarring, less postoperative inflammation and earlier visual recovery [7–11]. More recently, 27-gauge instruments released by different companies have shown encouraging results [7–9, 12, 13].…”

“…Subsequent years have shown that the modern MIVS have numerous advantages over 20-gauge vitrectomy and are associated with better patient comfort, less conjunctival scarring, less postoperative inflammation and earlier visual recovery [7–11]. More recently, 27-gauge instruments released by different companies have shown encouraging results [7–9, 12, 13]. …”

“…More complex cases including diabetic retinopathy, rhegmatogenous retinal detachment and nucleus fragments removal have been managed with the next generation of 27-gauge cutter probes [7, 9, 12–14, 18]. The thinner instrument can be safely introduced into smaller spaces between membranes and retina, serving as a multifunctional device and facilitating tissue dissection [7, 14, 18]. The decreased stiffness is still noted when compared to other gauges (i.e., half of the 25+ gauge stiffness), but the rigidity has been improved by shorter length needles or the introduction of a stiffness sleeve, such as the one released by Alcon [7].…”

“…The thinner instrument can be safely introduced into smaller spaces between membranes and retina, serving as a multifunctional device and facilitating tissue dissection [7, 14, 18]. The decreased stiffness is still noted when compared to other gauges (i.e., half of the 25+ gauge stiffness), but the rigidity has been improved by shorter length needles or the introduction of a stiffness sleeve, such as the one released by Alcon [7]. Khan et al published the largest case series using the 27-gauge vitrectomy system in 2016.…”

Vitrectomy for vitreous floaters

“…Additionally, we should take heed to our anterior segment surgeons and look to minimize the invasiveness of vitrectomy for floaters. Recently, I have begun using 27-gauge vitrectomy for floater removal in order to eliminate the need for a local block and postoperative eye patch [23,24]. The early results and patient feedback have been encouraging, as patients have started enjoying the visual benefits in the recovery room.…”