A quiet hand for microneurosurgery: twiddle your thumb

Abstract

Fatigue is both the most tremor-producing factor and the constant companion of a busy neurosurgeon. Because of the difficulty in controlling tremor-generating factors, the authors sought to develop a means of manipulating surgical instruments with minimal muscle movement while allowing accurate and repeatable movements in all conditions. The "quiet hand technique" is an isolation technique that creates a stable platform by forming the four fingers into a salute that thenceforth moves as one. Fine movements are supplied by the thumb. For instruments that open and close, the thumb abducts and adducts. For suture placement using a round needle holder, the thumb flexes and extends. Because only the thumb moves, the extent of movement is decreased and therefore momentum and inertia are limited as well. Previously, microsurgeons favored ballistic movements. With the quiet hand technique, however, tension movements are easy. The greater control makes tying 10-0 and 11-0 sutures more predictable. Although the quiet hand technique was developed for use in small-vessel anastomosis, the neurophysiological principles on which it is based apply to movement at all levels and are applicable to working a bipolar coagulator, pickups, a vascular clip holder, or other soft-tissue manipulators.

Learning Microvascular Anastomosis in Low Socioeconomic Vascular Models During Residency

“…This procedure provides wider ends, thus, increases patency and facilitates anastomosis. The end-to-side procedure is a preferred technique to preserve blood flow distal to the anastomosis, to manage size discrepancy and to avoid vascular spasm [9,12]. Closed technique is easier than open procedure as it is usually performed in larger vessels.…”

Measurement of tremor transmission during microsurgery

“…Although trainees generally took longer to complete an anastomosis than the expert – and often considerably so (up to around a factor of four times longer) – this difference would not be directly influential in the score we have devised, which averages over the active portions of time. Of course, in longer operations, fatigue may become more important . One further factor that may be investigated is a possible association between the typical magnitude of force imparted to the silicone vessels and substrate; it might be conjectured that gentler handling of the simulated materials may decrease the magnitude of a tremor signal imparted to the force sensor (24; cf.…”

“…Quantitative ability to determine tremor during microsurgery would yield a number of benefits: Providing objective feedback to trainee surgeons in their learning phase. Constituting one component of an assessment tool to objectively and quantitatively judge the performance of trainee surgeons (cf. ). Providing objective and quantitative measure of tremor in experienced surgeons approaching an age at which the probabilities of developing pathological tremor are elevated (see also ). …”

Short-Burst Bipolar Coagulation for Repairing Partially Damaged Brain Arteries Preserving Their Flow: Technical Note

“…In this step, a precise activation/deactivation of the bipolar device is of utmost importance: this requires a good "eye-hand-foot coordination", or an accurate teamwork with the scrub nurse if she/he has the control of the bipolar foot pedal. Bipolar forceps with blunt tips (25 Malis units,5 Watts) may be used for straight medium caliber vessels (18)(19)(20).…”