Name: a training and testing system for performing vascular reconstruction in vitro
Uploaded: 2019-10-26T13:00:00
Description: Watch this Scientific Journal Video about A Training and Testing System for Performing Vascular Reconstruction In Vitro at JoVE.com

This work was supported by grants from the Ministry of Education Innovation Team Development Program of China (No. IRT1279).

The protocol was carried out in accordance with the Guidelines for the Care and Use of Laboratory Animals and was approved by the Committee on the Ethics of Animal Experiments of Xi&#39;an Jiaotong University, Xi&#39;an, Shaanxi Province, China.
1. Preparation prior to the training
NOTE: The vascular reconstruction training machine is shown in Figure 1. It consists of a control panel and an operating floor.
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With the help of magnetic tractors and a magnetic suture puller, a trainee can complete vein anastomosis individually and precisely. Magnetic tractors pull the tissue that blocks the anastomosis field and provide suitable strength for stretching the veins in a vertical direction, thus achieving clear exposure for vein anastomosis. In traditional manual anastomosis, at least one assistant is required for surgical exposure. The use of magnetic tractors could achieve the required exposure and substitute for assistants. In a...

Vascular reconstruction is a basic skill required for surgeons. Although Obora1 and Holt2 invented several mechanical reconstruction methods to simplify the reconstruction of small vessels (diameters &#60;10 mm), these methods are not commonly applied in macrovascular anastomosis. Manual vascular anastomosis is still performed in many operations, including vascular surgery3, emergency surgery4, and solid organ transplantation5. Thus, it is essential for surgeons to practice manual vascular anastomosis. However, an optimal training system for vascular reconstruction in vitro is uncommon, and inexperienced surgeons must undergo considerable training in vivo on large animals6 before they can master the technique. Because failure is inevitable during initial training, many animals are likely to die of vascular complications, which is concerning regarding animal welfare. Further, during the procedure of end-to-end vascular reconstruction, to avoid mistakes in stitch positions or loose sutures, the surgeon needs at least one assistant to expose the posterior vascular wall and pull the suture. Thus, vascular reconstruction usually cannot be performed by the surgeon individually, and the efficiency of preparation is usually limited by the proficiency of the assistant.
Magnetic anchoring surgery has become a topic of interest in recent years7,8,9,10,11. The clinical trial by Rivas et al.7 showed that with his magnetic surgical instrument and following the principle of magnetic anchoring, surgeons can perform reduced-port laparoscopic cholecystectomy. The use of this instrument also allows for a reduced role for the assistant during open surgery. Through the magnetic field, the magnetic device is adsorbed onto an anchoring point. This magnetic anchoring device can act as a mechanical arm, grasping and retracting the tissue or organ, exposing the surgical field, and simplifying the operation. Based on this rationale, we invented magnetic tractors to retract the vascular wall and suture, and a magnetic suture puller to pull the polypropylene sutures.
The use of a vascular reconstruction training machine was another milestone in this study. It consists of an operating floor and a control panel: the vasculature is fixed on the operating floor, and the trainee can practice on it. After anastomosis, the trainee can set the perfusion parameters on the control panel in order to test the quality of anastomosis. Compared to previous vascular anastomosis training systems6,12,13,14, the use of this system provides two main advantages: First, magnetic devices can be used to expose the surgical field, so that the trainees can practice on it individually. Second, the trainee can check the effect of anastomosis using a perfusion test.
In the present study, we introduce a training and testing system where the trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique and the quality of reconstruction can also be tested. Limited by the design and size of the water inlet and water outlet on the operating floor, the training system can only perform end-to-end reconstruction on vessels with a &#62;5 mm diameter.

<table border="0" cellpadding="0" cellspacing="0" style="width:1140px;" width="1140">
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		<col />
		<col />
		<col />
	</colgroup>
	<tbody>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Circular permanent magnet</td>
			<td style="width:244px;">Hangzhou Permanent Magnet Group Co.LTD</td>
			<td style="width:161px;">20*1mm</td>
			<td style="width:519px;">Magnetic tractor</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Magnetic balls</td>
			<td style="width:244px;">Hangzhou Permanent Magnet Group Co.LTD</td>
			<td style="width:161px;">5mm</td>
			<td style="width:519px;">Magnetic suture puller</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Magnetic cylinders</td>
			<td style="width:244px;">Hangzhou Permanent Magnet Group Co.LTD</td>
			<td style="width:161px;">5*5mm</td>
			<td style="width:519px;">Magnetic suture puller</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Polypropylene suture</td>
			<td style="width:244px;">Johnson and Johnson</td>
			<td style="width:161px;">PROLENE 4-0</td>
			<td style="width:519px;">Used for anastomosis</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Silk suture</td>
			<td style="width:244px;">SILK</td>
			<td style="width:161px;">2-0&#65292;3-0</td>
			<td style="width:519px;">Used for fixing vascular and ligation</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Surgical insturments</td>
			<td style="width:244px;">Jinzhong Shanghai</td>
			<td style="width:161px;">JZ-2018</td>
			<td style="width:519px;">Suture scissors, tissue scissors&#65292; forceps, needle and needle holder</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Universal testing machine</td>
			<td style="width:244px;">Zwick GmbH&#38;Co</td>
			<td style="width:161px;">Z010</td>
			<td style="width:519px;">Used for testing the association between the length of traction wire and the traction force</td>
		</tr>
	</tbody>
</table>

a training and testing system for performing vascular reconstruction in vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has yet to be developed. In this study, we introduce an in vitro training and testing system using a magnetic anchoring technique with which a trainee can practice manual vascular reconstruction individually. Additionally, this system can also be used to test the quality of the reconstruction. The described system includes a vascular reconstruction training machine, magnetic tractors, and a magnetic suture puller. In this manuscript, we detail an end-to-end vein anastomosis using porcine right and left iliac veins. To identify the potential damage caused by a magnetic suture puller on the suture, we created three groups with six segments of 4-0 polypropylene sutures each: a control group with no intervention on the polypropylene suture, a group in which the polypropylene suture is manually pulled with sterile gloves 20x, and a magnetic puller group in which the magnetic puller pulled the polypropylene suture 20x. These groups were tested by light microscopy and breaking strength tests, and the effect of reconstruction was assessed. In the light microscopy test, the control group was less likely to be damaged (p &#60; 0.05) and the number of damaged points of the manual group and magnetic puller group were similar (p &#62; 0.05). The results of the breaking strength test were compared across groups and no significant difference was observed (p &#62; 0.05). The end-to-end anastomosis of the porcine iliac veins was successfully performed using this training system, and the reconstructed veins could undergo 2.0 kPa perfusion pressure. Using this training and testing system the trainee can practice manual vascular reconstruction in vitro individually with the aid of magnetic tractors and a magnetic suture puller, and the quality of the reconstruction can be tested.

The vascular reconstruction training machine is shown in Figure 1 and includes two main parts: the operating floor and the control panel. The operating floor consists of a water inlet, a water outlet, and a water storage basin. The two ends of the vasculature are tied to the water inlet and water outlet to test the effect of anastomosis. The length of the water outlet is adjustable, and we set the parameters (e.g., the perfusion pressure, duration of peak pressure, temperature, and pressure ...

Watch this Scientific Journal Video about A Training and Testing System for Performing Vascular Reconstruction In Vitro at JoVE.com

A Training and Testing System for Performing Vascular Reconstruction In Vitro

Here we present a training and testing system where a trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique. The system can also be used to test the quality of reconstruction.

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has ...

In this video, we introduce a novel training and testing system where the trainee can complete manual vascular reconstruction in vitro individually. Manual vascular reconstruction training is essential for young surgeons. In this study, we introduce a novel training and a testing system where the trainee can complete the manual vascular reconstruction in vitro individually using magnetic anchoring technique and the quality of reconstruction can be tested on it.This is vascular reconstruction training machine consisting two parts, control panel and the operating floor, at 0.9-percentage saline into machine before we start training. These are right and left iliac veins harvested from Burma pigs. Use tissue scissors to trim the ends of the veins and clear the excess tissues on the wall of the veins to make the veins smooth.These are magnetic vascular fracture, magnetic suture fracture, and magnetic suture puller. Tie the two veins on the water inlet and the water outlet of training machine with two of the silk sutures. In this video, we adopt the method of two point vascular anastamosis.Adjust the lens of water outlined of the training machine and ensure free tension of the ends of the two veins in a parallel direction. String in the veins and lay two 4-0 traction sutures at the six o'clock and 12 o'clock positions. Insert the needle of traction sutures from outside of the vein and then, insert from the inside of the outer vein.Wipe out the glove and the suture to avoid damaging the suture. Gently tie at least five knots to avoid tearing the wall of the veins. Use two stainless steel clamps of the magnetic suture tractor to grasp the traction sutures and attract the circular magnets of magnetic suture tractors on the ferromagnetic stainless steel operating floor.Adjust the position of magnetic attraction and it ensures that ends of two veins are stretched in a vertical direction. Use two vascular clamps of the magnetic vascular tractor to clamp the interior wall of the veins and the tractor, the circular magnets, of magnetic vascular tractors on the operating floor. Adjust the position of attraction and ensure that the interior walls of the veins are retracted and the posterior walls of the veins are clearly exposed.Attract the magnetic suture puller on operating floor. Leave the tail segment of the polypropylene suture at the 12 o'clock position for the traction suture and use the segment with the needle for continuous suture. Ensure the contact between intima to intima of two veins.Insert the first suture from the outside of the vein to the inside. In subsequent sutures, insert the needle from the inside of the vein and then, insert from the outside of the other vein. Check that the suture is not loose.After one suture, ensure that polypropylene suture is hung on the magnetic suture puller and pull the polypropylene gently until the magnetic ball presses the polypropylene. Extract the end with the needle of the suture with a force of about 0.3 newton whose direction is subsequently in parallel with the ball of the magnetic suture puller and then, continue on the next stitch. By using the magnetic suture puller, the tail of the polypropylene suture will be sufficiently tied.As the suture continue, the polypropylene suture will become shorter. According the length of the suture, select the most suitable one of three magnetic balls and then, press the suture under the magnetic ball. Insert the left suture from the inside of the vein to the outside to ensure contact between intima to intima of two veins.To avoid stenosis after anastamosis, ensure that the same suture margin and the needle spacing is maintained about one millimeter. Tie five millimeter away from the vein's wall to prevent the suture stenosis. This is also known as the growth factor.It is a reserved space away from the vessel wall when tying the first knot after anastamosis, so that vessels can expand rather than stenosis. The method of tying knots was same as before. After anastamosis of posterior walls, remove the magnetic vascular tractor and leave the tail as the tractor suture and use the segment with the needle at the six o'clock position for the anastamosis of the anterior walls.Insert the needle from outside of the vein and then, insert from inside of the other vein. Other methods were consistent with the method of anastamosis of posterior walls. The method to ensure the contact between intima to intima of two veins, the suture being not loose and not stenosis after anastamosis were consistent with the method of anastamosis in the posterior.After anastamosis of anterior walls, cut off two traction sutures. Set the peak perfusion pressure at two kilopascal for five seconds in 25 degrees centigrade with the deviation of 0.1 kilopascal on the control panel. If the vein does not leak, then the anastomosis succeeds.The profusion pressure ascended to the pique pressure and it maintained for five seconds. The length of the traction were in 30 centimeters and the range of traction for the magnetic tractor could provide is zero to 1.8 newton. The results of the breaking strength test show the magnetic suture puller does not damage the polypropylene suture.The results of the live microscope test show that there is no significant difference between the manual group and the magnetic puller group. In summary, with the aid of magnetic tractors and the magnetic suture puller, the trainee can perform manual vascular extraction individually.

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