CORRESPONDENCE The counter-sweep gently finishes the needle’s transmural passage In Reply: Passing the Needle and Pulling the without additional forward pull on the needle that might stretch Thread or slice through the wall. The counter-sweep is applied with a To the Editor: backhanded push with closed tips of the needle driver, following We appreciate these comments on our publication: the curve of the needle back to the swage to unfurl the tissues. “Intracranial–Intracranial A1 ACA-SVG-M2 MCA + M2 Meanwhile, the microforceps holds the needle steady with its MCA Double Reimplantation Bypass For a Giant Middle body curved up and its point lifted high. With these mechanics, Cerebral Artery Aneurysm: 3-Dimensional Operative Video.” therefore, there is no pulling of the needle, either in a line or along We applaud the authors for paying attention to the fine details of the curve of the needle. suturing technique, which is essential for improving skill. They When performing microanastamosis, our preference is to use raise the question about whether it is best to pull the needle in a 2 anchoring stiches followed by a running suture technique on straight line or along the curve of the needle. In short, the answer both sides. This minimizes knot tying and increases speed. As is neither. farascheckingfor patency,wepreferAcland’slifttestoverthe A bite passes the needle though arterial wall and transfers it to empty-and-refill test because it is less traumatic. However, these instruments on the opposite side in 4 steps: bite, grab, counter- tests are seldom used now because indocyanine green angiography sweep,and reload. The bite is the needle’s penetration through the provides visual confirmation of patency. We agree that the advent wall. The needlepoint is positioned at the point of penetration of endovascular technology and the results of trials such as the on one side of the wall and the microforceps’ tips are positioned Carotid Occlusion Surgery Study trial have limited the indica- on the opposite side of the wall. The driving hand is pronated tions for intracranial bypass. Nonetheless, proficiency with these (palm downward) to face the curve of the needle downward, important procedures is critical and relies heavily on simulated and the driver is rolled between the thumb and index finger to experience in the laboratory. align the needle perpendicular to the wall. The bite begins with a faint push and rotation of the wrist and fingers, ensuring that Disclosure the needle passes perpendicularly through the full thickness of The authors have no personal, financial, or institutional interest in any of the the wall and all of its layers. The push of the needle through the drugs, materials, or devices described in this article. wall with the driver synchronizes with the push of the wall across the needle with the microforceps. The 2 actions are equal and Michael T. Lawton, MD opposite, balanced in force and timing. The available two-thirds Justin Mascitelli, MD of the needle’s curvature is advanced with a supinating motion of Department of Neurosurgery the wrist and finger (palm upward) until the driver meets the wall Barrow Neurological Institute and microforceps on the other side. This motion consumes little Phoenix, Arizona of the hand’s biomechanical range. After the bite, the needle is grabbed with the microforceps. The body of the needle is grasped between the one-third closest to REFERENCES the needlepoint and the two-thirds closest to the swage, thereby 1. Balasubramanian C, Ganesan VG, Thamburaj V. Letter: Passing the needle protecting the needlepoint. The needle driver releases its hold and pulling the thread. Oper Neurosurg. 2018. doi: 10.1093/ons/opy094 [published on the needle and transfers control to the microforceps. The online ahead of print] 2. Benet A, Yousef S, Tabani H, Griswold D, Meybodi AT, Lawton MT. counter-sweep is next with the now-liberated needle driver. After Intracranial-intracranial A1 ACA-SVG-M2 MCA+M2 MCA double reimplan- releasing the needle, the driver swings to the other side of the tation bypass for a giant middle cerebral artery aneurysm: 3-dimensional operative arterial wall and sweeps the tissue off the back end of the needle, video. Oper Neurosurg. 2018;14(1):84. thereby completing the bite. Tissue is pushed backwards in a direction opposite to the advancing needle, which releases the 10.1093/ons/opy095 tension of the bite and relocates the wall to its original position. OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/ons/advance-article-abstract/doi/10.1093/ons/opy095/5001670 by Ed 'DeepDyve' Gillespie user on 08 June 2018
Operative Neurosurgery – Oxford University Press
Published: May 23, 2018
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