Microsurgery is surgery done with specialized instruments under an operating microscope with an underlying philosophy of delicate handling of the tissue, a commitment to maintaining normal architecture, minimum to no tissue trauma, and most importantly, preserving the woman's childbearing potential. Microsurgical techniques involve gentle handling of the tissue, keeping the surrounding tissues moist (dry tissue becomes damaged tissue and damaged tissue heals with scarring), use of very small sutures, minimum bleeding, not using sponges (that have a lot of lint and can be abrasive that can damage tissue); and an underlying philosophy that maintaining and/or restoring normal architecture and childbearing potential comes first and removing the pathology, a distant second.
Microsurgery uses techniques that have been performed by surgeons since the early twentieth century, such as blood vessel repair and organ transplantation, but under conditions that make traditional vascular surgery difficult or impossible. Reproductive surgeons started using the operating microscope for tubal an astomosis in the mid seventies, switching from magnifying loops, and pregnancy rates significantly increased and ectopic pregnancy rates decreased.
Microsurgical equipment greatly magnifies the operating field, provides instrumentation precise and delicate enough to maneuver under high magnification and allows the reproductive surgeon the ability to operate on structures barely visible to the human eye. A magnification of five to forty times (5-40x) is generally required for microsurgery. A lower magnification may be used to identify and expose structures, while a higher magnification is most often used for microsurgical repair. Gynecologic suturing usually requires gauges of 2-0 (0.3 mm) to 6-0 (0.07 mm). Conversely, gauges of 9-0 (0.03 mm) to 12-0 0.001 mm) are generally used for microsurgery. Dr. Nemiro uses 8-0, 9-0 and 10-0 micro-sutures for microsurgical end to end an astomosis in reversing a tubal sterilization. The most important tools used by the microsurgeon are the microscope, microsurgical instruments, and micro-sutures.
Lighting is enhanced by maintaining a low level of light in the rest of the operating room, while turning up the light intensity of the operating microscope. The operating microscope used by Dr. Nemiro has two operative lens, so both he and his assistant have their own view with controlled magnification and focus. The microscope is wired to a high definition monitor, HD camera and HD printer, so the entire OR team can see what is going on. This makes the procedure go more efficiently, and allows the opportunity to record the entire procedure and/or take high quality HD pictures to be able to show the family exactly what was done.
For a reproductive surgeon to learn and perform microsurgery, extensive training and practice are required. After a thorough introduction to the operating microscope and other microsurgical equipment, basic techniques are learned by operating on blood vessels and nerves of small animals. Dr. Nemiro used to practice as a resident and fellow, in the early morning hours when the OR was not being used, suturing 11-0 to 13-0 micro-sutures, trying to achieve a perfect "railroad tract" line. Specifically, surgeons must learn how to maintain correct posture (you are typically standing during reproductive surgeries) and to maintain constant visual contact with the microscope, how to properly hold and use the instruments, how to minimize the amount of hand tremor, and how to perform basic techniques, such as micro-suturing and micro-tissue manipulation. Extensive and ongoing practice is necessary for a reproductive surgeon to maintain adequate proficiency at microsurgical techniques. If these procedures are only being done several times a year, the surgeon will not be able to maintain his/her proficiency and expertise.
During his fellowship, Dr. Nemiro, received extensive experience and training in microsurgical surgeries and techniques, and reversals of female sterilization. He has done thousands since his fellowship years with excellent success rates. Those same microsurgical techniques are strictly followed in all his surgeries, whether they are by laparoscopy or during open cases (laparotomy). The goal is ALWAYS to preserve a woman's childbearing potential.
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