Microsurgery is a subspecialty of surgery involved in reconstruction of small anatomic structures. It was developed initially in the 1960’s to facilitate the repair of tiny blood vessels, using an operating microscope and surgical techniques already in use for ear surgery. It soon found wide application, especially in hand surgery and reconstructive plastic surgery. In the 1970”s, urological surgeons and infertility specialists began to apply microsurgical techniques to the management of sterilization reversal, especially fallopian tube reconstruction in women and vasectomy reversal in men.
Before microsurgery, vasectomy reversal had been attempted for many years, with almost universally poor results. Many variations of non-microsurgical techniques were developed to improve the success rates, including the use of stents and optical magnification with jeweler’s loops. However, very little progress was made until the introduction of true microsurgical technique. Epididymal reconstruction prior to the use of microsurgery always failed, and was rarely if ever attempted. This led to the general presumption that vasectomy could not be reversed with any reliability, and should not even be undertaken after 10 years post vasectomy.
Since the advent of microsurgical techniques, such generalizations are no longer true.
The first critical element in microsurgery is the operating microscope. These come in a wide variety of manufacturers and capabilities depending on their specific surgical use. They all share common features, however. There is a heavy movable stand and pedestal for stability, with an attached articulating arm which allows the optical portion to swing over the surgical area. The optical head generally has one or two pairs of binocular eyepieces, and a high intensity light source, allowing the surgeon (and an assistant, if one is needed) to see the operating area in high magnification (generally 15-40x) while having the hands free. The more sophisticated microscopes have foot pedal power control over zoom, focus, light, and position.
Specialized instruments have been developed to allow surgeons to work under high magnification with exceedingly small sutures. These instruments are machined to exacting tolerances, and must be treated with utmost care. Many microsurgical specialists purchase and maintain their own micro instruments to insure that they remain in perfect condition.
The sutures (stitches) used in microsurgery are extraordinarily fine. They are made from a monofilament nylon, and cannot be seen by the unaided eye unless they are against a white background. Each suture is manufactured by hand. To get some idea of the size of the structures repaired, take a look at a penny. The “o” in “God” is approximately the diameter of the inner layer of the vas deferens (0.2-0.3 mm); the epididymal tubule is about half this size — and far more delicate. Between 6 and 8 sutures are typically placed around the inner, mucosal layer of the vas, and a second outer layer (for mechanical strength) generally requires 8-12 sutures. Epididymal repair (VE) will use between 2 and 6 sutures on the tubule, depending on size and the specific technique used.