3 Essential Equipment Needed for Perforator Flap Breast Reconstruction and Operating Room Setup

10.1055/b-0036-141875

3 Essential Equipment Needed for Perforator Flap Breast Reconstruction and Operating Room Setup

David Greenspun

Every microsurgeon has a preference for specific instruments and operating room (OR) configurations. This chapter describes an approach to instrumentation and OR setup that has proved useful and reliable for the successful performance of perforator flaps. There is no absolute right or wrong way to organize the OR, and the equipment will not in itself determine the outcome of the surgery. However, giving careful thought to these matters will doubtless increase the surgeon’s comfort and efficiency.

Regardless of specific instrumentations used, familiarity with equipment and establishing consistency in the OR setup are important elements for achieving microsurgical success.1 Maintaining consistency of instrumentation and setup is extremely helpful, not just for the surgeon, but for the entire OR team. Therefore, it is certainly worth surgeons’ investing the time and energy in developing an approach that works well for them. The microsurgery equipment must always be well maintained, and owing to the delicate nature of certain microsurgical instruments, replaced with some frequency.

Evaluation and Selection of Instruments

For successful performance of perforator flap surgery, surgeons should evaluate microsurgical instrumentation and equipment and select the instruments with which they feel comfortable. This may require inspecting the myriad instruments that are already available in the OR. Surgeons’ height, hand size, and experience will likely have significant influence over their personal preferences. For example, surgeons who have larger hands may prefer instruments with longer length. It is important to point out that the selection of instruments and OR setup is a somewhat iterative process, subject to continual reevaluation. Continually try to eliminate extraneous instruments from the setup. Simplification of the setup by reducing the number of instruments facilitates operative efficiency, makes procedures easier for the nursing staff, and has obvious economic advantages. Of course, even infrequently used instruments that can be vital in certain challenging situations remain as components of the regular setup. In addition, the introduction of new technology and equipment sometimes requires the addition of instrumentation. My selection of instruments for flap harvest and microsurgical anastomosis are shown in Figs. 3.1 and Fig. 3.2, respectively.

**Fig. 3.1** Perforator flap harvest instrument setup. *Top row (left to right):* ultrasonic transmission gel for Doppler, skin stapler, small and large self-retaining Gelpi retractors, Richardson retractor, rake retractor, suture scissor. *Middle row (left to right):* automatic clip appliers, syringes. *Bottom row (left to right):* large right-angle clamp, small right-angle clamp, mosquito clamp, Westcott scissors, various forceps, tenotomy scissors, skin hooks, scalpels, marking pen.

**Fig. 3.2** Microsurgical Mayo stand setup. Microsurgical instruments are arranged atop a silicone mat to help protect their delicate tips. *Top row (left to right):* needle park housing containing microsurgical visibility background, microvascular occluding clamps, and cartridge of GEM MicroClips; Merocel gauze; syringe with heparin- containing irrigant. *Bottom row (left to right):* GEM microvascular anastomotic coupler, microvascular occluding clamp applier, vessel measuring gauge, coupler forceps, right-angle forceps, curved forceps, dilator forceps, fine-tipped forceps, needle holder, dissecting scissors.

It is important to note that regardless of the specific instruments that one chooses to use for perforator flap surgery, it is critical that a duplicate set of sterile, casecritical instruments be maintained and easily accessed, so that if a patient requires urgent reoperation and the primary set of instruments is unavailable (for example, the instruments are being cleaned and sterilized), another set is available. This principle applies to all microsurgical cases.

The use of a “case cart” specifically designated for perforator flap microsurgery enables all of the specialized equipment, instruments, and supplies used for these cases to be grouped and maintained together. This helps ensure that all of the necessary items will be available in the OR, and also allows for convenient transport of these items to the OR. This also means that key equipment will always be present in the OR, reducing the time spent searching for it and the burden put on the OR staff. It is also a good idea to maintain on hand a small stock of “extra” delicate microsurgical instruments, such as fine-tipped forceps, that are sometimes inadvertently damaged and rendered unusable, often at a most inopportune time. To this end, it is also preferable that instruments designated specifically for perforator flap surgery be used only for this purpose and not for general plastic surgery or hand surgery cases.

Given the complexity of perforator flap surgery, it is helpful to have one individual such as an OR nurse designated as a team leader to provide oversight of OR preparedness. Having an individual who understands the intricacies of this type of surgery, the importance of maintaining the equipment, and the value of consistency in the OR setup is extremely helpful to the whole team.