2 0 vicryl

The operation was performed preceded by changing the patient position into lateral decubitous position after breast surgeon excised the mass. The patients were placed in a lateral decubitus position with an arm on the same side bent to 90, which was fixed on the stand. Skin paddle of the of the latissimus dorsi flap was desinged in small size transverse elliptical shape (approximately under 4cm x 12cm) allowing for easy closure of the donor site and for hiding of the scar in the bra. The local aneshtetic injection is followed by musculocutaneous LD flap election; then, the patient was turned to the supine position and the elevated flap with the attached skin paddle was rotated through the dissected axillar tunnel to the anterior chest wall area. The donor site was closed primarily over the flap and drains in the usual fashion, The donor area was closed in two layers using 2-0 Vicryl (Ethicon, Inc., Somerville, N.J.) simple stitches to the fascia and 4-0 Vicryl (Ethicon) for the superficial dermis. The exact skin defect was outlined on the transferred skin paddle, and the rest was de-epithelized. The mini-LD flap was fixed to recover the bulk of the breast and partially deepithelialized latissimus dorsi skin paddle was secured to the lower edges of the breast pocket by using 2-0 Vicryl (Ethicon) considering the symmetric breast contour.

We made a cut to expose the carotid artery and internal jugular vein using a standard open surgical technique. Roughly 5 cm of the artery was exposed; the precise length depended on the muscular configuration of the sheep and was selected to avoid damaging muscles and/or the Vagus nerve. Before the carotid artery was clamped, 5,000 IU Heparin was administered intravenously to prevent clotting during anastomosis. The ends of the graft were cut at a 45-degree angle and anastomosed in an end-to-side fashion using 5–0 Prolene® (B Braun, Germany) first to the carotid artery and next to the jugular vein. After confirming the patency of the anastomosis and the grafts themselves, we ensured hemostasis. The wound was closed in two layers using self-absorbing 2-0 Vicryl® (Ethicon Inc., USA) in the subcutis and PDS® in the skin (Ethicon Inc.). After the wound was closed, it was sprayed with fluent banding OPSITE® (Smith & Nephew A/S, USA) to inhibit bacterial contamination.

The surgical procedure of SSH performed at our institution is conducted as follows: high posterior colpotomy is made towards the posterior cervix, then blunt preparation towards the right ischial spine to visualize the right sacrospinous ligament. The posterior side of the cervix is joined to the right sacrospinous ligament with two late-absorbable sutures (PDS sutures–0) at least 2 cm medial to the ischial spine. This suture is then passed through the posterior cervical wall, but not yet knotted. First, the colpotomy is closed via absorbable sutures (2/0 vicryl, Ethicon, Sommerville, NJ, USA). Where additional procedures such as anterior and/or posterior colporrhaphy were needed, they were performed at this stage. Only after are the pre-laid fixation sutures tied, whereby the cervix comes to lie about 4–6 cm cranial of the level off the vulva towards the sacrospinous ligament, without the cervix abutting the sacrospinous ligament, but so that the knot on the side of the ligament slips off slightly, in order to avoid the occurrence of necrosis or the cutting of the thread into the ligament. It, thus, follows closely the surgical procedure of SSH previously described by Schulten et al., however, in contrast, no surgical devices were used [16 (link)].