Simulated Surgery: Strabismus Surgery: Resection Techniques

In this video, we’ll illustrate how to carry out a lateral rectus resection, both on a simulated eye, and also demonstrating some clips of live surgery. Here we’re showing a left lateral rectus resection. A 5 millimeter resection just being measured. Many different ways, of course, of carrying out resection of muscle. Suturing. And in this particular case, we’re illustrating an interrupted suture technique. Many surgeons prefer using a continuous suture technique, which of course can also be practiced using these eyes. Once again, familiarity with the feel of the needle passing through the muscle and the opportunity to practice secure knot tying is essential for developing good surgical results in the future. The bulldog clip is just going to be placed here to secure the ends of the suture. The second suture is being placed now. Of course, we can’t mimic the effect of the muscles. There’s no bleeding and there’s no need to cauterize these muscles, but discussion about the role of cautery in both recession and resection techniques is obviously important preparation for live surgery. When it comes to removing the muscle from the globe, if you pull on the lateral rectus at this point, just as you’re dissecting it, you can reproduce that realistic posterior movement of the lateral rectus, when it is disinserted. As in real surgery, the rectus muscle stump is removed, and we spend a little bit of time here just removing the extraneous glue from the original insertion site, and this will enhance the realism of the reattachment process. You can see it’s quite a large blob of glue being removed. This is a live surgical clip of a left lateral rectus resection. Having hooked the muscle and cleaned the Tenon’s capsule from the lateral rectus tendon, placing a Chavasse squint hook to spread the muscle, we’re marking 5 millimeters posterior from the insertion, with some gentle cautery. And then using interrupted 6-0 vicryl. Here the first pass is made through the upper third of the muscle, coming out through the edge of the muscle, with the first pass regrasping the needle, and then passing full thickness with the second pass. Again, note how the suture is slung around the body, not the tip of the needle, to make it easier to regrasp the needle, as it emerges from the muscle. Double throw, and then single throws to secure the suture along this superior border. Reverse mounted needle, passing through the lower third, emerging through the edge of the muscle, twisting one’s wrist around to grasp the needle, and then holding the suture short, so it can be passed underneath the body of the needle, to make it point up towards the needle holders. Some surgeons prefer to put one or both sutures on a bulldog clip. Then a little bit of gentle cautery is performed, and Westcott scissors used to disinsert the muscle, making sure to cut the muscle a millimeter or so anterior to the sutures. Lifting up the remnant of the muscle, trimming it flush with the sclera, and applying some gentle cautery. Here we can see the lateral rectus being reattached to the globe, having undergone a 5 millimeter resection. The inferior pole of the muscle is reattached to the inferior edge of the original insertion. Again, a nice deep scleral pass is made, before pulling the muscle up to its correct position. The realism of this maneuver can be enhanced by just placing a little bit of gentle traction on the lateral rectus to mimic the posterior movement of the muscle that one would find after a resection procedure. Now the superior pole of the muscle is reattached to the sclera. Again, we emphasize the importance of a good spread of the muscle, to prevent any muscle sag. Muscle sag is very difficult to simulate with the model eyes, but the principle of spreading the muscle along the original insertion is an important one, which will stand the trainee in good stead, when they transfer to live surgery. And again, secure suturing technique, to make sure there’s no slippage of the muscle from its intended position. And again, a little bit of gentle traction on the lateral rectus or the medial rectus, if you’re operating on that, can enhance the realism of the simulation. Finally, the suture is just being trimmed at a safe length from the knot. And finally, some live footage of the same lateral rectus being reattached. So holding the inferior pole of the muscle with St. Martin’s, passing the needle through the sclera, not through the remnants of the muscle, which will lead to an insecure reattachment of the muscle. Assistant holding the conjunctiva and Tenon’s out of the way. A double throw in the needle holder, pulling the muscle up to the insertion, and sliding the suture down to secure the muscle against the original insertion. A swift passage of a second throw, and a third one, to secure the muscle in its position, and to prevent any slippage, cutting the suture 2 millimeters or so from the insertion. Again, holding the muscle right at the superior margin of the original insertion, placing the suture through at this point. A nice scleral bite. And reattaching the muscle. You can see how it’s beautifully spread here, so it’s now reattached along its length. Directly opposed to the original position of the lateral rectus. And cutting the sutures 2 millimeters from the knot. And displaying the muscle, nicely spread. These live surgical videos have been taken from the publication Strabismus Surgery, which Peter Davis and I co-authored in 2007, but the videos are in their original HD format, which wasn’t available with the original DVD that accompanied this book.