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skill of feeling is closely linked with the visual information which is obtained from the operating
microscope, supermicrosurgeons can finally anastomose very small lymphatic vessels of around 0.10 mm in
diameter. Needle selection is important too. Our selection of needle is 11-0 nylon suture for vessels of
around 0.30-0.80 mm in diameter, 12-0 nylon suture for 0.20-0.45 mm in diameter, and 12-0 s nylon suture
for less than 0.20 mm in diameter according to the hardness of the vessels.

The way of Isao Koshima’s supermicrosurgical anastomosis is called the “one-hand suture technique”,
because supermicrosurgeons create anastomosis as if they only used the right hand to make each suture.
However, this description of the supermicrosurgery is not correct in reality. In supermicrosurgery, surgeons
utilize both their hands equally to feel the lumen of the small vessels. The left hand has essential work.

ONE-HAND SUTURE TECHNIQUE
The most important technique in supermicrosurgery is the one-hand suture technique. The name of this
technique is from the extraordinal suture style as if microsurgeons only used their right hand in
anastomosing procedure for handling the needle. However, the left hand is also important for successful
LVA. This technique is the way to feel the intima of small vessels and movement of blood and lymphatic
fluid in the anastomosing vessel using surgeons’ five senses.

Understanding the technical difference between supermicrosurgery and traditional microsurgery is
important to know the spirit of Isao Koshima’s supermicrosurgery. In traditional microsurgery, the basic
microsurgical technique is an effective left-hand work to anastomose the relatively large vessels safely. The
left hand is used to insert the tips of forceps into the anastomosing vessel to dilate and keep the lumen in
non-supermicrosurgery [Figure 1]. The intima-to-intima coaptation manner in the anastomosis can be
performed by the insertion of the left-hand forceps into the anastomosing vessel on each suture without
picking the back wall up.

In contrast, supermicrosurgical anastomoses using small vessels less than 0.50 mm in diameter require
different usage of the surgeon’s hands [Figure 2]. In small vessels, only one side tip of the forceps can be
inserted and dilate the lumen. The traditional safe microsurgical technique using both tips of the forceps is
not applicable in anastomosing small vessels. In supermicrosurgery, the surgeons’ skills to feel the intima of
vessels and fluid flow itself are utilized as a safe way to create fine anastomosis.

To feel vessels and flow, the left-hand forceps are utilized to hold the last suture or the adventitia of
lymphatic vessel and vein during making sutures. This left hand is working both as a traction maker and as
a sensor of the special feeling by controlling the shape of the vessels and fluid movement in the
anastomosing vessels with proper tensioned traction. Whether the microsurgeon can feel the lumen and
flow in the vessels totally relies on the strength and direction of the left-hand traction and the right-hand
sensation at the tip of the needle via the needle holder. Supermicrosurgeons can complete the anastomosis
using the finger sensation of both their hands without inserting the tips of forceps into the anastomosing
vessels.

SUPERMICROSURGICAL LVA
LVA is a challenging procedure even for expert microsurgeons. One of the main technical difficulties of
LVA is the size of small lymphatic vessels. The lymphatic vessel adopted in LVA is small (mainly
0.20-0.70 mm in diameter), which is difficult detect, to dissect, and anastomose even in an operating
microscopic magnification.