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Micro Surgery in Reconstructive Surgery

Dr. Ashok K. Gupta

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Each passing decade brings newer techniques to provide solutions to certain complex and intricate problems, which had remained as Challenge in the past. Microsurgery has proved a “Panacea” for a large number of surgical problems, for which there were no alternatives earlier like Replantation of Amputated part to the body. It has been made possible to transfer a large block of live and functional tissue from one part of the body to another part using Microsurgery . A number of surgically inaccessible tissues have been made accessible by the fineness of Microsurgery and magnification. Since late 70’s, microsurgical techniques have stormed its utilization in almost all Surgical Specialties, benefiting millions of patients and Medical Practitioners all over the world.

What is “Microsurgery”? Is it a separate Surgical discipline or another Surgical hoax, which will have its time related natural death?

Microsurgery is a methodology, wherein; high power optical magnification through surgical ancillary like an Operating Microscope is being used. In the field of Reconstructive Plastic Surgery, advantages and revolutions brought about by microsurgical techniques are innumerable and un-parallel. Neuro-vascular transfer of a functioning muscle in cases of pre / post ganglionic Brachial Plexus traction injuries, post traumatic /excision loss of skeletal muscle or Volkmann’s Ischaemic Contracture and dynamic reanimation of facial paralysis, are a few of most significant contributions in last two decades.

Developments in this high precision technique were made possible by finer surgical instruments and sophisticated Operating Microscopes.

Microsurgery has progressed from: "*Amazement* to Advancement to Refinement "

A) Replantation of Amputated Parts:

It was a great Amazement, when a few reports of successful replantation of amputated parts appeared in Medical Journals and News Papers in early 70’s. Replantation of an Amputated Part has become a standard microsurgical procedure and a large number of parts have been replanted back to the body.

What is the Protocol for Replantation Procedure?

Parts like Scalp, Ear, Nose, Digits, Extremities, Phallus etc., which are amputated with a relatively sharp instrument or a machine without any crushing or traction effect and which are not grossly contaminated with life threatening infections, are most appropriate subjects for replantation.

The amputated part should be cleaned with an antibiotic and saline solution immediately and kept in a clean plastic bag. Thereafter, the plastic bag is sealed and kept in an ice container for a cold ischaemia. If the part is kept directly on the ice, it gets macerated and may not remain suitable for Replantation. General condition of the patient and that of the amputation stump is carefully assessed for suitability for Replantation, before starting the procedure. Conditions prohibiting prolonged anesthesia or excessive blood loss during the Accident may be a relative contra-indications for Surgery of Replantation.

I prefer to dissect the amputated part first, after the arrival of the part to the Operating Room, while the patient is being worked up for pre-anesthetic checks. It takes about two to four hours to debride and dissect the amputated part, which should always be done by the Senior Surgeon himself in following manner:

  1. Thorough wound debridement.
  2. Identification and dissection of one / two veins.
  3. Identification and dissection of Peripheral / Digital Nerves.
  4. Identification of various tendons in case of Extremities / Digits.
  5. Shortening of the bone for a proper Osteo – Synthesis.

After satisfying with above steps, the Amputated Part is irrigated with Hartmann’s solution and thereafter is wrapped in a sterile surgical towel and subjected to cold ischaemia. Prior to the dissection of the recipient site, the patient is suitably resuscitated and anaesthetized. The dissection is carried out in a similar order without a tourniquet; however, a tourniquet may be applied but kept un-inflated. In cases of proximal and major amputations, it is recommended to irrigate blood vessels continuously with a solution of saline + heparin + streptokinase. Having satisfied with suitability of the recipient site and the amputated part for replantation, the surgical procedure is undertaken as follows:

  1. Bony fixation using either External Fixater or K-wires.
  2. Repair of Extensor tendons and tagging stitches to skin.
  3. Anastomosis of one or two arteries.
  4. Anastomosis of veins. (Two Veins of adequate size.)
  5. Co-aptation of motor / sensory nerves.
  6. Repair of flexor tendons.
  7. Loose closure of skin or skin graft if under tension.
  8. Fasciotomy of skin and deep fascia in the amputated part in cases of proximal amputation and replantation, to avoid development of tight compartment compression syndrome following muscle edema and venous engorgement.

Honorary Plastic and Microsurgeon. Bombay Hospital and Medical Resch. Centre. Bombay Suite No. 16, II floor. Laud Mansion, 21 M. Karve Road, Bombay - 400 004

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