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Micro Surgery in Reconstructive Surgery

Dr. Ashok K. Gupta

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Topics

Ideally speaking, the replantation of an amputated part should be carried out within 6 – 8 hours after the amputation, but under certain physiological conditions, a replantation may be carried out as late as thirty hours. Distal amputations with a proper cold ischaemia, can be successfully replanted up to 24 – 30 hours, however, a proximal amputation or a subtotal amputation with a relative warm ischaemia may be impractical even after 4 – 6 hours. The amount of muscle mass in the amputated part is an extremely important factor, compromising immediate and delayed results in proximal replantation. The patient may develop Acute Renal failure or a Shocked Lung Syndrome (ARDS), following a Proximal or a Major replantation, due to metabolites products of disintegrated muscles. It may also lead to electrolyte imbalance and liver failure.

There are reports, wherein the amputated digits were kept in deep freeze and were replanted one by one, over a period of 3 – 4 days.

Delayed Proximal Replantation of Arm After 40 Hours.

How Safe Are They?

1) Mr. Gupta, a young Engineer, had an Industrial accident on 30.5.95 at around 10.30 AM at Bhopal (about 800 miles away from Bombay), wherein he had a total amputation of his right arm. An attempted replantation was carried out by the orthopedic surgeon, but realizing extensive nature of the injury and failure of replantation, the patient was shifted to Bombay, at around 4.00 PM on 31.5.95 in a condition of shock and peripheral circulatory failure.

His limb was rigid with Rigor Mortis and distal 1/2 of forearm, wrist, palm and fingers were turning black and mummified. No pulsation was felt at the elbow or wrist, nor there were any capillary bleeding on finger pinprick. An urgent DSA was performed, which confirmed complete arterial block at the subclavian artery and downwards. Microsurgical exploration was performed under general anesthesia, wherein it was noted that entire length of the brachial artery was completely thrombosed and contused due to trauma. TO RE-VASCULARIZE THE LIMB, a long saphenous vein graft was used between the subclavian artery and the brachial artery. It was around 2.00 AM on 1.6.95, that complete Revascularization of the limb could be accomplished, 40 hours after total amputation. The color of the forearm, wrist, palm and fingers gradually started turning pink and there was a brisk capillary bleeding from all fingers on needle prick. After waiting for poisonous venous effluent to be washed out of the circulation, remaining process of replantation of the arm was completed by around 4.00 A.M. and am very happy to inform that the patient has recovered completely with a fully surviving limb. It is a rare surgical feat to replant a proximal major amputation of the arm successfully, after 40 hours. Even at best of Medical Centers in the world, rarely such delayed re-plantations are undertaken. The Patient did not develop any systemic complications nor had any major wound sepsis.

2) Ms. Naaz, A young girl of 20 years, had her left arm amputated following an automobile accident, at around 2.00 PM on 3.6.95 at Pen (Raigarh Dist. Maharashtra). She was rushed to the nearby hospital, but was very bluntly told that replantation at such a high level is not possible anywhere in the country. However, her relatives contacted me and She was admitted to the Bombay Hospital on 3.6.95. For replantation of the limb. The operation of Replantation of the arm was started along with an orthopedic surgeon at around 11.40 P.M. on 3.6.95 and was successfully completed by around 8.30 AM on 4.6.95. Vein grafts were interposed between the brachial artery and two vena comitants, while two superficial veins could be anastomosed primarily. In this patient also, the distal amputated limb had developed Rigor Mortis, as there was no circulation of blood for more than 14 hours. She is also doing fine and her limb has survived fully.

Both these patients have received intensive postoperative care to avoid development of renal failure due to myo-globinurea, DIC, ARDS and septicemia and were subjected to Hyperbaric Oxygen therapy from 2nd postoperative day onwards. Both these patients have made an extraordinary progress and have been discharged from the hospital after 5-6 weeks respectively.

Both these patients have undergone revision of external fixation and bone grafting for non-union at the osteosynthesis site. Both the patients have started signs of re-innervation of muscles of the forearm and may require some operations in future to improve the hand function.

Multiple digit Replantation, although looks very exciting, consumes long operating time (an average of 5 – 8 hours per digit) and the final functional result may not be acceptable in all digits. I give an absolute priority to replantation of scalp, hand, phallus, thumb, index and middle finger. In selected patients like children, young and adults, professionals or where tips of fingers are extremely useful as in typists or computer operators, all efforts are made to replant even the most terminal part of each and every digit.

In situations, where the proximal stump of the amputated part is not suited for replantation, the amputated part may be re-attached to other part of the body using Microvascular anastomosis with other sparable blood vessels. (“Entopic Replantation”)

  1. It may be interesting to note that the youngest patient in the world literature in whom a digital replantation was performed is a neonate, whose little finger was amputated while delivering her through LSCS, within hours the finger was replanted.
  2. There are many other interesting incidents wherein four teams were working simultaneously for bilateral double amputations of both upper extremities.
  3. The accused party had to be bribed heavily to inform whereabouts of the amputated phallus, which was chopped off due to infidelity and thrown into a sanitary tank.
  4. The hand of one side had been replanted on to the forearm of opposite side as salvage procedure, with reasonable and acceptable functional and aesthetic results.

With natural and scientific progress in techniques of microsurgical tissue transfer and better understanding of growth and functional potential of transplanted tissues, we have entered an era of refinements. Along with a definite viability of the transplanted tissue, we have assured good functional results and a natural growth. Basic principles of Reconstructive surgery are:

Replace the Missing Tissue with a Similar Tissue

“Rob Peter to Pay Paul, (When Peter Can Afford it)”

Following are a few remarkable advances in Microsurgery:


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