Reconstructive microsurgery is a surgical field in which specialized operating microscopes and very small special instruments are used to perform delicate operations on small structures in our body.
What is Microsurgery?
Fifty times more than what can be seen with the naked eye. In microsurgery, a surgical field where sutures as thin as a hair are used under greater magnification, surgeons can repair cut vessels and nerves less than 1 mm in diameter.
Restoring vascular continuity and blood flow in the vein and repairing injured vessels and nerves are of great importance in correcting the deformities and dysfunctions caused by cancer and congenital differences. Advances in technology and surgical technique in the early 1960s provided surgeons with the opportunity to reattach severed fingers and limbs. It was a breakthrough in rehabilitation. In the early 1970s, free tissue transplants began, so surgeons transplanted organs from areas with excess muscle, skin, bone and intestines to open wounds and areas with tissue deficiencies using microvascular techniques.
Free tissue transplants, also known as free flaps, have provided great opportunities for reconstructive surgeons in the treatment of extremity and other organ cancers. Important strides have been made in the microsurgical treatment of the injured nerve. Peripheral nerve injuries, once seen as hopeless cases, have now become injuries where recovery of movement and sensation is also possible.
The damaged integrity of the cut nerves can be repaired with great precision with the help of the operating microscope, damaged or lost nerve parts can be repaired with nerve pieces called grafts, thus patients with facial paralysis or birth paralysis can be treated. With technical advances in nerve repair, functioning muscles can be transplanted to other regions, paralyzed faces and limbs can regain vitality. Nerves that have branches or can be divided by Nerve Transfers, damaged nerve Reconstructive microsurgery has witnessed great advances in emergency hand surgery, arm transplantation and face transplantation in the last ten years, and with these new techniques, the problems of severely injured patients that cannot be solved with classical methods can be solved. .
What is the Difference Between Open Surgery and Microsurgery?
The patient is put to sleep under general anesthesia. With an incision made in the lumbar region while lying prone, the skin tissues are passed and the thick membrane surrounding the muscles is opened. The lumbar muscles are stripped off the bone. A part of the bone called the "lamina" at the back of the spine and the connective tissue between the vertebrae are removed and the spinal cord and nerve are reached. The nerve is pulled aside with special tools and the hernia tissue pressing on the nerve is removed. Then the opened layers are closed by sewing.
There is no logical difference between open surgery and microsurgery. But during microsurgery, the surgeon uses a microscope. The function of the microscope is to illuminate the tissues the surgeon is working with and magnify the image. In this way, the surgeon does less damage to normal tissues compared to open surgery. The skin incision is smaller. Therefore, the membrane surrounding the muscles opens smaller. Less muscle mass is stripped from the bone. The amount of bone and connective tissue removed is less. Thus, after microsurgery, patients regain their normal and working life more quickly than open surgery. and the provision of other functions is called replantation. Re-circulation is generally called revascularization of the parts that are fully amputated or not completely separated from the body, even partially still connected, but without blood circulation.
Without functional and sensory gains, only revascularization cannot be considered a successful replantation. In daily life and especially in occupational accidents, injuries by breaking off the hands and fingers completely, namely amputation cases are common.
There is no circulation of the amputated part. color is white. The parts that are not fully amputated but have no circulation are also white in color. Since it is difficult to determine the degree of damage in the absence of circulation of crushed structures, detailed examination and exploration of these parts under magnification may be required if necessary. Thus, other additional injuries beyond the rupture separation line can be detected.
It is not always possible to replant every part of the body to its place. In addition, although it can be replanted, it is not mandatory to replant every amputee part. In each case, “Is amputation or replantation a better option for that patient?” The question should be answered by the surgeon who evaluates the patient as a whole. The characteristics of the affected extremity part, the type of injury of the patient, the general condition of the patient, his age and occupation are also factors to be considered while giving this answer. In addition to these systemic and general factors, there are extremity and injury site factors for replantation and revascularization. These are generally: the type of injury, its level, additional injuries in the same area.
How to Protect and Transport the Amputated Part?
The ischemia time of the ruptured part, that is, the time it leaves the blood circulation and the way it is stored are important. In hot (ambient temperature) or cold environments, the duration of bloodlessness, that is ischemia, is evaluated separately. If possible, the broken piece is removed from the injury site, washed with sterile saline or lactated Ringer's solution, and then wrapped in moist gauze cloths slightly moistened with this solution and placed in a waterproof nylon bag.
Then this plastic bag with the broken piece wrapped in gauze is placed in another bag containing ice water. This second bag should contain not only ice but also ice water and the broken piece should not come into direct contact with ice in any way. The ruptured part should never be cooled to a frozen state. The fragments that are protected and transported in this way are the ruptured pieces with the longest ischemia times.
How long is the bloodless period? How much of it is in the cold environment described above directly affects the success of the replantation surgery to be performed. Presence of a muscle component in the severed limb shortens this period. A finger without a muscle component can be stored and replanted for a longer period of time in cold ischemia under these favorable conditions. It can be replanted for up to 12 hours when cold ischemia is maintained under ideal conditions in hand or higher level amputees with a muscle component. After that, the chance of success is very low.
The ruptured piece should be washed with physiological saline and placed in a plastic bag (A) wrapped with sterile dressing if possible, and this bag should be placed in another container filled with ice (B, C), proximal Bleeding control should be done duly in the department, in case of incomplete serious injuries, the wound should be wrapped with a sterile dressing that does not tighten, and a plastic bag filled with ice should be placed on it (D), and it should be delivered to the replanting team or the duty center without delay.
How to Treat Is it done?
Replantation surgery, which is performed with microsurgery and atraumatic methods, is performed by Hand Surgery Specialists who have been trained in this subject. For replantation, a suitable operating microscope and a microsurgical operating set are required. Arteries and veins up to 1 mm can be anastomosed as standard. More experienced surgeons can anastomose vessels with a narrower diameter than this. Along with vascular anastomoses, nerve repairs, tendon, joint capsule and soft tissue repairs, if any, should be performed.
This type of surgery requires haste to ensure circulation without exceeding the ischemia time, but it is a very long and patience-requiring surgery. If more than one finger or bilateral anastomosis is to be performed on both extremities, of course, a second surgical team may be needed. If the vessels or nerves cannot be joined end-to-end, continuity is ensured by placing the vessel and nerve parts in the form of a bridge (graft). In complicated injuries, such mixed interventions take more time.
The thumb is always tried to be replanted. If there is an amputation of more than one finger, including the thumb, and the amputated thumb cannot be used. In this case, replantation can be performed by moving the appropriate finger to the place of the thumb.
What are the Indications?
The indications listed here can be evaluated in two separate categories as absolute or relative indications:
Replantation or “Absolute” indications for Revascularization:
- Thumb amputations
- Multiple finger amputations
- Wrist or palmar amputations
- Pediatric amputations
- Patients with high general motivation and high level of intelligence, intelligence, and understanding
- “Non-mandatory” indications for Replantation or Revascularization:
- Amputations from the level of the distal phalanx
- Amputations with bruise or avulsion injury
- Single finger amputations other than thumb
- Amputations above the elbow in advanced age
Contra-indications for Replantation or Revascularization that may vary from case to case, sometimes certain and sometimes considered partial:
- Additional injuries with a life-threatening risk accompanying the patient
- Forearm and more proximal level amputations (from the proximal half of the forearm) with an ischemia duration exceeding 6 hours
- Repeat amputations from more than one level
- Cases of bruises, burns or avulsion injuries
- If the warm ischemia time of the amputated part is over 16 hours for the fingers and 6 hours for the proximal wrist
- Overly dirty or contaminated wounds
Some pre-existing diseases:
- Diabetes
- Heart disease and atherosclerosis
- Recent myocardial infarction or cerebrovascular attack
- Smoking
- Amputations performed with the intention of suicide or self-intention (as a result of psychiatric illness)
How is the Surgical Treatment Performed?
Revascularization is the restoration of circulation by making vessel anastomoses.
Full amputation
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