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Microsurgery is an act of craftsmanship
Amputation is the traumatic severance of a limb, part of a limb or any other portion of the body. Incomplete amputation is where a part of the body remains attached through some tissue, such as skin, tendon or muscle. The reattachment of a completely amputated body part using an operating microscope or magnification loupe is called reimplantation. Reattachment of an incompletely amputated part is revascularization. Certain structures, such as bone, muscle, tendon and skin, can be reattached back to their original positions without the aid of microscopes and magnifications loupes. However, vessels and nerves, especially those of fingers, thumb and toes, cannot be repaired without the help of a microscope. The first reimplantations of a severed arm, hand and thumb were performed in the 1960s by surgeons in the United States, China and Japan, respectively. The lumen, the space within a tubular structure or part, such as a blood vessel, has a minute diameter of 1-1.5mm. To visualize the lumen of vessels and their walls, one needs a microscope and other specialized micro-instruments and micro-sutures. The latter are usually not visible to the naked eye, while the length of a micro-needle is only 3-5mm. To successfully perform microsurgery, a surgeon should, therefore, have extensive training in a microsurgical laboratory, well-equipped with microscopes, micro-instruments, micro-sutures and animals for experiments, including rats. Before executing microsurgical procedures on a human being, a surgeon should develop and master the technique of ‘microanastomosis’ of vessel 1mm or less in size. This is a connection between two tubular organs or parts like blood vessels. Such expertise can be acquired with continuous training in a microsurgical laboratory for four to six months. In such a setting, once the surgeon becomes familiarized with the microscope and micro-instruments, the precision of microanastomosis can be achieved by controlling hand tremors and developing a good hand-to-eye coordination. When his/her success rate of microanastomosis in microsurgical laboratory reaches beyond 90 per cent, the surgeon can perform microsurgical procedures on humans. Reimplantation is not simply the reattachment of severed structures, but is rather the reconstruction and reattachment of vessels, nerves, bone and tendons of an amputated part in such a way that it ultimately yields a viable, sensate and functional reattached part. To achieve this objective, one should perform microsurgical repair of vessels and nerves so that sensory recovery (return of sensation) and motion of joints return within two to three months of reimplantation. MICROSURGERY IN PAKISTAN: Dr Tahseen A. Cheema, a renowned orthopaedic and hand surgeon, is a pioneer and leader of this sub-specialty in Pakistan. In 1989, he reimplanted a completely amputated hand at wrist level in the Bahawal Victoria Hospital, Bahawalpur. This was the first reimplantation in the country. Subsequently, Dr Cheema has performed many reimplantations of upper extremities at different levels of the arm and forearm. Following him, numerous orthopaedic surgeons have tried reimplantations of severed upper extremities with mixed results. I performed the first reimplantation of a severed digit in Pakistan in 1996 at the Aga Khan University Hospital, and have thus far successfully completed 35 reimplantations.
Microsurgical techniques can be applied in various reconstructive procedures, including: 1. Re-implantation of severed digits, thumb or extremity at any level. 2. Toe to hand transfer for thumb and fingers reconstruction, after the thumb or finger has been lost due to trauma, infection or tumour. 3. Free vascularized tissue transfer (free flaps). When a block of tissue (skin with subcutaneous tissue, muscle or bone, alone or in combination), is harvested from one part of the body with feeding blood vessels and transferred to another part with the help of microanastomosis of vessel and nerve through a microscope, this is called free tissue transfer. PRESERVING AMPUTATED PARTS: If you come across a completely amputated thumb, finger, hand, toe or foot, what immediate measures will you need to undertake? First, apply a pressure bandage over the bleeding stump. Then take the amputated part, wash it with normal saline, distilled, mineral or tap water and clean it thoroughly. After this, wrap it in clean sterilized gauze. Put the amputated limb in a plastic bag containing normal saline, distilled or mineral water and seal it tightly. Take another plastic bag containing ice or ice-cold water. Put the first sealed bag into it. Finally, transport this bag to a medical centre where microsurgery and reimplantation experts are available. Never put ice-cold water or ice directly over the amputated part. | ||
A well-established discipline now, microsurgery is helping doctors reach tracts of the human body that were previously inaccessible |
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