dr. tc wong
TRANSCRIPT
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Principle of Microsurgery
AADO/HKSSH Conjoint Scientific Meeting 2009Dr. Wong Tak Chuen
MO Specialist, Department of O&T, PYNEH, HKSAR
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Definition
Microsurgery Surgery performed on very small structures, such as blood vessels & nerves, with specialized instruments under a microscope
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Purpose
1st microsurgery, using a microscope to repair blood vessels
Jules Jacobson of University of Vermont in 1960
1st successful replantation1964 by Harry BunkeRabbit's ear Blood vessels < 0.04 in (0.1 cm)~ vessels in human digit
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Numerous Techniques of Microsurgery
Otolaryngologists (ENT)Small, delicate structures of inner ear or vocal cords.
Ophthalmologists Remove cataractCorneal transplants
UrologistsVasectomies (male sterilization)
GynecologistsTubal ligations (female sterilization)
Plastic surgeonsReconstruct disfigured skin, muscles, or to transplant tissues from other parts of the body
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Equipment
MICROSCOPE5–40xLower magnificationIdentify & expose structures
Higher magnificationMicrosurgical repair
SURGICAL LOUPES2–6x
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Instruments
Forceps Needle holders Scissors Vascular clamps
controlling bleeding
clamp applicators Irrigators
washing structures
Vessel dilators opening up cut end of vessel
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Suture
Diameter (gauge) ranges in size & depends on procedure & tissue2‐0 (0.3 mm) ‐ 6‐0 (0.07 mm) 9‐0 (0.03 mm) ‐ 12‐0 (0.001 mm) for MSAbsorbable (broken down in body) vs Non‐absorbable (retaining its strength) Natural (silk, gut, linen) / synthetic (nylon, polyester, wire)Needle shapes (straight/ curved)Point types (rounded, cutting, or blunt)<0.15 mm for MS
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Techniques
BLOOD VESSEL REPAIRAnastomoses
End‐to‐End (between two cut ends)End‐to‐Side (connection of one cut end to the wall).
Expose the vesselIrrigationsecured with clampsContrast material placed behind 1st suture ‐ full thickness2nd & 3rd sutures ‐ 120°
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Techniques
End to End repair Arteries 1 mmbetween 5 & 8 stitches
veins 1mm between 7 & 10
clamps are released
End to Side repairOval‐shaped hole is cut on recipient vessel
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Nerve Repair
Process of connecting two cut ends of nerveNeurorrhaphy / Nerve anastomosis
Peripheral nervesBunches of nerve fibers called fasciclesEnclosed by perineuriumEpineurium is the outer layer
Nerve repair Suturing of epineurium onlyPerineurium onlyThrough both layers
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Pre‐op Preparation
InvestigationsBlood: CBP, L/RFT, Clotting profile…T&S / X‐matchX‐rays, CXRECGDoppler /Arteriogram
AdviceNo smokingNo drinking, coffee, cola…
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Pre‐op preparation
Donor SiteNo blood taking or IV accessPrevent injuryMarking of skin area by surgeon+/‐ prepare the donor site of skin graft
Recipient Sitedebrides all necrotic or slough tissue. +/‐Ensures wound swab for culture is –ve
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Replantation
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Replantation
Surgical attachmentRevascularization of a body part that has been completelyamputated
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Revascularization
Restoration of circulation to a devascularized but not completely amputated part
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Preserve the amputated parts
Placed in a bag after being wrapped in an sterile gauze dampened with NS
Bag placed in container & submerged in ice NS bath to maintain a temp of 4°CLabeling
Never by placed in a hypotonic or hypertonic solution
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Preserve amputated parts
Don’t try to detach Don’t stretch Moistened with NSLoosen dressing & crepeCool with ½ ice & ½H2O in plastic bagSupport with splint
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Relevant history
Mechanism of injuryAvulsion or crush
Time of injury Ischemic time
Emergency treatment rendered, including care provided to amputated part
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History
Patient’s ageHand dominanceOccupation/ vocational demands & expectationsPrevious hand injuries or disabilityOther major injuriesMedical/ psychiatric conditions that may preclude replantation
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Relevant physical examination
Location (level) of amputationSingle or multiple injury levels in the extremitySingle or multiple amputated partsCondition of amputated part (sign or crush or avulsion)Condition of the amputation stump
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Sequence for replantation
Wound debridementIdentification of arteries, veins, nerves & tendonsBone stabilizationExtensor tendon repairFlexor tendon repairVascular anastomosisNerve repairSkin closure
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Methods for bony stabilization
K wire or intraosseous wires can be placed rapidly & easily
Lag screw fixation or miniplate & screwsPlate fixation
major limb replantation
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Post‐op Care
Complete bed restKeep warm
warm Room ( ~26ºC )? lamp treatment
Bed cradleSupport operated limb Avoid torsion of pedicle
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Post‐op Care
ElevationHeart levelAbove heart levelOne pillow
Vital SignsBP/PBody Temp.I/O
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Post‐op Care
IVFHydration
Foley’s catheter measure output
NPOPain control
(No Puncture on affected site)
MedicationDextran 40AspirinPersantinAnalgesicAntibiotics
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Monitoring
ColourCapillary RefillTissue TurgorTemperatureDoppler SpO2Pin Prick
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Monitoring
ColourNormal PinkArterial fail PaleVenous fail Cyanotic
Capillary RefillNormal 1‐2 secArterial fail SlowVenous fail Fast
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Monitoring
Tissue TurgorNormal Full
Arterial fail Hollow, “Prune like”
Venous fail Tense, Distended+ Blisters
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Monitoring
TemperatureNormal: 30‐37ºCReplanted or flap: +/‐ 2‐3ºC? By touchBy Thermo ScanArterial / venous thrombosisfall below 30ºC, differential 2.5ºC
Arterial thrombosis/ Venous thrombosis:rapid fall 3ºC/ slowly fall 1‐2ºC
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Monitoring
DopplerVascular Doppler
Implantable Doppler Probe
Laser Doppler Flow meter
SpO2 Normal: ~ >90%Vascular compromise
Sudden fallNot ↑ on 100% O2 given
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Monitoring: Pin Prick
By Surgeon25 gauge needleNo.11 blade
Heparin promote bleeding
Normal: Bright red bloodSlow to start bleedingBleeds a short
Arterial Occlusion: Serum
No bleeding
Venous Occlusion:Bleeds briskBleeds a long time
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Pressure on flap
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Thank you