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MicrosurgeryMicrosurgery

The techniques of microsurgery are revolutionizing the operating theatre. The surgeon uses a microscope to view the inside of the body and can perform operations on tiny structures like nerves and blood vessels.

Microsurgery is a special technique used for any operation that involves minute, delicate or difficult to get at parts of the body. The ability to stitch together blood vessels with a diameter of just 2mm (0.04in) has revolutionized surgery and the techniques are used in a whole range of different operations. These include transplant surgery, plastic and reconstructive surgery for victims of severe accidents and burns, and eye surgery to implant a new lens or cornea.

NEW ADVANCES

Surgeons can unblock the Fallopian tubes in women who are infertile, reverse vasectomy, move sections of skin and muscle from one part of the body to another to fill defects left by injuries or burns, replace diseased bones in the middle ear, or treat deafness, restore severed fingers, toes, hands, even penises.

The very first microsurgical techniques were described as long ago as the 16th century by early surgeons operating on arteries, but they didn't become commonplace until as late as this century with the breakthrough development of the operating microscope.

In 1903, a vetinary surgeon named Hoephner described limb replantation in dogs. With the purification of the anticoagulant drug heparin, used to prevent blood clotting, the way was open for surgeons to rejoin blood vessels without the risk of dangerous clotting. At first, however, surgeons could only operate on large blood vessels, because fine stitching materials and delicate instruments had not been developed.

NEW VISION
The introduction of the operating microscope to hospitals in the 1920s revolutionized every type of surgery, and the first microsurgical operations were performed on the middle ear. By the 1950s, surgeons were experimenting with the same technique in eye surgery.

In 1958, surgeons performed the first operation to replant a leg, that of a Japanese girl, which had been amputated when she was run over by a train. The following year, another surgeon performed the first operation to unblock an infertile woman's Fallopian tubes using microsurgical techniques.

By the late 1960s, surgeons were regularly replanting severed limbs, and digits, and were working on rejoining nerves as well as blood vessels. In the 1970s, new organ transplants, such as those for heart and lungs, were being performed.

Another breakthrough came when surgeons learned to perform a living bone graft, succeeding in tranplanting bones complete with their blood vessels. Urologists also started using microsurgery for operations on babies and children with abnormalities of the urinary system, and vasectomy reversals began to be performed. The same techniques enabled surgeons to reconstruct the breasts of women who had had mastectomies due to breast cancer.

THE TECHNIQUES
Today, the techniques of microsurgery are fully developed, and surgeons are developing even more sophisticated techniques of organ transplantation. As the problem of the body rejecting foreign tissue is solved with the development of ever more safe and effective drugs to suppress the immune system, microsurgery will have an even more brilliant future in the field of composite tissue and organ transplantations.

The needles, scissors and scalpels that are used to perform microsurgery are small and delicate as are the forceps used to grasp them. The stitches used are as fine as a human hair. The small instruments and the delicate nature of the operations involved means that microsurgical operations have to be performed painstakingly slowly with the aid of an operating microscope to enable the surgeon to view the organs he is operating on. This microscope is fixed on a stand, which is moved up and down by means of foot pedals, leaving both the surgeon's hands free to perform the operation.

SUCCESS RATES

Not everyone is suitable for microsurgery. Age, occupation and the degree of injury has to be assessed. In children and young people, there is a greater degree of success. The most suitable type of injury for a rejoin operation is where there has been a clean cut or mild crushing injury.

In cases where there has been severe crushing, there is usually too much damage to nerves and blood vessels over a wide area and the risk of clotting is greater. Thumb replantation is one of the most successful operations, especially in children over five.

Afterwards, patients sometimes report extreme sensitivity to cold, though this usually improves slightly with time. Naturally, the limb or digit is not usually as strong as it was before. Secondary surgery on tendons and joints is sometimes needed to ease any stiffness and help improve function.

TIME FACTOR

For the best chance of success, replantation has to take place within as short a period of time after amputation as possible. For fingers, six hours is usually the maximum, though if they are cooled, they can be kept for longer. After a day, however, there will be irreversible damage to the blood vessels.

In the case of whole limbs, the time they can be kept is much shorter as there are large amounts of muscle which become damaged through lack of oxygen.

Other types of surgery that have been made possible by new microsurgery techniques include thick skin or muscle grafts, arteriole bypass operations within the brain, bringing down undescended testicles, grafting nerves to restore normal appearance of cases of facial palsy (paralysis), grafting toes onto the hand to replace lost fingers and thumb, and operating on the lymph vessels for the relief of lymphoedema -- the abnormal accumulation of lymph which causes swelling of limbs, often as a result of cancer.

Microsurgical techniques have also transformed the treatment of skin defects, especially where the bone is exposed. In a conventional skin graft, a thin layer of skin is taken from one part of the body and transferred to the affected area. However, this technique is not suitable for all types of injury.

NEW SKIN GRAFTS

In the past, skin with underlying tissue was moved by a complex series of operations to ensure it was never without a blood supply. The skin flap technique of microsurgery enables a segment of skin to be isolated, together with its artery, vein and nerve, and the whole segment can be stitched to a new supply at the site of the graft.

These techniques have brought some amazing successes, such as the surgeon who lost all four fingers of his hand when it was crushed in the 1985 Mexico City earthquake. After having two toes plus a flap of skin from his arm transplanted to his palm, he complete his training and is now a plastic surgeon.

Microsurgery can also enable surgeons to bypass blocked arteries in the brain after an attack of thrombosis by moving a neighbouring artery over and joining it to an artery beyond the one that is blocked.

THE OPERATION

Before an operation, a transfusion is given to correct any blood loss if necessary, after which the patient is given antibiotics, and X-rays are taken to assess the amount of damage. The amputated part is taken to the operating theatre where it is cleaned and key structures, such as arteries, veins, nerves and tendons are identified under the microscope. The amputated part is then rejoined, little by little, in a slow process.

After the operation, anticoagulant drugs are given to prevent blood clots, which may form due to slight narrowing of the artery and loss of the smooth lining at the join as a result of scar tissue. It will be obvious within a couple of weeks whether the re-attached part is going to survive.

MAKING A RECOVERY

It is usually several months before the full success of the operation can be gauged in terms of restoration of normal function. Some patients regain movement and sensation and are able to return to work in a matter of months.

Others have to endure months or years of swelling, stiffness and pain. About half of all patients need more surgery to help them achieve the best possible function. However, future refinements in a technique may make this less necessary.

     
     

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