E. Biemer · W. Duspiva Reconstructive Microvascular Surgery With Forewords by Ursula Schmidt-Tintemann and Dieter Buck-Gramcko With 315 Figures, some in Color Springer-Verlag Berlin Heidelberg NewY ork 1982 Priv.-Doz. Dr. EDGAR BIEMER Priv.-Doz. Dr. WOLFGANG DUSPIVA Klinikum rechts der Isar der Technischen UniversiHit Miinchen, Ismaninger StraBe 22, 8000 Miinchen 80, Federal Republic of Germany Translator: MYRA SOUTAR, PH.D. Language Editor: DAVID SOUTAR, F.R.C.S., Glasgow and West of Scotland Plastic and Maxillo-Facial Surgery Service, Canniesburn Hospital, Bearsden, Glasgow G61 lQL, Great Britain Translation of the German edition: Rekonstruktive MikrogefajJchirurgie © by Springer-Verlag Berlin Heidelberg 1980 ISBN-13: 978-3-642-68456-2 e-ISBN-13: 978-3-642-68454-8 DOl: 10.1007/978-3-642-68454-8 Library of Congress Cataloging in Publication Data Biemer, E. (Edgar), 1940 Reconstructive microvascular surgery. Translation of: Rekonstruktive MikrogefaBchirurgie. Includes bibliographies and index. I. Blood-vessels--Surgery. 2. Microsur gery. 3. Surgery, Plastic. 4. Transplantation of organs, tissues, etc. I. Duspiva, W. (Wolfgang), 1941 II. Title. [DNLM: I. Hand injuries-Surgery. 2. Microsurgery-Methods. 3. Replantation Methods. 4. Transplantation-Methods. 5. Vascular surgery-Methods. WG 170 B587r] RD598.5.B5413 617' .413059 81-23276 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under §54 of the German Law where copies are made for other than private use, a fee is payable to the "Verwertungsgesellschaft Wort", Munich © by Springer-Verlag Berlin Heidelberg 1982 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Reproduction of figures: Gustav Dreher GmbH, Stuttgart 2124/3130-543210 Foreword to the German Edition The importance of a new operating technique is not judged by the success of one individual case. Only careful observation of the results of numerous operations can show whether the technique may be prac tised widely and whether the effort expended is justified by the results. Only then, can a new technique take its place in the repertoire of an operative discipline. The time has come for plastic surgery to avail itself of microvascular surgical techniques and, where there is sufficient experience, the results are good. Clinical experience has shown that the replantation of amputated ex tremities can be rewarding when the criteria governing the indications for such surgery are followed rigorously. It is necessary to convey patients quickly to a medical centre which has a clinical organisation specialising in microvascular surgery. Follow-up investigations of the initial successes in replantation of fingers, hands and toes have shown us that such operations are of great importance, not only for the subjective wellbeing of the patients, but for their increased competence to return to work. Microvascular surgical techniques have also stood the test with regard to free transplantation of tissue, the fundamental advantages being the variable donor-site and a reduced hospital stay. Indeed, plastic surgery has developed microvascular surgery to an extent where the possibilities offered by this operative technique are inestimable. Certainly, in years to come, the technique will offer new paths for surgeons in many other areas of surgery. One needs little imagination to project the possible role of the technique in organ transplantation. The knowledge and experience of microvascular surgical techniques may belong to every surgeon, but for the plastic surgeon the theory and practice of these techniques are indispensible. It is to the authors' credit that in this book they not only reproduce their results, but more important, impart their personal experiences and thoughts. Their untiring surgical activity in this field has led to many new discoveries and their book includes everything from improvements in instrumentation and operative strategy to post-opera tive management and after-care. This book therefore, constitutes a piece of medical history and I am proud that colleagues from my own department have accomplished something so outstanding. Munich Prof. Dr. URSULA SCHMIDT-TINTEMANN v Foreword to the German Edition The major breakthrough in microsurgery followed the clinical applica tion of microvascular surgical techniques: the resulting success brought universal recognition. Many years previously, experimental studies had demonstrated the basic requirements of this technique and micro surgery of the peripheral nerves was practised in many clinics. The pioneers in in this new field of plastic surgery in Australia, China, Japan and the U.S.A. had a difficult and onerous start. There then followed, in the first half of the 1970's, increasing disseminated clinical activity which acted as a proving ground for the preceding experiments, and led to countless new possibilities for the application of microsurgi cal techniques. Edgar Biemer and Wolfgang Duspiva played a crucial role in the development of microvascular surgery in Europe. Through their initia tive, a replantation centre was established in Munich in November 1975, alongside the already existing replantation services in Vienna, at the two University Clinics for Plastic and Reconstructive Surgery (from June 1974), and in Hamburg at the" Berufsgenossenschaftliches Unfallkrankenhaus" (from April 1975). The Munich centre soon accu mulated a remarkably high number of replantation cases, surpassing the other centres. The authors stand unrivalled with an accumulation of300 replantations in two years, and a healing rate of86%. Nevertheless, microvascular surgery is not simply the activity of one or two surgeons. Success requires a team of well skilled micro surgeons, whose unflagging commitment, in conjunction with theatre sisters and anaes thetists, helps to bring these long operations to a successful conclusion. The overall organisation of a unit is strongly influenced by the intro duction of microsurgical operations and must adjust to the altered circumstances. Through good collaboration, these problems were hap pily solved in Munich and the high standard, to which this book testifies, became possible. Alongside replantation, free tissue transfer with microvascular anasto mosis is the realm of the microvascular surgeon. Such operations require planning, and, although not emergency operations like replan tations, they are, nonetheless, largescale. Careful attention to the indi cations for surgery combined with the surgeon's manual dexterity can offer many a patient significant help in his return to a professional working life. Publications in this new field of surgery are essential and the authors, despite their continuing work load, have provided the first comprehensive presentation on microvascular techniques in Germany. In the near future, microsurgical techniques will gain entry into all surgical disciplines, and thereby unleash new methods of treat ment. Hamburg Prof. Dr. DIETER BUCK-GRAMCKO VII Preface to the German Edition For many years, the operative manipulation of the most minute struc tures was frustrated by the limitations of the human eye. With the introduction of the operating microscope by Nylen (1921), fine detailed anatomy was made visible, so that structures could be prepared, pre sented and manipulated. Nylen used the microscope for treating dis eases of the middle ear. In 1946 Perrit in the U.S.A. introduced the operating microscope into the field of ophthalmic surgery. In 1964, Smith, Kunze and Mitchen published reports on their clinical experi ence using the operating microscope in nerve surgery. Using this tech nique, it was possible to divide a peripheral nerve into individual fascicle bundles and reapir each bundle precisely. Following on from these developments, the term" microsurgery" was introduced to cover that branch of surgery which was carried out using the" equiped" eye - either by using 10upe spectacle magnifica tion or, more commonly, the operating microscope. The term "micro vascular surgery" developed for the operative treatment of small ves sels below 2 mm in diameter. Experimental studies for the use of microsurgery in the clinical situation developed alongside its use on small research animals for transplantation models in immunological study. Microsurgical techniques were used in the transplantation of rat liver, kidneys, pancreas, heart and other organs. The clinical appli cation of these microsurgical techniques is nowadays called "recon structive microvascular surgery". Microvascular surgery, like micro surgery, is not an independent operative discipline, but is purely a technique which may be applied to different specialties, and its use in the future is thereby reinforced. Animal experimental work is an essential prerequisite for the mastery of microvascular surgical tech nique. In addition to the technical aspects, such experimentation in creases the experience of the surgeon by enabling research into suturing and the testing of new developments. Furthermore, regular training is imperative to maintain an optimum standard of safety and confi dence for use in the clinical situation. The first part of the book deals with operating microscopes, instrumen tation and microsurgery of vessels commonly used for practice. Meth ods, documentation and recording of results are presented, and the experimental basis of the techniques involved in microvascular suturing is explained in detail in specific cases. The second part of the book deals with the clinical application of microvascular surgery in replanta tion and transplantation surgery. The presentations are based on the experience of over 500 clinical cases. The detailed descriptions of the techniques and, in particular, the operating microscopes, instruments and suture materials, do not present a complete picture of all the operative procedures, nor all the available products, but are those with which the authors have had considerable experience. IX Acknowledgements The authors wish to record their special thanks to the many people who supported them and enabled them to gain the experimental and clinical experience on which this book is based. The preliminary work and subsequent laboratory investigations were made possible and en couraged by the support of the Director of the Institute for Experimen tal Surgery of the" Technische Universitat", Munich - Herr Professor Dr. G. BLt.JMEL. The countless organisational problems following the clinical application of this new technique, especially in the area of replantation surgery, were expertly handled by the Director of the Surgical Clinic and Outpatients Dept. of the T. U. in Munich - Herr Professor Dr. GEORG MAURER. Frau Professor Dr. URSULA SCHMIDT-TINTEMANN, Head of the Depart ment for Plastic and Reconstructive Surgery of the T. U., Munich, especially deserves our thanks for her continual support and encour agement throughout our work. Herr Professor Dr. E. KOLB and his colleagues from the Institute for Anaesthesiology and Herr Professor Dr. H. ANACKER and the Radiological Institute were most helpful throughout the clinical appli cation of microsurgery. The introduction of Xeroangiography by Herr Dr. KRAMANN has proved of great value in assessing the late results of replantation surgery. The authors wish to express their thanks to Herr Professor Dr. DIETER BUCK-GRAMCKO, Senior Surgeon of the Department of Hand Surgery and Plastic Surgery at the "Berufs genossenschaftliches U nfallkrankenhaus", Hamburg - Bergedorf for providing the Foreword, and in showing great interest in their work. The clinical application of microsurgery, particularly in the field of replantation surgery, was only made possible by inaugurating a 24 hour stand-by service. The willingness of our colleagues in the replantation team was of immeasurable importance; in addition to their duties in the various surgical units - plastic surgery, thoracic surgery, vascular surgery and orthopaedic surgery - they were ready to take on and perform a considerable amount of work. Those involved in providing this replantation service were: Dr. E. HERNDL, Dr. W. STOCK, Dr. J. HEISS, Dr. K. WERBER, Dr. W. GClTZ, Dr. K. GLAS, Dr. H. BARTELS, Dr. G. INGIANNI, Dr. G. MEYER-BUSCHE and Dr. H. SCHMUCK. The outstanding photographic documentation was pro vided by the Department of Photography of the Surgical Unit of the T.U., Munich. The authors are grateful for the support which they have recieved from the sisters, physiotherapists, occupational therapists and from all personnel in the operating theatres. The authors also acknowledge the help and support of Springer-Verlag and XI especially Miss TISMER for her considerable efforts in typing the manuscript. Much of the work was supported by the firms of Ethicon - Hamburg, Thomae-Biberach, Aesculap - Tuttlingen and the authors gratefully acknowledge the financial assistance from the Volkswagen Foundation, which made much of the experimental work possible. Munich E. BIEMER W. DUSPIVA XII Contents Part 1 Technique of Microvascular Surgery and Preliminary Experimental Studies . . . . . . . . . . . . .. 1 I. Development of Microvascular Surgery 3 II. Technical Equipment . . . . . . 4 1. Operating Microscope .... 4 2. Accessories and Documentation 7 3. Operating Seats 9 4. Instruments 9 5. Suture Material 15 III. Experimental Microvascular Surgery 16 IV. Suture Technique in Microvascular Surgery 17 1. Preliminary Remarks 17 2. End-to-End Anastomosis 18 3. End-to-Side Anastomosis 28 V. Complications of Microvascular Suture 30 1. Assessment of Microvascular Anastomosis 30 2. Patency Test . . . . 30 3. Microthrombectomies . . . . . . . 30 4. Micro-vein Grafts 30 a) Indications for Micro-vein Grafts 33 b) Donor Sites for Micro-vein Grafts 35 c) Rules for Micro-vein Grafts . . . 36 VI. Micromorphological Evidence at the Site of Anastomosis in Small Vessels .................. 40 VII. Medical Prophylaxis and Treatment of Vessel Thrombosis and Spasm . . . . . 47 1. Local Measures 47 2. Systemic Measures. 47 References 49 Part 2 Clinical Microvascular Surgery . . . . . 53 A Replantation with Microvascular Anastomosis (micro- replantation) 55 I. Definitions and Nomenclature 56 XIII 1. Replantation . . . 56 2. Amputation 56 3. Total Amputation 56 4. Subtotal Amputation 56 5. Revascularisation . . 57 6. Replantation: Macro- and Micro-replantation 58 II. Classification of Amputations in the Hand 59 III. Indications for Replantation . . . . . . 59 IV. Guide-lines for the Primary Treatment of Amputation Injuries . . . . . . . 62 V. Replantation Technique 63 1. Wound Debridement 64 2. Bone Shortening . . 64 3. Osteosynthesis . . . 65 4. Suturing of the Flexor Tendon and Tendon Sheath 67 5. Arterial Anastomosis . . . . . . . . . . . . 67 6. Nerve Suturing .............. 68 7. Management of the Extensor Tendon Apparatus 68 8. Vein Anastomosis 68 9. Skin Closure . . . . 68 10. Dressings . . . . . 69 11. Medicinal Treatment 69 VI. Considerations of Differing Levels and Mechanisms of Amputation . . . . . . . . . . . 70 1. Levels of Amputation in the Hand 70 2. Guillotine Amputations . . . . . 75 3. Crushing Injuries . . . . . . . . 75 4. Severe Crushing and Combination Injuries with Damage to the Amputated Part 76 5. Avulsion Injuries . . . . . . . . . . . . . . 79 6. Degloving Injuries . . . . . . . . . . . . . 79 VII. Primary Replacement of Destroyed Phalangeal Joints 85 VIII. Primary Finger Transplantation 88 IX. Post-operative Management 89 X. Physical Management 94 XI. Secondary Operations 95 XII. Results ...... 97 XIII. Microreplantation of Other Parts of the Body - (e.g., toes, ears, scalping injuries, and penile amputations) 99 XIV. Replanta~oti 'Service. . . . . . . . . . . . . . . . . 104 B Tissue Transplantation with Microvascular Anastomosis . 105 I. Development of Tissue Transplantation Using Microvascular Anastomosis ....... . . 105 XIV