2. What is the microsurgery?
Definition:Microsurgery is a surgical discipline that combines magnification with advanced diploscopes,
specialized precision tools and various operating techniques. These techniques are primarily used to
anastomose small blood vessels (arteries and veins) and to coapt nerves. Microvascular and microneural
coaptation allow for complex repair of human tissue after trauma, cancer and congenital deficiencies. Two
of the main purposes of microsurgery are to transplant tissue from one part of the body to another
and to reattach amputated parts. It is incorrect to state that microsugery is simply a general term
for surgery requiring an operating This loose definition does not convey the breadth and complexity of
the specialty. Yes, microsurgeons use microscopes, but that is a small part of what the specialty addresses.
In fact, microsurgery encompasses much, much more than this simple definition. The procedures
themselves are a mixture of surgical science and art and take many years of training to become
proficient.Microsurgery helps to heal wounds, restore function after trauma, and restore form after cancer.
It can assist in the recovery and healing of a wide array of medical issues, from emergency amputations to
reconstoration.
3. The microscope:The microscope itself has two binocular viewing fields (a
diploscope). This allows a surgeon and assistant to perform surgical
techniques under magnification from 4 to 40 times power. This allows
visualization of small structures, such as arteries, veins, nerves and
lymphatics. Visualization of these structures allows them to be surgically
manipulated, enabling the microsurgeon to:
Reattach amputated body parts (replantation)
Transplant tissue from one part of the body to another (microvascular
transplantation)
Repair nerves
Repair blood vessels
Manage complex soft tissue and bone infections
4. Overview image:Performing microsurgery: Two teams of microsurgeons using
operating diploscopes (binocular viewing fields). Photo: Walter Lin, MD. The
Buncke Clinic.
5. Microscope view:Microsurgery: A view from under the microscope of a
lymphovenous anastomosis. The grid is 1 mm. Bluish dye in the vessel is
isosulfan blue mixed with lymphatic fluid.
6. Free flap:Tissue isolated on a vascular pedicle and transplanted from
one part of the bod to another. Also known as a microvascular
transplant (our favored term, because of its precision) or free tissue
transfer.
Microvascularr transplant:Tissue isolated on a vascular pedicle and
transplanted from one part of the bod to another. Also known as a free
flap or free tissue transfer.
Free tissue transfer:Tissue isolated on a vascular pedicle and
transplanted from one part of the body to another. The term is
imprecise since it does not convey the necessity for microsurgery, and
may imply moving tissue without vascular repair. For instance, a skin
graft does not require micorusrgery yet could be considered a free
tissue transfer. A pollicization of the thumb from the index finger
requires the tranfer of the index ray to the thumb position. A transfer
implies moving from one place to another, such as index to thumb, but
does not necessitate removal from the original location. A transplant on
the other hand, reflecs removal from the original location, and
placement at another part of the body with vascular repair.
Diploscope:An operating microscope with separate binocular fields, one
for the surgeon and one for the assistant.
7. What does microsurgery involve?
Microsurgery involves making use of the following equipment:
microscope – used to magnify the area being targeted onto a monitor bright light source
– often combined with keeping the overall light levels in the operating theatre low
forceps and other instruments – these are specialised instruments designed for
precision and to counteract the natural tremor in a surgeon’s hand specialised thread
and needs – for stitchingThese tools are generally used to manipulate and repair blood
vessels and nerves.
8. Why is it done?
Microsurgery techniques are used in a wide range of medical fields, including neurosurgery, plastic
surgery, ophthalmology , orthopaedic surgery, and general surgery. The development of
microsurgery techniques has also made it possible to perform the following procedures:
free tissue transfer – if a patient has suffered from serious injury, and a part of the body cannot be treated
with skin grafts or stitching, free tissue transfer involves taking tissue from another part of the body to
achieve reconstruction replantation – this is an emergency procedure which aims to reattach a body part
which has been amputated, most commonly a finger or toe. transplantation – if replantation is not
possible, sometimes it is possible to reconstruct a body part via a transplant. The most commonly known
is a toe-to-thumb transplant, to replace an emergency procedure which aims to reattach a body part which
has been amputated, most commonly a finger or toe. transplantation – if replantation is not possible,
sometimes it is possible to reconstruct a body part via a transplant. The most commonly known is a toe-to-
thumb transplant, to replace an amputated thumb with the big toe.
9. What to expect
Microsurgery is performed under anaesthetic. After the operation you are likely
to need to stay in hospital for a few days. During this time:
the nurses will monitor the site of the procedure regularly you may be given
medication to thin your blood you may be given antibiotics to help prevent
infection you may be on an IV drip to keep the blood flowing properlyIt is also
important that you are kept warm and that the site of any replantation, whether
your hand or foot, is kept elevated to minimise swelling and let liquids drain.
When you leave the hospital, you’ll be given instructions for aftercare, which will
generally involve getting plenty of rest and refraining from smoking.
10. place of one lost (for example, a great toe replacing a lost or damaged
thumb).
Today, microsurgery can be lifesaving. Neurosurgeons can treat
vascular abnormalities found in the brain, and cancerous tumors can be
removed.
Read more:
11. INSTRUMENTS : forcepsneedle holders (for
suturing)scissorsvascular clamps (for controlling bleeding)
and clamp applicatorsirrigators (for washing structures in
the surgical field)vessel dilators (for opening up the cut end
of a blood vessel)various standard surgical tools
12. SUTURE MATERIALS. Suturing, or stitching, is done by means of specialized thread
and needles. The diameter (gauge) of suture thread ranges in size and depends on
the procedure and tissue to be sutured. Conventional suturing usually requires
gauges of 2-0 (0.3 mm) to 6-0 (0.07 mm). Conversely, gauges of 9-0 (0.03 mm) to 12-
0 (0.001 mm) are generally used for microsurgery. Suture thread may be absorbable
(able to be broken down in the body after a definite amount of time) or non-
absorbable (retaining its strength indefinitely), natural (made of silk, gut, linen, or
other natural material) or synthetic (made of nylon, polyester, wire, or other man-
made material). The type of suture thread used depends on the procedure and tissue
to be suturedThe suture needle comes in various sizes (diameters and length) and
shapes (straight or curved), and also with different point types (rounded, cutting, or
blunt). It comes with suture thread preattached to one end; this is called the swage.
As in the case of suture thread, the type of needle used depends on the procedure
and tissue to be sutured; generally, needles with a diameter of less than 0.15 mm are
used for microsurgery
13. Training
For a surgeon to perform microsurgery in a clinical setting, extensive training and practice
are required. A basic knowledge of anatomy and surgical techniques is essential. After a
thorough introduction to the operating microscope and other microsurgical equipment, basic
techniques are introduced using small animals as the experimental model. Specifically,
surgeons must be taught how to maintain correct posture and to maintain constant visual
contact with the microscope during surgery, how to properly hold and use the instruments,
how to minimize the amount of hand tremor, and how to perform basic techniques, such as
suturing. After becoming proficient at these skills, more advanced techniques can be taught,
including procedures regarding how to treat specific condi:Extensive and ongoing practice
is necessary for a surgeon to maintain adequate proficiency at microsurgical techniques.
For this reason, a microsurgical laboratory is made available to surgeons for training and
practice
14. Techniques
Most microsurgical procedures utilize a set of basic techniques that must be mastered
by the surgeon. These include blood vessel repair, vein grafting, and nerve repair and
grafting.
BLOOD VESSEL REPAIR. Blood vessel, or vascular anastomosis, is the connection of two
cut or separate blood vessels to form a continuous channel. Anastomoses may be end-
to-end (between two cut ends of a blood vessel) or end-to-side (a connection of one cut
end of a blood vessel to the wall of another vessel:The procedure for an end-to-side
anastomosis is similar, except that an oval-shaped hole is cut in the wall of the recipient
vessel. Sutures are first placed at each of the oval to connect the attaching vessel to the
recipient vessel, and then placed evenly to fill in the remaining spaces.:
15. VEIN GRAFTING. Vein grafting is an alternative procedure to end-to-end anastomosis and
may be pursued if cut ends of a blood vessel cannot be attached without tension.
Nonessential veins similar in diameter to the recipient blood vessel can be removed from
the hand, arm, or foot. If the graft is to be used to reconstruct an artery, its direction is
reversed so that the venous valves do not interfere with blood flow. End-to-end anastomosis
is then performed on each end of the graft, using the suture techniques described above.:
NERVE REPAIR. The process of connecting two cut ends of a nerve is called neurorrhaphy,
or nerve anastomosis. Peripheral nerves are composed of bunches of nerve fibers called
fascicles that are enclosed by a layer called the perineurium; the epineurium is the outer
layer of the nerve that encases the fascicles. Nerve repair may involve suturing of the
epineurium only, the perineurium only, or through both layers.:
