The Marvels of Microsurgery
By “Awake!” correspondent in Australia
A YOUNG mother, working in her home, suddenly heard an anguished scream. Rushing outside, she was horrified to find that her three-year-old son had just used an ax to chop off two of his younger sister’s fingers. A plumber, using a circular saw, accidentally amputated his middle finger and partially severed two others. A two-year-old boy fell off the back of his father’s farm grass cutter, and his foot got caught in the blades and was cut off at the ankle. A boilermaker amputated his right forearm about halfway between wrist and elbow when he crashed through a plate-glass window.
If these accidents had occurred about 10 years ago, all that could have been done would have been to provide medical attention to the wound. The amputated portion would have been discarded. Today, however, if you or any of your family are faced with situations such as these, the prospects for replacement and complete healing of the severed part would be excellent—if you can gain access to the marvels of microsurgery.
As the name suggests, microsurgery is performed under a microscope, enabling specially trained surgeons to join together arteries, veins and nerves, some smaller than one millimeter (1/25 of an inch) in diameter. Not only are body parts rejoined, but blood flow and feeling can be restored to amputated fingers and limbs.
Interestingly, the technique is not new. Early beginnings took place in Sweden in 1921 with ear, nose and throat surgery, and then with eye surgery in the 1940’s. Then in 1965, in Japan, an amputated thumb was replaced successfully, while in the next year in China, the first index-finger replacement was accomplished. In 1968 in Sydney, Australia, the world’s first successful finger replacement was performed on a child. Now, in many parts of the world, successful reattachment of amputated portions of the body (called replantation) is becoming a rather commonplace procedure.
Microsurgery’s Many Uses
While replantation is the most dramatic and usually the most publicized use of microsurgery, its uses are by no means limited to that one field. Many other major surgical procedures now make use of the marvels of microsurgery to accomplish results that would have been considered impossible a little over a decade ago.
For example, recent operations have involved the transference of flaps of skin, along with accompanying arteries, veins, nerves and even bone, from areas such as the groin, chest or top of the foot, to another part of the body that has been injured. Valuable contributions have also been made to the field of major surgery that necessitates the removal of large portions of tissue, such as with throat cancer where the formation of a new esophagus is needed. The vessels and nerves in the transferred portion are connected by microsurgery to those in the new location, while the donor area is similarly closed, or skin may be grafted to close the wound. Because just the one individual is involved, rejection problems are minimized.
Another major use of microsurgery that is rapidly expanding in scope is the reversal of sterilization operations for persons whose circumstances in life have changed. Although vessels as small as one third of a millimeter (0.0130 inch) are joined in reversing male vasectomies, one study showed a 90-percent restoration, with early pregnancy of the spouse in half of the case histories. Women’s Fallopian tubes have been rejoined with such good results that a recent newspaper headline claimed: “For sterilized mothers there’s an 80 p.c. chance of children . . . the 2nd time around.”
Research is being done to open more fields as well. Fetal surgery—operating on a baby while it is still in the womb—and the use of microlaser beam in surgery are just two of these.
Equipment and Technique
With microsurgery, the operating theater looks just the same as for general surgery—the gowned and masked surgical team, the operating table, the anesthetic trolley—along with one very obvious addition. Above the operating theater there is a large instrument that resembles a double-sided combination of binoculars and a movie camera. By using this, instead of directly viewing the patient, the microsurgeon (and usually his assistant as well) gains an enlarged stereoscopic view of the tiny vessels and other body parts that must be joined together.
The needles used resemble a baby’s eyelash and are difficult to see with the naked eye. The nylon thread, 0.018 millimeter (1/1400 of an inch) in diameter, a quarter the thickness of a human hair, is bonded to the needle so there is no need to thread it. The surgeons also use ultra-fine jewelers’ forceps, small vascular clamps, fine scissors and a special needle holder.
Individual knots must be used, as continuous stitching would prevent the necessary movement of a vessel with pulse. As many as 14 knots could be placed in a vessel about one millimeter (1/25 of an inch) in diameter. If you are familiar with hand sewing of cloth materials or leather, you can imagine how painstaking and time consuming it would be to tie such intricate microscopic knots. The technique was recently described as “probably one of the most difficult tasks in the world. The slightest tremor of the hand spells disaster.”
The Microsurgeon at Work
Watching the surgeons working at their task, one is impressed by the patience, concentration and coordination necessary to accomplish the desired result. Slow, gentle hand movements are required, so most microsurgeons avoid drinking coffee or alcohol before operating as these can produce tremors in the hands, imperceptible to the naked eye, but which appear like shaking when seen under the microscope.
Because of the techniques and special skills that are unique to this field, expert tutoring and years of training, practice and experiment are necessary. Australia is considered the world leader in microsurgery at the present time, which is fortunate, as statistics suggest that Australians tend to suffer more accidental amputations per person than any other industrialized Western nation.
Let us now ‘focus in’ on an operation to restore the completely severed palm of a hand to see what actually takes place during microsurgery. Skin, muscles, tendons, nerves, veins and arteries must all be reunited in a complex of microscopic knots.
Four arteries and four veins are rejoined to provide adequate circulation. Being thin walled, veins collapse and shrink and consequently can be very difficult to locate. Once located, it is essential for them to be cleaned out, trimmed and joined. If a length of vessel has been damaged, a bridging section from elsewhere in the body may be needed. By joining veins first and then arteries, blood loss can be lessened.
About 10 nerves to fingers are repaired, each nerve having five or six fiber bundles. Nine tendons and eight small muscles are also joined together. Finally, stitching is required for all skin structures. All together, about 180 microscopic stitches and 100 conventional ones have been inserted.
This particular operation lasted for about six hours. Depending on the objective, operations may vary in length from two to 20 hours. The replacement of just one finger takes four to six hours.
Emergency!—What to Do
Suddenly it happens! You, your loved one or your workmate accidentally amputates a finger, hand or leg. Do not panic! Place the severed part in a clean plastic bag (or rubber glove) and seal well so water cannot leak in. The part should then be kept cool—at about four to six degrees Celsius (39 to 43 degrees Fahrenheit). So place the bag in cold water containing lumps of ice and get it to the nearest hospital or microsurgical unit as quickly as possible. If a delay is involved, the part could be stored in a refrigerator, but not in a freezer. Do not pack the part in ice or immerse it in antiseptic solutions or disinfectants, as these destroy tissue and may make rejoining impossible. Do not even wash it, as it is important to keep the amputated part dry.
It is obviously a good idea to know the location of the nearest microsurgical unit. The Lancet, October 2, 1976, notes: “Regrettably, amputated digits are still being discarded by casualty officers when they should be cooled and dispatched with the patient to the nearest microsurgeon.”
The time periods for successful replantation vary for different members of the body. Amputated fingers have survived after 10 hours without effective cooling and over 30 hours when properly cooled. Experimenters replanted a dog’s leg after separation and refrigeration for 48 hours.
Limitations and Benefits
Success in reattachment is dependent on many factors. With a sharp guillotine-like amputation of a finger, there is close to a 100-percent chance of successful replantation. The prospects are reduced if tearing, crushing or other serious damage to tissue or bone has occurred. The microsurgeon may decide not to attempt the operation if the amputated part is too damaged. The patient’s condition is another possible limiting factor, as the person must be well enough to endure a long operation.
A recent survey in Australia showed a 70-percent success rate in replanted fingers and 80 percent in replanted arms. Another report showed that movement of replanted fingers was generally 80 percent of normal except for limitations of stretching of some joints. Exercise and physiotherapy generally are needed after the operation to restore function to the formerly amputated part. However, reattachment of amputated parts above the mid-forearm has so far produced disappointing results.
When a thumb has been amputated, great effort is made to restore it, as the thumb provides 40 percent of the efficiency of the hand. If the severed portion cannot be reattached, microsurgeons have been able to transfer the patient’s large toe. After the toe’s tendons, nerves, vessels and bones have been joined, the patient has feeling that is almost as good as it was in his original thumb.
“It’s funny how much like a thumb a big toe can look when it’s actually transferred,” one doctor commented. “It’s a fatter thumb than before, but that can be surgically improved.” To many people the thought of losing a big toe may not be too appealing, but, then again, a big toe is not needed for eating or writing or performing the myriad of tasks a thumb has to do each day.
After a short period of adjustment and training, a person can once again walk, run and share in sporting activities. A professional football player is one of a growing number of Australians who have big toes for “thumbs.”
People from all walks of life have derived benefit from the marvels of microsurgery. Take, for examples, the persons mentioned earlier. These are typical of hundreds of cases.
The little girl, now about a year older, has both fingers restored and her injured hand can scarcely be distinguished from the other. For the plumber, all fingers survived, but he does have some problems during cold weather. The two-year-old boy, now eight, runs, jumps and plays football normally. With regard to the boilermaker, his forearm was joined so well that he has taken up karate and can break roof tiles with his formerly cut-off arm.
Yes, microsurgery is a marvelous technique, able to accomplish a great deal of good for those in need. Even more wonderful, however, is the amazing healing capacity of the body. Surgeons may sew various body parts together, but inbuilt regeneration testifies to the greater wisdom of the One who designed our bodies. Appreciating this makes us echo the sentiments of the psalmist who said respectfully to our Grand Creator: “I shall laud you because in a fear-inspiring way I am wonderfully made.”—Ps. 139:14.