Table Of ContentCRC Handbook
of
Microsurgery
Volume I
Editor
Waldemar L. Olszewski, M.D., Ph.D.
Professor of Surgery
Department of Surgical Research
and Transplantology
Polish Academy of Sciences
Medical Research Center
Warsaw, Poland
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THE EDITOR
Waldemar L. Olszewski, M.D., Ph.D., is Professor of Surgery and Director of the
Department of Surgical Research and Transplantology Medical Research Center, Polish
Academy of Sciences in Warsaw, Poland. Dr. Olszewski graduated from the Medical Faculty,
Medical Academy in Warsaw, receiving the M.D. degree in 1954 and the Ph.D. degree in
1962. He obtained his surgical training in the Surgical Division, Warsaw City Hospital and
then the Department of Surgery, Medical Academy, Warsaw. He served as an Assistant
Professor at the Medical Academy and the Medical Research Center from 1962 to 1968 and
Associate Professor from 1968 to 1978. In 1978 he became Professor of Surgery. From
1962 to 1965 he was Deputy Director of the Department of Surgical Research, Medical
Research Center and it was in 1975 that he assumed the position of Director. Since 1974
he is associated with the laboratory of Hematology and Lymphology, Norwegian Radium
Hospital in Oslo, Norway.
Dr. Olszewski was a Research Fellow at the Royal Postgraduate Medical School in London
from 1962 to 1963 and at the Peter Bent Brigham Hospital, Harvard Medical School, Boston
in 1968 and 1969. Dr. Olszewski is a member of the European Society for Surgical Research,
International Lymphological Society, International Microsurgical Society, and the Interna
tional Transplantation Society. He served as President of the European Society for Surgical
Research from 1977 to 1978 and as a member of its Executive Committee until 1982. He
is a member of the Executive Committee of the International Lymphological Society, National
Delegate to the International Microsurgical Society, Associate Editor of Lymphology, Zeit-
schrift fur Experimentelle Chirurgie, and the Journal of Microsurgery. He has received
awards from the Polish Society of Surgeons, Polish Academy of Sciences, International
Lymphological Society, and the Purkynje Medical Society.
Dr. Olszewski is the author of more than 150 papers and has been the author or co-author
of 5 books. His major clinical interest relate to vascular and lymphatic surgery, and research
interests to the physiology of the lymphoid organs and immunoregulation.
ADVISORY BOARD
Sven-Erik Bergentz, M.D. Erminio Cariati, Prof. Dr.
Chairman Cátedra di Chirurgia Torácica
Department of Surgery Universita di Genova
Malmõ General Hospital Ospedale S. Martino
and Genova, Italy
Professor of Surgery
University of Lund
Malmõ, Sweden
Walter Brendel, Prof. Dr. Med., Dr. S. Karacsonyi, M.D., Ph.D.
Med. h. c. Professor of Surgery
Ludwig-Maximilians-Universitát München Semmelweis Orvostudomanyi Egyetem
Klinikum Grosshardern I. SZ. Sebészeti Klinika
Institut fur Chirurgische Forschung Budapest, Hungary
München, West Germany
T. S. Lie, Prof. Dr. Dr. h. c.
Chief and Professor
Section of Transplantation
Surgical University Clinic
University of Bonn
Bonn, West Germany
CONTRIBUTORS
Sven-Erik Bergentz, M.D. Carlos O. Esquivei, M.D.
Chairman Chief Resident
Department of Surgery Department of Surgery
Malino General Hospital University of California Davis
and Medical Center
Professor of Surgery Sacramento, California
University of Lund
Malrno, Sweden Jack M. Fein, M.D.
Associate Professor
Francesco Brunelli, M.D.
Department of Neurosurgery
Intern
Albert Einstein College of Medicine
Spedali Civili Brescia
Bronx, New York
2A Ortopedia
Brescia, Italy
Peter Haussmann, M.D.
Chief Surgeon
Giorgio Brunelli, M.D., Ph.D.
Department of Handsurgery, Plastic and
Professor
Reconstructive Surgery
Spedali Civili Brescia
DRK-Hospital Baden-Baden
Clinica Ortopédica Universita
Baden-Baden, West Germany
E.U.L.O.
2A Ortopedia
Brescia, Italy Jerzy Jablecki, M.D.
Resident of Surgery
John T. Burns, M.D., Ph.D. Department of Surgery
Assistant Professor Center of Replantation of Limbs,
Division of Orthopaedic Surgery Microsurgery and Surgery of Hand
Director, Orthopaedic Hand and Trzebnica k/Wroclaw, Poland
Microsurgery
University of Texas Medical School Janusz Kaczmarzyk, M.D.
Houston, Texas Resident of Surgery
Department of Surgery
Albert H. Capanna, M.D.
Center of Replantation of Limbs,
Neurosurgeon
Microsurgery and Surgery of Hand
Medical and Education Center
Trzebnica k/Wroclaw, Poland
Southern Nevada Memorial Hospital
Las Vegas, Nevada
H. B. Kapila, M.B.B.S., F.R.C.S.,
F.R.A.C.S., F.I.C.S.
Wallace H. J. Chang, M.D.
Surgical Fellow, Microsearch Foundation
Clinical Associate Professor of Plastic
of Australia
Surgery
Assistant to the Microsurgeon, Hornsby
Department of Plastic Surgery
and Ku-ring-gai Hospital
University of Washington
Assistant to the Microsurgeon, Mater
School of Medicine
Misericordiae Hospital
Seattle, Washington
Visiting Surgeon, Western Suburbs
Bernhard Endrich, Dr. Med. Hospital
Assistant Visiting Surgeon, Fairfield District
Department of Experimental Surgery Hospital
Surgical Center
Clinical Assistant in Surgery, Sydney
University of Heidelberg
Hospital
Heidelberg, F.R.G.
Sydney, Australia
P. J. Klopper, M.D. Paul Gabriel Lendvay, M.D.
Professor and Head Consultant, Plastic Reconstructive and
Lab. Experimental Surgery Microsurgeon
University of Amsterdam Sydney, Australia
Academic Hospital Wilhelmina Gasthuis
Amsterdam, The Netherlands Konrad Messmer, Dr. Med.
Professor and Chairman
Kazimierz Kobus, M.D., Ph.D. Department of Experimental Surgery
Associate Professor of Plastic Surgery Surgical Center
Medical Center of Postgraduate Education University of Heidelberg
Heidelberg, F.R.G.
Warsaw, Poland
and
Hospital of Plastic Surgery Hanno Millesi, M.D.
Polanica-Zdrój, Poland Professor and Head
Department of Plastic and Reconstructive
Surgery
Ryszard Kociçba, M.D., Ph.D.
1st Surgical Clinic
Associate Professor and Director
University of Vienna Medical School
Department of Surgery
and
Center of Replantation of Limbs,
Head
Microsurgery and Surgery of Hand
Ludwig-Boltzmann-Institute for
Trzebnica k/Wroc/aw, Poland
Experimental Plastic Surgery
Vienna, Austria
Willy J. Kort, Ph.D.
Erasmus Faculty
Michael Patkin, MBBS (Melb.), FRCS
Laboratory for Experimental Surgery
Eng., FRCS Ed., FRACS
Rotterdam, The Netherlands
Surgeon
Whyalla Hospital
Henryk Kus, M.D.
Whyalla, South Australia
Associate Professor of Surgery
Chief of the Chair and Clinic for
Maurizio Petrolati, M.D.
Traumatological Surgery
Plastic and Hand Surgeon
Medical Academy in Wroc/aw, Poland
Department of Plastic and Hand Surgery
Ospedale-Civile Legnano (Milano)
Daniel Y. Lahr, M.D.
Legnano (Milano), Italy
Medical Director
Davis & Geek Medical Research
Judith J. Petry, M.D.
American Cyanamid Company
Assistant Professor
Wayne, New Jersey
Department of Surgery
Division of Plastic Surgery
Deodat Lapczynski, M.D. University of Massachusetts
Resident of Surgery Medical Center
Center of Replantation of Limbs, Worcester, Massachusetts
Microsurgery and Surgery of Hand
Trzebnica k/Wroc/aw, Poland Charles L. Puckett, M.D.
Professor and Chairman
Kyu Chang Lee, M.D. Division of Plastic Surgery
Professor and Chairman Department of Surgery
Department of Neurosurgery University of Missouri
Yonsei University College of Medicine Health Sciences Center
Seoul, South Korea Columbia, Missouri
Pier Luigi Raimondi, M.D. Shuhei Torii, M.D.
Plastic and Hand Surgeon Assistant Professor
Department of Plastic and Hand Surgery Plastic and Microsurgical Division
Ospedale-Civile di Legnano (Milano) Department of Orthopedic Surgery
Legnano (Milano), Italy Nagoya University School of Medicine
Nagoya, Japan
John F. Reinisch, M.D.
Assistant Professor
Tsu-Min Tsai, M.D.
Department of Surgery
Clinical Instructor of Surgery
Division of Plastic Surgery
"Orthopaedics"
University of Missouri
University of Louisville
Health Sciences Center
Louisville, Kentucky
Columbia, Missouri
Jacques C. van der Meulen, M.D.,
Laurent Sedel, M.D.
Ph.D.
Professeur Agrégé
Department of Plastic and Reconstructive
Chirurgien des Hôpitaux de Paris
Surgery
Hôpital Saint Louis
University Hospital Rotterdam-Dijkzigt
Paris, France
Rotterdam, The Netherlands
Arlan R. Smith, M.D., Ph.D.
Academisch Ziekenhuis Dijkzigt D. Vickers, M.B.B.S., F.R.A.C.S.
Rotterdam, The Netherlands Consultant Orthopaedic Surgeon and
Microsurgeon
Kauko A. Solonen, M.D. Royal Brisbane Hospital
Professor and
Chief Surgeon Royal Childrens Hospital
The Orthopaedic Hospital of the Invalid Brisbane, Australia
Foundation
Helsinki, Finland Simo K. Vilkki, M.D.
Hand- and Microsurgeon, Orthopaedic
G. Jan Son ne veld, M.D. Surgeon
Department of Plastic and Reconstructive Department of Hand Surgery
Surgery The Orthopaedic Hospital of the Invalid
University Hospital Rotterdam-Dijkzigt Foundation
Rotterdam, The Netherlands Helsinki, Finland
John J. S tangei, M.D. Lídia Wilowska-Kociçba, M.D.
Section of Reproductive Endocrinology Head
and Infertility Department of Anaesthesiology
Division of Obstetrics and Gynecology Center of Replantation of Limbs,
New York Medical College Microsurgery and Surgery of Hand
Valhalla, New York Trzebnica k/Wrooiaw, Poland
TABLE OF CONTENTS
Introduction 1
GENERAL PROBLEMS IN MICROSURGERY
Microsurgery, Microinstruments, and Microsutures 5
Ergonomics and Microsurgery 13
Microsurgery Instruments — A New Philosophy 27
Microsurgery and Research 37
Microvascular Surgery: Coagulation, Fibrinolysis, and Principles
for Antithrombotic Therapy 49
Coagulation and Fibrinolytic Considerations for the Microvascular
Surgeon 65
Problems in Intravascular Coagulation in Microsurgery 73
Quantitative Analysis of the Microcirculation in the Awake Animal 79
NEUROLOGICAL MICROSURGERY
The Role of Microsurgery in the Treatment of Peripheral Nerve Injuries 109
Microsurgical Reconstruction of Peripheral Nerves — Own Experience 139
Surgical Treatment of Posttraumatic Lesions of the Brachial Plexus 157
Microsurgical Techniques of Brachial Plexus Neurotization 163
Microsurgical Treatment of Isolated Lesions of the Motor Branches
in the Hand and Forearm 173
Obstetric Plexus Palsy: Early Microsurgical Treatment 201
Microvascular Surgery for Cerebrovascular Disease 219
Microanastomosis and Total Bypass of the Cerebral Venous Sinuses
and Torcular Herophilus 241
Extracranial-Intracranial Microanastomosis Cerebral Revascularization
Operations 247
Microsurgical Treatment of Intracranial Arachnoid Cysts 251
Microlumbar Discectomy 259
Nerve Regeneration 263
Nerve Suturing and Nerve Grafting 275
Greater Omentum Transfer in X-Ray Lesions of the Brachial Plexus 289
Neurotization of Avulsed Roots of the Brachial Plexus by Means of
Anterior Nerves of the Cervical Plexus 295
REPLANTATION SURGERY
Replantation Surgery 301
Second Toe Autotransplantation to Replace Missing Fingers 317
Some Aspects of Upper Limb and Finger Replantation 341
Replantation of Amputations Involving the Upper Extremity 371
A Technique for the Replantation of Avulsed Thumbs 389
Toe-to-Hand Transfer 403
Toe-to-Hand Free Tissue Transfer 421
Dorsalis Pedis Flap 437
Postoperative Monitoring in Reconstructive Microsurgery with
Special Respect to Transcutaneous Oxygen Measurements 469
Ischemia Time Influencing Free Skin Flap Survival 479
INDEX 487
Volume I 1
INTRODUCTION
Wâldemar L. Olszewski
Microsurgery has become a technique for expanding the visual horizons of the surgeon.
It has extended the repertoire of his potentialities not only to treat the diseases but also to
improve function of organs or parts of the body, and has changed the ways of clinical
thinking by turning untreatable pathologies into treatable ones. We are witnessing a total
commitment to microsurgery by all surgeons. Microsurgical techniques have become a part
of every surgeon's training. They have become clinically applicable in every surgical spe
ciality. This situation has created a need for teaching and training not only in basic micro
surgical techniques but also in microsurgery in a given clinical speciality.
The progression from laboratory training into clinical surgery is a difficult one. Fast and
extensive progress has been made in microsurgical techniques and improvement of arma
mentarium, however, the knowledge of physiology of the body microstructures, their re
sponse to surgical trauma, healing process, and changes in blood coagulation and
microcirculation still remain far behind. The diagnostic procedures usually used for detection
of major pathologies are still not entirely suitable for detection of pathological changes of
structures the size of a 1-mm diameter artery or a small nerve branch. However, experimental
and clinical experience in these areas is accumulating rapidly and we may soon expect a
breakthrough in terms of integration of technicalities and open physiology in microsurgery.
In order to promote this trend, we have made an attempt to put together in two volumes
the experiences of clinical microsurgeons, experimentalists, and physiologists. Several recent
books on microsurgery have been presented in a synoptical form. This type of presentation
is extremely useful for newcomers into the field, however, it does not give an insight into
the nuances of microsurgical techniques and physiological events accompanying microsurg
ical operations. The premise upon which this book was written was that only and exclusively
personal experience in microsurgical operations and their effects on tissue or organ function
could be presented. The individual chapters were written by designers of microsurgical
instruments and materials, specialists in coagulation, microcirculation, and basic micro
surgical procedures, neurosurgeons, plastic and vascular surgeons, laryngologists, ophthal
mologists, gynecologists, experimental surgeons, and physiologists. Each of us has described
in our own words what we have done ourselves in microsurgery and what we know best,
without referring much to the literature. This constitutes the main value of the Handbook
of Microsurgery.
