Microsurgery
Encyclopedia
Microsurgery is a general term for surgery
requiring an operating microscope
. The most obvious developments have been procedures developed to allow anastomosis
of successively smaller blood vessels and nerves (typically 1 mm in diameter) which have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Although microsurgery is used mostly in plastic surgery
, microsurgical techniques are utilized by several specialties today, especially those involved in reconstructive surgery
such as: general surgery
, ophthalmology
, orthopedic surgery
, gynecological surgery
, otolaryngology
, neurosurgery
, oral and maxillofacial surgery
, and pediatric surgery
.
Gradually the operating microscope began to be used for ear operations. In the 1950s many otologists began to use it in the fenestration operation, usually to perfect the opening of the fenestra in the lateral semicircular canal. The revival of the stapes mobilization operation by Rosen, in 1953, made the use of the microscope mandatory, in spite of the fact that it was not used by the originators of the technique, Kessel (1878), Boucheron (1888) and Miot (1890). Mastoidectomies began to be performed with the surgical microscope and so were the tympanoplasty techniques that became known in the early 1950s. The stapes mobilization operation had varying results and was soon replaced by stapedectomy, first described by John Shea, Jr.; this was an operation that was always performed with the microscope.
Today neurosurgeons are very proud to use microscopes in their procedures. But it was not always so. In the late 1950s William House began to explore new techniques for temporal bone surgery. He developed the middle fossa approach and perfected the translabyrinthine approach and began to use these techniques to remove acoustic nerve tumors. The first neurosurgeon to make use of the surgical microscope was Prof. Gazi Yaşargill in Zürich, Switzerland.
The advances in the techniques and technology that popularized microsurgery began in the early 1960s to involve other medical areas. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by vascular surgeon, Jules Jacobson, of the University of Vermont in 1960. Using an operating microscope, he performed coupling of vessels as small as 1.4 mm and coined the term microsurgery. Hand surgeons at the University of Louisville (KY), Drs. Harold Kleinert and Mort Kasdan, performed the first revascularization of a partial digital amputation in 1963.
Nakayama, a Japanese cardiothoracic surgeon, reported the first true series of microsurgical free-tissue transfers using vascularized intestinal segments to the neck for esophageal reconstruction after cancer resections using 3-4mm vessels.
Contemporary reconstructive microsurgery was introduced by an American plastic surgeon, Dr. Harry J. Buncke
. In 1964, Buncke reported a rabbit
ear replantation, famously using a garage as a lab/operating theatre and home-made instruments.
This was the first report of successfully using blood vessels 1 millimeter in size. In 1966, Buncke used microsurgery to transplant a primate's great toe to its hand.
During the late sixties and early 1970s, plastic surgeons ushered in many new microsurgical innovations that were previously unimaginable. The first human microsurgical transplantation of the second toe to thumb was performed in February 1966 by Dr. Dong-yue Yang and Yu-dong Gu, in Shanghai China. . great toe (big toe) to thumb was performed in April 1968 by Mr. John Cobbett, in England. In Australia work by Dr. Ian Taylor saw new techniques developed to reconstruct head and neck cancer defects with living bone from the hip or the fibula.
Although primarily developed and used by plastic surgeons, a number of surgical specialties now use microsurgical techniques. Otolaryngologists (ear, nose, and throat doctors) perform microsurgery on structures of the inner ear or the vocal cords. Maxillofacial surgeons
and Otolaryngologists
use microsurgical techniques when reconstructing head and neck cancer
patients. Cataract surgery, corneal transplants, and treatment of conditions like glaucoma are performed by ophthalmologists. Urologists and gynecologists can frequently now reverse vasectomies and tubal ligations to restore fertility.
s and thumb
s are the most common but the ear
, scalp
, nose
, face
, arm
and penis
have all been replanted. Generally replantation involves restoring blood flow through arteries
and vein
s, restoring the bony skeleton and connecting tendons and nerves as required.
Initially, when the techniques were developed to make replantation possible, success was defined in terms of a survival of the amputated part alone. However, as more experience was gained in this field, surgeons specializing in replantation began to understand that survival of the amputated piece was not enough to ensure success of the replant. In this way, functional demands of the amputated specimen became paramount in guiding which amputated pieces should and should not be replanted. Additional concerns about the patients ability to tolerate the long rehabilitation process that is necessary after replantation both on physical and psychological levels also became important. So, when fingers are amputated, for instance, a replantation surgeon must seriously consider the contribution of the finger to the overall function of the hand. In this way, every attempt will be made to salvage an amputated thumb, since a great deal of hand function is dependent on the thumb, while an index finger or small finger may not be replanted, depending on the individual needs of the patient and the ability of the patient to tolerate a long surgery and a long course of rehabilitation.
However, if an amputated specimen is not able to be replanted to its original location entirely, this does not mean that the specimen is unreplantable. In fact, replantation surgeons have learned that only a piece or a portion may be necessary to obtain a functional result, or especially in the case of multiple amputated fingers, a finger or fingers may be transposed to a more useful location to obtain a more functional result. This concept is called "spare parts" surgery.
The first microsurgical experiments (porto-caval anastomosis in the rat) were performed by Dr. Sun Lee (pioneer of microsurgery) at the University of Pittsburgh in 1958. After a short time, many models of organ tranplants in rat and mice have been established. Today, virtually every rat or mouse organ can be transplanted with relative high success rate.
Microsurgery was also important to develop new techniques of transplantation, that would be later performed in humans. In addition, it allows reconstruction of small arteries in clinical organ transplantation (e.g. accessory arteries in cadaver liver transplantation, polar arteries in renal transplantation and in living liver donor transplantation).
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
requiring an operating microscope
Operating microscope
An operating microscope is an optical microscope specifically designed to be used in a surgical setting, typically to perform microsurgery.Design features of an operating microscope are: magnification typically in the range from 4x-40x, components that are easy to sterilize or disinfect in order to...
. The most obvious developments have been procedures developed to allow anastomosis
Anastomosis
An anastomosis is the reconnection of two streams that previously branched out, such as blood vessels or leaf veins. The term is used in medicine, biology, mycology and geology....
of successively smaller blood vessels and nerves (typically 1 mm in diameter) which have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Although microsurgery is used mostly in plastic surgery
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...
, microsurgical techniques are utilized by several specialties today, especially those involved in reconstructive surgery
Reconstructive surgery
Reconstructive surgery is, in its broadest sense, the use of surgery to restore the form and function of the body, although Maxillo-Facial Surgeons, Plastic Surgeons and Otolaryngologists do reconstructive surgery on faces after trauma and to reconstruct the head and neck after cancer.Other...
such as: general surgery
General surgery
General surgery, despite its name, is a surgical specialty that focuses on abdominal organs, e.g., intestines including esophagus, stomach, small bowel, colon, liver, pancreas, gallbladder and bile ducts, and often the thyroid gland . They also deal with diseases involving the skin, breast, soft...
, ophthalmology
Ophthalmology
Ophthalmology is the branch of medicine that deals with the anatomy, physiology and diseases of the eye. An ophthalmologist is a specialist in medical and surgical eye problems...
, orthopedic surgery
Orthopedic surgery
Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
, gynecological surgery
Gynecological surgery
Gynecological surgery refers to surgery on the female reproductive system. Gynecological surgery is usually performed by gynecologists. It includes procedures for benign conditions, cancer, infertility, and incontinence, and various other conditions. Gynecological surgery may occasionally be...
, otolaryngology
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
, neurosurgery
Neurosurgery
Neurosurgery is the medical specialty concerned with the prevention, diagnosis, treatment, and rehabilitation of disorders which affect any portion of the nervous system including the brain, spine, spinal cord, peripheral nerves, and extra-cranial cerebrovascular system.-In the United States:In...
, oral and maxillofacial surgery
Oral and maxillofacial surgery
Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
, and pediatric surgery
Pediatric surgery
Pediatric surgery or paediatric surgery is a subspecialty of surgery involving the surgery of fetuses, infants, children, adolescents, and young adults...
.
History
The otolaryngologists were the first physicians to use microsurgical techniques. A Swedish otolaryngologist, Carl-Olof Siggesson Nylén (1892–1978), was the father of microsurgery. In 1921, in the University of Stockholm, he built the first surgical microscope, a modified monocular Brinell-Leitz microscope. At first he used it for operations in animals. In November of the same year he used it to operate on a patient with chronic otitis who had a labyrinthine fistula. Nylen's microscope was soon replaced by a binocular microscope, developed in 1922 by his colleague Gunnar Holmgren (1875–1954).Gradually the operating microscope began to be used for ear operations. In the 1950s many otologists began to use it in the fenestration operation, usually to perfect the opening of the fenestra in the lateral semicircular canal. The revival of the stapes mobilization operation by Rosen, in 1953, made the use of the microscope mandatory, in spite of the fact that it was not used by the originators of the technique, Kessel (1878), Boucheron (1888) and Miot (1890). Mastoidectomies began to be performed with the surgical microscope and so were the tympanoplasty techniques that became known in the early 1950s. The stapes mobilization operation had varying results and was soon replaced by stapedectomy, first described by John Shea, Jr.; this was an operation that was always performed with the microscope.
Today neurosurgeons are very proud to use microscopes in their procedures. But it was not always so. In the late 1950s William House began to explore new techniques for temporal bone surgery. He developed the middle fossa approach and perfected the translabyrinthine approach and began to use these techniques to remove acoustic nerve tumors. The first neurosurgeon to make use of the surgical microscope was Prof. Gazi Yaşargill in Zürich, Switzerland.
The advances in the techniques and technology that popularized microsurgery began in the early 1960s to involve other medical areas. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by vascular surgeon, Jules Jacobson, of the University of Vermont in 1960. Using an operating microscope, he performed coupling of vessels as small as 1.4 mm and coined the term microsurgery. Hand surgeons at the University of Louisville (KY), Drs. Harold Kleinert and Mort Kasdan, performed the first revascularization of a partial digital amputation in 1963.
Nakayama, a Japanese cardiothoracic surgeon, reported the first true series of microsurgical free-tissue transfers using vascularized intestinal segments to the neck for esophageal reconstruction after cancer resections using 3-4mm vessels.
Contemporary reconstructive microsurgery was introduced by an American plastic surgeon, Dr. Harry J. Buncke
Harry J. Buncke
'Harry J. Buncke', MD was an American plastic surgeon who has been called "The Father of Microsurgery" for his contributions in the history and development of reconstructive microsurgical procedures...
. In 1964, Buncke reported a rabbit
Rabbit
Rabbits are small mammals in the family Leporidae of the order Lagomorpha, found in several parts of the world...
ear replantation, famously using a garage as a lab/operating theatre and home-made instruments.
This was the first report of successfully using blood vessels 1 millimeter in size. In 1966, Buncke used microsurgery to transplant a primate's great toe to its hand.
During the late sixties and early 1970s, plastic surgeons ushered in many new microsurgical innovations that were previously unimaginable. The first human microsurgical transplantation of the second toe to thumb was performed in February 1966 by Dr. Dong-yue Yang and Yu-dong Gu, in Shanghai China. . great toe (big toe) to thumb was performed in April 1968 by Mr. John Cobbett, in England. In Australia work by Dr. Ian Taylor saw new techniques developed to reconstruct head and neck cancer defects with living bone from the hip or the fibula.
Although primarily developed and used by plastic surgeons, a number of surgical specialties now use microsurgical techniques. Otolaryngologists (ear, nose, and throat doctors) perform microsurgery on structures of the inner ear or the vocal cords. Maxillofacial surgeons
Oral and maxillofacial surgery
Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
and Otolaryngologists
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
use microsurgical techniques when reconstructing head and neck cancer
Head and neck cancer
Head and neck cancer refers to a group of biologically similar cancers that start in the upper aerodigestive tract, including the lip, oral cavity , nasal cavity , paranasal sinuses, pharynx, and larynx. 90% of head and neck cancers are squamous cell carcinomas , originating from the mucosal lining...
patients. Cataract surgery, corneal transplants, and treatment of conditions like glaucoma are performed by ophthalmologists. Urologists and gynecologists can frequently now reverse vasectomies and tubal ligations to restore fertility.
Free tissue transfer
Free tissue transfer is a surgical reconstructive procedure using microsurgery. A region of "donor" tissue is selected that can be isolated on a feeding artery and vein; this tissue is usually a composite of several tissue types (e.g., skin, muscle, fat, bone). Common donor regions include the rectus abdominis muscle, latissimus dorsi muscle, fibula, radial forearm bone and skin, and lateral arm skin. The composite tissue is transferred (moved as a free flap of tissue) to the region on the patient requiring reconstruction (e.g., mandible after oral cancer resection, breast after cancer resection, traumatic tissue loss, congenital tissue absence). The vessels that supply the free flap are anastomosed with microsurgery to matching vessels (artery and vein) in the reconstructive site. The procedure was first done in the early 1970s and has become a popular "one-stage" (single operation) procedure for many surgical reconstructive applications.Replantation
Replantation is the reattachment of a completely detached body part. FingerFinger
A finger is a limb of the human body and a type of digit, an organ of manipulation and sensation found in the hands of humans and other primates....
s and thumb
Thumb
The thumb is the first digit of the hand. When a person is standing in the medical anatomical position , the thumb is the lateral-most digit...
s are the most common but the ear
Ear
The ear is the organ that detects sound. It not only receives sound, but also aids in balance and body position. The ear is part of the auditory system....
, scalp
Scalp
The scalp is the anatomical area bordered by the face anteriorly and the neck to the sides and posteriorly.-Layers:It is usually described as having five layers, which can conveniently be remembered as a mnemonic:...
, nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...
, face
Face
The face is a central sense organ complex, for those animals that have one, normally on the ventral surface of the head, and can, depending on the definition in the human case, include the hair, forehead, eyebrow, eyelashes, eyes, nose, ears, cheeks, mouth, lips, philtrum, temple, teeth, skin, and...
, arm
Arm
In human anatomy, the arm is the part of the upper limb between the shoulder and the elbow joints. In other animals, the term arm can also be used for analogous structures, such as one of the paired forelimbs of a four-legged animal or the arms of cephalopods...
and penis
Penis
The penis is a biological feature of male animals including both vertebrates and invertebrates...
have all been replanted. Generally replantation involves restoring blood flow through arteries
Artery
Arteries are blood vessels that carry blood away from the heart. This blood is normally oxygenated, exceptions made for the pulmonary and umbilical arteries....
and vein
Vein
In the circulatory system, veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart...
s, restoring the bony skeleton and connecting tendons and nerves as required.
Initially, when the techniques were developed to make replantation possible, success was defined in terms of a survival of the amputated part alone. However, as more experience was gained in this field, surgeons specializing in replantation began to understand that survival of the amputated piece was not enough to ensure success of the replant. In this way, functional demands of the amputated specimen became paramount in guiding which amputated pieces should and should not be replanted. Additional concerns about the patients ability to tolerate the long rehabilitation process that is necessary after replantation both on physical and psychological levels also became important. So, when fingers are amputated, for instance, a replantation surgeon must seriously consider the contribution of the finger to the overall function of the hand. In this way, every attempt will be made to salvage an amputated thumb, since a great deal of hand function is dependent on the thumb, while an index finger or small finger may not be replanted, depending on the individual needs of the patient and the ability of the patient to tolerate a long surgery and a long course of rehabilitation.
However, if an amputated specimen is not able to be replanted to its original location entirely, this does not mean that the specimen is unreplantable. In fact, replantation surgeons have learned that only a piece or a portion may be necessary to obtain a functional result, or especially in the case of multiple amputated fingers, a finger or fingers may be transposed to a more useful location to obtain a more functional result. This concept is called "spare parts" surgery.
Transplantation
Microsurgical techniques have played a crucial role in the development of transplantation immunological research because it allowed the use of rodents models, which are more appropriate for transplantation research (there are more reagents, monoclonal antibodies, knockout animals, and other immunological tools for mice and rats than other species). Before it was introduced, transplant immunology was studied in rodents using the skin transplantation model, which is limited by the fact it is not vascularized. Thus, microsurgery represents the link between surgery and transplant immunological research.The first microsurgical experiments (porto-caval anastomosis in the rat) were performed by Dr. Sun Lee (pioneer of microsurgery) at the University of Pittsburgh in 1958. After a short time, many models of organ tranplants in rat and mice have been established. Today, virtually every rat or mouse organ can be transplanted with relative high success rate.
Microsurgery was also important to develop new techniques of transplantation, that would be later performed in humans. In addition, it allows reconstruction of small arteries in clinical organ transplantation (e.g. accessory arteries in cadaver liver transplantation, polar arteries in renal transplantation and in living liver donor transplantation).