Microsurgery involves operating on small structures using a microscope. It was first used successfully in the 1960s to repair blood vessels. Key equipment includes microscopes and fine instruments. Microsurgery techniques are used to repair blood vessels, nerves, and tendons. Proper pre-op preparation and post-op care, such as monitoring for vascular complications, are important for successful microsurgery outcomes like replantation of amputated body parts.

1. Basics of
Microsurgery
Dr. Bipul Borthakur
Professor,
Dept of Orthopaedics, SMCH

2. DEFINITION
• Microsurgery
The specialised technique of using a compound
microscope when operating on small and intricate
structures of the human body
The procedure is also defined as sewing together of
tendons, nerves or blood vessels to correct a disease,
injury or congenital defect

3. HISTORY
 1stmicrosurgery,using amicroscopeto repair
bloodvessels
JulesJacobsonofUniversity of Vermontin1960
 1st successfulreplantation
1964by Harry Bunke
Rabbit'sear

4. EQUIPMENT
 MICROSCOPE
5–40x
Lowermagnification
· Identify&expose structures
Highermagnification
· Microsurgical repair
 SURGICAL LOUPES
2–6x

5. INSTRUMENTS
 Forceps
 Needleholders
 Scissors
 Vascularclamps
 controllingbleeding
 clampapplicators
 Irrigators
 washingstructures
 Vesseldilators
 openingupcutendofvessel

6. SUTURES
 Diameter(gauge)rangesinsize&dependson procedure &tissue
 2‐0(0.3mm)‐6‐0(0.07mm)
 9‐0(0.03mm)‐12‐0(0.001mm)forMS
 AbsorbablevsNon‐absorbable
 Natural/synthetic
 Most commonly used- Nylon and Prolene
 When not in use the needle can be placed in the foam in an inclined
position ready for easy lifting

7. TECHNIQUES
 BLOOD VESSEL REPAIR
 Anastomoses
· End‐to‐End(between two cutends)
· End‐to‐Side (connectionof one cutendto thewall)
 Expose thevessel
 Irrigation
 secured withclamps
 Contrast material placedbehind
 1stsuture‐fullthickness
 2nd &3rdsutures ‐120°

8. TECHNIQUES
 End to End repair
Arteries 1mm
· between5&8 stitches
veins1mm
· between 7&10
clamps arereleased
 End to Side repair
Oval‐shapedholeiscuton recipientvessel

9. NERVE REPAIR
 Processofconnectingtwocutendsofnerve
 Neurorrhaphy /Nerveanastomosis
 Peripheralnerves
 Bunchesofnervefiberscalledfascicles
 Enclosed byperineurium
 Epineuriumistheouterlayer
 Nerverepair
 Suturingofepineuriumonly
 Perineuriumonly
 Through bothlayers

10. PRE OP PREPARATION
 Investigations
Blood: CBP,L/RFT, Clotting profile…
X‐rays,CXR
ECG
Doppler /Arteriogram
 Advice
No smoking
No drinking alcohol,coffee

11. • Donor Site
No blood takingorIV access
Prevent injury
Marking ofskin areaby surgeon
+/‐preparethedonor siteof skin graft
• RecipientSite
debrides all necroticor slough tissue.
+/‐Ensures woundswab for culture is–ve

12. REPLANTATION

13. REPLANTATION
 Surgicalattachment
 Revascularization of a body
partthathasbeen
completely amputated

14. REVASCULARIZATION
 Restoration of circulation to a devascularizedbut
not completely amputatedpart

16. PRESERVATION OF
AMPUTATED PARTS
 Placedinabag afterbeing
wrapped in an sterile gauze
dampened with NS
 Bag placed in container &
submerged iniceNS bath
to maintain atempof 4°C
 Labeling
 Never placedina hypotonic or
hypertonic solution

17. PRESERVATION OF
AMPUTATED PARTS
 Don’t try to detach
 Don’t stretch
 Moistened with NS
 Loosen dressing &
crepe
 Cool with ½ ice &½H2O
in plastic bag
 Support with splint

18. RELEVANT HISTORY
 Mechanism ofinjury
Avulsion orcrush
 Time ofinjury
Ischemic time
 Emergency treatment rendered, including
careprovidedto amputatedpart

19. HISTORY
 Patient’s age
 Hand dominance
 Occupation/ vocational demands&
expectations
 Previous hand injuriesor disability
 Other majorinjuries
 Medical/psychiatricconditions that may
precludereplantation

20. PHYSICAL EXAMINATION
 Location (level) ofamputation
 Single or multipleinjurylevelsinthe
extremity
 Single or multipleamputated parts
 Condition of amputated part (sign or crush or
avulsion)
 Condition of the amputation stump

21. SEQUENCE FOR
REPLANTATION
 Wound debridement
 Identification ofarteries,
veins, nerves &tendons
 Bone stabilization
 Extensor tendonrepair
 Flexor tendonrepair
 Vascular anastomosis
 Nerve repair
 Skin closure

22. METHODS OF BONY
STABILISATION
 K wireor intraosseous wires
can be placed rapidly & easily
 Lag screw fixation or miniplate & screws
 Plate fixation
major limbreplantation

23. POST OP CARE
 Completebedrest
 Keepwarm
1. warmRoom(
~26ºC)
2. lamp treatment?
 Bedcradle
 Support operatedlimb
 Avoid torsionof pedicle

24. POST OP CARE
 Elevation
Heart level
Above heartlevel
One pillow
 VitalSigns
BP/P
BodyTemp.
I/O

25. POST OP CARE
 IVF
 Hydration
 Foley’scatheter
 measureoutput
 NPO
 Pain control
 (No Punctureon affectedsite)
 Medication
 Dextran40
 Aspirin
 Persantin
 Analgesic
 Antibiotics

26. MONITORING
 Colour
 CapillaryRefill
 TissueTurgor
 Temperature
 Doppler
 SpO2
 Pin Prick

27. MONITORING
 Colour
Normal  Pink
Arterial fail  Pale
Venous fail Cyanotic
 Capillary Refill
Normal  1‐2 sec
Arterial fail  Slow
Venous fail Fast

28. MONITORING
 Temperature
Normal:30‐37ºC
Replanted orflap: +/‐2‐3ºC
?By touch
By ThermoScan
Arterial /venousthrombosis
· fallbelow30ºC,differential2.5ºC
Arterial thrombosis/ Venousthrombosis:
· rapidfall3ºC/slowly fall1‐2ºC

29. MONITORING
 Doppler
Vascular Doppler
ImplantableDoppler
Probe
Laser DopplerFlow
meter
 SpO2
 Normal: ~>90%
 Vascularcompromise
Sudden fall
Not on 100% O2 given

30. MONITORING : PIN PRICK
 By Surgeon
25 gaugeneedle
No.11blade
 Heparin
promotebleeding
 Normal:Brightredblood
 Slowtostartbleeding
 Bleeds ashort
 ArterialOcclusion: Serum
No bleeding
 Venous Occlusion:
Bleeds brisk
Bleedsalong time

31. THANK YOU
“jātasya hi dhruvo mṛtyurdhruvaṃ janma mṛtasya ca
tasmādaparihārye’rthe na tvaṃ śocitumarhasi”
“Death is certain for the born, and re-birth is certain for the
dead; therefore you should not feel grief for what is
inevitable.”