MICROSURGERY (grech, mikros small + surgery) — a recent trend in various fields of surgery, method to-rogo are operative measures with use of optical means, special tools and the thinnest suture material.
at the end of 19 century the first attempts to apply a microscope to operations were made. Operations with use of a microscope were performed in the beginning only by ophthalmologists and otorhinolaryngologists. Further the operative microscope and microsurgical methods began to apply in neurosurgery. Naylen (S. of Nylen) in 1921 for the first time used a special operative microscope for ear operations. From now on thin microsurgical instruments and a suture material began to be created. From 70th of operation with use of magnifying optics begin to be applied in surgery of vessels, in plastic surgery, at organ and tissue transplantation, in gynecology, urology and other areas. In surgery of vessels microsurgeries were for the first time executed by Jacobson (J. Jacobson, 1960); the same author possesses work on experimental microsurgery of vessels of small diameter. In neurosurgery implementation of a new method is connected with a name of Rand (R. W. Rand, 1967), to-ry made an average brain artery operation of a thrombectomy. Ancestors of intracerebral microsurgery were Longkhid and the Pool (JV. Longheed, J. L. Pool, 1966) which for the first time applied microsurgical methods concerning intracranial aneurisms.
Experimental M. originates since 1960. Are engaged in it in each microsurgical center, and work is conducted in two directions: training and training of the surgeon; research of new opportunities of a method: development and improvement of new tools, a suture material, approbation of new techniques (use of the laser and ultrasound), creation on a lab. animals of the small size of new pilot models (renal transplantation, studying of artificial circulation on rats etc.).
The international congresses and symposiums on M. are held since 1966. In a number of the countries the centers M. with several specialized departments (an injury of a brush, plastic surgery, neurosurgery, gynecology, urology), department of rehabilitation and physical therapy and experimental laboratory function. Basic purpose of such centers — rendering the emergency surgical help to victims at an injury of a brush and fingers since replantation of fingers, brushes, extremities, it is possible to carry out, only using microsurgical methods.
In the USSR the first a wedge, M.'s department was organized in 1973 in All-Union research in-those clinical and experimental surgery of M3 of the USSR (since 1980 — All-Union scientific center of surgery of the USSR Academy of Medical Sciences) in Moscow. There were centers M. in a number of the large cities and the capitals of federal republics later; their purpose — first of all rendering the emergency surgical help to patients with an injury of a brush and fingers, replantation of fingers and a brush, carrying out operations on limf, vessels.
Modern operative microscope (see. Operative microscope ) provides 40 — 50-fold blowup of an object. The microscope is located on special brackets, has two appearance of fastening — by means of the support standing on a floor and a ceiling support, to-rye allow to move it by means of an electric motor. For traffic control of a microscope, and also change of extent of blowup of an object and focusing there is a special pedal or the manual operating console. Carrying out microsurgical manipulations requires the smooth movement of a microscope and its instant fixing on the chosen point. An object vertically and at an angle 5 — 16 ° is lit (coaxial lighting). The last allows to create big relief to the structures seen in a surgery field. A lens of a microscope with the moving focal length (zoom lens). During the carrying out operations on vessels and other areas (except operations in the eyes and ENT organs) it is necessary that two surgeons at the same time could see a surgery field (tsvetn. fig. 1). Counting on it all modern operative microscopes are equipped. The possibility of registration by means of a photo and movie camera, and also connection of a television camera allows to give studies and scientific research.
Except an operative microscope, for microsurgeries it is possible to use the magnifying glass points providing 2 — 7-fold increase. Nek-ry models of a magnifying glass points (e.g., the LOMO model, Leningrad) have the special lighting provided with a fiber light guide.
Microsurgical instruments are extremely various; they are created especially for each operation and even for its separate stage. In the late sixties began to be made special tools for M. of vessels; they can be divided into four groups. Separating — scalpels, scalpels spears, shaving edges in the special holder, diamond scalpels (tsvetn. fig. 2), a microscissors having handles in the form of springs and the branches of various form adapted for different stages of operation. The holding tools — different ranorasshiritel, hooks. Accessory and special instruments — tweezers of different function, Bougie, conductors, clip-on earrings, artery forceps, needle holders (tsvetn. fig. 3).
To a suture material in microvascular surgery impose especially high requirements. Atraumatic needles with synthetic thread 16 — 25 microns thick are applied. Thickness of a needle of 70 — 130 microns, length of 3 — 6 mm, a needle is bent on 3/4 circles. Synthetic thread shall be absolutely smooth, possess high degree of not wettability, areactivity, it is easy to be tied by means of tools. The broadest application is found by thread with a diameter of 10/0 (ten zero), 20 — 25 microns thick.
It is applied, especially at operations on limf, vessels (to dia, their 0,3 — 0,6 mm), the so-called metallizovanny suture material prepared by putting metal for the end of synthetic thread; this metallizovanny end by special processing turns into a needle. Also metal needles for thread with a diameter of 12/0 (16 microns) are offered, however such fine needles are not strong. In order that it is easy to puncture a wall of a thin vessel, the microsurgical needle shall be given a mirror-like polish.
All microsurgical instruments extremely of withdrawal pains are also easily damaged therefore they are placed in special metal laying with holders. Laying is inserted into a special box, together with a cut and sterilized.
After operation microsurgical instruments carefully clear of blood and clots, it is the best of all ultrasound. Then they are dried up warm air and apply special lubricant on hinges and nodes, edges shall not contain silicone, after that make dry-heat sterilization.
Features of the equipment and the organization of microsurgery
Operations under an operative microscope are carried out sitting. The surgeon sits in an elbow-chair that provides fixing of a forearm and a brush, an opportunity to carry out the thin and exact movements only fingers. For protection of a surgery field from drying it is constantly irrigated, and then liquid is sucked away spaghettis. Bipolar electrothermic coagulation of small vessels allows to exclude setting of ligatures. Better to distinguish minute structures under a microscope, it is necessary to enclose under them thin pieces of a color film. A technique of recovery of an integrity of arteries and veins same, as well as at usual manual vascular seam (see), use separate noose sutures more often.
The main conditions of success of microsurgery are care of a hemostasis, the minimum injury of fabrics, lack of extravasates, uniformity of imposing of stitches of a vascular seam, setting of nodes by means of tweezers, use of anticoagulants, spasmolysants. As tests for judgment of success of operation serve discoloration and temperatures of skin, character of a pulsation of a vessel, a condition of a suture line, absence of hypostasis of a distal segment given manual pletizmografiya (see), an ultrasonic floumetriya (see. Ultrasonic diagnosis ).
The problem of replantation of fingers and brush by means of M. is difficult both in organizational, and in the technical plan. In the cities at the industrial enterprises and buildings it is necessary to instruct medical staff, workers and employees how to keep and transport completely amputated or torn off fingers, brushes, extremities. They cannot be washed out or processed any antiseptic agents, for delivery them on all first-aid posts it is necessary to have sterile plastic packages of the different size. Place the torn-off fingers or a brush in one package, tie it and stack in other package of the bigger size, at the bottom to-rogo pieces of ice lie. Such «container» can be sent in to lay down. establishment where the victim is brought. Before sending the victim in to lay down. establishment on the injured extremity impose a plait, and on a wound a sterile bandage.
From the technical point of view it is necessary to provide high precision of all receptions during operation, sometimes for a long time (10 — 14 hours and more). As one surgeon cannot operate so long time, work is carried out by replaceable crews. Each center M. has 4 — 6 teams of surgeons; duration of continuous operation of one crew 3 — 4 hours.
Bystry delivery of the victim and the correct storage of a sawn-off part of an extremity or fingers are important (it is the best of all in the conditions of a hypothermia).
Microsurgery of vessels of a shin it is widely applied at their occlusion of various origin (e.g., atherosclerosis, arteritis), but generally sick with gangrene of fingers and feet or in a pregangrenous stage. Performance of reconstructive operations under a microscope allows to make more precisely an anastomosis on vessels of any diameter, including and on small vessels of foot that improves results. Shunting of autoveny is performed proksimalno — with a femoral artery, distally — with a fibular artery (fig. 1). Very often after such reconstructive operations hypostasis, most likely owing to changes of a hemodynamics develops. Thrombosis of the shunt is possible; in these cases apply anticoagulants, Streptokinasa, perform repeated operations (thrombectomies by means of a balloon catheter of Fogarti). The favorable long-term results after operations on vessels of a shin are stable within several years.
Microsurgery at replantation of fingers and a brush. The greatest success was achieved by M. for the purpose of replantation of fingers and a brush. At establishment of indications to replantation of fingers consider funkts, the importance of a finger, the nature of an injury, a profession of the victim. In all cases the attempt of replantation is shown at amputation of a thumb or single-step amputation of several fingers of a brush. At amputation of a brush its replantation is shown in all cases.
Contraindications — the heavy life-threatening combined damages, somatopathies in stages of a decompensation, age of patients are more senior than 70 years.
Arteries of fingers at children have to dia. 0,3 mm, adults have 1,5 — 2 mm. It is successful it is possible to put a stitch under a microscope on vessels to dia, to 0,3 mm. At recovery of each artery it is necessary to connect not less than two veins and to recover their passability. The m allows to execute primary interfastsikulyarny seam of manual nerves a bunch to a bunch (see. Nervous seam ), if necessary to make plastics of skin. Thus, carry out operations on all structures of a brush at its severe combined injury. The sequence of the main stages of microsurgery on fingers and a brush following; roughing-out of a replantat, fixing of bone fragments or recovery of joints, recovery of sinews, anastomosis of arteries and veins (fig. 2), recovery of nerves, plastic of skin.
On the basis of experience of domestic surgeons the following classification of amputations of a brush and fingers is offered: guillotine, a separation of a finger, amputation from crush, scalped amputation.
At guillotine amputation (the acute tool therefore edges of a wound equal) engraftment, according to B. V. Petrovsky et al. (1977), is reached in 78% of cases. The most adverse form of damage is the separation of a finger (fig. 3, a) when muscles of razgibatel or sgibatel of fingers come off on a forearm, and vessels are damaged repeatedly at the different levels. At all patients with an injury of a thumb in the field of a separation of a sinew of a muscle from an abdomen the hematoma is formed, edges on 3 — 8 days along with the developed hypostasis squeezes vessels on a forearm that quite often leads to thrombosis of a manual artery with the subsequent necrosis of a replantirovanny finger. At separations successful replantation of a finger (fig. 3) is possible if use long autovenozny shunts to plastics of an artery and a vein of a finger. Feature of postoperative maintaining such patients sometimes having fractures of bones of a forearm is the exception of a complex of actions of administration of heparin in connection with extensiveness of an injury in a zone of a separation of a finger and in a zone of a separation of a sinew from a muscle and danger of bleeding.
Scalped amputations (scalping of a finger with a rupture of vessels and a change usually nail: at a phalanx) arise during the gearing by the wedding ring or a ring which is put on a finger for the fixed subject. At such amputation the main vessels are broken off at the basis of a finger that results in its frailty.
At all types of amputation recovery of a blood-groove on the main vessels can provide engraftment of a finger even when the patient is brought in a hospital in many hours after an injury. At amputation from crush crush of soft tissues and multisplintered fractures of bones are observed. The main feature of operations at such damages is use of autovenozny inserts in arteries and veins, and in nek-ry cases at amputation of a brush — full replacement of a palmar arterial arch with an autovenozny transplant (fig. 4).
After replantation of fingers by a microsurgical method good anatomic and funkts, results make more than 50%.
Replantation of a brush is carried out at various levels of its amputation. At full (guillotine) amputation (fig. 5) recovery of the main arterial and venous blood-groove (fig. 6), plastic of nerves and sinews gives good funkts, result (fig. 7).
Microsurgery of absorbent vessels. The operative measures applied at treatment of a lymphostasis divide into three groups: the operations directed to assignment of a lymph from affected areas of an extremity in healthy; the operations directed to drainage of a lymph from patholologically the changed nadfastsialny ways to subfascial; operations on creation of a limfovenozny anastomosis, to-rye from all operations on limf, vessels yield the best results, but are most difficult on technology of performance.
At the beginning of the 60th messages on use of a limfovenozny anastomosis on type a lymph node — a vein for treatment of a lymphostasis appeared.
In 1967 Politovsky (M. of Politowski) with soavt, reported about use of an anastomosis limf, a node with a vein to 16 patients with primary lymphostasis of extremities. Further Peytel (J. - Page of Patel) et al. (1969), A. Firica et al. (1969), A. V. Pokrovsky et al. (1971), A, A. Troshkov et al. (1973), etc. used this method.
For the first time the limfovenozny anastomosis directly between limf, a vessel and a vein in clinic was executed in 1950 by N. I. Makhov. He replaced three limf, a vessel of a hip in a big saphena of the patient with a lymphostasis of the lower extremity. Sedlachek (1969) gives one case of creation of a direct limfovenozny anastomosis between limf, a vessel and a vein at the patient with a filariasis.
Yamada (J. Jamacia, 1969) in an experiment on animals at operation of creation of a limfovenozny anastomosis used an operative microscope. In 1976, O'Brien (V. M. of O'Brien) reported about use in clinic of a limfovenozny anastomosis with use of the microsurgical equipment at 10 patients with a lymphostasis of upper extremities.
In the USSR in All-Union scientific center of surgery of the USSR Academy of Medical Sciences of operation of a direct limfovenozny anastomosis under a microscope for the purpose of treatment of a lymphostasis of extremities are applied since 1973 (St. 150 operations). The purpose of operation — to create outflow of a lymph directly in venous system is lower than the level of obstruction limf, ways.
Indications to operation, and also the solution of a question of the level of imposing of an anastomosis are defined on the basis of data of the lower straight line limfografiya (see), and also taking into account duration of a disease, degree of manifestation of fibrous regeneration of fabrics and frequency of the complications preceding operation, first of all an erysipelatous inflammation, a cut leads to a sclerosis limf, vessels that excludes a possibility of operational treatment.
Operations make in subnodal and inguinal areas at a lymphostasis of the lower extremities (fig. 8, and, b) and in an elbow pole — at a lymphostasis of upper extremities. After a section of skin allocate as the bigger number of the largest collectors limf, vessels and small branches of saphenas is possible.
In case of coincidence of diameter limf, a vessel and an adjacent vein an anastomosis impose on type the end in the end. If diameter of a vein exceeds diameter limf, a vessel and also if there is a need for an anastomosis between several limf, vessels and one vein, they are imposed on type the end sideways (to 10 — 12 anastomosis). In the postoperative period intramusculary enter heparin on 20 000 — 30 000 PIECES a day within 7 days with gradual replacement with its Phenilinum. Within 4 — 6 months after operation the operated extremity is bandaged an elastic roller. At the majority operated positive takes remain a long time.
Microsurgery of bilious ways. The first message on use of microsurgeries on the bilious ways was made by J. Jacobson in 1964. Rand (V. of W. Rand) and soavt, in 1970 made experiments on sewing together of the general bilious channel under an operative microscope thanks to what it was possible to receive absolutely tight seam, through to-ry bile does not filter. In clinic these authors to 5 patients executed a so-called ideal choledochotomy — sewing up of a wound of the general bilious channel tightly thread to dia. 8/0 — 9/0 without its drainage; the phenomena of peritonitis were not observed after that. Various repeated reconstructive interventions on the bilious ways are also more productive during the use of the microsurgical equipment.
Microsurgery in ophthalmology allowed to set the new tasks essentially unavailable to the decision by traditional methods; it led to creation of a number of new eye operations. Use of new hardware at traditional methods of surgery made them more perfect and safe.
The fact that M. in ophthalmology began to develop earlier and more intensively, than in other areas, to a certain extent is explained by the fact that eye operations always approached microsurgical.
The first special operative microscope in eye surgery was applied by Perrit in 1946. Modern installations for eye M. reached high degree of perfection. In the mid-sixties were developed new needles for eye M. (fig. 9), thickness nek-ry of them makes apprx. 0,5 mm. These needles not to a lesser extent, than an operative microscope, promoted full transformation of eye surgery. The suture material for M. of an eye has thickness of 15 — 40 microns, most often 25 microns (fig. 10).
M.'s beginning of an eye as scientific direction is usually carried to 1966 when the International committee of research group on microsurgery of an eye was formed.
Thanks to M. of an eye a number of new operations, napr was developed, at glaucoma — sinusotomy (see), a trabekulotomiya (see. Trabekulotomiya, trabekulektomiya ), a cataract — a fakoemulsifikation (see. Cataract ), short-sightedness — keratomilez (see), aphakias — keratofakiya (see), an injury of an eye — so-called anatomo-reconstructive operations, etc. Without use of microsurgical methods replanting in an eye of an artificial crystalline lens, artificial cornea, vitreofagiya, plastic interventions on an iris, a ciliary body, removal of intraocular foreign bodys, intraocular tumors etc. are almost impossible.
Achievements in the area eye M. were an important part of the complex research awarded the Lenin award, edges is awarded to M. M. Krasnov. M. M. Krasnov, T. I. Broshevsky and A. P. Nesterov for a cycle of researches on microsurgery of glaucoma are conferred State awards.
Further development of M. of an eye is connected with improvement of hardware, search of new surgical methods on the basis of the new equipment, with beznozhevy M.'s development on the basis of use of energy laser (see) and ultrasound (see. Ultrasonic therapy ).
Microsurgery in otorhinolaryngology. The first attempts are carried out I microsurgeries on an ear under control of primitive optical devices undertaken in the second half of 19 century. So, Berthold (E. Berthold, 1879). Ales (E. T. Ely, 1881), A. Polipter (1893), etc. made plastics at perforation of a tympanic membrane. In the same time operations on muscles of a drum cavity and their sinews are developed. Removal of a stirrup in an experiment and clinic was executed by Kessel (Kessel, 1876).
The operations combined by the general term «tympanoplasty» are offered at the beginning of 20 century. Windowing of a labyrinth (formation of a new window of a threshold instead of natural, blocked by otosklerotichesky process) is developed by Passov (A. Passow, 1897), R. Barani (1907). Operations on a stirrup are developed in 1958 and 1963 by J. J. Shea.
In 1964 for improvement and widespread introduction in practice of operations on recovery of hearing at patients with an otosclerosis to A. I. Kolomiychenko, V. F. Nikitina, N. A. Preobrazhensky, S. N. Hechinashvili and K. L. Hilov the Lenin award is awarded.
Microsurgeries on a throat began to develop since 1960 when the special operative microscope with focal length apprx. 400 mm was designed, modern methods of anesthesia are developed, special tools are created.
In modern conditions microsurgeries are practically made on all ENT organs. The main of them: windowing of a labyrinth and operation on a stirrup at otosclerosis (see), tympanoplasty (see), made for the purpose of improvement of hearing at hron, an inflammation of a middle ear, section of a drum string, destruction of neuroplex of a promontorium (the cape, T.), opening perilymphangeal spaces of an inner ear, a sakkulotomiya and nek-ry other interventions at Menyer's disease (see. Menyera disease ), removal of a giperplazirovanny mucous membrane and the high-quality new growths of a throat having the wide basis, removal of voice folds at their paralyzes and at the isolated malignant new growths, a biopsy, etc. (see. Throat ).
All microsurgical interventions which are carried out on ENT organs are carried out by means of special tools. In the USSR a number of sets of microtools is created: for a tympanoplasty, for operation at an otosclerosis, for microsurgeries on a throat, on an ear.
Microsurgery in neurosurgery. The first publications about use of an operative microscope in neurosurgery belong to the beginning of the 60th of 20 century. House (W. F. House, 1961), Kurz and Doyle (T. Kurze, J. Century of Doyle, 1962) applied M; for translabyrinth removal of small neurinoma of an acoustical nerve (see. Eighth cranial nerve ). In the subsequent the microsurgical method with success was used at treatment of other tumors — cranyopharyngiomas (see), tumors hypophysis (see), basal meningiomas (see), etc., and also vascular damages of a brain. In 1963 Mr. of S. N. Chou reported about successful removal of an embolus from an average brain artery. The pool, Colton (J. L. Pool, R. P. Colton, 1966), Rand, Dzhannetta (R. W. Rand, R. J. Jannetta, 1967), E. I. Zlotnik et al. (1975) with success applied a microscope at operations for aneurisms of vessels of a brain (see. Aneurism of vessels of a brain ).
Use of a microsurgical method made necessary studying of microanatomy of a brain as is normal, and at its various defeats.
For performance of operations under a microscope in neurosurgery the corresponding microsurgical tools are used: tweezers and scissors with tiny branches, the stupid and cutting hooks, vacuum venting, a special suture material. Due to depth and narrowness of an operational wound microtools for neurosurgical operations differ in bigger length, many of them have the shtykoobrazny form thanks to what hands of the surgeon do not close a surgery field. For the shift of a brain and its long fixing in a certain situation the automatic retractors fixed on a skull of the patient are widely used. During the performance of microsurgeries the pointed bipolar coagulation which is almost not causing warmings up of surrounding fabrics has special value.
Indications to use of a microsurgical method in neurosurgery continuously extend. Nek-ry operations, napr, creation of a microanastomosis between branches superficial temporal and average brain arteries, are possible only during the use of a microscope. Microsurgeries apply also at aneurisms of vessels of a brain, spinal vascular malformation, neurinoma of an acoustical nerve, cranyopharyngiomas, basal meningiomas, tumors of a trunk and a spinal cord and some other diseases.
At vascular defeats of a nervous system using microsurgical methods the following operations are carried out: cliping of vessels (see) or bandaging of arterial aneurisms; removal of the arteriovenous aneurisms which are especially located in functionally important structures of a brain and in a spinal cord; recovery of passability of large vessels of a brain (internal sleepy, average brain arteries) at their occlusion; creation of an anastomosis between arteries of a brain and arteries of covers of a skull. Use of microsurgical methods at operations for the tumors which are located near a brainstem and large vessels (basal meningiomas, cranyopharyngiomas, neurinoma of an acoustical nerve, etc.), keeps normal vascularization of a brain, cranial nerves and other important brain structures. The small adenomas of a hypophysis which are shown only endocrine disturbances, using microsurgical methods, it is possible to remove separately, having kept a hypophysis.
At operations on a peripheral nervous system microsurgical methods apply to an interfastsikulyarny seam of the injured nerve. At pain syndromes by means of the microsurgical equipment carry out a number of operations on a spinal cord — tractotomy (see), partial rhizotomy, etc.
Results of treatment in all specified cases it is much better, than during the use of standard surgical practices.
Microsurgery in gynecology. On a possibility of use of microsurgical methods in gynecology, generally at sewing together uterine tubes (see), Jacobson for the first time specified (J. Jacobson, 1960). Further reported about similar operation with the purpose of recovery of passability of uterine tubes Platte (Platt, 1964), Virtts (J. W. Wirtz, 1965), etc.
The indication to recovery of uterine tubes the end in the end is their obliteration, especially on average and uterine departments. A contraindication — existence of inflammatory process in an abdominal cavity.
At sewing together of the ends of a uterine tube use an operative microscope with 10-fold increase that helps to define more precisely borders of a resection of affected areas of a uterine tube and to carefully connect its ends. Optimum drag prevents any twisting of a gleam and anguishes of a mucous membrane of a pipe in the area of an anastomosis.
Sewing together is made separate noose sutures an atraumatic needle. The mucous membrane is not sewed, connect only a muscular layer directly adjacent to a gleam of a uterine tube. Connection of the ends of a uterine tube can be made with use of an endoprosthesis most often from polyethylene (a so-called protector) and without it. The endoprosthesis is entered temporarily into a gleam of a uterine tube from a cavity of the uterus and removed through the ampullar end. The outside end of an endoprosthesis is removed through a section of a front abdominal wall or through a vagina.
Operation is technically difficult since the uterine tube has small diameter. Besides, quite often there are difficulties during the carrying out from a cavity of the uterus in a gleam of a pipe of a temporary endoprosthesis (at introduction it can easily be made the false course).
Recovery of passability of uterine tubes does not mean recovery them funkts, activities yet. Improvement and implementation of the microsurgical equipment in gynecology will allow to achieve more successful results at recovery of generative function of the woman.
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B. V. Petrovsky, V. S. Krylov; And. H. Konovalov (neyrokhir.), M. M. Krasnov (oft.), Yu. B. Preobrazhensky (ENT specialist.), V. P. Smetnik (gin.).