Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 31:
Replantation Surgery
  Under loupe magnification, the part or parts are examined, gently washed with hexachlorophene in emulsion and water, and the condition noted. Final examination, however, is done under the operating microscope. Shredded tendon ends and skin are debrided. The neurovascular and tendon structures are identified and tagged with fine sutures after dissecting out adequate lengths. This process is not only essential but timesaving. When preparing amputated digits, one typically makes a midlateral incision to identify the neurovascular structures.25 A problem with a longitudinal incision directly over neurovascular structures is that swelling may make closure difficult over the vascular anastomoses. For this reason, some authors prefer an oblique incision, closed later with a Z-plasty,26 which allows flap coverage of the anastomosis without an incision directly over the microsurgical repair. Dorsal veins are also identified, dissected from the subdermal tissue of the dorsal flap, and tagged. Volar veins, when present, should also be tagged. At this time, bone shortening or trimming should be done. K-wires, interosseous wires, or fixation plates are placed in the amputated bone fragment. Once the part is ready, it is kept cool in a sterile basin placed over ice.

When the emergency room evaluations are completed, the patient is brought to the operating room. General anesthesia is preferred because it is less likely to produce complications than prolonged regional anesthesia. A Foley catheter is inserted. Pneumatic tourniquets are placed on the proximal part of the injured extremity and on the donor extremity from which nerve, vein, and skin grafts may be harvested. The amputation stump is examined and the structures are identified and tagged.


In proximal extremity amputations, temporary plastic shunts allow rapid reperfusion of the extremity, which in turn allows a less hurried examination and identification of the structures, and if necessary, bone fixation, without extending the ischemia time. The shunts, placed first in the arteries, reperfuse the extremity; bleeding should be permitted before re-establishing venous continuity to clear the system of any toxic metabolic products produced by ischemia.27 When the artery is shunted first, the principal veins can be identified for the venous drainage repair of the replanted part. Arterial shunting without venous shunting can lead to significant blood loss. Replacement can be accomplished with

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