Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 31:
Replantation Surgery
  with similar microsurgical techniques, even though they are frequently discussed separately.37,38 These delicate procedures must be performed with the utmost precision. To avoid fatigue and improve control of the microinstruments, the surgeon must sit comfortably, with wrists and hands well supported. Before beginning the repair, confirm that there is good bleeding from the proximal artery (apply the "squirt test") and the distal veins. It is critical to the success of the anastomosis to choose vessels at a level at which they appear normal. This is difficult to assess with crush or avulsive injuries. The color of normal vessel is an opalescent, pearly gray. Stretched or traumatized vessels are speckled because of multiple ruptures of the vaso vasorum, producing the "measles sign." Inspect the vessel ends and clear them of any blood or platelet clots. Trim and clean the vessel ends of adventitia and cut the ends squarely for accurate approximation with no intervening tissue. After the vessels are dilated, inject heparinized saline beyond the vascular clamps. The artery or vein being anastomosed should be well exposed and easily seen; retract any overhanging tissues that may obscure the vessels. Large microvascular clamps are helpful in preventing the vessel from retracting into the tissues. Vascular clamps and gentle suction create a dry, "bloodless" field.

If the vessel ends cannot be easily approximated, one should not hesitate to use vein grafts several centimeters long for a tension-free anastomosis. If possible, the vessel ends should be of equal size. Although discrepancies of 2:1 are acceptable, patency rates fall off abruptly at 3:1.


Anastomosis can also be established by a crossover vessel technique such as the radial digital artery to the ulnar digital artery, or by vessel transposition using the digital artery of the adjacent digit as the proximal vessel (Fig. 31-5).

When the arterial blood flow is established, the veins are easier to identify. As noted earlier, in larger amputated parts, arterial flow flushes out metabolic breakdown products. Veins are repaired with interposing vein grafts, by mobilizing veins with selective division of branches to lengthen the vein (Fig. 31-6), or by transposing cutaneous flaps that contain veins.

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