Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 39:
Anesthesia for Microsurgery
  Lithotomy Position. Although not as commonly used as the positions described above, the lithotomy position presents different problems. When the patient is being positioned, both legs should be elevated with the hips flexed and placed in the leg holders simultaneously. Patients who have had hip surgery or total hip joint replacements must be handled with special care to prevent dislocation. The following neuropathies can occur from improper positioning.14 1. Obturator-excessive flexion of the hip. 2. Saphenous-compression against the metal leg holder. 3. Femoral-excessive angulation of the thigh. 4. Common peroneal-compression on the lateral aspect of the knee.

Problems Related to Head and Neck Surgery

When extensive reconstructive surgery involves the face, mandible, or neck, a somewhat different set of problems may arise. Pressure neuropathies caused by position are not as likely, but care must be taken to see that all extremities are protected. A thick foam mattress is routinely used. Nasotracheal intubation is frequently used for such cases. If the tube is not correctly positioned, it may cause pressure on the nasal ala, resulting in tissue ischemia and necrosis. Proper connectors, padded if necessary, and frequent observation prevent this complication.

For certain head and neck procedures, an orotracheal tube is preferable, but it may become dislodged when the position of the head is changed. In this situation, the tube can be securely anchored by passing a dental wire around the tube and wiring it to a tooth. This also provides secure fixation if the tube is to be left in for postoperative care.


Regional Anesthesia for Microvascular Surgery

Various forms of regional anesthesia are being used in microvascular surgery. It is most commonly used in hand surgery. Regional anesthesia is rarely used in major free flap transfers except when both the donor and recipient sites are on the lower extremities. In that case, a continuous lumbar, epidural, or spinal anesthetic may be used.

Because regional block anesthesia is frequently used for surgery of the upper extremities at some centers, we will review the main types of blocks used and some of the problems and complications of each type of block. For specific techniques of performing the blocks, the reader is referred to several excellent texts14-17 and a recent review article.18

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