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Microsurgery is a general term for
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pa ...
requiring an operating microscope. The most obvious developments have been procedures developed to allow
anastomosis An anastomosis (, plural anastomoses) is a connection or opening between two things (especially cavities or passages) that are normally diverging or branching, such as between blood vessels, leaf veins, or streams. Such a connection may be norm ...
of successively smaller blood vessels and nerves (typically 1 mm in diameter) which have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Microsurgical techniques are utilized by several specialties today, such as
general surgery General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thy ...
,
ophthalmology Ophthalmology ( ) is a surgical subspecialty within medicine that deals with the diagnosis and treatment of eye disorders. An ophthalmologist is a physician who undergoes subspecialty training in medical and surgical eye care. Following a me ...
,
orthopedic surgery Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
,
gynecological surgery Gynecological surgery refers to surgery on the female reproductive system usually performed by gynecologists. It includes procedures for benign conditions, cancer, infertility Infertility is the inability of a person, animal or plant to r ...
,
otolaryngology Otorhinolaryngology ( , abbreviated ORL and also known as otolaryngology, otolaryngology–head and neck surgery (ORL–H&N or OHNS), or ear, nose, and throat (ENT)) is a surgical subspeciality within medicine that deals with the surgical a ...
,
neurosurgery Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and pe ...
, oral and maxillofacial surgery,
plastic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes cranio ...
, podiatric surgery and
pediatric surgery Pediatric surgery is a subspecialty of surgery involving the surgery of fetuses, infants, children, adolescents, and young adults. History Pediatric surgery arose in the middle of the 1879 century as the surgical care of birth defects requ ...
.


History

Otolaryngologists were the first physicians to use microsurgical techniques. A Swedish otolaryngologist, Carl-Olof Siggesson Nylén (1892–1978), was the father of microsurgery. In 1921, in the University of Stockholm, he built the first surgical microscope, a modified monocular Brinell-Leitz microscope. At first he used it for operations in animals. In November of the same year he used it to operate on a patient with chronic otitis who had a labyrinthine fistula. Nylen's microscope was soon replaced by a binocular microscope, developed in 1922 by his colleague Gunnar Holmgren (1875–1954). Gradually the operating microscope began to be used for ear operations. In the 1950s many otologists began to use it in the fenestration operation, usually to perfect the opening of the fenestra in the lateral semicircular canal. The revival of the stapes mobilization operation by Rosen, in 1953, made the use of the microscope mandatory, although it was not used by the originators of the technique, Kessel (1878), Boucheron (1888) and Miot (1890). Mastoidectomies began to be performed with the surgical microscope and so were the tympanoplasty techniques that became known in the early 1950s. The stapes mobilization operation had varying results and was soon replaced by stapedectomy, first described by John Shea, Jr.; this was an operation that was always performed with the microscope. Today
neurosurgeons Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and per ...
are very proud to use microscopes in their procedures. But it was not always so: many prestigious centers did not accept that idea and it had to be developed in relative isolation. In the late 1950s William House began to explore new techniques for temporal bone surgery. He developed the middle fossa approach and perfected the translabyrinthine approach and began to use these techniques to remove acoustic nerve tumors. The first neurosurgeon to make use of the surgical microscope was a Turkish emigrant, Gazi Yasargil. In 1953 he studied neurovascular surgery during work with Prof. Hugo Krayenbühl in Switzerland. His ideas interested Dr. Pete Donaghy, who invited Yasargil to his microvascular laboratory in
Burlington, Vermont Burlington is the most populous city in the U.S. state of Vermont and the seat of Chittenden County. It is located south of the Canada–United States border and south of Montreal. As of the 2020 U.S. census, the population was 44,743. It ...
. After his return to
Zürich , neighboring_municipalities = Adliswil, Dübendorf, Fällanden, Kilchberg, Maur, Oberengstringen, Opfikon, Regensdorf, Rümlang, Schlieren, Stallikon, Uitikon, Urdorf, Wallisellen, Zollikon , twintowns = Kunming, San Francisco Z ...
in 1967 Yasargil concentrated on discovering clinical applications to their novel inventions. Publications on that topic: ''Micro-Vascular Surgery'' and ''Microsurgery Applied to Neurosurgery'' won him international recognition. His lifelong experiences with microsurgery were recapitulated in the four-volume textbook entitled simply ''Microneurosurgery''. Advances in the techniques and technology that popularized microsurgery began in the early 1960s to involve other medical areas. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by vascular surgeon, Julius H. Jacobson II of the University of Vermont in 1960. Using an operating microscope, he performed coupling of vessels as small as 1.4 mm and coined the term ''microsurgery''. Hand surgeons at the
University of Louisville The University of Louisville (UofL) is a public research university in Louisville, Kentucky. It is part of the Kentucky state university system. When founded in 1798, it was the first city-owned public university in the United States and one ...
, Drs. Harold Kleinert and Mort Kasdan, performed the first revascularization of a partial digital amputation in 1963. Nakayama, a Japanese cardiothoracic surgeon, reported the first true series of microsurgical free-tissue transfers using vascularized intestinal segments to the neck for esophageal reconstruction after cancer resections using 3–4 mm vessels. Contemporary reconstructive microsurgery was introduced by an American
plastic surgeon Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniof ...
, Dr. Harry J. Buncke. In 1964, Buncke reported a
rabbit Rabbits, also known as bunnies or bunny rabbits, are small mammals in the family Leporidae (which also contains the hares) of the order Lagomorpha (which also contains the pikas). ''Oryctolagus cuniculus'' includes the European rabbit sp ...
ear replantation, famously using a garage as a lab/operating theatre and home-made instruments This was the first report of successfully using blood vessels 1 millimeter in size. In 1966, Buncke used microsurgery to transplant a primate's great toe to its hand. During the late sixties and early 1970s,
plastic surgeons Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniof ...
ushered in many new microsurgical innovations that were previously unimaginable. The first human microsurgical transplantation of the second toe to thumb was performed in February 1966 by Dr. Dong-yue Yang and Yu-dong Gu, in Shanghai, China. Great toe (big toe) to thumb was performed in April 1968 by Dr. John Cobbett, in England. In Australia work by Dr. Ian Taylor saw new techniques developed to reconstruct head and neck cancer defects with living bone from the hip or the
fibula The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity ...
. A number of surgical specialties use microsurgical techniques. Otolaryngologists (ear, nose, throat and head and neck surgeons) perform microsurgery on structures of the inner ear and the vocal cords. Otolaryngologists and maxillofacial surgeons use microsurgical techniques when reconstructing defects from resection of head and neck cancers. Cataract surgery, corneal transplants, and treatment of conditions like glaucoma are performed by ophthalmologists. Urologists and gynecologists frequently now reverse vasectomies and tubal ligations to restore fertility.


Free tissue transfer

Free tissue transfer is a surgical reconstructive procedure using microsurgery. A region of "donor" tissue is selected that can be isolated on a feeding artery and vein; this tissue is usually a composite of several tissue types (e.g.,
skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...
,
muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of mus ...
, fat,
bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...
). Common donor regions include the
rectus abdominis muscle The rectus abdominis muscle, ( la, straight abdominal) also known as the "abdominal muscle" or simply the "abs", is a paired straight muscle. It is a paired muscle, separated by a midline band of connective tissue called the linea alba. It ex ...
,
latissimus dorsi muscle The latissimus dorsi () is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. The word latissimus dorsi (plural: ''latissimi dorsorum'') comes from L ...
,
fibula The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity ...
, radial
forearm The forearm is the region of the upper limb between the elbow and the wrist. The term forearm is used in anatomy to distinguish it from the arm, a word which is most often used to describe the entire appendage of the upper limb, but which in ...
bone and skin, and lateral arm skin. The composite tissue is transferred (moved as a free flap of tissue) to the region on the patient requiring reconstruction (e.g.,
mandible In anatomy, the mandible, lower jaw or jawbone is the largest, strongest and lowest bone in the human facial skeleton. It forms the lower jaw and holds the lower teeth in place. The mandible sits beneath the maxilla. It is the only movable bone ...
after
oral cancer Oral cancer, also known as mouth cancer, is cancer of the lining of the lips, mouth, or upper throat. In the mouth, it most commonly starts as a painless white patch, that thickens, develops red patches, an ulcer, and continues to grow. When on ...
resection,
breast The breast is one of two prominences located on the upper ventral region of a primate's torso. Both females and males develop breasts from the same embryological tissues. In females, it serves as the mammary gland, which produces and sec ...
after cancer resection, traumatic tissue loss, congenital tissue absence). The vessels that supply the free flap are anastomosed with microsurgery to matching vessels (
artery An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pu ...
and
vein Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated ...
) in the reconstructive site. The procedure was first done in the early 1970s and has become a popular "one-stage" (single operation) procedure for many surgical reconstructive applications. Image:footwound.JPG, Traumatic foot/ankle soft tissue wound from motor vehicle accident Image:footwound2.JPG, Anterio-lateral thigh flap free-tissue transfer reconstruction


Replantation

Replantation is the reattachment of a completely detached body part.
Finger A finger is a limb of the body and a type of digit, an organ of manipulation and sensation found in the hands of most of the Tetrapods, so also with humans and other primates. Most land vertebrates have five fingers ( Pentadactyly). Chamber ...
s and
thumb The thumb is the first digit of the hand, next to the index finger. When a person is standing in the medical anatomical position (where the palm is facing to the front), the thumb is the outermost digit. The Medical Latin English noun for thumb ...
s are the most common but the ear,
scalp The scalp is the anatomical area bordered by the human face at the front, and by the neck at the sides and back. Structure The scalp is usually described as having five layers, which can conveniently be remembered as a mnemonic: * S: The ski ...
,
nose A nose is a protuberance in vertebrates that houses the nostrils, or nares, which receive and expel air for respiration alongside the mouth. Behind the nose are the olfactory mucosa and the sinuses. Behind the nasal cavity, air next passe ...
,
face The face is the front of an animal's head that features the eyes, nose and mouth, and through which animals express many of their emotions. The face is crucial for human identity, and damage such as scarring or developmental deformities may aff ...
, arm and
penis A penis (plural ''penises'' or ''penes'' () is the primary sexual organ that male animals use to inseminate females (or hermaphrodites) during copulation. Such organs occur in many animals, both vertebrate and invertebrate, but males d ...
have all been replanted. Generally replantation involves restoring blood flow through
arteries An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pu ...
and
vein Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated ...
s, restoring the bony skeleton and connecting tendons and nerves as required. Robert Malt and Charles Mckhann reported the first replantation of two human upper extremities by microvascular means in 1964, with the first arm replanted in a child after a train injury in 1962 in Boston. Initially, when the techniques were developed to make replantation possible, success was defined in terms of a survival of the amputated part alone. However, as more experience was gained in this field, surgeons specializing in replantation began to understand that survival of the amputated piece was not enough to ensure success of the replant. In this way, functional demands of the amputated specimen became paramount in guiding which amputated pieces should and should not be replanted. Additional concerns about the patient's ability to tolerate the long rehabilitation process that is necessary after replantation both on physical and psychological levels also became important. So, when fingers are amputated, for instance, a replantation surgeon must seriously consider the contribution of the finger to the overall function of the hand. In this way, every attempt will be made to salvage an amputated thumb, since a great deal of hand function is dependent on the thumb, while an index finger or small finger might not be replanted, depending on the individual needs of the patient and the ability of the patient to tolerate a long surgery and a long course of rehabilitation. However, if an amputated specimen is not able to be replanted to its original location entirely, this does not mean that the specimen is unreplantable. In fact, replantation surgeons have learned that only a piece or a portion may be necessary to obtain a functional result, or especially in the case of multiple amputated fingers, a finger or fingers may be transposed to a more useful location to obtain a more functional result. This concept is called "spare parts" surgery.


Transplantation

Microsurgical techniques have played a crucial role in the development of transplantation immunological research because it allowed the use of rodent models, which are more appropriate for transplantation research (there are more reagents, monoclonal antibodies, knockout animals, and other immunological tools for mice and rats than other species). Before it was introduced, transplant immunology was studied in rodents using the skin transplantation model, which is limited by the fact that it is not vascularized. Thus, microsurgery represents the link between surgery and transplant immunological research. The first microsurgical experiments (porto-caval anastomosis in the rat) were performed by Dr. Sun Lee (pioneer of microsurgery) at the University of Pittsburgh in 1958. After a short time, many models of organ transplants in rat and mice have been established. Today, virtually every rat or mouse organ can be transplanted with relative high success rate. Microsurgery was also important to develop new techniques for transplantation, that would be later performed in humans. In addition, it allows reconstruction of small arteries in clinical organ transplantation (e.g. accessory arteries in cadaver liver transplantation, polar arteries in renal transplantation and in living liver donor transplantation).


Treatment of infertility

Microsurgery has been used to treat several pathologic conditions leading to infertility such as tubal obstructions, vas deferens obstructions, and
varicocele varicocele is an abnormal enlargement of the pampiniform venous plexus in the scrotum. This plexus of veins drains blood from the testicles back to the heart. The vessels originate in the abdomen and course down through the inguinal canal as p ...
, which is one of the most frequent cause of male infertility. Microsurgical drainages by placing microvascular bypasses between spermatic and inferior epigastric veins as proposed by Flati et al. have been successfully performed in treating male infertility due to varicocele. Microsurgical treatment has been shown to significantly improve fertility rate also in patients with recurrent varicocele who had previously undergone non-microsurgical treatments.


References

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External links


E-Medicine Microsurgery Principles

Video recorded through Microscope of Ulnar Artery Repaired using Microsurgical Techniques
Surgery Oral and maxillofacial surgery Plastic surgery Otorhinolaryngology