Watching the surgeons working at their task, one is impressed by the patience, concentration and coordination necessary to accomplish the desired result. Slow, gentle hand movements are required, so most microsurgeons avoid drinking coffee or alcohol before operating as these can produce tremors in the hands, imperceptible to the naked eye, but which appear like shaking when seen under the microscope.
Because of the techniques and special skills that are unique to this field, expert tutoring and years of training, practice and experiment are necessary. Australia is considered the world leader in microsurgery at the present time, which is fortunate, as statistics suggest that Australians tend to suffer more accidental amputations per person than any other industrialized Western nation.
Let us now ‘focus in’ on an operation to restore the completely severed palm of a hand to see what actually takes place during microsurgery. Skin, muscles, tendons, nerves, veins and arteries must all be reunited in a complex of microscopic knots.
Four arteries and four veins are rejoined to provide adequate circulation. Being thin walled, veins collapse and shrink and consequently can be very difficult to locate. Once located, it is essential for them to be cleaned out, trimmed and joined. If a length of vessel has been damaged, a bridging section from elsewhere in the body may be needed. By joining veins first and then arteries, blood loss can be lessened.
About 10 nerves to fingers are repaired, each nerve having five or six fiber bundles. Nine tendons and eight small muscles are also joined together. Finally, stitching is required for all skin structures. All together, about 180 microscopic stitches and 100 conventional ones have been inserted.
This particular operation lasted for about six hours. Depending on the objective, operations may vary in length from two to 20 hours. The replacement of just one finger takes four to six hours.
Emergency!—What to Do
Suddenly it happens! You, your loved one or your workmate accidentally amputates a finger, hand or leg. Do not panic! Place the severed part in a clean plastic bag (or rubber glove) and seal well so water cannot leak in. The part should then be kept cool—at about four to six degrees Celsius (39 to 43 degrees Fahrenheit). So place the bag in cold water containing lumps of ice and get it to the nearest hospital or microsurgical unit as quickly as possible. If a delay is involved, the part could be stored in a refrigerator, but not in a freezer. Do not pack the part in ice or immerse it in antiseptic solutions or disinfectants, as these destroy tissue and may make rejoining impossible. Do not even wash it, as it is important to keep the amputated part dry.
It is obviously a good idea to know the location of the nearest microsurgical unit. The Lancet, October 2, 1976, notes: “Regrettably, amputated digits are still being discarded by casualty officers when they should be cooled and dispatched with the patient to the nearest microsurgeon.”
The time periods for successful replantation vary for different members of the body. Amputated fingers have survived after 10 hours without effective cooling and over 30 hours when properly cooled. Experimenters replanted a dog’s leg after separation and refrigeration for 48 hours.
Limitations and Benefits
Success in reattachment is dependent on many factors. With a sharp guillotine-like amputation of a finger, there is close to a 100-percent chance of successful replantation. The prospects are reduced if tearing, crushing or other serious damage to tissue or bone has occurred. The microsurgeon may decide not to attempt the operation if the amputated part is too damaged. The patient’s condition is another possible limiting factor, as the person must be well enough to endure a long operation.
A recent survey in Australia showed a 70-percent success rate in replanted fingers and 80 percent in replanted arms. Another report showed that movement of replanted fingers was generally 80 percent of normal except for limitations of stretching of some joints. Exercise and physiotherapy generally are needed after the operation to restore function to the formerly amputated part. However, reattachment of amputated parts above the mid-forearm has so far produced disappointing results.
When a thumb has been amputated, great effort is made to restore it, as the thumb provides 40 percent of the efficiency of the hand. If the severed portion cannot be reattached, microsurgeons have been able to transfer the patient’s large toe. After the toe’s tendons, nerves, vessels and bones have been joined, the patient has feeling that is almost as good as it was in his original thumb.
“It’s funny how much like a thumb a big toe can look when it’s actually transferred,” one doctor commented. “It’s a fatter thumb than before, but that can be surgically improved.” To many people the thought of losing a big toe may not be too appealing, but, then again, a big toe is not needed for eating or writing or performing the myriad of tasks a thumb has to do each day.
After a short period of adjustment and training, a person can once again walk, run and share in sporting activities. A professional football player is one of a growing number of Australians who have big toes for “thumbs.”
People from all walks of life have derived benefit from the marvels of microsurgery. Take, for examples, the persons mentioned earlier. These are typical of hundreds of cases.
The little girl, now about a year older, has both fingers restored and her injured hand can scarcely be distinguished from the other. For the plumber, all fingers survived, but he does have some problems during cold weather. The two-year-old boy, now eight, runs, jumps and plays football normally. With regard to the boilermaker, his forearm was joined so well that he has taken up karate and can break roof tiles with his formerly cut-off arm.
Yes, microsurgery is a marvelous technique, able to accomplish a great deal of good for those in need. Even more wonderful, however, is the amazing healing capacity of the body. Surgeons may sew various body parts together, but inbuilt regeneration testifies to the greater wisdom of the One who designed our bodies. Appreciating this makes us echo the sentiments of the psalmist who said respectfully to our Grand Creator: “I shall laud you because in a fear-inspiring way I am wonderfully made.”—Ps. 139:14.