|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| 3. Apply traction on the back wall sutures to move them away from the front wall and reduce the possibility of suturing the back wall to the front wall.
4. Evert the vessel end by having the assistant place traction on the adventitia.
5. Continuously clean the microfield with heparinized saline irrigation to prevent the microsutures from adhering to the wound area and breaking or tearing the vessel wall.
6. For an accurate arteriotomy, use a 9-0 suture.50-52
7. At the completion of the anastomosis, irrigate the vessel surface with papaverine to relieve vascular spasm.
8. Apply the fill-refill test to check blood flow across the anastomosis. 53
9. Remove the adventitia on both sides of the anastomosis to break up local spasm.
10. Tie all branches to correct "segmental branch spasm."
FLEXOR TENDON REPAIR
Primary flexor tendon repair should be done whenever possible; in some cases, a primary tendon transfer from a nonreplantable digit may be used. If the wound is clean, placing a primary tendon rod may be considered.
Stiffness caused by flexor tendon adhesions is a primary cause of unsatisfactory function after replantation. Rehabilitation of the flexor tendon should be started as soon as possible, despite the risk of tendon rupture.
In digital replants, tendons can usually be recovered with tendon retrieval forceps. To accomplish this, the assistant holds the forearm while maintaining the wrist in a flexed position to retrieve flexor tendons, or in an extended position to retrieve extensor tendons. A transverse Bunnel needle will hold the tendons in place to prevent retraction while the ends are trimmed and half a modified Kessler suture of 3-0 Prolene is placed before osteosynthesis. The repair can be completed easily after osteosynthesis is performed.
Some authorities prefer to place hemi-Kessler sutures and to complete neurovascular repairs before repairing the flexor tendons. With this technique, the neurovascular anastomoses can be done with the digits in extension, allowing a better view of the structures.
Most nerves can be repaired primarily, usually with tension-free anastomoses, owing to the bone shortening done earlier. The ends of the nerve are examined under the microscope for a "yeux d'escargot" sign (fascicles protruding from the cut end of the nerve).54 The end usually requires some trimming, which may be more extensive in avulsive injuries.
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