Ce este

microchirurgia?

Ce sunt microchirurgii?

Microchirurgia
ntr-un sens mai larg, microchirurgia = chirurgie sub magnificaie
(microscop, lupe, +/- aparatura de endoscopie cu zoom optic sau
digital) + instrumente speciale i materiale de sutur performante.
Adevarata microchirurgie, este chirurgia care se realizeaz doar
cu ajutorul microscopului.
In cadrul Chirurgiei Plastice, microchirurgia reconstructiv
include:

chirurgia microvascular (anastomoza vaselor sub 2mm),

microneural (neurorafia nervilor periferici),

microlimfatic (reconstrucia vaselor limfatice) i
microtubular (reconstrucia structurilor anatomice tubulare
canal Stenon, canale deferente, trompe uterine, etc).
microscop vine din greac mikros = mic si skopein = a vedea

1590 Zacharias Jansen

- primul microscop
primul microscop
operaional - n a doua
jumtate a secolului 17
- Antonie van
Leeuwenhoek.

1919 - Nylen, un chirurg O.R.L. suedez, a realizat primele

operaii sub un microscop monocular la nivelul urechii
medii. Colegul i eful su, Holmgren, a extins aplicaiile
microscopului operator (Zeiss, binocular) la interveniile
pentru otoscleroz, la nivelul urechii interne (1923).

Carl Olof
Nylen

Oftalmologii Richard Perrit & Ignacio

Barraquer au fost urmtorul grup de
medici care au folosit microscopul
operator pe la mijlocul anilor 40 .

Primele aplicaii n tehnicile microvasculare au aprut n

decada a cincea a secolului, legate de progresele
nregistrate n chirurgia cardiac i transplantul de organe
n special transplantul renal.
1958 - apare istoricului articol al lui Siedenberg, despre
repararea vaselor mici, cu calibrul de 3-5 mm - bazele
microchirurgiei reconstructive. Astfel a fost trecut pentru
prima dat grania vaselor cu diametrul de 3 mm.

1960 - Jules Jacobson i Suarez, n America, introduc

tehnica microchirurgical n chirurgia arterelor coronare
+ instrumente fine cu design special + microscop cu
magnificaia de 25X.
Jacobson a fost primul care a folosit teremenul de
microchirurgie.

Replantari
1962
Robert Malt, Boston:
Prima replantare a unui
membru uman. Malt
replanteaza cu succes bratul
unui baiat de 12 ani care a
suferit un accident de tren

Microchirurgie vascular

1966 - Harry Buncke, Los Angeles

Replantari

1963 Zhong-Wei Chen - Shanghai

Replantare

prima replantare digitala realizata de

Tamai folosind un microscop operator

Microchirurgie experimental

60 - Sun Lee, Korea

Microchirurgie experimental

60 - Acland & OBrien

Bernard McC. OBrien

1963
1-ul laborator
experimental de
microchirurgie
1978
30-40 000 anastomoze
>300 cazuri clinice
St. Vincents Hosp,
Melbourne

Chirurgia replantrii
La finele anilor '70
Chen - China
Kleinert - USA
Biemer - Germany
OBrien - Australia
Tamai - Japan

Transfer liber tisular

1972
McLean & Buncke
Harii & Ohmori
Daniel & Taylor
OBrien
1975
Taylor

Magnificatie
Lupe

Microscoape

Instrumente de microchirurgie
sunt prelungirile fine ale minii chirurgului,
vrfurile lor sunt punctele finale de contact
cu pacientul

12-0 50 micron suture material

hair

100micron
50micron

12-0 50 micron suture material

hair

30micron

Aplicatiile microchirurgiei
Chirurgie Plastic i Reconstructiv
Ortopedie
Oftalmologie
Chirurgie BMF
Urologie
Chirurgie Pediatric
ORL
Chirurgie General
Chirurgie Cardio-vascular
Neurochirurgie
Transplantologie
Chirurgie Oncologic
Obstetric i Ginecologie
Psihiatrie Tratamentul transsexualismului

W
I

Prof Earl Owen

Asocierea complex: microscop operator, instrumentar specific i

material de sutur performant, devine oportun doar n prezena unui
chirurg instruit, dotat constituional cu anumite caliti :
Calitati fizico - biologice
Vedere foarte bun

Manualitate natural,
nnscut

Coordonarea perfect a
gesturilor

Rezisten fizic
Calitati dobndite prin
antrenament

Manualitate dobndit
automatisme
Tehnic meticuloas

Auto-disciplin

Cunotine teoretice

Calitati psihice, comportamentale

Rezistenta psihica
Capacitate de concentrare si de
mentinere a starii de concentrare
pe durata lunga de timp
Capacitate de observaie precisa,
de analiza corecta a situatiilor si
de alegere a solutiei optime
Rbdare
Perseveren,
Continciozitate
Responsabilitate
Spirit inventiv
Via echilibrat
Capacitate de integrare n munca
de echip
Dorin de autoperfecionare
Respect pentru detalii
Auto-disciplin
Delicatee
Entuziasm

Pozitia de lucru

Position the needle in the stems of the needleholder at least 1mm from the jaw tips, not at he very end
Keep the axis of the needle and the stems of the forceps perpendicular to each other.
This is the most effective position to driving the needle against the tissue resistance in a straight line

Basic Microsuturing Technique

Preliminary suturing exercises on non animal models

Rubber sheets
Silicone tubes
Leafs

Latex (rubber) sheets training

Rubber sheet
8/0
Place the needle tip perpendicular to
the point of entrance and pass the
needle.
After passing the needle tip should
emerge from the undersurface the
entrance point as near to the
perpendicular as possible
This procedure can be facilitated by
everting the cut edge of the rubber
sheet with the slightly opened tips of
the forceps inserted under the cut
edge.

The exit bite should be the same size

as the entrance bite
Used the slightly opened tips of the
forceps as a conterpressor and pass
the needle between them.
Pull the needle through following its
curvature

Technique of tying knots

Practice until the sutures are

parallel to each other, perpendicular
to the sutured edges and equally
spaced
Start working with the incision line
in a vertical position at a slow
rhythm
Continue the suturing practice with
the line of incision at different
positions in order to further
improve coordination and accuracy
of handling microinstruments as
well as placing microneedles

Silicone or polyethylene tubes

simulating microsurgical vessel anastomoses

Rubber sheets
simulating microsurgical nerve sutures

Leaf suture
Kaufman 1984, Ballantyne 1985

Plant tissue is friable and non elastic it tolerate roughness poorly and documents
technical errors

Enlarge needle holes resulting from improper pulling of the needles and/or
excessive tightening of the knots

Petal suture

Principiile si Tehnicile Chirurgiei

Microvasculare
pe model animal

Anatomy

Anastomoza
vaselor femurale

Technica suturii vasculare

Se indeparteaza peretele anterior
de cel posterior
Acul este plasat langa punctul in
care pensa tine adventicea si este
introdus perpendicular pe vas
Trebuie sa traveseze toata
grosimea peretelui.
Distanta fata de marginea
vasului la care se introduce acul
trebuie sa fie de 2X mai mare
decat grosimea peretelui
vascular.

Viitor
microchirurgie asistat
endoscopic
microchirurgie robotic
prefabricare de lambouri
inginerie
tisular

Viitor ndeprtat
Chirurgul i microchirurgul vor dispare, fiind nlocuii de
experi n genetic, multiplicare i manipulare celular.
Replantarea

Controlarea i direcionarea multiplicrii, a

diviziunii i diferenierii celulare.

Vindecarea = depozit de colagen
tipuri celulare histologice.

nlocuirea variatelor