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MICROCHIRURGIA

RECONSTRUCTIVA

RECONSTRUCTIVE
MICROSURGERY

MICROCHIRURGIE
RECONSTRUCTIVE

Microchirurgia ansamblu de tehnici chirurgicale


ce se efectueaza cu ajutorul magnificatiei date
de microscop

Tehnicile sunt in special folosite in chirurgia


plastica dar si in ortopedie, ginecologie, O.R.L.,
B.M.F. sau chirurgia generala
Au fost dezvoltate tehnici ,instrumentar si
aparatura ca sa permite realizarea anastomozei
vaselor mici dar si a nervilor
Prima replantare de brat - 1962
Primul transfer microchirurgical de epiploon - 1972

Microsurgery-assembly of the surgical technique


is performed using microscopic magnification

Techniques are mainly used in plastic surgery but


also in orthopedics, gynecology, ENT, BMF or
general surgery
Techniques have been developed, instruments and
equipment to allow anastomosis of small vessels
and nerves but
First replanting arm - 1962
The first microsurgical transfer of omentum - 1972

Microchirurgie-assemblage de la technique
chirurgicale est ralise en utilisant
microscopique magnification

Techniques sont principalement utiliss dans la


chirurgie plastique, mais aussi en orthopdie,
gyncologie, ORL, BMF ou chirurgie gnrale
Des techniques ont t dveloppes, des
instruments et de l'quipement pour permettre
une anastomose de petits vaisseaux et les nerfs,
mais
Le premier bras replantation - 1962
Le premier transfert de microchirurgie de piploon
- 1972

Mijloacele microchirurgiei
reconstructive
Microscopul operator, sau lupele
operatorii(x3-4) pentru timpii pregatitori
Instrumentarul microchirurgical
Materiale de sutura specifice
Aparatura adecvata ( coagulator bipolar,
microaspirator, monitor Doppler)
Mobilier medical adecvat (masa, scaun)
Tehnici specifice ( in functie de tesutul
reconstruit)

Means of reconstructive
microsurgery
Operating microscope or magnifying
glasses operators (x3-4) times
preparatory
microsurgical Instruments
Specific suture materials
Equipment (bipolar coagulator,
microaspirator, Doppler monitor)
Appropriate medical furniture (table,
chair)
Techniques (depending on the tissue
reconstructed)

Moyens de microchirurgie
reconstructive
Microscope ou loupe d'exploitation des
oprateurs des verres (x3-4) fois
prparatoires
microchirurgie Instruments
Matriel de suture spcifiques
quipement (bipolaire coagulateur,
microaspirator, Doppler moniteur)
Mobilier mdical appropri (table, chaise)
Techniques (selon les tissus reconstruits)

conditii particulare
De anestezie ( durata mare ,
pozitionari particulare ale
pacientului)
De echipa operatorie
De sala dotari si ingrijiri post
operatorii

particular conditions
Anesthesia (long duration, the
particular positioning of the patient)
The surgical team
The room facilities and postoperative care

conditions particulires
Anesthsie (longue dure, le
positionnement particulier du
patient)
L'quipe chirurgicale
Les quipements de pice et les
soins post-opratoires

Microscopul operator:
Conditii:
Manevrabilitate
Lumina rece intensa
Magnificare 6-50 X
Postul secundar sa
cuprinda aceles camp
operator
Control electic la
pedala al zoom-ului si
focalizarii
Stabil
Distanta focala mare

The microscope operator


Conditions:
handling
Intense cold light
6-50 X magnification
Secondary station
to include the same
field operator
Control of choice in
foot zoom and focus
stable
Focal high

l'oprateur de microscope
conditions:
conditions:
manipulation
Lumire froid intense
6-50 grossissement X
Station secondaire
pour inclure le mme
oprateur de champ
Contrle des choix en
zoom pied et de se
concentrer
curie
Focal haut

Instrumentarul
microchirurgical:

Proportii balansate
Finete, pecizie
Rezistente
Nemagnetizabile
Inchidere elastica
Suprafete nereflectorizante

Microsurgical instruments:

Balanced proportions
Finesse pecizie
Elements
Nemagnetizabile
elastic closure
non-reflecting surfaces

Les instruments de
microchirurgie:

Des proportions quilibres


Pecizie Finesse
Elements
Nemagnetizabile
Fermeture lastique
surfaces non rflchissantes

Material de sutura
Monofilament 9/0, 10/0, 11/0
Ac rotund cu egal cu al firului de
sutura
Tehnicile microchirurgicale se deprind
in laborator si trebuie sa ajunga la o
rata de reusita a anastomozei de
peste 90% .

Suture Material
Monofilament 9/0, 10/0, 11/0
Round needle with a tie to the wire
suture
Microsurgical techniques they learn
in the laboratory and must reach a
success rate of over 90% of the
anastomosis.

Matriel de suture
Monofilament 9/0, 10/0, 11/0
aiguille ronde avec une cravate la
suture de fil
Techniques de microchirurgie, ils
apprennent en laboratoire et doivent
atteindre un taux de russite de plus
de 90% de l'anastomose.

Principiile tehnicilor de chirurgie


microvasculara
Integritatea si normalitatea vaselor
de reparat (manipulare atraumatica)
Vasele sa posede diametre similare
Absenta tensiuni, rotatiei, plicaturii
intre capetele vaselor anastomozate
Anastomoza termino-terminala, si
termino- laterala

Principles of microvascular surgery


techniques
Integrity and normality vessels
repaired (atraumatic manipulation)
Vessels possess similar diameters
Absence of tension, rotation,
plicature between end anastomosed
vessels
Termino-terminal anastomosis and
end-to-side

Principes de techniques de
chirurgie microvasculaire
Les navires de l'intgrit et de la
normalit rpars (manipulation
atraumatique)
Les navires possdent des diamtres
similaires
Absence de tension, rotation, plicature
entre vaisseaux anastomoss fin
Anastomose termino-terminale et bout-cte

Timpi operatori
Debridare perivasculara
Prepararea vaselor (irigare endoluminala,
inlaturarea spasmului vascular, rezectia
vasului pana in zona cu perete normal,
excizia adventicei)
Clamparea si pozitionarea (apropierea
capetelor vasculare)
Sutura
Deschiderea clampelor( (intai cea distala),
si verificarea patentei suturii

Operating times
debridement perivascular
Preparation vessels (endoluminal
irrigation, removing vascular spasm,
resection of the vessel wall by normal
excision adventitia)
Clamping and positioning (near the ends
vascular)
suture
Opening clampelor (first distal) and
checking patent suture

Dure de fonctionnement
dbridement perivascular
Les navires de prparation (irrigation
endoluminale, en supprimant un spasme
vasculaire, la rsection de la paroi du
vaisseau par excision normale adventice)
Serrage et de positionnement (prs de la
vasculaire extrmits)
suturer
Clampelor (premier distal) d'ouverture et
la vrification de suture de brevet

Anastomoza vasculara
microchirurgicala

Repararea si grefarea nervilor


periferici
Fibrele nervilor periferici
(axonii si celulele
Schwann) sunt invelite
de tesut conjunctiv
(endonerv), fibrele sunt
grupate in fascicule
invelite de perinerv, iar
trunchiul nervos este
invelit de epinerv.
Nervii periferici pot fi
alcatuiti din unul sau
mai multe fascicule
aceste putind fi
organizate sau nu in
grupe fasciculare.

Repair and grafting of


peripheral nerves
Peripheral nerve fibers
(axons and Schwann
cells) are wrapped by
connective tissue
(endonerv), the fibers
are grouped in bundles
wrapped by perinerv
and nervous trunk is
covered by epinerv.
Peripheral nerves may
consist of one or more
such beams and can
be organized in groups
or fascicular.

La rparation et la greffe des


nerfs priphriques
Les fibres nerveuses
priphriques (axones et
les cellules de Schwann)
sont envelopps de tissu
conjonctif (endonerv), les
fibres sont groupes en
paquets envelopps par
perinerv et le tronc
nerveux est couvert par
epinerv.
Les nerfs priphriques
peuvent tre constitus
d'une ou de plusieurs de
ces poutres et peuvent
tre organiss en
groupes ou fasciculaires.

Clasificarea leziunilor nervului

Neurapraxia-bloc de
conducere, continuitate
axonala pastrata,
recuperare rapida
Axonotmesis- intrerupere
anatomica a axonului, dar
cu pastrarea invelisurilor
conjunctive.
Neurotmesis-intreruperea
completa a trunchiului
nervos.
Seddon

Sunderland

Classification of nerve injuries

Neurapraxia-block
management, preserved
axonal continuity, quick
recovery
Axonotmesis-anatomical
disruption has axon, but
keeping coatings
conjunctiva.
Neurotmesis-complete
interrupt nerve trunk.

Seddon
Sunderland

Classification des lsions nerveuses


Gestion bloc neurapraxie,
la continuit axonale
prserv, une
rcupration rapide
Perturbation
axonotmsis-anatomique
des axones, mais en
gardant revtements
conjonctifs.
Tronc nerveux
interruption neurotmsiscomplet.

Seddon
Sunderland

Degenerescenta posttraumatica a
nervului

Repararea microchirurgicala a nervului

Aplicatii in chirurgia
plastica
Lambouri libere microvasculare
transferul intr-o singura operatie a unui
fragment de tesut compozit (cutanat,
muscular ,osteo-muscular) la distanta prin
anastomoza microchirurgicala a unei
artere si vene a lamboului la o artera
respectiv vena din zona receptoare
Indicate in acoperirea defectelor de
substanta ce nu pot fi acoperite cu grefe
de piele sau lambouri locale

Avantaje :
Se efectueaza intr-un
singur timp operator
Permite repararea
imediata a
tendoanelor, osului,
Disponibilitatea multor
zone donatoare, cu
suprafete mari
Rezultate cosmetice
bune ale defectelor
secundare
Asigura un aport
vascular suplimentar in
zona receptoare
Permite mobilizarea
precoce

Dezavantaje:
Operatii lungi ,
laborioase
Disponibilitate redusa
a vaselor receptoare

Complicatii
Generale (legate durata mere a
interventiei) :anestezice, neurapraxia
pozitionala, trombo-embolism
Locale : obstructia anastomozei prin
tromboza, hematom extern, cu
necroza lamboului, infectii,
complicatii la nivelul zonei donatoare

Applications in plastic
surgery
Microvascular free flap - transfer in a
single operation of a composite sample of
tissue (skin, muscle, bone and muscle)
remotely by microsurgical anastomosis of
arteries and veins of the flap in an artery
or vein in the recipient
Substance listed in covering defects that
can not be covered with skin grafts or local
flaps

advantages:
It is performed in a
single operative time
Allows immediate
repair of tendons, bone,
Availability of multiple
donor areas with large
areas
Good cosmetic results
of secondary defects
Provides additional
vascular supply in the
receiving
Allows early
mobilization

disadvantages:
Operations long and
laborious
Reduced availability of
receiving vessels

Complications
General (about apples during the
intervention): anesthetics, positional
neurapraxia, thrombo-embolism
Local: anastomosis obstruction by
thrombosis, external hematoma, flap
necrosis, infection, complications at
the donor site

Applications en chirurgie
plastique
Lambeau libre microvasculaire transfert en une seule opration d'un
chantillon composite de tissus (peau,
muscle, os et muscles) distance par
microchirurgie anastomose des artres et
des veines du volet dans une artre ou une
veine du destinataire
Substance figurant dans la couverture des
dfauts qui ne peuvent tre couverts par
des greffes de la peau ou des lambeaux
locaux

avantages:
Elle est ralise en un
seul temps opratoire
Permet la rparation
immdiate des tendons,
des os,
Disponibilit de multiples
zones donneuses avec de
grandes zones
De bons rsultats
cosmtiques de dfauts
secondaires
Fournit vascularisation
supplmentaire dans la
rception
Permet une mobilisation
prcoce

inconvnients:
Oprations long,
laborieux
Disponibilit rduite
de recevoir des
navires

Complications
Gnral (sur les pommes au cours de
l'intervention): anesthsiques,
position neurapraxie, thromboembolie
Local: obstruction anastomose par
une thrombose, hmatome externe,
ncrose du lambeau, infection,
complications au niveau du site
donneur

Zone donatoare pentru lambouri


libere

Plaga atona plantara


Lambou radial
Anastomoza
vasculara la
vasele tibiale
posterioare
Anastomoza n.
cutanat
antebrahial la n.
safen intern

Replantarea
Reatasarea chirurgicala a unui
segment de mebru toracic sau pelvin
complet amputat
Revascularizarea- idem dar in cazul
unei amputatii incomplete
(segmentul amputat pastreaza
conexiuni tisulare, dar isuficiente
pentru a-i asigura supravietuirea)

Plantar atonic wounds


radial flap
Vascular
anastomosis to
the posterior tibial
vessels
Forearm
cutaneous
anastomosis n to
n internal
saphenous

Replantation
Surgical reattachment of a segment
of such membership chest or pelvic
completely amputated
Revascularization-idem but
incomplete if an amputation
(amputation segment preserves
tissue connections, but isuficiente to
ensure survival)

Plaies atones plantaires


lambeau radial
Anastomose
vasculaire dans
les veines tibiales
postrieures
Avant-bras
cutane
anastomose n n
saphne interne

Rempotage
Recollement chirurgical d'un segment
d'une telle poitrine d'adhsion ou
pelvienne compltement ampute
Revascularisation idem mais
incomplte si une amputation
(segment d'amputation prserve
connexions tissulaires, mais
isuficiente pour assurer la survie)

Indicatii: absolute ( copil, police ,


proximal de F1,) , relative (F2, proximal
de cot, considerente ocupationale)
Contraindicatii: afectiuni vasculare
sistemice, neoplazici,
politraumatismengrave, striviri
avulsii,timp de ischemie calda peste
limitele admise (6 ore pt amputatii
proximale, 12 ore pt amputatii distale),

Directions: absolute (child, police,


proximal F1), relative (F2, proximal to
the elbow, occupational
considerations)
Contraindications: Systemic vascular
diseases, neoplastic,
politraumatismengrave, bruising
avulsii for warm ischemia over limits
(6 hours for proximal amputations,
12:00 for amputations distal)

Itinraire: absolus (enfant, police, F1


proximal), par rapport (F2 proximales au
coude, considrations, professionnels)
Contre-indications: maladies vasculaires
systmiques, noplasique,
politraumatismengrave, avulsii
ecchymoses d'ischmie chaude audessus des limites (6 heures pour les
amputations proximales, 12h00 pour
amputations distales)

Timpi operatori
Identificarea si marcarea structurilor vasculare si
nervoase in ambele segmente
Debridarea plagilor, fasciotomii
Osteosinteza (rapid si simplu) dupa scurtarea
capetelor osoase
Repararea tendoanelor extensoare
Anastomoza arteriala (cu verificarea perfuziei
segmentului distal)
Anastomoza venoasa
Repararea tendoanelor flexoare
Repararea nervoasa
Sutura tegumentara

Operating time
Identification and marking of vascular and nerve
structures in both segments
Wound debridement, fasciotomii
Osteosynthesis (fast and easy) by shortening the
bone ends
Extensor tendon repair
Arterial anastomosis (with verification perfusion
distal segment)
venous anastomosis
Flexor tendon repair
nerve repair
Suture tegumentary

Temps de fonctionnement
L'identification et le marquage des structures
vasculaires et nerveuses dans les deux segments
Dbridement des plaies, fasciotomii
Ostosynthse (simple et rapide) en
raccourcissant l'os se termine
Rparation du tendon extenseur
Anastomose artrielle (avec vrification segment
distal de perfusion)
veineuse anastomose
Flexor rparation du tendon
rparation nerveuse
suture tgumentaire

Replantarile proximale prezinta riscuri mai


mari desi tehnic sunt mai usoare. Segmentul
amputat contine mai mult tesut muscular,
care in conditii de ischemie calda
elibereaza prin distrugerile celulare
mioglobina si radicali liberi. Dupa realizarea
anastomozelor vasculare toti acesti produsi
de degradare trec in circulatia sistemica,
producand sindromul de reperfuzie cu
tulburari de ritm cardiac, blocaj renal, deces.

Replanting proximal pose higher risks


though are technically easier. Amputated
segment contains more muscle tissue,
which in conditions of ischemia "hot"
myoglobin released by cellular damage and
free radicals. After taking all these vascular
anastomoses degradation products pass
into the systemic circulation, causing
syndrome "reperfusion" with heart rhythm
disorders, kidney failure, death.

Replantation proximales prsenter des risques


plus levs que sont techniquement plus facile.
Secteur amput contient plus de tissu
musculaire, ce qui dans des conditions
d'ischmie myoglobine "chaud" publi par les
dommages cellulaires et les radicaux libres.
Aprs avoir pris tous ces anastomoses
vasculaires produits de dgradation passent
dans la circulation systmique, provoquant le
syndrome "reperfusion" avec des troubles du
rythme cardiaque, l'insuffisance rnale, la mort.

Conduita in caz de
amputatie
Recuperarea segmentului amputat,
plasarea intr-o punga de plastic etansa,
imersia intr-o suspensie de apa cu
gheata, notarea orei
Hemostaza bontului proximal
Resuscitare, analgezie i.v. ( NU
medicatie per os- in vederea anesteziei
generale)

Conduct case of amputation


Recovery amputated segment, placing
it in a sealed plastic bag, immersed in
a slurry of ice water and time notation
Proximal stump Haemostasis
Resuscitation, analgesia intravenously
(No medication orally, in view of
general anesthesia)

Mener des cas d'amputation


Rcupration amput secteur, le plaant
dans un sac plastique scell, immerg
dans une suspension d'eau glace et de la
notation de temps
Hmostase du moignon proximal
Ranimation, l'analgsie par voie
intraveineuse (Aucun mdicament par voie
orale, en raison de l'anesthsie gnrale)