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The authors report their own experience of microsurgery for surgical treatment of lumbar disc herniation. Series include 30 cases with a one year of mean follow up. Comparative studies are discussed according to others microsurgical series already published. Good care of peridural fat and gently retraction of the root seem to be main factors for good functional result.
In the rat, a characteristic response to motor denervation is an increased flow of inorganic phosphate across the muscle cell membranes. This reaction is specific for the neurogenic atrophy and is fully reversible on reinnervation. In the present study, the muscle cell permeability to inorganic phosphate has been used as a criterion in assessing the efficiency of four different techinques. Microsurgery was carried out on peroneal nerve using a Zeiss OMP I operating room microscope. The technique were: I. Bringing together the two nerve segments with two epineural stitches (Ethilon 11/0 thread). II. Tight suture with eight epineural stitches (Ethilon 11/0 thread). III. As in II but with SSC 11/0 thread. IV. As in III but combined with postoperative corticotherapy. 32P radiophosphate incorporation was measured in the extensor digitorum longus and in the tibialis anterior. The best results were obtained with the first and simpler procedure. However, in some respects, equivalent results were observed with the fourth procedure associating a tight suture with postoperative corticotherapy. It follows that in the rat, it is indicated either to minimize the surgical trauma or to counteract the fibrosis attending the surgical trauma.
Microsurgery for primary and secondary lymphedema at present consists of shunts between lymphatic vessels and veins. The surgical technique has been well established for more than a decade. The problems consist of the irreversible changes in the peripheral lymphatic system and in the connective tissues, as well as the obliteration of the deep lymphatics, best suited for lymphaticovenous anastomoses. These changes are recognized only late, after clinical swelling becomes manifest. Therefore, lymphaticovenous shunts should be performed prophylactically. Their number should be sufficiently high to solve the quantitative problem, caused by the reduced lymphatic transport capacity.
UNLABELLED: In 1974 the carbon dioxide laser was adapted to the operating microscope for reconstructive pelvic surgery. A protocol was designed to test the efficacy of this surgical modality and a new study begun. Complete documentation of laparoscopic findings, surgical technique, and pre- and post-operative hysterosalpingograms are kept on videotape. One hundred cases will be entered into this study. Patency and pregnancy failures will be compared with patency and pregnancy successes to determine, if possible, the reasons for failure. In this paper detailed descriptions of the surgical techniques employed in the first 61 cases are presented. PRELIMINARY RESULTS in terms of patency and pregnancy experience to date are reported. PRELIMINARY RESULTS: Eighty-two couples have been evaluated at the Reproductive Biology Unit. Sixty-one cases have undergone fertility enhancement laser microsurgery and/or interim medical management prior to surgery for infertility. Bilateral patency or patency of the only existing fallopian tube was demonstrated post-treatment in 93% or 57 of the cases. Eliminating those cases who are not at risk of pregnancy due to elective contraception or medical prohibition during Danocrine therapy (28), conception has occurred in 10 of 33 patients. This represents approximately one of every three patients at risk. Considering the limited exposure to pregnancy, these results are very encouraging.
The anaesthetic requirements for microsurgery of the larynx are described and techniques in frequent use reviewed. A method involving the Coplans nasotracheal cuffed tube and using controlled ventilation is described and its advantages detailed. The illustrations and blood gas measurements support the authors' view that this technique is the most satisfactory at present available.
Laryngeal microsurgery by means of the laser involves anesthetic constraints regarding mainly the mode of ventilation during operation. The principal techniques and different anesthetic protocols are discussed. The two main criteria for the choice of method appear to be the permeability of the laryngeal passage and the patient's general condition and history. The two principal methods proposed are high frequency jet ventilation and ventilation controlled by a protected intubation tube.
--A few assessments concerning general methodology of microsurgery and surgical repair of the Fallopian tubes are presented. --Some serials on the operating room setting-up are proposed on a practical point of view. --The value of the microsurgical approach is then reviewed for each particular technique of tuboplasty.
The problems of microsurgery for lymphedema consist of the discrepancy between the excellent technical possibilities, especially of microsurgical lympho-venous shunts and the subsequently insufficient reduction of the lymphedematous tissue fibrosis and sclerosis. Generally, the lymphatic surgeon considers the lymphatic system to be a canalicular system of drainage tubes, of lymph collectors. Bypassing a lymph block through peripheral lympho-venous shunts should therefore solve the problem of lymphstasis, present in each type of lymphedema. In chronic lymphedema however, not only the canalicular lymphatic system, but also the tissues, and integral part of the lymphatic system, are affected. In chronic lymphedema, canalicular repair, for reasons of quantitative lymph drainage, exceptionally only provides a "restitutio ad integrum" of the tissues, altered by lymph stasis.
Endonasal ethmoid surgery necessitates similar preconditions as stapes surgery (dry operative field, operation microscope with parallel illumination, antibiotics, operative training on a cadaver). Today, by applying flunitrazepam (thorazine, nitroprussid) the patient can be operated on in amnesia with local anaesthesia and a blood pressure between 70-90 mm Hg. Comparing the historic development in ear and nose surgery we expect a similar spreading of endonasal sinus microsurgery as could be seen in stapes surgery. In more than 3,000 cases we have noticed no complication, apart from a passing blindness lasting less than 40 minutes.
To evaluate the antithrombotic effect of sulfinpyrazone on blood vessels (1-2 mm diameter) injured by microsurgical procedures, twenty male rabbits were chosen at random to receive sulfinpyrazone (10 mg/kg/die) or placebo three days prior to and on the morning of vascular microsurgery, which consisted of a complete transverse section, or a longitudinal section 1 cm long, of the femoral artery and vein, followed by interrupted suture. Scanning electron microscopy revealed consistently less fibrin and blood cell adhesion to the endothelial areas adjacent to the surgical trauma in the animals treated with sulfinpyrazone than in those treated with placebo. Our results agree with those reported in the literature, demonstrating the antithrombotic effects of sulfinpyrazone at the level of the vascular endothelium injured by various kinds of trauma and are sufficiently encouraging to justify testing this drug in the prevention of vascular thrombosis following microsurgical procedures in man.
The trend in the treatment of bone tumors links to the preservation of function. This can be achieved by a better operative technique and interdisciplinary cooperation. The microsurgery offers here new ways. After radical resection of the tumor, the defect is bridged by a plate and a microvascular free fibula graft. Additional cancellous bone grafts produced a stable reconstruction of the resected area.
Microsurgical techniques have changed the outcome of infertility surgery. Tubal anastomosis for reversal of sterilization has resulted in pregnancy rates of up to 65%. In cases of salpingostomy, the ectopic pregnancy rate is quite high. In ovarian microsurgery, postoperative adhesions can be avoided and a 54% pregnancy rate achieved with endometriosis surgery.
A survey is given of animal experiments as microsurgical training models as a preparation for clinical retransplantation and autotransplantation of the testicles and reconstruction of the urinary tract. The value of vessel-anatomic and angiographic examinations and blood-flow measurements for the reconstruction of vessels in the region of the testicles is pointed out. Practice in the form of animal experiments are considered to be a basic precondition for the clinical use of andrological microsurgery. The value of and problems involved in microsurgical operations on experimental animals and autopsy specimens for microvascular anastomoses and vaso-vasoneostomy or vasoepididymoneostomy are discussed. The success of refertilizing measures using microsurgical techniques instead of conventional operations can be demonstrated in the literature of recent years.
A technique of oesophago-jejunostomy in the neck is described using an isoperistaltic jejunal Y loop with added vascularisation from the internal mammary vessels via microsurgical anastomoses. This technique is used either for solely palliative purposes when the tumour is inoperable, or after oesophagectomy as a method of reconstruction of the digestive tract. An experimental study in the dog of replacement of the cervical oesophagus using a free gastric, jejunal or colonic transplant indicates the possibility of envisaging these techniques in the near future in man after circular total pharyngo-laryngectomy. The importance of these modern technique made possible by microsurgery is of two types: --value in adequate treatment of the tumour, since the resection can be extensive, the length of the graft being such that the whole of the oesophagus can be replaced; --functional value since the result is immediate and of good quality.
Vascular microsurgery was applied late to gynaecology. The authors evaluate its use in transplantations of the uterus, the ovaries and the tubes and the experimental as well as the clinical angles. The vascular pedicles that can be used in women are studied from the anatomical point of view as well as the functional and technical angles in order that surgical protocols can be worked out logically for transplantation of the tubes and ovaries.
The article is concerned with the results of the first experience of the work of a new Leningrad Center of microsurgery for the replantation of fingers and hand after the traumatic amputation. The operations were performed urgently within the first hours after traumas. The replantation included a microsurgical step recovering the integrity of the vessels and nerves by means of an operation microscope, special instruments and suture material. In eleven patients 22 operations were fulfilled with good near and late results. The results of surgery were found to depend on the damage character and time of admission of the patients to the hospital.
The essential requirements for correct anaesthesia in microsurgery of the middle ear are described and results obtained with an association of Althesin and NLA drugs in 52 stapedectomies, 27 tympanoplasties, and 14 myringoplasties are presented. Althesin was injected i.v. to induce anaesthesia. Maintenance was obtained by means of the continuous venous perfusion of a 10% solution. The usefulness of the association was apparent from the good cardiac stability noted throughout anaesthesia, during which adrenaline was routinely infiltrated via the external meatus. In addition, the manageability of Althesin enabled a modest degree of hypotension to be established during certain stages of the operation. This enabled the intraoperative bleeding that is one of the major snags in this type of surgery to be reduced in some cases. Other benefits related to the degree of postoperative sedation required and the low toxicity of the drugs employed.
This report about endonasal microsurgery has two sections: the first one deals with anatomy and the structure of nasal cavities, the methods as well as the technical and technological means required for the different types of surgery. The second section deals with nasal pathology in general and the new possibility of endonasal treatment. Endonasal surgery is not recent but the introduction of the use of the operating microscope gives such a precision in conception and realisation as to open new vistas concerning pathology and the corresponding treatment of nasal diseases. This is what we tried to demonstrate.