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102

6 Selection ofAnesthesia forFinger Reconstruction

ideal anesthetic effect, which will reduce the dosage of each drug to reduce or eliminate the side effects of them. Ketamine is safe for general anesthesia in children but will cause dreaminess, hallucinations, and other symptoms when used in adults. During general anesthesia, physiological changes would occur on the whole human body organs which need close observation by anesthetists. The serious complications after general anesthesia include laryngospasm, aspiration, interruption of airway access, etc., which rarely occur. On the other hand, nausea, vomiting, drunkenness and postoperative pain, etc., are more common.

6.2.2 Region Block Anesthesia

Region block anesthesia is commonly used in hand surgery which has fewer effects on body’s physiological activities and major organs such as the heart, liver, and kidney and can be used in those patients with severe cardiovascular diseases, respiratory diseases, and kidney diseases. Its mechanism is to block local nerve conduction, on one hand, blocking nerve impulses of operation position to the central nervous system, on the other hand, blocking nerve impulses of contraction from central nervous system to local blood vessels which relieves patients’ pain, improves blood circulation and reduce vasospasm.

The advantages of region block anesthesia including: (1) During anesthesia, the patient is conscious and a variety of protective reexes are present. For patients with full stomachs, there is a risk of aspiration pneumonia once consciousness is lost under general anesthesia. (2) Compared with general anesthesia, region block anesthesia has fewer complications such as nausea, vomiting, atelectasis, forgetfulness, lethargy, and restlessness. (3) The difculty and workload of nursing of region block anesthesia are relatively small. Most of the patients could back to their wards directly instead of going to the post-anesthesia care unit (PACU). (4) Region block anesthesia can provide postoperative analgesia for patients which will reduce the possibility of sympathetic tension caused by early pain after reconstruction and vascular crisis caused by vasospasm.

Although region-block anesthesia has these advantages, there are still many factors that limit its use of it: (1) It takes a long time for region-block anesthesia to begin to work, and there is a possibility of incomplete anesthesia. Sometimes it may be changed to general anesthesia due to intraoperative needs. (2) Multiple site operation which requires a combination or multiple anesthesia. (3) Finger reconstruction takes a long time and needs patients to maintain a stable position at the same time, otherwise, the movement of patients would interfere with the operation. (4) During the operation, there will still be a sense of vibration or proprioception, or even a sense of pressure which will cause patients to be nervous.

Region block anesthesia includes subarachnoid block anesthesia, epidural block anesthesia, and peripheral nerve block anesthesia.

Subarachnoid Block Anesthesia

Local anesthetic drugs injected into the subarachnoid space mainly act on the spinal nerve root and achieve anesthetic effect. In toe-to-hand reconstruction, it can be used instead of epidural block anesthesia when the toe is cut off.

Announcements: To maintain the IVs owing smoothly so as to supply medicines and necessary treatment timely; To keep blood pressure stable in rst 20min by supplementing the blood volume since blood vessel dilates that effective circulation is relatively insufcient; When the anesthetic plane is too high, the patients may appear chest tightness, shortness of breath or pronunciation obstacle which should be treated with oxygen mask, etc.; Strict aseptic techniques must be required.

Contraindications: Patients with severe hypovolemia; Patients with coagulation disorder; Patients with infection at the puncture site; Diseases of central nervous system, especially of spinal cord or spinal radiculopathy, may be followed by long-term paralysis after anesthesia; Patients with spinal cord trauma or history of severe low back pain and unexplained spinal cord compression; Patients with severe infections.

Epidural Block Anesthesia

Local anesthetic drugs injected into the epidural space that blocks the conduction of part of the spinal nerves which has a stage function. Lower epidural block anesthesia or sacral canal block anesthesia are often used in toe-to-hand reconstruction of donor site.

Announcements: Procient in puncture technology, strictly prevent penetration of the dura mater; The experimental dose of local esthetic drugs should be injected after catheterization, and then the required dose could be continued to be injected if no signs of subarachnoid block anesthesia appear 5 min later; Rescue medicine and equipment should be prepared in case of occurrence of total spinal block.

The contraindications of epidural block anesthesia are the same as that of subarachnoid block anesthesia.

Peripheral Nerve Block Anesthesia

Brachial Plexus Block

Brachial plexus block is the most commonly used anesthesia in hand surgery. The brachial plexus is mainly consisted of the anterior branches of C5-8 and T1 which supplies sensation and movement of the upper limbs. The brachial plexus nerve is enclosed by the sheath formed by the prevertebral fascia and the scalenus facia in the interscalene. The anes-

6.2 Methods ofAnesthesia

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thetic drugs must be injected into the sheath to be effective including 4 ways that are supraclavicular approach´ subclavian approach, interscalene approach, and axillary approach.

1. Supraclavicular brachial plexus block: The needle should be inserted 0.5cm above the midpoint of the clavicle and to nd the rst rib, along which, move the needle from the outer edge of the scalenus anterior to the anterior edge of the scalenus medius, when anesthesia occurs, inject 10–20 mL solution. The advantages of this method are good anesthetic effect, quick onset, small side effects, and fewer complications. When Supraclavicular brachial plexus block is applied, the affected limb can be placed on the side of body without moving. The disadvantages are the possibility of pneumothorax, phrenic nerve block, Honer syndromes, etc.

2. Subclavian brachial plexus block: After nding the groove between the scalenus muscles, then move the ngers downward and touch pulse of the subclavian artery and the needle should be inserted from the posterior margin of the subclavian artery. If the pulse is not touched, the needle could be inserted in front of the scalenus medius. When anesthesia occurs, inject 20–40mL solution. The advantages of this method are simple operation, small dose of anesthetic, quick onset and the disadvantages are pneumothorax, phrenic nerve block, recurrent laryngeal nerve block, etc.

3. Interscalene brachial plexus block: Find the interscalenus sulcus and insert the needle between the index nger and the middle nger at the level of cricoid cartilage which is the level of the transverse process of the sixth cervical vertebra. Insert slowly until anesthesia appears and inject solution. The advantages of this method are simple operation, especially suitable for fat patients; good effect with small dose, especially suitable for surgery on upper limb and shoulder; avoid causing pneumothorax; avoid causing infection and spread of tumor. The disadvantage is that the ulnar block is not complete or has no effect at all. The remedy is to increase the volume of anesthetics of block the ulnar nerve in the elbow.

4. Interscalene brachial plexus block: The main methods of operation include axillary artery puncture, anesthesia around axillary artery, and extensive inltration around axillary artery. The advantages of this method are simple and safe, however, there are relatively more arteries and veins in this area which may be injured, and there is even possibility that a large dose of local anesthetics will enter blood and cause systemic toxicity.

Sciatic Nerve Block Anesthesia

The sciatic nerve generally passes through the infrapiriformis foramen, in this position, it is located on the ventral side

of the gluteus maximus which is relatively supercial that is often used for ultrasound-guided subgluteal sciatic nerve block anesthesia. For cases requiring tourniquet, it is recommended to reduce the discomfort of patients to the tourniquet. Sciatic nerve block alone cannot reduce the tourniquet response, so it is necessary to combine femoral nerve and obturator nerve block.

Femoral Nerve Block Anesthesia

The traditional method is to nd the pulse of femoral artery and insert the needle between lateral of femoral artery and inferior of the inguianl ligament, the appearance of anesthesia or motor reaction means the correct position of the needle tip is. Under the guidance of ultrasound, the femoral nerve, artery, and vein can be clearly seen that can ensure the local anesthetic uid to wrap around the whole femoral nerve avoid blood vessels injury.

Lateral Femoral Cutaneous Nerve Block Anesthesia

The traditional method is to insert the needle 2cm below the anterior superior iliac spine, when the resistance disappears, suggesting that the needle tip has passed through the fascia lata. Move the needle to inject 10–15mL local anesthetics in a fan both inside and outside. Ultrasound-guided method has two ways: the inferior inguinal ligament approach and the inferior superior ligament approach. Existing evidence suggests that the superior ligament approach is more complete and stable than the inferior inguinal ligament approach in blocking the lateral femoral cutaneous nerve.

Obturator Nerve Block Anesthesia

The traditional method is not easy to operate and the effect is not stable. Under the guidance of ultrasound which can clearly judge the anatomical structure and improve the success rate of obturator nerve block.

Peri-Ankle Nerve Block Anesthesia

The peri-ankle nerves include the tibial nerve, sural nerve, supercial peroneal nerve, deep peroneal nerve, and saphenous nerve. Peri-ankle nerve block alone is usually used for foot surgery without tourniquet, and the operation time is short, or as a remedial measure for incomplete nerve block.

Peri-Elbow Nerve Block Anesthesia

The ulnar nerve, median nerve, radial nerve, medial, and lateral cutaneous nerve can be blocked around the elbow joint. This method is generally only used as a supplement in the case of incomplete brachial plexus block for the reason that the volume of anesthetics used to block multiple nerves at the same time is no less than that used in brachial plexus block and patients cannot tolerate the pain of the tourniquet.

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6 Selection ofAnesthesia forFinger Reconstruction

Peri-Wrist Nerve Block Anesthesia

It is simple and common in hand surgery which can keep ngers active during surgery. The median, ulnar and radial nerve can be blocked.

6.3 Selection ofAnesthesia

General anesthesia is the most commonly used in nger reconstruction which has advantages of quick effect, convenient management, and high safety. General anesthesia drugs have a vasodilating effect which is good for the blood perfusion of reconstructed tissue. Patients can be completely calm which is also good for suture of small blood vessels and nerves. However, patients in emergency surgery usually have

full stomachs which are not suitable for general anesthesia since it will increase the possibility of regurgitation and aspiration which can be life-threatening. In these cases, nerveblock anesthesia or nerve-block anesthesia combined with sedation is more commonly used. In particular, the second method can not only satisfy the need for a completely painless surgical site but also keep patients calm during the operation. After general anesthesia, patients usually experience severe pain at the surgical site, so many hospitals are carrying out nerve block anesthesia combined with general anesthesia which rst solve the problem of postoperative analgesia, second the dose of anesthetics is far less than application of general anesthesia alone which reduce side effects of the drug dose-related, shorten the awake time, be more comfortable after anesthesia.

Fundamental Skill forFinger

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Reconstruction

Abstract

The basic skills of nger reconstruction mainly include the basic techniques in operation and the prociency of anatomy. We will just discuss the training of operating skills. The characteristics of operation skills in microsurgery including: (1) It is generally operated under a microscope which needs an adjustment process; (2) The eld of vision and the operating space are relatively small to be found again once moved; (3) The eld of vision will turn to vague if the lens or eyes move up and down a little which needs to be adapted again; (4) Slight instability or movement of surgeon’s hands would affect the quality of suture. Therefore, a microsurgeon must experience a certain period of formal training before participating in operation. As nger reconstruction is one of the most complicated and difculty operation in microsurgery, the training of skills is especially necessary.

Keywords

Surgical skill · Finger reconstruction

7.1 Micro-Suture Operation Training

ofSmall Blood Vessels

Micro-suture of small blood vessels is a standard of basic skill for microsurgeon. An excellent microsurgeon must have experienced hundreds of times training in micro-suture operation.

7.1.1 Training Should BeStep byStep

Don’t be in a rush for quick results, instead of going step by step at the early stage of training. The position of sitting, head, neck, shoulder, elbow, wrist, hand, and how to take the micro equipment need gradual training and repeated practice under guidance of superior physician so as to be mastered. The height of the microscope and the angle of the eyepiece

should be adjusted according to the height of surgeons, it will be more comfortable when the eyepiece is viewed at head level or slightly lower within 30°. A comfortable sitting position should be with chest and waist relaxed. A good position for operation should be with shoulders relaxed, elbows, forearms, and hands supported. Follow the principle from low to high, from big to small, and from coarse to ne when trained. Practice of microscope needs to use a lower magnication of the eyepiece, generally starting from four to six times which is with a bigger vision and better light that is easier for eye-to-hand coordination training. Then increase the magnication and suture smaller vessels step by step. To practice suturing about 20 anastomotic sites every day and you will be more skilled 1week later.

7.1.2 Placement andUse ofMicrosurgery Instruments

Microsurgery requires that the operation is generally divided into a square table (upper limb operation area) and a operation table (trunk and lower limb operation area). The table surface should be smooth, with appropriate height, and the position of which should be reasonable with the surgeon’s position. Blood-stained gauze, used equipment, even cotton balls and thread ends will affect the operation under the microscope so it is very important to keep the table surface clean. Put the microforceps and scissors on the front of the left-hand side of the surgeon, the needle and thread on the right side, and the other instruments should be placed on the instrument table that could make the surgeon get and put down the instruments much more easily without having to take their eyes off the microscope. There are two ways to nd the needle again and continue to sutrue: one is to put the needle in the eld of vision of the microscope, see the needle clearly and continue to suture; the other way is just like the normal way of surgical suture which is more suitable for beginners since their eyes can take a short break from the lens to avoid eye strain.

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7 Fundamental Skill forFinger Reconstruction

7.1.3 Select Needle andThread According toVessel Diameter

The quality and patency rate are directly affected by the thickness of needle and thread. If the thread is too thick, the vascular cavity will be occupied, and the foreign body reaction will make the vascular cavity narrow if the thread is too thin, the tension will be too small to be tight which will cause thrombosis. Therefore, the appropriate suture needle and thread should be selected according to the vessel diameter. Generally, 7-0 to 8-0 nylon needle and thread are suitable for vessels of 2–3mm in diameter; 9-0 nylon needle and thread is suitable for vessels of about 1mm in diameter; 9-0 to 10-0 nylon needle and thread is suitable for vessels of 0.5mm in diameter; 12-0 nylon needle and thread is suitable for vessels of under 0.3mm in diameter.

7.1.4 Distance Between Suture Stitches, Breadth ofSuturing Margin, andNumber ofStitches Should BeAppropriate

The number of stitches should be determined according to diameter of the blood vessel. On this basis, Distance between suture stitches, breadth of suturing margin should be properly mastered. It has been reported that the number of stitches, distance between suture stitches, breadth of suturing margin are not properly master all will affect the quality of anastomosis. The vessel diameter should be measured rst, then the number of stitches could be determined, after the distance between suture stitches, the breadth of suturing margin could be determined based on it. For example, when the vessel is 1mm in diameter, 8–9 stitches will be suitable if 9-0 nylon needle is used, and distance between suture stitches, breadth of suturing margin should be 0.3mm; 12–14 stitches will be suitable If 12-0 nylon needle is used, and distance between suture stitches, breadth of suturing margin should be 0.2mm.

7.2 Skill andKey Points forSmall Blood Vessel Suture

7.2.1 Clear Exposure ofBlood Vessels

No matter where the vascular injury is, it must be clearly exposed for easy operation under microscope. Tissues 1–2cm around anastomosed site should be dissociated along the blood vessel. Any tissue that affects vision should be

sutured and xed on both sides or excised. Light blue or yellow silicon rubber sheet can be set under the blood vessel makes the vision more clear to be sutured.

7.2.2 The Suture Must BeintheNormal Vascular Segment

The blood vessels should do a debridement again before sutured. A section (generally 0.5–0.8cm) on the proximal and distal end should be dissociated and observed. Following situation means the vascular wall, especially the intima has been damaged in different degrees which will cause thrombosis after anastomosis should be excised: Peripheral bleeding, hematoma of the outer membrane mostly caused by vascular branch tear and vascular wall damage; “red line sign” indicates that there is compression, twist, contusion or tear in the vascular wall; “stain ribbon sign” indicates that there is rupture of the muscularis due to tension or rotation injury. Even if the appearance of the vessel seems normal, when it is washed, there is a occulent oating substance in the lumen, or mural thrombus that cannot be washed out, etc. which also indicates that the intima is damaged and needs to be excised until the intima is smooth, complete, pink, and there is no oating substance and mural thrombus, etc. In order to ensure the success rate of anastomosis, it is necessary to suture in normal vascular segment.

7.2.3 The Size ofAnastomosed Vessels Should BeSimilar

The size of end-to-end anastomosed vessels should be similar, if it is not, anastomosis will be more difcult and probe to thrombosis. When the diameter difference is more than 1/3, the smaller end should be cut into inclined plane or sh mouth to increase the diameter.

7.2.4 The Tension ofBlood Vessels Should BeProper

Due to the physiological elasticity of blood vessels when they are cut, the ends will retract to both sides and the degree of retraction is related to vascular nature, diameter, length of dissociation, and limb position. Generally, arteries with a diameter of about 1mm, dissociated by about 2cm, can naturally retract a distance between 0.5 and 1cm which will still meet the physiological requirement of tension. However, most of the damaged vessels would be with defects, after

7.3 Suture Methods

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debridement, the defects may reach about 1cm. If they are dissociated and peripheral tissue is sewn up with a few stitches to reduce tension, the vascular suture may be still allowed. When the actual defect is over 2cm, it should be repaired by vascular replantation.

7.2.5 The Operation Should BeSteady, Accurate, Light, andSkillful

The so-called non-injury operation refers to the reduction of iatrogenic injury to the minimum in the process which needs surgeons to be steady, accurate, light, and skillful. Every involved in the operation, including assistants, nurses, anesthesiologists as well as the patients must keep the operating table steady and quiet. Avoid clumsy and awkward movements as possible as you can, such as backhand suture and nger knotting, etc.

7.2.6 Distance Between Suture Stitches, Breadth ofSuturing Margin, andNumber ofStitches Should BeAppropriate

Just described as above (Sect. 7.1.3).

7.2.7 Proper Trim ofOuter Membrane atBroken End andFlushing

The outer membrane at broken end is easily inserted into lumen which should be properly trimmed. The outer membrane has a supporting and nourishing effect on the vascular wall, when it is trimmed too much, it is not conducive to the stability and healing of the anastomotic site. In the process of suture, heparin saline solution (12.5 mg of heparin per 100mL of normal saline solution should be regularly dripped to keep anastomotic site wet and clean, however, the dripping liquid should not be too much so as not to affect the stitching and knotting.

7.2.8 Maintain theVascular Bed Healthy andFlat

The anastomotic site must be surrounded by smooth and healthy tissue for patency and healing. The vascular is uneven, even on the uneven fracture end or steel plate screw, and the surrounding tissue with poor blood supply can stimu-

late vasospasm or thrombosis. Therefore, before suturing blood vessels, muscles and fascia with good blood supply should be paved under the blood vessels or cover the bones or xations rst. After the suture is completed, it is better to be covered with surrounding healthy muscles, fascia, and other soft tissues to leave no ineffective cavity which can not only prevent vasospam but also be helpful for healing.

7.2.9 Stitching andKnotting Should BeAccurate andProper

When the needle is inserted, the needle tip and vascular wall should be vertical, preferably no less than 60°-70°, in this way, the distance between the needle and vascular wall is shortest, resistance is small, and the damage is light. Knotting tightness should be proper, align with the two broken ends, slightly eversion on the outside, and align with the inner membrane are good.

7.2.10 The Sequence ofStitches Should BeProper

No matter what suture method is used, the principle is the sequence of stitches should be simple, easy to master the distance between suture stitches, breadth of suturing margin and number of stitches, small damage to vascular vessels.

7.3 Suture Methods

There are many microvascular suture methods, just described as follows, which can be chosen according to own preferences.

7.3.1 End-to-End Anastomosis

End-to-end anastomosis is the most common method for microvascular at present which conforms to the physiological blood ow direction and can maintain the maximum blood ow rate. Because of the doctors’ habit, the suture method and needle sequence are different.

Three Stay Sutures End-to-End Anastomosis (Fig.7.1)

It is invented by Carrel in 1902. The advantages of this method are that it is convenient to add stitches by lifting traction line at each point, avoiding the suture to the opposite

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7 Fundamental Skill forFinger Reconstruction

Fig. 7.1 Three stay sutures end-to-end anastomosis (Carrel)

Fig. 7.2 Two stay sutures end-to-end anastomosis

side wall, and the vascular rotation is less. However, the disadvantage is that it is not easy to grasp the isometric three xed points, so the number of needles, needle spacing, edge spacing are difcult to achieve uniform.

Two Stay Sutures End-to-End Anastomosis (Figs.7.2 and7.3)

It is 180° equidistant two xed points suture method. The advantages of this method are more clear to expose, more convenient to suture, and easy to grasp needle spacing and edge spacing. However, the disadvantages are that when the two-needle traction line is raised, the lumen will be deviated and the tube wall will close together, especially the thinwalled vein, which is easily be sewn to the opposite side; When it is stitched to the opposite wall, the blood vessels need to be rotated 160°-180°, which is easy to damage the blood vessels.

Fig. 7.3 Suture the lateral wall and needle sequence at equidistant two points (Wang 1982)

Fig. 7.4 Nonequidistant two stay sutures end-to-end anastomosis

Nonequidistant Two Stay Sutures End-to-End Anastomosis (Fig.7.4)

It is invented by Cahett in 1967. The advantage of this method is that the anterior wall of the vessel between two traction lines is smaller at 120°, while the posterior wall is larger at 240°. In this way, when the anterior wall is sutured, the posterior wall will drop down and leave the anterior wall, avoiding the suture to the posterior wall. However, the disadvantage is that the number of needles is not easy to grasp, and the vessel needs to be rotated 180°to suture the posterior wall which is easy to damage the vessel.

Isometric Four Stay Sutures End-to-End Anatomosis oftheAnterior Wall (Fig.7.5)

The advantages of this method are that the exposure is clear, easy to operate, needle spacing, edge spacing, and needle number are easy to grasp. The disadvantage is that the vessel

7.3 Suture Methods

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109

Fig. 7.5 Isometric four stay sutures end-to-end anatomosis of the anterior wall

Fig. 7.6 Isometric four stay sutures end-to-end anatomosis of the posterior wall and twine sutures

needs to be rotated 180° to suture the posterior wall which is easy to damage the vessel.

Isometric Four Stay Sutures End-to-End Anatomosis ofthePosterior Wall (Figs.7.6 and7.7)

The advantage of this method is that the lumens can be seen clearly with each stitch, and the suture to the opposite side wall can be avoided. But its disadvantage is that number of needles is not easy to grasp, the needle spacing, and edge spacing is also difcult to achieve uniform.

Fig. 7.7 Insertion anastomosis (Lauritzen 1978) and sleeve insertion anastomosis (The arrow points to the direction of blood ow)

Fig. 7.8 Isometric four stay suture exstrophy mattress anatomosis (Wang 1982)

Continuous Anastomosis (Figs.7.8 and7.9)

It is advisable to use continuous anastomosis to keep the tightness of each stitch at the length that can be used for knotting after cutting, when the posterior wall is nished, cut

Fig. 7.9 Isometric four stay suture end-to-side exstrophy mattress anatomosis and needle sequence (Wang 1982)

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7 Fundamental Skill forFinger Reconstruction

all the lines and tie them or cut one at a time which can improve suture speed and avoid the suture to the opposite side wall, but the number of needles and margins are not easy to grasp, and its appearance is messy.

Side Wall Stayed Sutures Anastomosis

End-to-Side Anastomosis

When one of the vessel should not be cut off or the diameter of the two broken ends is too large, end-to-side anastomosis can be used.

Lateral opening (window): When end-to-side anastomosis is adopted, it should be opened more than 2cm away from the vascular ligation site to prevent blood clots formed at the ligation site from affecting the patency of suture. And the opening should be slightly larger than or equal to the diameter of the broken end to be anastomosed, so as not to cause stenosis.

The angle of this method is generally about 45°, but some people think there is difference between 45° and 90°. However, the angle should not be too small which will be more difcult to suture and affect blood ow.

Sleeve Insertion Anastomosis

In 1978, Lauritzen and Mayer conducted an experimental study on femoral vessels of rats with diameter less than 1 mm with the method of sleeve insertion anastomosis at almost the same time and achieved good results. In 1980, Chen zhongwei conducted an experimental study on 100 femoral arteries of rats with diameter 0.6–0.8mm with this method and obtained a 98% long-term potency rate which attracted much attention and became one of the most commonly used suture methods.

The advantages of this method are that there are no or few suture line in lumen, and no damage to the vascular intima; The operation is simple and time saving; Generally speaking, the diameter of about 1 mm needs only 3–4 stitches which can be completed within 8–10min. However, it also has some disadvantages that it is not suitable for end-to-end anastomosis; when the vascular length is insufcient and the diameter varies too much, it cannot be used; When the diameter is less than 0.5mm or larger than 3mm, the patency rate is lower than that of end-to-end anastomosis.

Small Vessel Transplantation

In the process of limb vascular injury or severed limb (nger) replantation, blood vessels with severe contusion are often encountered which must be removed, resulting in a shortage of blood vessels; or in the process of transplantation since the vascular pedicle is short and cannot be sutured with the recipient vessel, small vessel transplantation is required. Autogenous vein graft is most commonly used, autogenous artery graft is also used in special cases.

Notices

1. A detailed examination must be conducted before the vascular resection which should be of appropriate diameter and length according to the condition of the recipient area for transplantation.

2. Autologus supercial vein is the best material for small vessel transplantation. The great saphenous vein, the small saphenous vein, and the cephalic vein are often used to supply the large vascular defects in limbs; The supercial veins of forearm, dorsal of hand, and dorsal of foot are the common donor areas for small vessel defect transplantation.

3. When cutting blood vessels, non-invasive operation and open cutting must be insisted on, excessive pulling and squeezing of blood vessels should not be done, which can reduce vascular stimulation and injury.

4. The diameter and length of transplanted vessels should be appropriate.

5. The transplanted vessels should be placed in healthy soft tissue, covered or wrapped by surrounding muscles, fascia, etc., which can reduce vascular stimulation and facilitate vascular healing.

6. Spasmodic and anticoagulant drugs should be used after small vessel transplantation.

7. In the process of operation, the bleeding should be stopped thoroughly to avoid hematoma and a drainage strip should be placed if necessary. Postoperative antibiotics should be routinely used to prevent infection.

References

Lauritzen. A new and easier way to anastomose microvessels. An

experimental study in rats. Scand J Plast Reconstr Surg. 1978, 12:291–294.

Wang CQ. Study on microvascular suture method. People’s Military

Surgeon, 1982(1).