Replantation Surgery

AFTER

BEFORE

Replantation Surgery

One of the most spectacular surgical procedures is the re-attachment of an amputated extremity. The procedures are known as replantation surgery. The name is similar to transplantation surgery. In transplant surgery a body part or organ is removed from one patient and transplanted to another. In replantation surgery a body part which has been accidentally removed is re-attached or replanted to the original patient. All of us have read about farmers or equipment operators who have lost an arm or a leg in an accident. Once these procedures were headline news but, with advances in medicine and the availability of surgical microscopes and microsurgical instrumentation, these procedures are now more common than you may realize. Several factors are involved in successful replantation surgery. The method of injury, the location of the injury, the age of the patient, the health of the patient, the method of transporting the body part and the time from injury to the time in surgery are all factors affecting the outcome.

Actual Patient of J. E. Lomax, M.D.

The method of injury will often determine the success of the replant. Sharp, clean amputations will result in easier repairs with less surrounding soft tissue injuries to address. Jagged tearing injuries produce significant damage to soft tissue and associated blood vessels reducing the chance of successful re-attachment of the body part. The cleaner and sharper the amputation the easier the replantation surgery.

The location of the amputation will also determine the outcome. Injuries involving mostly bone and tendon and very little muscle will heal better. However the further you get out on an extremity the smaller the vessels get, making the re-attachment more difficult. The ideal location will be one of moderate sized vessels, minimal muscle, mostly tendon and nerve. Areas such as the hand or foot are the best. Legs and forearms can be re-attached but the amount of muscle and nerve involved may limit their function after successful re-attachment. Simpler structures are always easier to replant but every amputated extremity should be considered for possible re-attachment.

Patient health is a consideration whenever surgery is anticipated. In patients undergoing replantation surgery specific pre-operative and post-operative factors are important. Pre-operative factors include but are not limited to diabetes, peripheral vascular disease, and smoking. Any process which will impair healing or cause poor blood flow will decrease the chance for success. Post-operative factors such as smoking, diabetes, lung problems, liver disease, heart problems, and vascular disease all reduce the chance for a successful replant. Despite the numerous factors which may impact the outcome of replantation surgery, everyone should initially be considered a candidate for replantation.

The method of transportation of the amputated body part and the time from injury to re-attachment are the only post-trauma or injury factors we can control. The time from injury to surgery is the golden interval.

In the typical finger amputation the "warm ischemic time" is four hours. This means the time from amputation to the start of the surgical procedure should be no longer than four hours if the finger is not kept cold. If the finger is kept cold the "cold ischemic time” now goes out from six to eight hours. The issue is how to best keep the finger cold. The proper way to transport a finger is...

1) Wrap it in a moist hand towel or wash rag.

2) Place in a water proof bag.

3) Remove as much air from the bag as possible & seal.

4) Place the bag on ice for transporting.

5) Make sure the tissue does not come in direct contact with the ice.

Safe transport of the body part can make or break the success of the attempted replant.

Replantation surgery should be considered in every traumatic amputation. Only an experienced replantation surgeon can make an adequate assessment of all the factors affecting the potential outcome of surgery. As the availability of replantation surgery becomes more widespread, the time of transport and the speed with which the patient can get into the operating room will diminish. This will offer more individuals a greater opportunity for a successful outcome. Dr. Lomax at Soderstrom Dermatology Center has over twenty years of experience in this field of surgery and is ready to assist you in any way he can.