01. Microchirurgie - Introducere f

7/25/2019 01. Microchirurgie - Introducere f

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Ce esteCe estemicrochirurgia?microchirurgia?


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Ce sunt mCe sunt microchirurgiicrochirurgii?i?


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Microchirurgia Microchirurgia ntr-un sens mai larg,ntr-un sens mai larg, microchirurgiamicrochirurgia == chirurgie sub magnificaiechirurgie sub magnificaie(microscop, lupe,(microscop, lupe,+/-+/- aparatura de endoscopie cu zoom optic sauaparatura de endoscopie cu zoom optic saudigital)digital) ++ instrumente speciale i materiale de sutur! performanteinstrumente speciale i materiale de sutur! performante## de$arata microchirurgie, este chirurgia care se realizeaz! doarde$arata microchirurgie, este chirurgia care se realizeaz! doar

cu a%utorul microscopului"cu a%utorul microscopului"&n cadrul Chirurgiei 'lastice, microchirurgia reconstructi$!&n cadrul Chirurgiei 'lastice, microchirurgia reconstructi$!includeinclude

chirurgia micro$ascular! (anastomoza $aselor sub mm),chirurgia micro$ascular! (anastomoza $aselor sub mm),microneural! (neurorafia ner$ilor periferici),microneural! (neurorafia ner$ilor periferici),

microlimfatic! (reconstrucia $aselor limfatice) imicrolimfatic! (reconstrucia $aselor limfatice) imicrotubular! (reconstrucia structurilor anatomice tubulare microtubular! (reconstrucia structurilor anatomice tubulare canal tenon, canale deferente, trompe uterine, etc)"canal tenon, canale deferente, trompe uterine, etc)"

microscopmicroscop $ine din greac! mi ros. = mic si s opein. = a $edea$ine din greac! mi ros. = mic si s opein. = a $edea


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15901590 acharias 0ansenacharias 0ansen-- primul microscopprimul microscopprimul microscopprimul microscopoperaionaloperaional-- 1n a doua 1n a doua %um!tate a secolului 23 %um!tate a secolului 23-- #ntonie $an#ntonie $an4eeu5enhoe "4eeu5enhoe "


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19191919 - 67len, un chirurg 8"9"4" suedez- 67len, un chirurg 8"9"4" suedez, a realizat primele, a realizat primeleoperaii sub un microscop monocular la ni$elul urechiioperaii sub un microscop monocular la ni$elul urechiimedii" Colegul i eful s!u, :olmgren, a e;tins aplicaiilemedii" Colegul i eful s!u, :olmgren, a e;tins aplicaiilemicroscopului operator ( eiss, binocular) la inter$eniilemicroscopului operator ( eiss, binocular) la inter$eniilepentru otoscleroz!, la ni$elul urechii interne (2< )"pentru otoscleroz!, la ni$elul urechii interne (2< )"

Carl OlofCarl OlofNylenNylen


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'rimele aplicaii 1n tehnicile micro$asculare au ap!rut 1n'rimele aplicaii 1n tehnicile micro$asculare au ap!rut 1ndecada a cincea a secolului, legate de progreseledecada a cincea a secolului, legate de progresele 1nregistrate 1n chirurgia cardiac! i transplantul de organe 1nregistrate 1n chirurgia cardiac! i transplantul de organe * 1n special transplantul renal" * 1n special transplantul renal"19581958 - apare istoricului articol al lui iedenberg, despre- apare istoricului articol al lui iedenberg, desprerepararea $aselor mici, cu calibrul de - mmrepararea $aselor mici, cu calibrul de - mm-- bazelebazelemicrochirurgiei reconstructi$e" #stfel a fost trecut! pentrumicrochirurgiei reconstructi$e" #stfel a fost trecut! pentruprima dat! prima dat! graniaD $aselor cu diametrul de mm"graniaD $aselor cu diametrul de mm"


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19601960 - 0ules 0acobson i uarez, 1n #merica, introduc- 0ules 0acobson i uarez, 1n #merica, introductehnica microchirurgical! 1n chirurgia arterelor coronaretehnica microchirurgical! 1n chirurgia arterelor coronare ++ instrumente fine cu design special + microscop cuinstrumente fine cu design special + microscop cumagnificaia de E"magnificaia de E"

0acobson a fost primul care a folosit teremenul de0acobson a fost primul care a folosit teremenul demicrochirurgiemicrochirurgieDD""


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ReplantariReplantari

2


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Gicrochirurgie $ascular!Gicrochirurgie $ascular!

1966 -1966 - Harry BunckeHarry Buncke, L, Los Angelesos Angeles


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9eplantar9eplantar ii

2


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ReplantareReplantare

* * prima replantare digitala realizata deprima replantare digitala realizata de

IamaiIamai folosind un microscop operatorfolosind un microscop operator


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Gicrochirurgie e;perimental!Gicrochirurgie e;perimental!

JJFB -FB -un 4eeun 4ee , Korea, Korea


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Gicrochirurgie e;perimental!Gicrochirurgie e;perimental!

JJFB - #cland > 8L rienFB - #cland > 8L rien


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ernard GcC" 8L rienernard GcC" 8L rien

2


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Chirurgia rChirurgia replanteplant!r!r iiii4a finele anilor P3B4a finele anilor P3BQQChen - ChinaChen - China

QQ Kleinert - R #Kleinert - R #QQiemer - Serman7iemer - Serman7QQ8J rien - #ustralia8J rien - #ustraliaQQIamai - 0apanIamai - 0apan


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II ransferransfer liber tisularliber tisular2 unc eQQ :arii > 8hmori:arii > 8hmoriQQTaniel > Ia7lorTaniel > Ia7lorQQ8J rien8J rien

2


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GagnificatieGagnificatie4upe4upe

GicroscoapeGicroscoape


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&nstrumente&nstrumentede microchirurgiede microchirurgiesunt prelungirile fine ale mUinii chirurgului,sunt prelungirile fine ale mUinii chirurgului,$Urfurile lor sunt punctele finale de$Urfurile lor sunt punctele finale decontcontactactcu pacientulcu pacientul


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12-0 50 micron suture material

50micron50micron

100micron100micronhair hair


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12-0 50 micron suture material

hair hair

30micron30micron


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#plicatiile microchirurgiei#plicatiile microchirurgieiChirurgie 'lastic! i 9econstructi$Chirurgie 'lastic! i 9econstructi$ !! 8rtopedie8rtopedie8ftalmologie8ftalmologieChirurgie GVChirurgie GVRrologieRrologieChirurgie 'ediatric!Chirurgie 'ediatric!894894Chirurgie Seneral!Chirurgie Seneral!Chirurgie Cardio-$ascular!Chirurgie Cardio-$ascular!6eurochirurgie6eurochirurgieIransplantologieIransplantologieChirurgie 8ncologic!Chirurgie 8ncologic!8bstetric! i Sinecologie8bstetric! i Sinecologie'sihiatrie * Iratamentul transse;ualismului'sihiatrie * Iratamentul transse;ualismului


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WWII

OO

SSDD

MM

Prof Earl Owen


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f


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#socierea comple;! microscop operator, instrumentar specific i#socierea comple;! microscop operator, instrumentar specific imaterial de sutur! performant, de$ine oportun! doar 1n prezena unuimaterial de sutur! performant, de$ine oportun! doar 1n prezena unui

chirurg instruit, dotat constituional cu anumite calit!ichirurg instruit, dotat constituional cu anumite calit!i

Calitati Dfizico - biologice.Calitati Dfizico - biologice.Oedere foarte bun!Oedere foarte bun!Ganualitate Dnatural!.,Ganualitate Dnatural!.,D1nn!scut!.D1nn!scut!.Coordonarea perfect! aCoordonarea perfect! agesturilorgesturilor9ezisten! fizic!9ezisten! fizic!

Calitati dobUndite prinCalitati dobUndite prinantrenamentantrenament

Ganualitate dobUndit! *Ganualitate dobUndit! *automatismeautomatismeIehnic! meticuloas!Iehnic! meticuloas!#uto-disciplin!#uto-disciplin!Cuno tine teoreticeCuno tine teoretice

Calitati psihice, comportamentaleCalitati psihice, comportamentale9ezistenta psihica9ezistenta psihicaCapacitate deCapacitate deconcentrareconcentrare si desi dementinere a starii de concentrarementinere a starii de concentrarepe durata lunga de timppe durata lunga de timpCapacitate deCapacitate deobser$aiobser$aiee precisprecisa,a,

de analiza corecta a situatiilor side analiza corecta a situatiilor side alegere a solutiei optimede alegere a solutiei optime9!bdare9!bdare'erse$eren!,'erse$eren!,Con tinciozitateCon tinciozitate9esponsabilitate9esponsabilitatepirit in$enti$pirit in$enti$Oia! echilibrat!Oia! echilibrat!Capacitate de integrare 1n muncaCapacitate de integrare 1n muncade echip!de echip!Torin! de autoperfecionareTorin! de autoperfecionare9espect pentru detalii9espect pentru detalii#uto-disciplin!#uto-disciplin!

TelicateeTelicateeWntuziasmWntuziasm


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'ozitia de lucru'ozitia de lucru


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'osition the needle in the stems of the needleholder at least 2mm from the %a5 tips, not at he $er7 end'osition the needle in the stems of the needleholder at least 2mm from the %a5 tips, not at he $er7 endKeep the a;is of the needle and the stems of the forceps perpendicular to each other"Keep the a;is of the needle and the stems of the forceps perpendicular to each other"Ihis is the most effecti$e position to dri$ing the needle against the tissue resistance in a straight lineIhis is the most effecti$e position to dri$ing the needle against the tissue resistance in a straight line


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asic Gicrosuturing Iechni@ueasic Gicrosuturing Iechni@ue

'reliminar7 suturing e;ercises on non animal models'reliminar7 suturing e;ercises on non animal models

9ubber sheets9ubber sheetsilicone tubesilicone tubes4eafs4eafs


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9ubber sheet9ubber sheetM/BM/B'lace the needle tip perpendicular to'lace the needle tip perpendicular tothe point of entrance and pass thethe point of entrance and pass theneedle"needle"

#fter passing the needle tip should#fter passing the needle tip shouldemerge from the undersurface theemerge from the undersurface theentrance point as near to theentrance point as near to theperpendicular as possibleperpendicular as possibleIhis procedure can be facilitated b7Ihis procedure can be facilitated b7e$erting the cut edge of the rubbere$erting the cut edge of the rubbersheet 5ith the slightl7 opened tips ofsheet 5ith the slightl7 opened tips ofthe forceps inserted under the cutthe forceps inserted under the cutedge"edge"


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Ihe e;it bite should be the same sizeIhe e;it bite should be the same sizeas the entrance biteas the entrance bite

Rsed the slightl7 opened tips of theRsed the slightl7 opened tips of theforceps as a conterpressor and passforceps as a conterpressor and passthe needle bet5een them"the needle bet5een them"'ull the needle through follo5ing its'ull the needle through follo5ing itscur$aturecur$ature

h fI h i@ f 7i


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Iechni@ue of t7ing notsIechni@ue of t7ing nots


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'ractice until the sutures are'ractice until the sutures areparallel to each other, perpendicularparallel to each other, perpendicularto the sutured edges and e@uall7to the sutured edges and e@uall7spacedspacedtart 5or ing 5ith the incision linetart 5or ing 5ith the incision linein a $ertical position at a slo5in a $ertical position at a slo5rh7thmrh7thmContinue the suturing practice 5ithContinue the suturing practice 5iththe line of incision at differentthe line of incision at differentpositions in order to furtherpositions in order to further

impro$e coordination and accurac7impro$e coordination and accurac7of handling microinstruments asof handling microinstruments as5ell as placing microneedles5ell as placing microneedles


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9ubber sheets9ubber sheets simulating microsurgical ner$e suturessimulating microsurgical ner$e sutures

f


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4eaf suture4eaf sutureKaufman 1984, Ballantyne 1985


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'lant tissue is friable and non elastic * it tolerate roughness poorl7 and documents'lant tissue is friable and non elastic * it tolerate roughness poorl7 and documentstechnical errorstechnical errors


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Wnlarge needle holes resulting from improper pulling of the needles and/orWnlarge needle holes resulting from improper pulling of the needles and/ore;cessi$e tightening of the notse;cessi$e tightening of the nots


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'etal suture'etal suture


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'rincip'rincip iileiile sisi IehniIehni cilecile ChirurgieiChirurgieiGicro$ascularGicro$ascularee

pe model animalpe model animal


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#natom7#natom7


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#nastomoza#nastomoza


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#nastomoza$aselor femurale$aselor femurale


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IechniIechni caca suturisuturii $ascularei $asculare e indeparteaza peretele anteriore indeparteaza peretele anteriorde cel posteriorde cel posterior#cul este plasat langa punctul in#cul este plasat langa punctul in

care pensa tine ad$enticea si estecare pensa tine ad$enticea si esteintrodus perpendicular pe $asintrodus perpendicular pe $asIrebuie sa tra$eseze toataIrebuie sa tra$eseze toatagrosimea peretelui"grosimea peretelui"Tistanta fata de margineaTistanta fata de marginea$asului la care se introduce acul$asului la care se introduce acultrebuie sa fie de E mai maretrebuie sa fie de E mai maredecat grosimea pereteluidecat grosimea peretelui$ascular"$ascular"


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ViitorViitor


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Viitor Viitor

mmicroicrochirurgiechirurgie asistasistat!at!endoscopicendoscopic

mmicroicrochirurgiechirurgie roboticrobotic!!

prefabricare de lambouriprefabricare de lambouri inginerieinginerie

tisular!tisular!

h l $h l $ d f d l d Viitor ndeprtat Viitor ndeprtat


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QQChirurgul iChirurgul i micromicrochirurgul $or disparechirurgul $or dispare,, fiind 1nlocuii defiind 1nlocuii de e;pere;per ii 1 1 n geneticn genetic!! ,, multiplicare i manipularemultiplicare i manipularecelcelular!ular! ""QQ9eplanta9eplantarearea ControlControlarea iarea i direcdirecionareaionarea multiplic!riimultiplic!rii,, aadi$idi$iziuniiziunii ii diferendifereniierii celulareerii celulare""QQOindecareaOindecarea = depo= depozzitit dede colagencolagen 1nlocuirea 1nlocuirea $ari $ariateloratelor tipuri celularetipuri celularehistologicehistologice""


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01. Microchirurgie - Introducere f

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