DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Traumatic amputation of right thumb and index finger.
POSTOPERATIVE DIAGNOSIS: Traumatic amputation of right thumb and index finger.
OPERATION PERFORMED: Completion ray amputation of right index finger and microvascular thumb replantation with repair of bone, tendons, nerves.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, and after induction of general endotracheal anesthesia, the right upper extremity was prepped with Betadine scrub and paint and draped out sterilely. We first started with two teams, one team worked on the patient irrigating the wounds with a Pulsavac, debriding, and then cutting back. After looking closely at the index finger, determination was made that it was not replantable. We trimmed this back, debrided the skin edges, retracted nerves, and then closed the wounds with 5-0 nylon suture.
We then went over and opened the thumb up, identified the proximal end of the flexor pollicis longus, and identified both neurovascular bundles. Nerves were easily identified and cleaned off. On the back table, the other team went ahead and debrided and cleaned off the thumb. We trimmed back just about 3.5 mm of bone just to give us a flat surface. We were so close to the joint, we did not go any further, opened him up volarly in a zig-zag type fashion and found both the radial and ulnar digital arteries and nerves on the thumb. Dorsally, we pulled the skin back and he had several nice veins we thought we could get into without too much difficulty. We went back then to the arm itself and trimmed back the bone about 5 mm and it had a nice flat surface. We ran two 0.035 K-wires retrograde up the thumb and then ran them back and affixed them to the proximal phalanx of the thumb. We then performed an end-to-end modified Kessler repair of the tendon with a core suture of 4-0 Ethibond and a 6-0 Prolene over and over around it, then repaired the extensor tendon with a 4-0 Ethibond figure-of-eight.
At this point, we brought the microscope in and carefully cleaned off the arteries on both sides. It was elected because of the large size of the ulnar artery to go ahead and repair this first and use the microscope. We let the tourniquet down and had good pulsatile flow in both neurovascular bundles. Performed an end-to-end anastomosis, and despite the fact that the caliber was quite large, probably in the order of 2.5 to 3 mm, the artery did not flow and therefore we took it down and redid it. Then, we got flow, flipped the hand over, found the dilated veins and did two venous anastomoses, but noted as we finished the second one, that the thumb was pale and not bleeding anymore. We flipped the hand back again and looked at the anastomosis. Technically, it appeared to be okay. We teased the artery a little bit and then we got flow again and it ran for about 20 minutes and stopped.
At this point, we cleaned off the radial artery proximally and distally. It was smaller, probably about half the caliber, about a millimeter and a half or so, but we hoped this would open immediately and have good pulsatile flow into the artery. Then, the thumb pinked up nicely. Went back then to the ulnar side and took it down. The patient had a lot of atherosclerosis in the vessel and we trimmed him back probably another 5 mm or so. We mobilized it, repaired it several times, and just really could never get it to flow, probably because of the atherosclerosis in the vessel and probably due to some trauma related issues. However, the radial side continued to flow quite nicely. We then brought the microscope back in again and repaired both the nerves in an end-to-end fashion with 9-0 suture. We then gently tacked the skin back together with some 5-0. The patient tolerated the procedure well, was awakened and transferred to the recovery room in stable condition.
