Escolar Documentos
Profissional Documentos
Cultura Documentos
History of Microsurgery
Susumu Tamai, M.D., Ph.D.
Kashihara City, Nara, Japan
282e
www.PRSJournal.com
Fig. 1. Dr. Alexis Carrel. (From Guthrie CC. Blood Vessel Surgery
and Its Applications. New York: Longmans, Green & Co; 1912.)
Fig. 2. Triangulation method of vascular end-to-end anastomosis by Dr. Carrel. (From Guthrie CC. Blood Vessel Surgery and its
Applications. New York: Longmans, Green & Co; 1912.)
Technological improvements in operating microscopes such as coaxial illumination,20 motorized zoom,21 and binocular viewing made microsurgery more reliable. There had been few
advances since the early work of Hopfner4 and
Carrel and Guthrie,5 but multiple teams simultaneously began to investigate experimental extremity replantation in the United States,22 Russia,23
and Japan.24,25
In 1958, Onji and I attempted to revascularize
an incompletely amputated thigh on a 12-year-old
girl at Nara Medical University Hospital. The extremity was lost 4 weeks after revascularization because of overwhelming infection and thrombosis.
In August of 1959, we successfully restored the
nerve supply in another patient with incomplete
amputation at the level of the thigh. The patient
was able to ambulate within 2 years and there
remained only a small area of hypalgesia on the
lateral aspect of her leg without foot drop after 20
years. These early experiences led to a program of
experimental surgery in limb replantation at our
clinic that continued for the next 20 years. We
investigated the physiology of ischemia-reperfusion injury and the systemic toxicity related to
replanting tissue after prolonged warm ischemia.
We concluded that the clinical replantation surgery should be limited to the hand or digits until
unsolved problems of systemic toxicity associated
with larger tissue units were resolved. For that
purpose, we needed finer instruments and techniques to accomplish microvascular anastomosis, as developed by Jacobson and Suarez.16,17 We
were, however, limited at the beginning by the lack
of operating microscopes in Japan.
In 1962, Malt and McKhann26 performed the
first replantation of a completely severed arm in a
12-year-old boy in Boston. Two years later, Kleinert
and Kasdan27 successfully revascularized an incompletely amputated thumb. In 1963, Chen and
colleagues28 successfully replanted a completely
amputated hand in Shanghai.
These successes led to new efforts to develop
reconstructive microsurgery around the world.
During the 1960s, Buncke29 31 performed numerous experiments involving replanting or transplanting tissues in laboratory animals. He developed many important principles and techniques
and has been called the founding father of microsurgery. Simultaneously, John Cobbett from
East Grinstead, England, and others were also
starting their microsurgical work.
Our program in Japan at Nara Medical University began in the spring of 1964. It has been very
283e
Fig. 4. A monoscope for otologic surgery used first by Dr. Nylen in 1921. (From Stahle J. Carl Olof
Nylen (18921978): Den foerste att tillaempa otomikroskopi. Sven Oenh-Tidskr. 2005;3:44.)
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Fig. 10. The developmental process of the Tamai microvascular double clip. (Above, left) A pair of Heifetz clips
connecting with a 23-gauge hypodermic needle. (Above, right) A home-made double clip. (Below, left) A prototype double clip manufactured by Crown Co. (Below, right) The first metal double clip, commercially available
from Crown Co.
286e
DEVELOPING PERIOD OF
MICROSURGERY (1971 TO 1980)
The decades of the 1970s witnessed numerous
important advances. Experimental tissue transfer
continued at several centers around the world,
and important strides were made in clinical microsurgery. In 1971, Strauch et al.43 first reported
pedicled vascularized rib transfer to the mandible
in dogs, demonstrating the possibility of vascularized bone transfer. In the same year, Tamai et al.39
experimented with free vascularized whole knee
joint transplantation in dogs. They showed the
possibilities of not only vascularized bone graft but
287e
Year
President
Chairman
Congress Site
1
2
3
4
5
6
7
8
9
10
11
12
13
1972
1973
1975
1977
1979
1981
1983
1985
1988
1991
1993
1996
1999
H. Millesi
H. Millesi
J. R. Cobbett
H. J. Buncke
M. Ferreira
B. McC. OBrien
B. Strauch
S. Tamai
Z. W. Chen
G. I. Taylor
E. Biemer
J. B. Steichen
J. Baudet
H. Millesi
H. Millesi
J. R. Cobbett
H. J. Buncke
M. Ferreira
B. McC. OBrien
B. Strauch
A. Gilbert
K. Harii
E. Biemer
H. Millesi
R. Pho
W. Shaw
Vienna, Austria
Vienna, Austria
East Grinstead, England
San Francisco, California
Guaruja, Brazil
Melbourne, Australia
New York, New York
Paris, France
Fuji, Japan
Munich, Germany
Vienna, Austria
Singapore
Los Angeles, California
288e
Developments also included advances in congenital hand malformations using transfers of the
great-toe and second-toe growth plates.78
There were descriptions of new flap designs
and refinements of previously described donor
sites, including such important ones as the scapular flap,79 the fibula osteocutaneous flap,80 and
the peroneal flap.81 The deep inferior epigastric
perforator flap was reported by Koshima and
Soeda82 in 1989, introducing a new era of flap
design based on cutaneous perforators throughout the body.
The role of reconstructive microsurgery in extremity trauma was advanced by Marko Godina83
in a landmark 1986 publication of 532 patients. He
established the principles of early debridement
and free-tissue transfer and aggressive rehabilitation to achieve salvage of extremities with optimal
functional results.
Significant advances were made in the problem of brachial plexus injuries, including phrenic
nerve transfer by Gu et al.84 and functional muscle
transfer, which was introduced by Akasaka et al.85
in 1991 and further developed by Doi and
colleagues,86 who reported double free-muscle
transfers to restore not only elbow function but
also prehension.87
In experimental microsurgery, in 1981, Nakayama and associates88 reported a study of a flap
nourished by arterial inflow through the venous
system. Ji and colleagues,89 in 1984, reported experimental venous flaps in rabbits. Honda et al.,90
in 1984, reported venous skin grafts for skin defects on replanted digits. Applying principles of
minimally invasive surgery, Lin and Levin91 reported use of balloon-assisted endoscopic harvesting of tissue for microsurgical transfer in 1991.
Buntic and Buncke92 successfully performed
replantation of an amputated tongue in a 15-year-
Year
President
Chairman
Congress Site
1
2
3
4
5
6
7
8
9
10
11
12
13
14
1970
1972
1974
1976
1978
1981
1982
1984
1986
1989
1992
1994
1996
1998
D. W. van Bekkum
M. J. Orloff
G. Mazzoni
I. Hashimoto
E. Owen
F. Chavez-Peon
M. J. Orloff
J. M. Dubernard
G. Brunelli
K. Harii
J. Terzis
S. Tamai
H. B. Williams
W. Boeckx
D. W. van Bekkum
M. J. Orloff and R. Cortesini
G. Mazzoni
F. Chavez-Peon
T. S. Lie
E. Owen
J. M. Dubernard
S. Arena
G. Brunelli
T. S. Chang
P. Soucacos
S. Tamai
H. B. Williams
K. N. Malizos
289e
Year
President
Chairman
Congress Site
1
2
3
4
2001
2003
2005
2007
V. Meyer
F. C. Wei
W. Morrison
J. K. Terzis
F. C. Wei
G. Germann, H. Steinau
G. Loda
A. Beris
Taipei, Taiwan
Heidelberg, Germany
Buenos Aires, Argentina
Athens, Greece
290e
Achievements
1
Jassinowski, 1889
Murphy, 18972
Carrel, 19023
Hopfner, 19034
Guthrie, 19125
McLean, 19166
Nylen, 19549
Holmgren, 192312
Barraquer, 195614
Malis, 196415
Jacobson and Suarez, 196017
Littmann, 195420
Troutman, 196521
Snyder et al., 196022
Lapchinsky, 196023
Onji et al., 196324,25
Malt and McKhann, 196426
Kleinert and Kasdan, 196527
Chen et al., 196328
Buncke and Schulz, 196529
Buncke et al., 196630
Buncke and Schulz, 196631
Komatsu and Tamai, 196832
Tamai et al., 197033
Smith, 196734
Bora, 196735
Hakstian, 196836
Ito et al., 197637
Krizek et al., 196538
Chen et al., 198241
Cobbett, 196942
Strauch et al., 197143
Tamai et al., 197239
Daniel et al., 197144
Fujino et al., 197245
McLean and Buncke, 197246
Harii et al., 197447
Daniel and Taylor, 197348
Research Laboratory in
Shanghai, 197650
Harii et al., 197651
Ueba and Fujikawa, 198352
Taylor et al., 197553
Miller et al., 197654
McCraw and Furlow, 197555
Baudet et al., 197656
James, 197657
Tamai et al., 197758
Cohen et al., 197759
Taylor and Watson, 197860
Hill et al., 197861
Millesi et al., 197366,67
Urbaniak et al., 198173
Morrison et al., 198075
Wei et al., 199176
Tsai et al., 198277
Gilbert and Teot, 198279
Chen et al., 198380
Yoshimura et al., 198481
Koshima and Soeda, 198982
Gu et al., 198984
Akasaka et al., 199185
Doi et al., 199587
Nakayama et al., 198188
Honda et al., 198490
Lin and Levin, 199691
Buntic and Buncke, 199892
Dubernard et al., 199993
Experimental/Clinical
First experimental
Experimental and clinical
Experimental
Experimental
Experimental
First
First clinical
Clinical
First
First experimental
Experimental
Experimental
Experimental
First clinical
First clinical
First experimental
First experimental
First experimental
First clinical
First experimental
First experimental
First experimental
First clinical
Experimental and clinical
First experimental
First clinical
First clinical
First experimental
First experimental
First experimental
First experimental
First clinical
First clinical
First clinical
First clinical
First clinical
First clinical
First
First
First
First
First
clinical
clinical
clinical
clinical
clinical
First clinical
First clinical
First
First
First
First
First
First
First
First
First
First
First
First
First
First
First
clinical
clinical
clinical
clinical
clinical
clinical
clinical
clinical
clinical
clinical
experimental
clinical
clinical
clinical
clinical
(Continued)
291e
Achievements
94
Hand allotransplantation
Face allotransplantation
Flap prefabrication and tissue engineering
Peripheral nerve tissue engineering
Tissue-engineered nerve conduit
Tissue-engineered nerve conduit
In addition to the further development of allogeneic composite tissue or organ transplantations, I believe the combined use of microsurgical
composite tissue transfers with the technique of
regenerative medicine will open another new field
of microsurgery in the next decade. For the readers better understanding, historical achievements
in microsurgery, which appeared in order in this
article, are listed in Table 4.
Susumu Tamai, M.D., Ph.D.
1017 Toichi-cho
Kashihara City, Nara 634-0008, Japan
susumu@tamai.md
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