A surgeon ponders the rewards of youthful risks.
By Kenneth M. Rose
I was a lot more daring then. Everyone was. Fellowships do that to young surgeons. There is always a wonderful sense of danger. Not encumbered by the threat of lawsuits, fearless, hiding behind the shield of the university, we would all try things that we would now shy away from in private practice. Happily for the patients, what we tried usually worked out well for them. Besides, it was fun.
I graduated from Penn in 1982 with a major in Political Science and then attended medical school at the New York Medical College. In 1993, as a hand-surgery fellow at a major trauma center in South Florida, I, along with two colleagues, successfully replanted two fingers on the left hand of a mentally disturbed man. This man was injured, as the ambulance driver put it, while “pulling a John Wayne.” John, as we called him, was running on the roof of a commuter train when he fell between the cars. His entire right arm and left index and middle fingers were severed. The severed arm was too badly crushed to be salvaged. The trick for us, then, would be to harvest the index and middle fingers from the amputated right arm and replant them to the left hand. (The original fingers were smashed under the wheels of the train and could not be saved.)
Before I explain how replantation surgery is performed, you should be aware of several facts. First, it is inadvisable to replant digits on a mentally unstable person. This is because it is believed that they are incapable of following the rigid rehabilitation regime required of these patients following surgical repair. Some have even been known to pull off their freshly replanted fingers. Therefore it is considered a potential waste of expensive medical resources. Second, and most important, replanting severed digits is a long and tedious procedure. It requires expert facility in microscopic surgical techniques and, with multiple amputations, can take up to 24 hours to complete. As fellows, none of us had any experience replanting fingers. We were all very early in our training and had only read about such procedures in our textbooks. Were we up to the task? We would soon find out.
Despite our collective lack of experience, and the contraindication I have already mentioned, we decided, somewhat selfishly, that this man needed to have his fingers replanted anyway. We therefore directed our new patient to the operating room. As we moved him to the operating table, and began to unwrap his bandages, we realized that we (and therefore John) were in trouble.
Although we all had experience dealing with multiple trauma patients, nothing quite prepared us for what we were about to see. What had once been a man, was now a dismembered, bloody mess. His right arm came to us in an ice-filled plastic garbage bag. The arm was cut off high near the shoulder and the stump was a bleeding mass of muscle, bone, and grease stains. Just seeing the lifeless, amputated arm made us realize what a gigantic task lay before us. I have to admit that, for all my surgical bravado, I was a little scared.
While the anesthesia team stabilized the patient, the three of us decided to divide up into teams. We would need to conserve our energy. Pete, our attending, in his first month out of training, would prepare the left hand for replantation. I, the most junior, would help him. Our third member, Norman, would complete the amputation of the left arm as well as harvest the right index and middle fingers.
Anatomically, the fingers consist of bone, nerves, blood vessels, and tendons. There are two sets of tendons in each finger: the flexors, which are powerful and allow the fingers to bend toward the palm of the hand, and the extensors, which allow the fingers to stretch out, away from the palm. Replantation requires that these structures be repaired in a specific order. Namely, the bones are repaired first, then the flexor tendons, the extensor tendons, and finally the arteries, veins, and nerves. This is necessary so that the most delicate structures can be repaired last.
The initial job for Pete and me was to isolate and prepare the left hand’s tiny blood vessels and nerves for the new donor grafts. Each finger has two sets of these structures with one set running up each side of the fingers like telephone cables. These are the neurovascular bundles. Therefore, the loss of two fingers meant we had to locate 12 separate structures—two bundles consisting of three structures per finger.
As I sat down to assist Pete, the realization struck me that I had absolutely no idea what I was doing. We sat at the operating table facing each other. The injured hand, and the microscope we would use, was placed between us. At nearly six feet tall and weighing several hundred pounds, the scope is a monster. It has two optical sites so two surgeons can work together. The lens hangs over the surgical field.
Behind us was a table full of microsurgical instruments. These are not like regular surgical instruments. They are much smaller and extremely delicate. Under magnification every hand movement I made was so greatly exaggerated that my hands would constantly shoot out of the visual field. I was then forced to look around the scope, find my misguided hand, and visually bring it back into view. Although I was a well-trained surgeon, I felt completely uncoordinated.
Looking through the lens I found that handling a digital artery was like trying to grab a greasy strand of hair with a tweezers. My frustration mounted as each vessel irreverently slid away from my grasp. Small vibrations on the operating table were transformed into momentary earthquakes. Tiny feeding vessels would hemorrhage so explosively that they would blot out the operative field. The surgical suture, which is about the width of a fine hair, became an eight-armed octopus entangling itself over my instruments. I soon developed a massive migraine headache and a severe case of eyestrain. In the background, I could hear Norman cursing his own slow progress. Overall it appeared the beginning was not going well for any of us, especially John.
After several difficult hours, Pete and I had isolated the necessary vessels. Norman had successfully harvested, en block, the index and middle fingers from the amputated limb. He left us ample artery, vein, and bone to make it easier to place them in their new position on the patient’s left hand. We were now ready to replant.
The bones are fixed with small metal (titanium) plates, which we were all familiar with. The tendon repairs also went smoothly. Neither procedure required the microscope. At this juncture, with my head pounding, I decided to take a break and let my colleagues continue without me. As I looked up at the clock, I was shocked to see that 41/2 hours had elapsed. There would be many more to come.
I didn’t go far. I curled up in the corner of the operating room and closed my eyes. The floor felt refreshingly cool beneath me. It was difficult to sleep, though. The sound of the high-speed drill, the warning sounds of the anesthesia machine, and, most frequently, Pete cursing at a misadventure impeding their progress, prevented me from nodding off. As I closed my eyes, I could hear Pete screaming at Norman, “Hey, be careful, you’re going to tear the vessel.” At one point I heard him say, “We never should have taken on this case.”
Luckily, fingers, unlike arms or legs, do not have much muscle mass. Death of the muscle fibers from lack of blood is what destroys amputated body parts and prevents them from being re-attached. An arm, for example, preserved in an ice bath without blood supply, will survive for only six hours or less. A finger, however, if properly maintained, can last up to 24 hours or more. Therefore, despite our plodding pace, there was little worry of the amputated pieces dying. The favorable physiology of the severed fingers was counterbalancing our collective lack of experience. At least we had that on our side.
After a few hours, I was ready to return and give Pete a break. While I was resting, they had managed to repair one complete neurovascular bundle. Blood was now flowing through John’s middle finger! Now it was my turn to try microsurgery. Among the three of us, Norman and I had no microsurgical experience. Without Pete, I anticipated a significant slowdown in progress. I was right.
We were both very uncoordinated under the microscope. Each stitch took three tries or more. Multiply this by eight stitches per vessel and it would take two hours to repair one vessel. Unlike the comparatively sturdy arteries, I was surprised to find the digital veins had the consistency of wet toilet paper. This made it virtually impossible for me to place sutures where I wanted them to go. Worse still, Norman was getting irritable. Following my successful placement of a stitch (after many aborted tries) he hissed sarcastically, “Congratulations, you finally got one.” I began agree with Pete. We never should have taken on this case.
It was the middle of the night now, and despite my rest period, I was still tired. Norman was getting more irritated at our mistakes and Pete’s snoring in the corner of the operating room was not helping our state of mind. My concentration was beginning to falter rapidly.
When Pete finally returned, Norman and I had managed to get a few more structures together. The hours passed and by morning the last anastomosis was finished. Both fingers were now warm and pink. Seventeen hours after we started, the two fingers were replaced and alive. Although I was exhausted, it was a wonderful feeling of accomplishment.
When the microscope was finally pulled away from the table I noticed something unusual. We had replaced the left middle and index fingers with those from the right hand en block. Therefore the right index finger was now in the left middle finger position and the right middle finger was in the left index finger position. Apparently, while I was sleeping, Norman and Pete had decided that, given our collective inexperience, it would be easier to transplant the fingers this way rather than split them up and replant them separately. I had been concentrating so hard all night, I never noticed. Although John now had a funny looking hand (it reminded me of a constantly rising bar graph), it was alive and functional.
The surgical repair of an amputated limb is just the beginning for the patient. In the early post-operative period, one must refrain from smoking and consuming any food containing caffeine. These substances cause the tiny digital vessels to constrict and therefore restrict blood flow. Assuming the replanted fingers make it through the first few weeks after surgery, many months of rehabilitation with a skilled occupational therapist will follow. Initially the fingers will be extremely stiff and painful. Sensation will return in about one year. Patience is very important as one learns to use his hands all over again.
The next morning we arrived at the hospital with a sense of cautious optimism. Would the fingers still be alive? As we entered our patient’s room, we found John sitting leisurely in a chair. He was finishing off a cigarette, using the tips of his replanted fingers as holders. He proudly informed us he had only smoked three that day, well below his four-pack-a-day habit. We quickly extinguished the cigarette and reiterated our warning about inhaling nicotine. There are a multitude of other possible post-operative complications. Most commonly, blood clots form in the digital arteries or veins, which can jeopardize the grafts. A complication of this type would necessitate emergency surgery. Despite his constant smoking, John somehow managed to avoid any post-operative problems. He got to keep his fingers.
Now, whenever I have the occasion to perform replant surgery in private practice, I recall my experience with Pete, Norman, and John in the summer of 1993. Throughout my career, many other patients have benefited from the surgical skills I learned that night. Many have useful hands today because we decided to be daring then.
Dr. Kenneth M. Rose C’82 practices plastic surgery in New York City.