The
surgeon must insure adequate blood supply with debridement, revascularization,
or both. Vascular injuries and particularly those associated with muscle
devascularization place severe time constraints on the surgeon. Although
revascularization may be the most important step of the operation, it should
not be the first step taken. An orderly planned approach is needed to give
the best chance for limb salvage (Fig. 20).
Debridement
is critical: postoperative infection is evidence of inadequate debridement.
Debridement must include tissues that are devascularized and those that
can not be revascularized. Debridement should be approached in the same
fashion as tumor surgery: removal, not rinsing; surgical excision, not
scrubbing. Debridement is best done under tourniquet control and before
vascular repairs, which reduces intraoperative blood loss and allows for
the most accurate evaluation of injury. Pulsatile irrigation should be
withheld until after sharp debridement, for it may blur evidence of the
zone of injury. Muscle ischemia time should be limited to four hours, but
definitive vascular repairs should be deferred until after debridement,
skeletal fixation, and repair of muscular tenderness structures adjacent
to the site of vascular or repair. This requires planning and a deliberate
stepwise approach, and may involve provisional revascularization with a
shunt (Fig. 20). A common pitfall
in the management of large wounds involving transection of artery and muscles
is for the first step to have vascular surgeon perform vascular repair
using a vein graft. Then, after adjacent muscles are repaired, the original
ends of the vessel are indirectly approximated to the extent that the vein
graft becomes redundant, kinks, and must be removed. Debridement and muscle
repair prior to vessel repair "bypasses" this scenario. If grafts are needed,
vein grafts are ge nerally satisfactory for forearm vessels, but in the
palm and fingers, branches and small diameter may be difficult to match
with vein grafts. In some circumstances, a branched arterial graft from
the thoracordorsal system may provide a solution.
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