Possibilities of Using the Deep Inferior Epigastric Vascular Pedicle as a Source of Revascularization for Free Microsurgical Autotransplants

The dissertation is dedicated to the study of the deep inferior epigastric vascular pedicle (DEIVP) as a potential source of revascularization for free microsurgical autotransplants transplanted into the urogenital area. The research encompasses topographic-anatomic, histologic, and hemodynamic characterization of the DEIVP conducted on sectional material from 50 fresh cadavers, as well as a clinical analysis of the use of this vascular pedicle in free microsurgical autotransplantation procedures. The author proposes a three-stage algorithm for DEIVP investigation, defines contraindications to its use for the first time, and conducts an analysis of vascular complications arising from its application as a source of blood supply for autotransplants.

Relevance of the topic: Among the achievements of plastic, reconstructive, and vascular surgery as a whole, and microsurgery in particular, the method of free microsurgical transplantation of tissues and their complexes has undoubtedly become one of the most significant. This method revolutionized the field in the 1970s of the twentieth century and became the method of choice for pathological conditions and locations of defects where other traditional plastic surgery methods are either not feasible or prognostically unfavorable (Petrovsky B.V. et al., 1976, 1977; Stepanov G.A. et al., 1976; O'Brien B.M., 1981; Druk N.F. et al., 1983; Milanova I.O. et al., 1985, 1989; Nerobeev A.I., 1988; Trofimov E.I., 2001; Daniel R.K. et al., 1973; Harii K. et al., 1974).

The method of free microsurgical autotransplantation of revascularizable free tissues and their complexes possesses a number of advantages: single-stage operation with reduced treatment duration; selection of viable donor sites taking into account the requirements of the recipient area; full blood supply of transplanted tissues and restoration of their sensitivity; absence of the need for prolonged immobilization; wide functional and aesthetic possibilities (Krylov B.C. et al., 1982; Milanova I.O. et al., 1989, 1999, 2001; Acland R.D., 1972; Harii K. et al., 1973, 1978, 1983; Biemer E. et al., 1978).

Methods of traditional plastic surgery based on the use of local or adjacent tissues are not always applicable in reconstructive and reconstructive surgery of the urogenital area. This is due to the quantitative insufficiency of local tissues, significant limitation of the direction of their relocation, and the inevitable disruption of their blood supply after excision and transfer (Milanova N.O. et al., 1994, 1999; Adamyan R.T., 1996; Karibekov T.S., 2005; Stock J.A. et al., 1989). The method of free microsurgical autotransplantation of tissues and their complexes allows a new approach to solving the aforementioned tasks and is effectively applied in the treatment and correction of congenital and acquired diseases, as well as consequences of injuries of the urogenital area.

The main purpose of free microsurgical transplantation of tissue complexes is to restore adequate blood circulation in the recipient area. Microsurgical technique makes it possible to perform full transplantation of various tissues and their complexes with axial blood supply by means of microvascular anastomoses between the vessels of the tissue complex and the vessels of the recipient area, to which this complex is transplanted; in this case, the localization and character of the lesion do not affect the use of the method (Krylov B.C. et al., 1976; Belousov A.E. et al., 1988; Milanova N.O. et al., 1990, 2002; O'Brien B.M., 1977).

The outcome of any free microsurgical autotransplantation of tissues and their complexes depends largely on the choice and use of adequate and reliable sources of revascularization of free microsurgical autotransplants. As early as 1956, Millard D.R. formulated the main problem of plastic surgery as "an eternal struggle between beauty and adequate blood supply."

In the Department of Reconstructive Microsurgery of the State Scientific Center of Surgery named after Academician B.V. Petrovsky of the Russian Academy of Medical Sciences, the deep inferior epigastric vascular pedicle (DEIVP) is used as the main source of revascularization of free microsurgical autotransplants and their complexes transplanted into the urogenital zone.

At the same time, it is necessary to note the insufficient coverage in the scientific literature of the methodology for the use of the DEIVP as a source of revascularization of free microsurgical autotransplants; there are isolated, sometimes contradictory data on the topographic-anatomic and hemodynamic characteristics and features of the DEIVP. There are no scientifically substantiated indications and recommendations for the use of this vascular pedicle, nor are there studies investigating changes in hemodynamic parameters during intraoperative rotation of the DEIVP used as a source of revascularization of free microsurgical autotransplants.

The necessity of studying these questions determined the relevance of the chosen topic and the undertaken work, its goal and objectives.

Goal of the research: to study the anatomic and hemodynamic features of the DEIVP and the possibility of its use for revascularization of free microsurgical autotransplants and their complexes transplanted into the urogenital area.

To achieve the stated goal of the research, the following tasks were set:

1) to study anatomic variants of the DEIVP structure.

2) to determine the anatomic possibilities of rotation and placement of the DEIVP, excluding its kinking and compression by surrounding tissues.

3) to study the hemodynamic characteristics of the DEIVP and determine the influence of variants of its location in surrounding tissues on them.

4) to determine contraindications to the use of the DEIVP as a source of revascularization of free microsurgical autotransplants and their complexes transplanted into the urogenital area.

5) based on the analysis of the results of operations in which the DEIVP was used as the source of blood supply for free microsurgical autotransplants and their complexes, to identify the frequency and causes of vascular complications leading to impairment of blood circulation in the autotransplants.

Scientific novelty of the work

For the first time, the vascular anatomy of the DEIVP was studied in depth from the perspective of its use as a source of revascularization of free microsurgical autotransplants, based on sectional studies of 50 fresh cadavers, during which its metric characteristics, points of origin of the main branches, and variability of the vessels forming the DEIVP were determined.

For the first time, based on own clinical studies, the intraoperative hemodynamic characteristic of arterial blood flow of the DEIVP was studied and given using the Dopplerographic method, and the possibility of using the DEIVP as recipient vessels for revascularization of free autotransplants and their complexes transplanted into the urogenital area was substantiated.

A three-stage algorithm for DEIVP investigation was proposed, which most rationally, efficiently, and reliably helps to diagnose the underlying vascular pathology, intraoperative hemodynamic changes, and also monitor vessel patency in the postoperative period.

For the first time, contraindications to the use of this vascular pedicle for revascularization of free microsurgical autotransplants transplanted into the urogenital zone were studied and determined.

A detailed analysis of vascular complications in free microsurgical autotransplantations where the DEIVP was used as the source of blood supply for free microsurgical autotransplants was provided, with their frequency and causes identified.

Practical significance of the work

Based on own sectional material and clinical observations, topographic-anatomic and hemodynamic characteristics of the DEIVP were presented for the first time, their features were described, and the possibility of using the DEIVP as recipient vessels for revascularization of free microsurgical autotransplants transplanted into the urogenital area was substantiated.

Implementation of the results of the work

The results and conclusions of clinical, sectional studies, and practical developments were implemented in the activities of the Department of Reconstructive Microsurgery of the State Scientific Center of Surgery named after Academician B.V. Petrovsky of the Russian Academy of Medical Sciences.

Dissertation defense

The materials of the dissertation work were reported and discussed at:

- the tenth congress of ESPRAS, August 30 – September 3, 2005, Vienna, Austria;

- the third international conference of young physicians, September 19–21, 2005, Yerevan, Armenia;

- the fifth international congress of plastic, reconstructive, and aesthetic surgeons, April 12–14, 2006, Yerevan, Armenia.

The dissertation defense was held at the joint scientific conference of the Department of Reconstructive Microsurgery of the State Scientific Center of Surgery named after Academician B.V. Petrovsky of the Russian Academy of Medical Sciences on June 16, 2006.

Publications

Thirteen scientific papers on the topic of the dissertation were published in domestic and foreign scientific journals, materials of scientific conferences, symposia, and congresses.

Volume and structure of the work