异体手移植的手术设计与操作

Operative design and technique of human hand allotransplantation

目的 探讨异体手移植的手术设计与技术操作要点。方法 对 2例右手缺失患者行异体手移植 ,1例双手及前臂中远段缺失者行异体双手及前臂移植。参照自体断肢再植的基本程序 ,依次行受区准备、供肢准备、移植手组织的重建。首先确定骨骼再接平面 ,将桡 (尺 )骨作阶梯状截骨、对合、螺钉固定后 ,先缝合前臂腹侧屈腕屈指深肌腱 (肌腹 ) ,吻合尺、桡动脉后行静脉放血 ,再吻合头静脉、贵要静脉 ,再缝合腹侧屈腕、屈指浅肌腱 (肌腹 )及背侧伸肌腱 (肌腹 ) ,最后缝合神经、皮肤。术后给予抗免疫排斥的药物治疗。结果 3例 4肢手术时间为 7h 5 2min、9h 10min、9h 2 8min、10h 5min ,供手缺血时间为 6h、6h 19min、8h 5 9min、7h 5 8min。术后 2例 3肢移植手血循环良好 ;1例 1肢于术后 3h发生静脉危象 ,经手术探查后恢复血循环。术后随访 2～ 14个月 ,移植手均存活良好 ,无免疫排斥反应发生 ,功能恢复顺利。结论 异体手移植手术设计的重点 ,是依据手缺失残端的位置来确定受 -供体手的移植平面 ,组织重建的顺序为骨骼、深层肌腱 (肌腹 )、动脉、静脉、浅层肌腱 (肌腹 )、神经和皮肤。

Objective To introduce the operative design and technique of human hand allotransplantation. Methods Hand allotransplantation was performed in two patients with right hand defect. In another patient with loss of both hands and distal 2/3 of the forearm, bilateral allotransplantation of hands and forearms was done. The operations were done according to the procedures of autogenons limb replantation: preparation of the recipient area, preparation of the donor limb, and reattachment of the corresponding structures. The level of bony reconnection was determined first. The radius and ulna of the recipient site and the donor limb were approximated after step like osteotomy and fixed with screws. After suturing of the flexor digitorum profundus, the ulnar and radial arteries were anastomosed. Aftev blood had feowed out ofveins for severd minutes of veins, the cephalic and basilic veins were anastomosed. Suturing of the flexor digitorum superficialis and the wrist, and then the wrist and finger extensors, coaptation of the nerves, and skin closure were done consecutively. Postoperatively, immunosupressive drugs were used to prevent rejection. Results Transplantation of four hands in three cases lasted 7 hours and 52 minutes , 9 hours and 10 minutes, 9 hours and 28 minutes, and 10 hours and 5 minutes respectively. The ischaemic time of the transplanted hands was 6 hours, 6 hours and 19 minutes, 8 hours and 59 minutes, and 7 hours and 58 minutes respectively. Blood circulation of three hands in two cases were fluent while venous crisis occurred in another case 3 hours postoperatively, which was corrected by surgical exploration. All transplanted hands survived without rejection reaction over 2 to 14 months period of follow up. Satisfactory restoration of the function was obtained. Conclusions It was of emphasis to determine the replantation level in accordance with the stumps of the patient's hands in the operative design of hand allotransplantation. The corresponding structures were reattached in the following order: bones, deep muscles and tendons, arteries, veins, superficial muscles and tendons, nerves and skin.