European Journal of Orthopaedic Surgery & Traumatology (2019) 29:247–254 https://doi.org/10.1007/s00590-019-02378-7 GENERAL REVIEW • GENERAL ORTHOPAEDICS - MICROSURGERY The history of microsurgery Andreas F. Mavrogenis1 · Konstantinos Markatos2 · Theodosis Saranteas3 · Ioannis Ignatiadis4 · Sarantis Spyridonos4 · Marko Bumbasirevic5 · Alexandru Valentin Georgescu6 · Alexandros Beris7 · Panayotis N. Soucacos1 Received: 2 January 2019 / Accepted: 4 January 2019 / Published online: 10 January 2019 © Springer-Verlag France SAS, part of Springer Nature 2019 Abstract Microsurgery is a term used to describe the surgical techniques that require an operating microscope and the necessary spe- cialized instrumentation, the three “Ms” of Microsurgery (microscope, microinstruments and microsutures). Over the years, the crucial factor that transformed the notion of microsurgery itself was the anastomosis of successively smaller blood vessels and nerves that have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Cur- rently, with obtained experience, microsurgical techniques are used by several surgical specialties such as general surgery, ophthalmology, orthopaedics, gynecology, otolaryngology, neurosurgery, oral and maxillofacial surgery, plastic surgery and more. This article highlights the most important innovations and milestones in the history of microsurgery through the ages that allowed the inauguration and establishment of microsurgical techniques in the feld of surgery. Keywords Microsurgery · Orthopaedics · Plastics Introduction Over the years, the crucial factor that transformed the notion of microsurgery itself was the anastomosis of successively Microsurgery is a term used to describe the surgical tech- smaller blood vessels and nerves (typically 1 mm in diam- niques that require an operating microscope and the neces- eter) that have allowed transfer of tissue from one part of sary specialized instrumentation (the three “Ms” of Micro- the body to another and re-attachment of severed parts. Cur- surgery: microscope, microinstruments and microsutures). rently, with obtained experience, microsurgical techniques are used by several surgical specialties such as general sur- * Andreas F. Mavrogenis gery, ophthalmology, orthopaedics, gynecology, otolaryn- [email protected] gology, neurosurgery, oral and maxillofacial surgery, plastic surgery and more [1, 2]. 1 First Department of Orthopaedics, National This article aims to highlight the most important innova- and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562 Holargos, Athens, Greece tions and milestones in the history of microsurgery through the ages that allowed the inauguration and establishment of 2 Biomedical Research Foundation of the Academy of Athens, Athens, Greece microsurgical techniques in the feld of surgery. 3 Second Department of Anesthesiology, First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece Organs transplantation and revascularization 4 Department of Upper Extremity Surgery, Hand Surgery and Microsurgery, KAT Hospital, Athens, Greece 5 Orthopaedic and Traumatology University Clinic, The idea of organs transplantation and vascular (arterial) Clinical Center of Serbia, School of Medicine, University repair originates in the mythology and early writings of of Belgrade, Belgrade, Serbia Antiquity [3, 4]. In Greek mythology, there are numerous 6 Clinical Hospital of Rehabilitation, University of Medicine examples of chimeric gods, heroes and beasts with organs Iuliu Hatieganu, Cluj Napoca, Cluj, Romania of diferent species. The word “chimeric” refers to chimera 7 Department of Orthopaedics, University of Ioannina, School (Fig. 1), a mythological creature usually depicted as a lion of Medicine, Ioannina, Greece Vol.:(0123456789)1 3 248 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:247–254 description of a wound suture and the suture materials used is attributed to the Indian physician Sushruta in 500 BC [3]. The initial technique for the treatment of arterial injuries or diseases was described by Hippocrates and his successors in Greek antiquity [5–7]. According to them, a destroyed small artery was condemned during surgery; therefore, these physi- cians developed techniques and sutures for ligation of vessels to stop bleeding. Such primitive sutures were described in the ffth century BC by Hippocrates and later in the Roman era by Aulus Cornelius Celsus. In the second century AD, Galen described the use of gut absorbable suture; his techniques were followed by others including Oribasius and Paul of Aegina in the early Middle Ages. Subsequently, in the Arabic world, Abulcasis developed the catgut suture with a surgical needle Fig. 1 Statue depicting the mythological Chimera of Arezzo (Etrus- for wound repair and vessels ligation. In the fourteenth–ff- can, ffth century BC; Archeological Museum of Florence, Italy) teenth century, the barber surgeons of the era neglected liga- ture and started using cautery to prevent bleeding during with the head of a goat arising from its back and a snake traumatic amputations in wars. In that era, the Italian barber instead of a tail. Chimera was thought to live in Lycia, surgeon Gasparo Tagliacozzi performed successful skin auto- nowadays Turkey, and its sight was an omen of disaster. It graft transplantations, but his techniques failed when he used was fnally killed by Bellerophon with the help of Pegasus, allografts because of tissue rejection and necrosis [3]. another chimeric creature with the body of a horse and During the Renaissance in the sixteenth century, the work wings of an eagle. Satyrs, sirens and others are examples of Ambroise Paré (1510–1590) was remarkable [5–7]. He is of mythological creatures, which were human-like but had often considered the father of modern surgery due to his suc- body parts from other species [4]. cess in treating war injuries, developing surgical techniques In the New Testament, Jesus restored the ear of a servant and avoiding cauterization and amputations in favor of the that had been cut by the sword of Saint Peter. Additionally, use of ligatures to stop massive bleeding. He was the frst to according to the Christian tradition, Saint Peter reimplanted describe a technique for the anastomosis of an injured artery the breasts of Saint Agatha that were pulled of during tor- through the use of ligature and he even described his own ture, and Saint Marc reimplanted a soldier’s hand that was version of a tourniquet to reduce bleeding of a limb during amputated in a battle [3]. an operation. Nevertheless, the outcomes of his techniques Historic accounts of transplantation are legendary without were not optimal because the tourniquet had to be held in the necessary technical and scientifc background to support place by an assistant, usually hard to be found in a battle- them. In ancient China, Pien Chi’ao reportedly exchanged feld, the lack of prolonged anesthesia required for the repair hearts between a man of strong spirit but physically weak of an artery and the primitive antisepsis techniques of his and another man with weak spirit but physically strong in an era. He often fnally rejected the eforts to save a damaged attempt to achieve balance in each man [3]. Roman Catholic artery in an injured limb, and he ended developing amputa- accounts report the third century Saints–physicians Damian tion techniques with the use of extended ligature sutures to and Cosmas as replacing the gangrenous leg of the Roman control bleeding and save the lives of injured soldiers with deacon Justinian with the leg of a recently deceased Ethio- major limb trauma [5–7]. pian. Similarly, in the second century BC the Indian surgeon Early notable microsurgical attempts are documented in Sushruta used skin autografts for reconstruction of the nose 1759 by Hallowell who repaired a wound in the brachial and rhinoplasty with uncertain results [3]. artery by hand suture. In 1802, Jones studied the healing process in vascular injuries in animals and stressed the importance of the neointima that was regenerated at the suture site [3]. Revascularization techniques before the advent of microsurgery The advent of microsurgery Since the beginning of recorded history, various suture mate- rials have been used [3, 5–7]. The earliest reports of surgical A few notable developments in the history of medicine and sutures date in 3000 BC in ancient Egypt; the oldest known surgery paved the application of microsurgical techniques. In suture is found in a mummy from 1100 BC. A detailed 1718, Jean Louis Petit (1674–1750), with the assistance and 1 3 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:247–254 249 constructive genius of the mechanic Peron, developed a tour- niquet that did not compress the region through which large arteries and veins were passing, and it could be defated as necessary. The apparatus used a screw for compression of the limb, compression was better localized, once applied it could be held frm in place without the help of an assistant, and it could also be left in place if secondary bleeding was feared. This tourniquet allowed the application of complex surgical techniques without the fear of hemorrhagic shock from massive bleeding [8]. The Dominican monks Salvino D’Amato of Florence and Alessandro della Spina of Pisa are often accredited with the invention of the spectacles at the end of the thirteenth cen- tury [9] and subsequently