Hand transplant surgery

In September 1998 the world’s first hand transplant was performed in Lyon, France. A new era in reconstructive surgery had begun. This case highlighted the potential for composite tissue allotransplantation (CTA). While CTA is not a new technique, it unifies the principles of reconstructive microsurgery and transplant surgery, achieving the goals of absolute correction of a defect with anatomically and physiologically identical tissue with none of the issues of donor site morbidity associated with autologous tissue transfer.The adoption of this technique for non-life threatening conditions to improve quality of life has generated a number of new ethical considerations. Additionally, the prominence of transplanted hands has led to much discussion around the issue of body identity and psychological assessment of potential recipients. This is fundamental to any hand transplantation programme. With the advent of hand transplantation dawning in the UK, we review the many ethical considerations that contribute to this new frontier.     

Hand port-assisted laparoscopic surgery

The dramatic benefits of laparoscopic cholecystectomy or appendectomy for patients encouraged surgeons to use minimal access operative technique in the treatment of other more complex surgical procedures [2, 3]. The authors report on their experiences with 14 patients operated by hand-port assisted laparoscopic technique for benign colorectal diseases. The mortality rate was zero. The operation times compared to the laparoscopically operated previous 14 patients with equal diagnosis did not differ significantly (hand-port: 124-186 min; lap.: 121-176 min). The begin of bowel movements and the postoperative hospital stay were comparable to those of laparoscopic surgery. There were no major complications. No conversion to an open procedure was necessary. As the hand-port device allows the surgeon to insert his (usually non-dominant) hand into the abdominal cavity during the procedure, the hand-port device seems to combine the laparoscopic benefits with the advantages of a conventional open approach (manual exploration, blunt dissection, control of hemostasis) without loss of pneumoperitoneum [10]. Even though hand-assisted operations have not gained widespread acceptance, they recently demonstrated their value especially in more complex laparoscopic procedures like splenic and gastric resections, nephrectomy and colorectal surgery [6, 10, 18, 21, 23-24]. The regaining of tactile sensation which is an essential surgical tool may encourage less experienced colleagues to perform more complex operations. The authors suggest that the hand-port device could be a useful tool in the armentarium for colorectal surgery. Further randomized trials are needed to evaluate the benefits of this technique.     

Hand surgery. Soft tissue defects

The presence of soft tissue defects in the hand indicates serious traumatic damage that may compromise the systems involved in movement, circulation or touch and therefore jeopardize functional rehabilitation. This overview highlights the significance and the various causes of soft tissue defects. Several types are distinguished. Selection criteria for various flap procedures are outlined with reference to the need for elevation of the hand, the necessity for early movement, adequate wound drainage, and range of motion therapy. The characteristics required of flap tissue are described, such as surface characteristics, ability to restore sense of touch, cosmetic appearance, ability to close deep volume defects, and potential for revascularization of adjacent tissue. Finally, commonly used, selected flaps are presented with notes on their advantages, disadvantages, and modifications, the techniques required and the indications for each.     

Hand surgery in organ transplant patients

PURPOSE: This study presents a series of organ transplant patients who developed problems that affected their upper extremities, related to the organ transplant operation itself, to the patient's underlying systemic disease, to long-term immunosuppression, or to subsequent hand injury after the organ transplant surgery. METHODS: A retrospective chart review of 40 organ transplant patients with upper extremity problems at 3 major organ transplant centers was performed. RESULTS: Six general problems were identified that affected the hand and upper extremity in these transplant patients: inflammatory conditions (16), nerve compression syndromes (18), infections (6), neoplasms (6), vascular problems (4), and trauma (14). Thirty-eight patients had 72 separate hand procedures. No problems were encountered with postoperative infections, and skin and bony healing occurred uneventfully. CONCLUSIONS: Organ transplant patients are prone to developing atypical infections, skin malignancies, ischemia, and various nerve compression syndromes that affect the hand. These patients with upper-extremity problems should be treated in a manner similar to any patient without prior organ transplant.     

Hand surgery and quality of life.

The outcome in patients having surgery to the hand was assessed subjectively using a questionnaire that covered activities of daily living (ADL), hand pain and psychological well-being. The questionnaires were completed on average 6.9 months preoperatively and 20.6 months postoperatively by 15 patients with osteoarthritis undergoing trapeziectomy and 25 patients with rheumatoid arthritis undergoing Swanson arthroplasties of the metacarpophalangeal joints. Surgery resulted in significant improvements in reported ADL and hand pain, in both groups. Improvement in perception of hand function and health was only seen in the osteoarthritic group. There was no improvement in arthritis activity, mood or quality of life in either group. These results confirm that surgery for arthritis of the hand relieves pain and improves ADL. However, it has a greater effect in patients with localized osteoarthritis than in those with rheumatoid arthritis.