Text: Anna Gorczyca, Nowiny 24
photos Tomasz Jefimow
Zbigniew Antas vaguely remembers the events of that morning. He was sawing firewood. Suddenly he felt a strong burning sensation in his forearm. He looked and saw a part of his forearm fall to the ground.
At the same time, Andrzej Iwaniec, deputy head of the department of orthopedics, traumatology, hand microsurgery and surgery at the Specialist Hospital in Jasło was conducting the first of six orthopaedic procedures scheduled for that day. When doctors found out that the ambulance service was taking a patient to the hospital for urgent replantation, they cancelled the remaining scheduled procedures. There is only one operating room in the department. A team assembled quickly: four orthopaedists (Andrzej Iwaniec, Wiesław Małek, Piotr Bęben, Wiesław Krajewski) and two anaesthesiologists (Sławomir Dunaj and Maciej Szybieniecki). For the next seven hours, they were going to sew on a severed hand in a 59-year-old patient from Bączal Dolny. The left forearm was cut off, slightly obliquely, between the wrist and the elbow – recalls Andrzej Iwaniec.
How come?
I still can’t understand why it happened – says Zbigniew Antas.
I used a miter saw with guards so it seemed perfectly safe to me.
He doesn’t know how his forearm got under the blade. – I saw a part of my left forearm fall to the ground and blood gushing out – he says. – I instinctively squeezed my arm with the other hand. The machine stopped, but I couldn’t move because my clothes got trapped in it. Only when I managed to pull it out did I run home – he continues.
Fortunately, he was not alone. The wife immediately realized what had happened. She dressed the wound, bandaged it, called an ambulance. – I know that the ambulance arrived as soon as possible, but for me those moments of waiting seemed like eternity – recalls the 59-year-old. – My wife tried to talk to me all the time so that I would not lose consciousness.
He did not think about the part of his body that had remained by the saw. – I was more afraid of whether I would live or bleed to death – he admits.
He remembers how the rescuers took care of him, gave him oxygen, an injection. – Then, when I was already in the ambulance, they went to the yard to look for the hand.
In hospital, he was told that there was a chance that the severed limb could be sewn on. He signed a consent for replantation. – I knew that they had performed such an operation in Jasło before. I trusted the doctors.
Bones, arteries, nerves …
In the operating room, the orthopaedists were divided into two teams. Two of them took care of the severed hand and the other two with the remaining stump.
Before sewing, they had to clean the two parts, identify the respective matching muscles, tendons, vessels, nerves, and veins. – To find them, you need to know the topography and anatomy well – emphasizes dr Iwaniec.
When the individual elements are dissected, the laborious reattachment begins.
First, the bones – with screws and plates. They constitute the structure that “holds” the replanted limb in place. The orthopaedists had to shorten the bones by 2 to 3 centimetres before joining them.
In this type of injury, the cut muscles contract. If we were to fuse the bones without shortening them, there would be no muscles and tendons to fill the space – explains Iwaniec.
Then the arteries: it’s about getting your blood flowing as quickly as possible. The rule is to saw the thickest one, the ulnar artery, first.
Once the hand gets “nutrition”, you can go on – says Iwaniec. He explains that you must also remember to suture the muscles directly adjacent to the artery to prevent subsequent damage.
The blood was circulating, it was okay
The anastomosis of the ulnar artery is the first important moment during the surgery. – The clamp is released for a moment to check that the vessel is patent. This was a critical moment. Everyone was looking at the dead hand, white as snow. If blood begins to gradually fill the empty vessels and starts circulating, it is a sign that everything is fine.
In this case it was so – doctors say. – And after connecting the second artery, they could say: “the hand lives”. Still, the vessels had to be clamped so that the patient would not lose too much blood. The veins are connected almost at the very end.
Nerves come first. There is not time to wait. Their proper connection determines the subsequent regeneration and the extent to which the patient regains feeling in the hand. – We managed to efficiently connect three very important nerves – explains Iwaniec.
Individual groups of muscles and tendons are sewn along the nerves. Then you need to find and connect the main veins: then the blood flowing from the arteries can finally be drained (without this the hand turns blue, which results in amputation). Finally – the skin.
A pulse oximeter on the index finger checks the blood oxygen saturation. It was not bad: 70-80 percent After seven hours, the doctors could finally leave the operating theatre.
Our emotions were still running high as we discussed the procedure. It was only after a long while that we felt… very hungry. And we ordered a substantial dinner – Iwaniec smiles.
Thread thinner than hair
He arrived back at the hospital late in the evening. – I wanted to see what the forearm looks like, how swollen it is. In the first hours after the surgery, despite the successful course of the procedure, anything can still happen. The most serious risk is associated with blood clots – he says.
Vessel suturing requires utmost care. They have very fragile walls. It is important not to damage the endothelium, as this may cause the occurrence of embolism. The surgical suture used is thinner than hair. The smallest vessels are sutured under multiple magnification, because it is easy to lose sight of the suture.
We did it without a microscope, but we took turns frequently because it’s really tedious work. Eyes hurt, fingers go numb, neck gets stiff – says Iwaniec.
In the evening after the surgery, the hand did not look too good, but the next day it turned pink. A simple test (checking the capillary pulse at a fingertip) confirmed that circulation had been restored. – However, you have to wait a few days before you can start celebrating a successful surgery – the doctors point out.
In the case of Mr. Antas, we could already allow ourselves to be optimistic. After a week, the hand was still warm, had a good colour, and the oedema was not significant – says Iwaniec.
We could sew on more
The orthopaedists of the hospital in Jasło are very skilled in suturing and repairing injured fingers or hands. There are many such injuries. Completely severed limbs are rare. They had performed a surgery similar to the one of Zbigniew Antas only once before. Five years ago.
The daily routine of the department includes scheduled joint replacements and surgeries in patients after injuries and accidents. Every fifth procedure is related to hand surgery and microsurgery.
Doctors repair deformed and stiff hands, relocate fingers, correct defects after injuries and previous surgeries, transfer tendons, restore nerves.
After a serious injury, it is very difficult to fully restore feeling in the hand – says Bogdan Naszkiewicz, head of the department. – Injured nerves regenerate very slowly, one millimetre a day. But they are still not 100% functional.
Zbigniew Antas has a good chance that his limb will function as before – thanks to the fact that he received immediate specialist treatment. He was lucky because he was a “catchment area” patient.
Naszkiewicz admits that he often had to refuse to admit a wounded person with a severed finger or hand from Małopolskie or Lubelskie Voivodeship and send rescuers who arrived with the patient to centres in Trzebnica near Wrocław or Szczecin.
We regret this because we could carry out more replantations, but we don’t have the appropriate facilities – he explains.
The department has only one operating room and it is busy every day. Planned treatments are scheduled for 3 years ahead. Hand replantation takes many hours and involves a large team. This means that a few patients would have to be rescheduled that day.
For years, I have dreamed of performing replantations on a larger scale – says Naszkiewicz. – For this you need an additional operating room and a team with the appropriate skills on a constant standby. So far, it has not been possible to achieve this.
Zbigniew Antas talks about his awakening in a hospital bed.
I was very weak after many hours under anaesthesia, but I remember that my right hand immediately reached for the left one. To check if it was still there. He could feel it under the bandages. It was there!
He still can’t help doing it. Every now and then he touches the fingers protruding from under the bandages and gently moves them. – You can check that they are still warm – he says.