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Handchir Mikrochir Plast Chir 2018; 50(02): 101-110
DOI: 10.1055/s-0043-118597
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Farbkodierte Duplexsonographie und „Power-Doppler“ in der Perforatorchirurgie – Erhöhung der Patientensicherheit durch effiziente Planung

Colour duplex sonography and “Power-Duplex” in Perforator Surgery – Improvement of patients safety by efficient planning
Adrien Daigeler
1   Berufsgenossenschaftliche Unfallklinik Tübingen, Klinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie
,
Cornelius Schubert
2   Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Klinik für Plastische Chirurgie und Schwerbrandverletzte
,
Tobias Hirsch
2   Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Klinik für Plastische Chirurgie und Schwerbrandverletzte
,
Björn Behr
2   Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Klinik für Plastische Chirurgie und Schwerbrandverletzte
,
Marcus Lehnhardt
2   Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Klinik für Plastische Chirurgie und Schwerbrandverletzte
› Author Affiliations
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Publication History

05/06/2017

08/03/2017

Publication Date:
12 February 2018 (online)

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Zusammenfassung

Einleitung Unterschiedlichste Techniken mit spezifischen Vor- und Nachteilen kommen zur Lokalisation der Gefäße in der Perforatorchirurgie zum Einsatz. Stabdoppler sind handlich aber ungenau bei der exakten Perforatorlokalisation. Die Angio-CT ist teuer, zeitaufwendig, strahlenintensiv und invasiv. Die Duplexsonographie dagegen ist eine zuverlässige, einfach einzusetzende und verfügbare Alternative für die prä-, intra- und postoperative Gefäßdarstellung. Der Powerdoppler bietet eine noch größere Sensitivität und kann Gefäße bis 0,5 mm Durchmesser sicher darstellen.

Material und Methoden Der Einsatz von Farb- und Powerdoppler bei der präoperativen Planung wird anhand von Bildern, die die Identifizierung septaler Gefäße beim ALT, die Darstellung von Empfängergefäßen und die Planung von gestielten Perforatorlappenplastiken zeigen, illustriert. Es wurden konsekutiv 33 freie Lappenplastiken (21 ALT, 5 DIEP, 4 FCI, 2 MSAP, 1 tib. post. perforator Lappen) zur Unterschenkel- und Brustrekonstruktion, sowie 19 gestielte Perforatorlappenplastiken am Rumpf und den Extremitäten zur Defektdeckung nach Tumor und Trauma für die Auswertung eingeschlossen.

Ergebnisse Die Detektionsgenauigkeit für das Verfahren lag bei 100 %, bedeutend, dass der identifizierte Perforator in einem Radius von 0,5 cm um die präoperative Markierung lag. Auch der Gefäßverlauf (septal vs. intramuskulär) wurde zu 100 % korrekt dargestellt. In der Serie trat kein Lappenverlust auf. Es handelt sich um eine nicht invasive, sichere und kostengünstige, aber zeitaufwendige und untersucherabhängige Technik.

Diskussion Durch die Sichtbarmachung von Arterien und Venen und der exakten Lokalisierung des Fasziendurchtritts wird das Lappendesign erleichtert. Perforatoren können zentral in den Lappen gelegt, der Perforatorverlauf speziell bei ALT-Lappen dargestellt und damit aufwendige Präparationen durch den Muskel vermieden werden.

Abstract

Introduction There are many techniques to identify vessels in perforator surgery, each with specific disadvantages. Handheld Dopplers are easy to use, but inaccurate with respect to the exact localisation of the perforator. Angio-CT is invasive, time consuming, and expensive. In contrast, duplex sonography is a reliable, easy-to-use and availabe alternative for pre-, intra-, and postoperative visualisation of vessels. Power Doppler further increases sensitivity and allows visualisation of vessels smaller than 0.5 mm in diameter.

Material and Methods The use of duplex sonography and power Doppler in preoperative planning is illustrated in photographs that show how to identify the course of the septal vessel in free ALT flaps, to ensure that there are competent recipient vessels and to plan pedicled perforator flaps. In all 33 free flaps (21 ALT, 5 DIEAP, 4 FCI, 2 MSAP, 1 tib. post. perf. flap) for lower leg and breast reconstruction and 19 pedicled perforator flaps at the trunk and the extremities were harvested with this technique and used to cover post traumatic and tumour defects.

Results The detection accuracy of duplex sonography was 100 % with reference to the perforator being found within 0.5 cm of the duplexed point and the correct detection of the vessel course (septal vs. intramuscular). No flap loss was observed in this series. This is a non-invasive, reliable, and inexpensive, but time consuming and investigator-dependent technique.

Discussion By direct visualisation of the arteries and veins, the exact localisation of fascia penetration can be detected and flaps can then be better designed. Perforators can be centred in the flaps. The course of perforators can be visualised – especially in ALT flaps – and time consuming dissections through muscle can be avoided.

Schlüsselwörter

freie Lappenplastiken - Mikrochirurgie - gestielte Lappenplastiken - Mikrochirurgie - Perforans-Lappenplastiken - Mikrochirurgie - bildgebende Verfahren - Farbdoppler - Duplex - Sonographie

Key words

colour duplex - power doppler - sonography
 

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