Robots were introduced worldwide more than 20 years ago; however, no strategic plan has been made for their clinical application in the areas of hand surgery and microsurgery in Japan. Among the many advantages of the da Vinci^®, the most important for hand and micro surgeries are microscopic surgery that can be conducted endoscopically. In the present report, endoscopic microsurgeries currently conducted in Europe and the US are described. In addition, the content of the Robotic Surgery Master Course conducted using the da Vinci^® simulator, which began in August 2019 at Juntendo University Urayasu Hand Surgery Center aiming at its clinical application, is reported. We will also describe the learning curve observed during the training for mastering robotic surgery for clinical application. Lastly, we will make suggestions in order for Japan to be on the same standard level of robotic microsurgery as many other leading countries.

In flap reconstruction surgery in the plastic surgery field, blood flow evaluation is performed at multiple times such as preoperative evaluation of flap feeding vessels, intraoperative flap blood flow evaluation, and postoperative flap monitoring. As blood flow evaluation methods, visualizing methods, such as ultrasonography, CT angiography, MR angiography, and ICG angiography, and digitalizing method, such as ultrasonography, laser blood flow meter, transcutaneous carbon dioxide pressure measurement, and tissue oxygen saturation measurement, have been reported. An ideal blood flow evaluation method is one that anyone can easily and objectively use regardless of experience, but a universal blood flow evaluation method has not been established.
We believe that it is important to perform consistent preoperative, intraoperative, and postoperative blood flow evaluations by combining different evaluation methods that visualize and digitalize flap blood flow.

Introduction: The purpose of this study was to review cases in which pedicled flap transfer was performed for traumatic soft-tissue defects in the acute phase and to discuss the indications of the pedicled flaps.
Patients and Methods: Nineteen cases (15 males and 4 females, mean age 52.3 years) of pedicled flap transfer were investigated to assess the flap survival rate, early additional surgery, and deep infection. In addition, we compared groups with and without complex injuries.
Results: Fourteen flaps survived and partial necrosis occurred in 5. The survival rate was 73.7%. There were 3 cases in which the necrotic area was further expanded after flap surgery. Six cases required additional surgery in the early phase (5 additional flaps and 1 amputation) . Deep infection developed in 4 cases, 3 of which required early additional surgery. Early additional surgery was required in 6 of 10 cases in the complex injury group and 0 of 9 cases in the no complex injury group, with a significant difference.
Conclusion: For severe open fractures with complex injuries, more reliable soft tissue reconstruction is required. When a pedicled flap is selected, the effects of trauma on the pedicle, the site of the defect, and the extent of the defect should be carefully considered.

Although treatments of trauma and degenerative disease around the wrist joint are improving, and minimally invasive techniques are attracting attention, nerve injuries occurring during surgery can be detrimental. Injury of the superficial (dorsal) branch of radial or ulnar nerve, which occurs after distal radius fracture fixation, CMCJ arthroplasty, or TFCC repair, is common.
Severe pain and abnormal sensation caused by such effects become refractory and resistant to conservative treatment, thus leading to ADL disturbance.
Refractory pain that is resistant to conservative treatment is an important indicator for surgical intervention. In such cases, nerve reconstruction with or without flap coverage depending on the nerve condition, such as a sign of allodynia or scar formation, is performed. Nine patients with these symptoms underwent surgery. The severity of the symptom had a negative impact on the clinical results. Although early intervention with only mild scarring resulted in satisfactory outcomes, severe chronic cases were often incurable. Flap coverage may be an effective procedure in terms of protecting the repaired nerve and preventing further scarring. Based on my experience, I recommend this treatment strategy considering the clinical symptoms and pathology.

Traumatic major arterial injuries of the proximal upper extremity are relatively uncommon. We investigated the characteristics and postoperative outcomes of 20 arterial injuries in 19 patients. We retrospectively reviewed the medical records of the patients, consisting of 14 males and 5 females, with an average age of 39 (range 5-68) years. Patients with complete amputation of the extremity were excluded. The injuries were accompanied by fractures in 12 patients, nerve injuries in 11, muscle rupture in 8, thoracic injuries in 7, and others in 5. The average injury severity score (ISS) was 15 (range 4-41) points. Regarding surgical procedures, end-to-end anastomosis was performed for 10 arteries, vein graft for 8, and suture repair for 2. The average time of reperfusion after arterial injury was 6 hours and 38 minutes. Postoperative complications included compartment syndrome in 3 patients, skin necrosis in 2, and infection in 1. Extremities were preserved in all patients. According to the latest post-operative evaluation using Chen’s criteria, Grade I was observed in 7 patients, GradeⅡin 3, GradeⅢin 2, and GradeⅣin 7. Blunt force injury, nerve injury, fracture, and muscle rupture as accompanying injuries were significant risk factors for a poor prognosis.

We report our experience and results of fingertip replantation using the artery-only technique without vein or nerve repair. We performed a retrospective review of 18 patients who underwent fingertip replantation between 2013 and 2018. A total of 19 fingertips that were salvaged by microsurgical anastomosis of the digital arteries, but not digital veins, were included in this study. An incision of a few millimeters was made over the fingertip. None of the nail plate was removed and no medical leeches were used. The incision was scratched to maintain bleeding until physiological venous outflow was restored. Of 19 fingertips, 14 (73.7%) replanted fingertips survived. There were 5 replantation failures. Only one patient required blood transfusion. The survival rate in the present study was lower than that in previously reported studies with venous repair. If venous repair is not possible on the day of injury, salvation should be attempted within a few days.

Brest reconstruction using a free abdominal flap is an effective procedure with excellent patient satisfaction, as it enables substantial restoration of breast form and softness. In recent years, deep inferior epigastric artery perforator flaps, which preserve the rectus abdominal muscle, have become less invasive and widespread. High success rates have been reported due to technical refinements and advances in anatomical knowledge. However, the risk of free flap necrosis due to thrombosis remains. We report a series of re-operated cases suspected of postoperative thrombosis after breast reconstruction using free abdominal flaps between April 2013 and March 2020. A total of 308 cases and 342 flaps were assessed, and 21 cases required re-operation due to suspected thrombosis. We detected main perforator thrombosis in 19 of the 21 cases. Variables, such as the time from the initial operation until thrombosis detection, the time from detection to re-operation, findings of the flap, presence of thrombosis, and postoperative course, were retrospectively analyzed. Thirteen cases were diagnosed within 24 post-operative hours and eight re-operated within 5 hours were salvaged. Five cases were diagnosed 4 or more days after the initial operation and only one was salvaged. In the case of late-onset thrombosis, detection was often delayed. It is important to detect thrombosis early and to re-operate within 5 hours.

We report the case of an 80-year-old female with anterior tibial artery injury during open reduction and internal fixation (ORIF) of the tibia. She sustained bilateral lower limb degloving injuries and an open right tibial fracture in a traffic accident. CT angiography demonstrated occlusion of the posterior tibial and peroneal arteries, and right anterior tibial artery displacement. She underwent external fixation of the right tibia at the time of injury. ORIF of the right tibia was performed once the degloving injury healed. Postoperatively, her right foot felt cold with an absent dorsal artery pulse on Doppler auscultation. The posterior tibial artery pulse was present and her toe bled on needle puncture. CT angiography revealed occlusion of the anterior tibial artery at the fracture site with bypass from the posterior tibial and peroneal arteries to the posterior tibial artery. She underwent re-operation for revascularization using the saphenous vein. Postoperatively, the dorsal artery pulse became palpable and foot circulation improved. Arterial injuries in the lower leg do not always exhibit typical symptoms. In the case of poor foot circulation, arterial injury should be considered.

We report a case in which a posterior tibial artery perforator flap was used to treat pain and difficulty in ambulation that developed after tarsal tunnel syndrome surgery.
The patient was a 70-year-old male who sustained a right foot fracture at age 18 and developed flexion contracture of the first toe. At age 66, he underwent contracture release and tarsal tunnel release at another hospital. After surgery, he developed pain in his calf and foot, making ambulation difficult.
He presented with dysesthesia around the tarsal tunnel. He had spontaneous movement of the great toe, consistent with a diagnosis of “painful legs and moving toes syndrome.” Nerve conduction study demonstrated a significant decrease in the CMAP amplitude of the posterior tibial nerve. On sonography, decreased flow was observed in the posterior tibial artery. On ankle dorsiflexion, the posterior tibial vein became occluded. Tenography and diagnostic block demonstrated compression of the posterior tibial nerve over a wide area.
Extensive neurolysis of posterior tibial nerve was performed, followed by posterior tibial artery reverse perforator flap transfer. Postoperatively, dysesthesia and pain resolved. He was able to walk without a cane.
The flap was effective in providing blood flow and soft tissue coverage over the extensively scarred posterior tibial nerve.

High-pressure injection injury to the hand is rare and is frequently underestimated; therefore, improper treatment can result in permanent functional loss or amputation. We report a case of high-pressure injection injury of the middle finger in a 56-year-old man sustained while painting the bottom of a ship. At 27 hours after injury, we performed sufficient debridement by emergency surgical operation, and pain and swelling of the injured finger improved. However, skin necrosis of the affected finger resulted from insufficient circulation. The finger was reconstructed using a free radial forearm flap at 19 days after initial surgery. One year after injury, the patient returned to work and had a pain-free hand with almost normal function. Prompt surgical intervention can improve the outcomes of high-pressure injection injury of the hand.

The anterolateral thigh (ALT) flap has gained widespread popularity in head and neck surgery. Its benefits include a long vascular pedicle, a large but not-too-thick skin island, and a donor site sufficiently far from the head to enable two-team approaches. The descending branch of the lateral circumflex femoral artery (LCFA) is thus commonly used as an artery for anastomosis, but the main trunk is used when the pedicle length is short or the descending branches are included in flaps such as chimeric flaps. The LCFA often has a large vessel diameter, making anastomosis between flap and recipient vessels in the neck area difficult due to small recipient vessel diameters. In this report, we present the reconstruction of a buccal mucosal defect (after buccal cancer resection) using a transverse LCFA branch as a donor artery, which matched the recipient facial artery in diameter and thus facilitated simpler end-to-end anastomosis. The transverse LCFA branch is therefore a reliable donor artery choice for ALT flaps.