Chapter 11: Techniques of Amputation in Vascular Disease

GENERAL CONSIDERATIONS AND HISTORY

Brief History

Amputation has been described in Roman and Greek literature 2000 years old, with techniques of preoperative planning, vascular control, bone preparation, and soft tissue flap coverage similar to those of modern times.^1,2 Because of the high mortality and minimal anesthesia, emphasis was placed on speed, with most surgeons using large “amputation knives” to complete the soft tissue cleavage in a single, circular cut, some of which can still be found in many surgical trays even today (Figure 11-1).³ Lending to this, the word “amputation” takes its roots from the Latin ambi (around) and putare (to prune). Much like the rest of western medicine, the practices of amputation suffered a dramatic setback during the next millennium, and little is known about the evolution of the procedure during this time. Arabic surgeon Albucasis made many great innovations during the medieval period, including publishing an illustrated surgical text, but his work was slow to spread to other countries.¹ With the advent of high-powered weapons came a higher demand for battlefield amputations during the fifteenth century, which was subsequently delegated to barbers in order to offload overworked physicians. These dirt-to-doctor individuals were referred to as “barber surgeons,” whose ranks gave rise to many of the innovators of modern amputation techniques over the following century.⁴

Still, the practices used at the time were far from technical or precise. After swiftly cutting down to bone, vessels were then found in the proximal mass and quickly controlled with clamps, thermocautery, and hemostatic materials. It wasn’t until the sixteenth century that the development and popularization of vessel ligatures by French surgeon Ambroise Pare, and subsequently the tourniquet by Petit, made the procedure exceedingly safer for patients. Although others had previously described the importance of planning soft-tissue coverage, seventeenth-century English surgeon C. Lowdham is credited with the innovation of flap coverage in order to allow for a lower tension closure.^1,3 The nineteenth century saw further advancement with Lister’s introduction of antiseptic technique, as well as the widespread use of general anesthetics, which allowed not only for fewer complications, but increased surgical time to achieve better hemostasis, better bone preparation, and a more meticulous closure.^1,5

With these and further advancements, amputation has become a routine life-saving procedure used for an increasing number of indications. The sentiment that these procedures should not be considered a salvage operation, but rather a comprehensive treatment option to improve patient outcomes is echoed throughout the modern history of amputation and the vascular community in general. In this chapter, we will primarily focus on lower extremity amputations in the setting of vascular disease, and provide a framework for providers in evaluating, planning, performing, and postoperatively ...