Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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12-MARCH-2009 AHMAD ISMAEEL AWWAD 26 YEARS
BULLET INJURY TO THE LOWER THIRD OF LEFT SCIATIC NERVE.
The patient came to the
clinic 25-February-2009 complaining of complete
loss of function of the left sciatic nerve,
after suffering bullet injury 07-December-2008
with subsequent "repair" 15-December-2008.
On examination the patient
showed complete absence of the function of the
sciatic nerve below its subdivision. The inlet
was from the medial third of the thigh medially
and the outlet was at the popliteal fossa.
Considering that the relatives were informed
that further exploration was decided by the
first neurosurgeon, it was decided to undergo
Despite the fact, that the
previous incision was performed out of the
trajectory of the sciatic nerve, it was decided
to use it for the planned operation and to use
lazy extensions to conform with the needed
exposure of the proximal part of the sciatic
nerves and the common peroneal and tibial
nerves. Dissection started to expose the sciatic
nerve above the scar, the the tibial nerve was
exposed at the popliteal fossa and from under
the gastrocnemius muscle after bisecting the
arcade of the solius muscle. The common peroneal
nerve was exposed before its division to the
deep and superficial branches.
Using Inomed ISS with DNS and
EMG protocol, the was complete denervation of
both tibial and common peroneal nerves.
Neurolysis of the exposed
nerves toward the scarous region, confirmed
complete absence of the tibial and common
peroneal nerves with the last 2-3 cm of the
sciatic nerve before its subdivion.
The tibial nerve was bisected
at the scar, and the proximal part was cut
several times, until the nerve became having
acceptable bundles. The same was done to the
left common peroneal nerve and last to the
sciatic nerve. The resulting gap was 80 mm
between the sciatic and both tibial and common
peroneal nerves. Dissection of the sciatic nerve
and the tibial nerve was performed around 20 cm
above and below to regain some extralength.
The sciatic nerve was subdivided to its major
trunks to regain some ample and to avoid severe
angulation of the trajectories of the nerves.
The perineurium of the tibial nerve and the
tibial division of the sciatic nerve were
acceptable and intentionally some scar was left
adherent to them, so as to use them for tight
and strong hold of the anastamosis. The
anastamosis of the tibial division of the
sciatic nerve was achieved with the tibial nerve
with the knee positioned in 70 degrees without
The proximal part of the
common peroneal nerve had good perineurium, but
the distal part of the peroneal subdivion was
lacking a good perineurium. An anastamosis was
performed between these two stumps with the knee
flexion 90 degrees.
During closure with the knee
in 90 degrees in flexion, the anastamosis of the
peroneal nerve disrupted. It was decide to
harvest sural nerve graft 40 mm length 5 bundles
collected together and cross anastamosis was
performed with common peroneal nerve and the
peroneal subdivion of the sciatic nerve. The
wounds were closed routinely and complete POP
was used to keep the knee in 90degrees position.
The patient had undergone
early exploration of the common peroneal nerve
at the first surgery and it was stitched to the
The bullet injury usually
cause wide-spread injury to the nerves and to
have more or less acceptable regeneration of the
nerves the stumps must have good fibrillary
To obtain such requirement a
huge gaps usually took place and the surgeon
must be ready to find the appropriate solutions
to the arising problems.
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Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .