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Epineural Nerve Repair

    Images kindly provided by Donald Serafin M.D., Duke University Medical Center  

- Discussion:
    - epineural repair is currently the gold standard for repair, as no prospective studies have indicated than fasicular repair is superior;
    - it is probably most indicated w/ pure sensory or pure motor nerves;

- Technique:
    - expsure: see: Phalangeal Incisions:
    - debridement:
         - zone of injury must be defined;
         - damaged nerve ends are sharply debrided to clean edge of fasicles;
         - to overcome small defects that occur w/ nerve transection and debridement, the nerve ends must be mobilized to some degree;
    - rotational alignment:
         - an attempt is made to align group fasicles and/or longitudinal epineural vessels;
         - if nerve ends are retracted, the ends can be approximated by transfixing the epineurium at each end with small straight needles, 
                 which are then driven into soft tissue;
    - epineural repair:
         - initially two sutures spaced 180 deg apart are inserted;
         - with small nerves, only two or three sutures (8-0) may be required, where as with larger nerves, up to 6 sutures may be reqired;
         - microvascular forceps lift epineurium and needle is driven thru epineurium;
               - generally only the epineurium is included in the repair;
               - on some occassions, such as median nerve lacerations at the wrist, the internal epineurium can be included in the external 
                      epineural stitch inorder to better oppose group fasicles;
         - after the suture is tied, one end is left long, to facilitate further repair;
         - 2nd suture is placed 120 deg apart, again leaving one end long;
               - remaining anterior sutures can now be applied;
         - now one suture is passed beneath and around nerve, and w/ gentle traction the nerve should twist around 180 deg;
               - traction is maintained by using microsurgical clips which are applied to soft tissue;
         - remaining sutures are applied;
    - management of tension at nerve site repair