Dr. Igor Zakaryan, Chief of Plastic and Reconstructive Surgery Central Republic Hospital. Stepanakert, Artsakh Republic

Plastic Surgeon Dr. Igor Zakaryan Advances Trauma Surgery in Artsakh

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By Levon R. Karamanoukian

STEPANAKERT — Surgeons in the Republic of Artsakh recently performed complex microsurgery to reattach the right arm of a 20-year-old man after a traumatic and life-threatening industrial injury. According to surgeons at the Central Republic Hospital in Stepanakert, Tigran Musayelyan sustained a mechanical avulsion injury that spared his life, but completely amputated his upper right arm, on September 8, 2022. (In medicine, an avulsion injury is one in which a body structure is torn off by either trauma or surgery.)

The patient was transported by the medical transport team, equipped with military life support equipment, in critical condition to the trauma unit where he was immediately evaluated by reconstructive surgeon Dr. Igor Zakaryan, Chief of Plastic and Reconstructive Surgery at Central Republic Hospital.

“A decision was made to perform complex reconstruction and microsurgical reattachment of the upper limb to improve his long-term functional outcome,” said Zakaryan. Organizing a critical care team composed of trauma surgeons, anesthesiologists, orthopedic surgeons, vascular surgeons, and medical specialists, Zakaryan recognized a unique window to salvage the severely mutilated limb and reattach it to the body.

“The decision to perform limb replantation is crucial and time-sensitive; even small delays in timing can mean the difference between success and failure…we were faced with the life-changing decision to restore function to this young man,” added Zakaryan.

Limb replantation requires complex microsurgery. “The chance of success is severely reduced in patients with avulsion rather than sharp cutting injuries to the soft tissue. The actions of Dr. Zakaryan and the trauma team at Central Republic Hospital in Stepanakert are nothing short of spectacular,” said California plastic surgeon Dr. Raffy Karamanoukian, who authored a paper on the feasibility of robotic microsurgery in the Journal of Reconstructive Microsurgery. “Replanting an upper arm in an avulsion injury requires expertise and coordinated trauma protocols that can help resuscitate and stabilize a potentially life-threatening injury.”

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Over the last decade, Karamanoukian has performed many reconstructive surgeries in Stepanakert, Artsakh, and collaborated with Zakaryan at Central Republic Hospital. The surgical collaboration between US and Artsakh surgeons allows for a high level of expertise in the management of severe tissue trauma.

One factor that allowed this success was the quick response time; the patient was transported to Central Republic Hospital with the severed limb in a record one hour from the time of injury, where an on-call trauma surgery team was prepared to resuscitate and stabilize the patient for surgery. As the medical transport team evacuated the patient, experienced paramedics with military trauma expertise, retrieved and prepared the limb for possible transplant.

Tigran Musayelyan, Age 20. One month after right arm replantation in Artsakh Republic.

The goal of replantation was to restore vital blood circulation first, followed by complex and staged repair of bone, tendons, muscles, and nerves that maintain upper limb function. “This surgery is complex from the standpoint of cardiovascular shock,” reported Dr. Hratch Karamanoukian, a board certified cardiothoracic surgeon in the United States. “The acumen of these surgeons attests to the highest level of medical and surgical achievement in trauma critical care,.”

The microvascular repair and replantation procedure lasted a total of four hours, with Zakaryan’s reconstructive surgery team successfully re-approximating and stabilizing the skeletal bone, re-establishing vascular perfusion to the limb, and re-attaching crucial nerves and tendons back together.  The patient remained in critical condition as a result of cardiovascular shock and remained in the intensive care unit. After several weeks of inpatient care, Musayelyan has been discharged but will require long-term rehabilitation to restore function to the limb, according to Zakaryan.

“The work of the trauma team at Central Republic Hospital supports the social and cultural framework of our homeland,” said Zakaryan. “Our decision to restore function to this young man remains a duty and sacrifice to our nation.”

 

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