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Doctors at microsurgery cutting-edge

Update: March, 24/2013 - 18:19
No pain, no gain: Dr Nguyen The Hoang (left) makes the first incision into a patient's thigh to take out a slender muscle to be later grafted onto her left leg. — VNS Photo Truong Vi

A pioneering method of reconstructive surgery by Vietnamese doctors has been recognised by a prestigious German foundation and one, Dr. Nguyen The Hoang, has won plaudits for his outstanding achievements in the field. Nguyen My Ha reports

While today's reconstructive surgery in Viet Nam is a highly-skilled and refined process, its grisly origins were borne out of chaos.

Decimated by the U.S. bombardment during the American War, many soldiers were badly disfigured by the combination of bombs, bullets and chemical agents, requiring major reconstructive surgery.

The first foundations were laid by the late Professor Nguyen Huy Phan, who founded the Plastic and Reconstructive Surgery Institute under Military Hospital 108 to rehabilate the wounded troops and help them return to normal life.

And while the aims remain the same, the surgeons and techniques have evolved appreciably.

On a grey foggy morning in Ha Noi, Dr. Nguyen The Hoang, 48, heads to work as usual, braced for a gruelling day in the operating theatre.

A patient requires constructive plastic surgery after a motorbike accident two weeks previously. Following two operations, the wound did not heal and the flesh remained rotten, exposing her bone.

Now Dr. Hoang will try to cut out the rotten flesh and parts of her lower leg bone, before grafting a muscle from her right thigh onto her lower left leg. He must then connect the veins and arteries, before finally grafting skin to cover the whole wound.

Starting from 10am, the operation is scheduled to last at least five hours.

Three other doctors and a nurse assist Dr. Hoang during the operation.

Two clean the wound, while Dr. Hoang and another doctor open the right thigh to get to the gracillis, a long thin muscle along the inner edge of the limb.

"I get hold of the muscle now," he says, exposing the reddish muscle which is slender and delicate.

"I must be very careful here," he explains, "this muscle is lying next to the leg artery and if I make a mistake by slicing through the blood vessel, the artery can be broken causing blood to spurt onto the ceiling. Most importantly, the patient can die."

Thankfully, Dr. Hoang does not make a mistake and before he goes out for a break, the muscle is safely secured in its new home.

Dr. Hoang and part of his team walk up one flight of stairs to the canteen for lunch. It's a basic lunch meal comprised of half a plate of rice, a few slices of stir-fried pork, vegetables and a small bowl of soup.

It's surprisingly simple, the same all-in-one plate meal the average worker would have. "Uncle Hoang is very talented," says one of the operating team - M.D. Tran Cao Thuong, 35.

"He not only teaches and guides us now, my father said he worked harder and spent many long hours grafting when he was still an aspiring young doctor joining the 108 hospital.

"He would work in the hospital during the day, then in the evening, he would goback to check on his patients after evening language classes."

Hoang signed up for French and German evening language classes in one of the many centres that mushroomed around Ha Noi in the mid 1990s.

These became regular fixtures after the country went through major economic and socialchanges with doi moi, the renovation policy launched by the country's ruling Communist Party in its 1986 Congress.

Having gone to the country's school system, where he majored in Russian as a teenager, Hoang found few problems picking up the new languages. He signed up for French, because the medical system in Viet Nam was heavily influenced by the French system and later added German as the country's Academic Exchange Service (DAAD), offered postgraduate scholarships in Germany.

"I passed the tests and won a scholarship to study at the Technical University of Munich, one of Europe's oldest," Hoang recalled when we met in his office.

For three years from 1994 until 1997, Hoang left his young wife and daughter in Ha Noi to pursuit his dreams in Munich.

"Everyday I go to the lab at 6am and returned to the apartment at 10pm," he says. "I was very lucky to have Dr. Edgar Biemer, one of the world's best surgeons, as my professor for the Medical Doctorate.

"At first, I failed so many times. At some points I felt hopeless, although I never lost sight of where I was heading."

"The first three months were difficult and I'd made little progress. After so many failed attempts, finally I was successful and the rest of the doctorate went smoothly."

In 1997 he obtained the Medical Doctorate with distinction.

He then stayed for two more years to work as an assistant professor at Technical University of Munich.

Dr. Hoang then returned to Central Military Hospital 108 for seven years until 2006, when he received a Humboldt Fellowship to conduct further research in Germany.

During his second stint in Germany, Hoang not only worked on his Ph.D.Habil., but also participated in a pioneering surgery that marked a major milestone in his career.

In 2008, at the Hospital Rechts der Isar in Munich, he was one of five principal surgeons in a 16-hour operation to graft two-arms for a patient who lost both in an accident. The surgery was so successful that the patient's life was turned around with him being able to use his new arms to perform daily tasks.

German honour: President of the Alexander von Humboldt Foundation, Dr Helmut Schwarz, presents Dr Hoang the Frederich Wilhelm Bessel research award in a ceremony attended by the Military Attache and First Secretary of the Vietnamese Embassy in Berlin. — VNA/VNS Photo Van Long

In his office, Dr. Hoang proudly displays before and after photos of the patient and the operating team, carefully framed. He received the Karl Max von Bauerfeind Medal in 2008 for the outstanding success of the operation.

During the brief lunch break at the Hospital 108 operating centre in Ha Noi, he speaks softly and is reluctant to discuss his own success. A doctor walks by, saying hello and shaking hand with Hoang. "Congratulations," he said, "on winning the new award from Germany." He was the Chairman of the Viet Nam Society of Surgeons.

The prestigious scientific award the man mentioned was actually a 45,000-euro award named after Frieddrich Wilhelm Bessel, the 19th century German astronomer.

News had spread around the hospital long before Dr. Hoang officially accepted the award in a ceremony held just last Monday in Berlin.

Speaking to Viet Nam News on the phone, DAAD Regional Office Director Hannelore Bossmann says, "This is not an award you can apply for, "it's a nomination."

She adds: "A council of scientists have evaluated the post-doctoral research of Dr. Hoang with his German colleagues and were impressed by the excellent merit of his work."

An announcement on the foundation's website reads, "Scientists and scholars, internationally renowned in their field,...who in future are expected to continue producing cutting-edge achievements which will have a seminal influence on their discipline beyond their immediate field of work, are eligible to be nominated for a Friedrich Wilhelm Bessel Research Award."

"I was rather surprised," says Dr. Hoang, "because I believe there are other scientists who have also made outstanding achievements.

"I think of my father, who always supported me and guided me into this medical career and was with me at every tough time during my long years abroad. He died before I could tell him I dedicated this award to him, my mother, my wife and daughter."

The future

The Fredrich Wilhelm Bessel research award was presented to Dr. Hoang as a researcher in a team led by Dr. Staudenmeier for their latest findings in the field of microsurgery.

In an article titled "Neovascularisation and free microsurgical transfer of in vitro cartilage-engineered constructs," Nguyen The Hoang et al documented their experiments on a dozen female rabbits. "Cartilage tissue engineering shows to have tremendous potential for the reconstruction of three-dimensional cartilage defects," reads the study abstract.

The researchers present an effective method to create cartilage-engineered constructs by isolating chondcrocytes from biopsies, amplifying them and then seeding them onto scaffolds.

Pioneering surgery: Dr Hoang with Marcus Merk, the world's first patient to have both of his arms successfully grafted, at Munich's University Hospital Rechts der Isar in 2008. — Photo courtersy of Dr Hoang

In each prefabricated skin flap, arteriovenous vascular was implanted to provide maximal blood flow. Six weeks later, the neovascularised flaps with embedded cartilage-engineered constructs were completely removed and then transferred into position using microsurgery.

"The results show that all neovascularised skin flaps with embedded constructs were successfully free-transferred as free flaps. All constructs showed histological stability in both size and form," according to the article.

To put it simply, Dr. Hoang says: "It's as if someone loses an ear or a nose, we take the tissues of his/her cartilage, multiplying them in appropriate condition, feed them into scaffolds to take shape, then implant arteries to feed blood to it. We then plant it into the patient's body under a prefabricated skin flap until it's ready for transfer as a free flap to replace the lost ear.

"I believe this is the future of reconstructive surgery," Hoang says firmly.

Next year Hoang will work with the team led by Staudenmeier, Ph.D., M.D. at the Ear Nose Throat Department, University Hospital Rechts der Isar under the Technical University of Munich.

Until the future approaches, reality strikes hard.

By 1pm, the new site has been cleaned and is ready for grafting and microsurgery. Dr. Hoang looks through a microscope with the magnifying lense at 19 times the power of the human eye to perform the microsurgery.

Looking into the microscope, I was awestruck at the beautiful frame I was seeing. It was like a brand-new shining abstract lacquer just unveiled before my eyes. The scene was so beautiful and powerful with the shining red blood, the white veins and the purple muscle, lit under a high-voltage operating light.

Microsurgery is a general term for surgery with the help of an operating microscope to stitch severed blood veins, tendons and peripheral nerves.

The 56-year-old woman was sitting behind her brother on the motorbike after a family reunion dinner to celebrate her mother's 90th birthday.

After 7pm on the 5th of the Lunar Year, her life would never be the same again. The bike she was on was hit by a drunk driver knocking her down onto the road, breaking her lower left leg.

If this operation is successful, chances are that she will have to go through further surgery to reconstruct the lower leg bone, as the back of the bone is healed but the front part will have to be grafted. She will walk again, but may not be able to continue farming as she used to.

Last year, Viet Nam had almost 10,000 deaths from road accidents with the number of limbs lost or broken unknown. Total losses caused by this is estimated to total 2.5 per cent of the country's GDP, according to the National Traffic Safety Committee. Bearing that in mind, the work of reconstructive plastic surgeons like Dr. Hoang plays such a vital role.

There are three elements needed to make a good plastic surgeon, according to a principal textbook written by Prof. Nguyen Huy Phan that each student must read: passion, a clear mind and a gift for precise hand movements.

"I think all you need is the love for what you do," Hoang says over his lunch. Looking around the dining room full of young aspiring doctors, Dr. Hoang's quietness seems to be an unusual trait.

Asked if he needs complete silence in the operating room, he said, "No, the atmosphere is very friendly." I didn't believe him until I was actually hanging around the operating room with two teams in action at the same time.

Young doctors talk to the young nurses with beautiful eyes. They chat, they flirt and laugh, while Hoang, very patiently and diligently sews each of the 11 knots around the thinner than 1mm-wide veins.

"Don't you feel distracted by their jokes?" I ask.

"No," comes the reply. "Thanks to their youthfulness, I can concentrate on what I am doing."

The easy-going atmosphere in the operation room eventually takes its toll though. Near the end of the surgery, Dr. Hoang discovers the skin flap the assisting doctor prepared for him was not large enough to cover the wound.

He was then forced to take another flap and prepare it to be sewn over the rest of the wound. It takes him an extra half hour to finish the surgery.

"Doesn't he ever get angry? Does he ever shout?" The other doctors in the team shake their head. "No, he just checks what the mistake was and says we must pay attention next time. He won't tolerate yet another mistake." — VNS

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