How the Seed of Microvascular Surgery That Was Sown by Prof. Julius H. Jacobson in 1960 Germinated and Blossomed

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This article was originally published in Japanese by myself in the Journal of Japanese Society of Reconstructive Microsurgery (2016;29:125–135), and I would like to submit its translated version to the Journal of Reconstructive Microsurgery to make it available to more microsurgeons worldwide. Many young microsurgeons are unaware that Prof. Jacobson is a general surgeon, not an orthopaedic or plastic surgeon, who originated our subspeciality of microvascular surgery in 1960.

According to his resume, Julius H. Jacobson, II, MD, the father of microsurgery, was born on July 2, 1927, in Toledo, Ohio, United States. He was a Jewish-American, and details regarding his parents are unknown. However, his grandfather, also named Julius H. Jacobson, was a renowned surgeon who served as the Dean of Toledo Medical School, though he died prior to the birth of his grandson. Dr. Jacobson's grandmother, Regina Landow, also had a medical degree, though she married immediately after graduating from medical school and had a child; therefore, she may have never practiced medicine. Due to his father's occupation, Dr. Jacobson lived in several cities as a child, including Chicago, Detroit, and New York.

In 1947, Dr. Jacobson graduated from the University of Toledo and began military service in the navy during World War II. Upon his return to the United States, he took entrance examinations for 23 medical schools, but failed them all as an abundance of veterans were competing for medical school admission. In lieu of medical school, Dr. Jacobson attended the University of Pennsylvania, earning a master's degree in cell physiology in 1948. He earned his doctorate of medicine from Johns Hopkins Medical School in 1952 and completed residency in thoracic surgery, where he became the chief surgical resident, at the Presbyterian Hospital in New York. By 1959, Dr. Jacobson was an instructor of surgery at Columbia University in New York and an assistant attending surgeon at the Columbia-Presbyterian Medical Center. He eventually became an Associate Professor of Surgery and the Director of Surgical Research at the University of Vermont College of Medicine in Burlington, Vermont ([Fig. 1]).[1] [2] [3] [4]

Fig. 1 Professor Julius H. Jacobson working in the hyperbaric chamber. This photograph was obtained courtesy the Mount Sinai Hospital, New York City.

Shortly after Dr. Jacobson's arrival at the University, an investigator from the Department of Pharmacology inquired about the most optimal method of the complete denervation of the murine carotid artery.

Dr. Jacobson believed that the best technique to achieve the denervation would be to cut the artery once and reanastomose it, though the anastomosis of a blood vessel with an outer diameter of 6.0 to 7.0 mm was not possible at that time. According to Dr. Jacobson, the human eye is not capable of skillfully controlling hand movements under these circumstances. Even the slightest suture error that would otherwise not be problematic could lead to a failed anastomosis of the canine carotid artery, which has an outer diameter of smaller than 3.0 mm. Therefore, Dr. Jacobson used a magnifying glass to enhance his vision and a jeweler's loupe to achieve carotid artery anastomosis, though his attempts were not successful.

Dr. Jacobson then realized that the Presbyterian Hospital had an otolaryngological operating microscope (Zeiss OPMi-1) for stapes mobilization. Though the staff of the operating room were incredibly resistant to move the device to the animal laboratory, he was able to borrow the microscope. While the microscope allowed for the successful anastomosis of the canine carotid artery, the surgical instruments and suture materials were too large, and the procedure was limited by hand tremors.

The first use of a monocular microscope for surgery was reported for the treatment of chronic otitis media in 1921 by Dr. Nylen, a 30-year-old otolaryngologist at the Karolinska Medical Institute in Sweden.[5] In 1922, Dr. Holmgren of the same Medical Institute, who was Dr. Nylen's Chief, fixed a light source to a Zeiss binocular microscope for use during the surgical treatment of otosclerosis perforation.[6]

Afterward, Dr. Jacobson worked hard to prepare surgical instruments and suture materials suitable for microsurgery, including jeweler's forceps. As the Castroviejo-type instruments that are routinely used in ophthalmology were all too small for his needs, Dr. Jacobson contacted V. Muller & Storz Co. to make instruments of suitable length for deep surgery.

In 1950, Perritt[7] presented the use of a microscope in ophthalmic surgery and Barraquer[8] attached a slit lamp to an operating microscope and developed a ceiling-suspended microscope that was used for corneal and anterior chamber surgery. The contributions of otolaryngologists and ophthalmologists to the development of surgical microscopes should not be overlooked.

Dr. Jacobson used the vascular clamp that had been developed by pediatric surgeon Willis Potts for the treatment of blue baby syndrome, and later made an adjustable vise that allowed for the left and right movement of the instrument.[9]

No sutures thinner than 6–0 were available in 1960 according to the annually published United States Pharmacopeia (USP) standard. Therefore, Ethicon Co. provided Dr. Jacobson with a 127-μm needle attached to a 25-μm thread, which would later be marketed as a 10–0 suture.

The biggest challenge for Dr. Jacobson was the development of an operating microscope through which the operator and assistant could simultaneously observe the same surgical field with an easily adjusted magnification. American Optical Co. and Bausch & Lomb did not agree that a microscope that met these conditions would be marketable. Dr. Jacobson turned to Carl Zeiss Co., a German company that manufactured ophthalmological and otolaryngological microscopes, who immediately sent Dr. Hans Littman, an expert in operating microscopes. Two months after consulting with Dr. Jacobson, Dr. Littman had constructed a prototype of a two-person binocular microscope.

Dr. Jacobson traveled to Germany to see the completed diploscope, which was capable of magnifying 5 to 40 times and had a focal length of 40 cm. This new microscope allowed the operator and assistant to observe the same surgical field with no complications. Dr. Jacobson immediately shipped the microscope to his laboratory in Vermont. Later, he donated it to the Smithsonian Institute in Washington, DC, where it is currently on display.

Slight improvements to the microscope have been made over the years, and ∼10,000 units have been sold worldwide. In Japan, a microscope was brought to the Department of Orthopedic Surgery at Nara Medical University Hospital in 1964, where it played a significant role in the world-first successful replantation of a completely amputated thumb in July 1965.

After procuring a diploscope, surgical instruments, and suture materials, Dr. Jacobson equipped his laboratory with 160 dog cages and began practicing the anastomosis of various tubular tissues including arteries, veins, lymph vessels, nerves, ureters, vas deferens, and fallopian tubes. Dr. Jacobson also conducted finger amputations and replantation of dogs and organ transplantation of rats, though no reports regarding these procedures were published.

When Dr. Jacobson first presented his findings regarding microvascular anastomosis at the Surgical Forum of the American College of Surgeons, Dr. Humphries, who was the chief of vascular surgery at the Cleveland Clinic, stated, “This technique is very interesting as an experimental study, but it is clinically impractical to use a microscope in the operating room.” Dr. Jacobson later wrote, “People generally welcome new ideas but do not actually try to experience them,” and, “Younger people are eager to accept new things, but they often hesitate when they grow older.” [3]

Dr. Jacobson and his colleague Dr. Suarez published their procedures in 1960[10] in a paper that has since been considered the bible of microvascular anastomosis. The vascular anastomosis techniques described by Dr. Jacobson and Dr. Suarez follow the three-stay suture technique reported by Alexis Carrel in 1902[11] and use continuous sutures.

Dr. Jacobson worked with Dr. Donaghy, the chief of neurosurgery at the University of Vermont, to apply the microsurgery techniques to middle cerebral artery thromboendoarterectomy.[12] Dr. Donaghy was aware that placing a drop of water on the anastomotic site expanded the surgical field due to the convex lens effect, and he recognized the importance of microsurgery and became a master of the technique. In 1958, Dr. Donaghy opened the Microsurgery Research & Training Laboratory in Burlington.

Dr. Jacobson also taught Dr. Donald Effler, the chief of thoracic surgery at the Cleveland Clinic, techniques for coronary artery bypass graft anastomosis, making a significant contribution to the subsequent development of this field.

In 1963, Dr. Jacobson moved to Mount Sinai Hospital in New York, where he became the chief of vascular surgery. Prof. Yutaka Onji (1920–1988), my mentor at the Department of Orthopedic Surgery of Nara Medical University, visited Dr. Jacobson that year to observe the vascular anastomosis and purchase microsurgical instruments. Dr. Jacobson gave Prof. Onji two 8–0 monofilament nylon sutures, which were the thinnest sutures in the world at that time.

After returning to Japan, Prof. Onji taught Dr. Jacobson's vascular anastomosis to my senior colleague Shigeo Komatsu and me. We practiced the technique on dogs without a microscope for ∼1 year.

In 1965, Dr. Yasargil, a famous neurosurgeon from Zurich, Switzerland, learned vascular anastomosis techniques under a microscope from Dr. Jacobson at Mount Sinai Hospital.[13] Afterward, Jacobson introduced him to Dr. Donaghy of Vermont, and the two worked together to develop microneurosurgery, applying microvascular techniques to temporo-middle cerebral bypass and middle cerebral thromboendoarterectomy. The development of the bipolar coagulator by Dr. Malis, a Professor of Neurosurgery at Mount Sinai Hospital, spurred the development of this microneurosurgery.[14]

Dr. Donaghy and Dr. Yasargil conducted the first microsurgery course at the Mary Fletcher Hospital in Burlington, Vermont, in October 1966. Attendees included plastic surgeons Dr. Harry J. Buncke, Mr. John R. Cobbett, and Dr. James W. Smith, who are known as the pioneers of reconstructive surgery.

Dr. Buncke (1922–2008) was trained in plastic surgery in Glasgow, Scotland, in 1957. His famous mentor Thomas Gibson questioned, “Wouldn't it be possible to conduct tissue transplantation if small feeding vessels could be anastomosed ?” which was not forgotten by Dr. Buncke. In 1959, Dr. Buncke moved to San Mateo, California, and consulted with Prof. Blackfield of Plastic Surgery at the University of California, San Francisco. Dr. Buncke obtained a grant of $500 (175,000 yen at the time) to conduct composite tissue transplantation research using vascular anastomosis. In 1960, attending a speech by Dr. Jacobson at a conference of the American College of Surgeons, Dr. Buncke became interested in microvascular anastomosis. He borrowed an otolaryngologic microscope from the San Mateo County Hospital in evenings or weekends and converted his garage into a laboratory. Mrs. Constance Buncke, a dermatologist, served as his assistant. Dr. Buncke focused on the development of suture materials and opened a 35-μm hole in a 75-μm stainless steel needle. He collected silk threads from cocoons obtained from a Japanese silk company in San Francisco, dyed them blue, and passed them through the holes. Afterward, he obtained nylon single threads from DuPont Co. and made a prototype of monofilament nylon suture.

In 1966, Dr. Buncke conducted research using a Zeiss diploscope and five monkeys in the Microsurgery Research Laboratory of Prof. Robert Chase at Stanford University. Several microsurgeons, including Dr. Arvon Daniller and Dr. Berish Strauch, were trained in this laboratory. Dr. Buncke was active as a world leader in reconstructive microsurgery, publishing reports of the replantation of a monkey thumb,[15] transplantation of the big toe to the hand,[16] and replantation of a rabbit ear.[17] He was considered as a Father of Microsurgery worldwide ([Fig. 2]). While serving as a Clinical Professor at Stanford University and University of California, San Francisco, he opened the Buncke Clinic for plastic surgery at the Davies Medical Center.

Fig. 2 Dr. Harry J. Buncke's laboratory. Dr. Buncke (right) and Mr. Cobbett are shown looking through a diploscope while Tamai is observing from behind. This photograph was taken with Tamai's camera in 1976.

Mr. Cobbett (1930–2016) was trained as a plastic surgeon in East Grinstead, United Kingdom, and was a pioneer of microsurgery at Queen Victoria Hospital. He reported that an eccentric stay suture (two sides at a 120-degree angle apart) could be used to prevent accidental sutures on the posterior side of a vessel as the anterior side was sutured.[18] In 1968, Mr. Cobbett transplanted a big toe onto the missing part of a thumb,[19] which was the first surgery of its kind in the world, though Yang reported five successful cases of thumb reconstruction using the second toe in 1966.[20]

Dr. Smith (1927–2006) was a plastic surgeon at Cornell University Medical College, and I visited his castle-like residence in Greenwich, New York, when he was an Associate Attending Surgeon in New York Hospital. Dr. Smith had a close relationship with Dr. Seiichi Omori, a Professor of Dermatology at the University of Tokyo. Dr. Smith practiced peripheral nerve microsurgery and was known for his funicular suture technique, the skewer method.[21]

In 1964, Dr. Tetsuo Ito (1913–2002), a Professor Emeritus of Orthopedic Surgery at Kyoto University, also reported a funicular suture technique using 8–0 silk thread that resulted in favorable clinical outcomes.[22]

Few orthopaedic surgeons worldwide began amputation/replantation surgery and microsurgery during the early 1960s. In 1958, an 11-year-old girl presented to the hospital of Nara Medical University after her thigh was run over by a train. According to Prof. Onji's instructions, we conducted the replantation surgery. A senior orthopaedic surgeon attempted vascular anastomosis, but was not successful, as the affected area necrosed 4 weeks postoperatively. In 1959, a 47-year-old woman presented with a cut in her proximal thigh by an electric saw at a sawmill. Fortunately, her femoral artery and vein and part of the skin remained intact. The femur was fixed and the sciatic nerve, muscles, and skin were sutured, resulting in a successful outcome.[23]

Based on these experiences, Prof. Onji indicated that even a completely amputated limb could be replanted if blood circulation is restored as soon as possible following cleansing and debridement of the wounds. I conducted limb amputation/replantation research using canine models in graduate school, beginning in 1960. During this research, I recognized the necessity of microsurgical techniques. After my mentor Prof. Onji visited Dr. Jacobson in 1963, my senior colleague Komatsu and I practiced vascular anastomosis techniques. After the Zeiss diploscope was obtained in 1964, we practiced vascular anastomosis using canine blood vessels with outer diameter of ∼1.0 mm.

In July 1965, we successfully performed the world-first replantation of a completely amputated thumb at the level of metacarpophalangeal joint using the two 8–0 monofilament nylon sutures given from Dr. Jacobson to Prof. Onji.[24] The following year, after my colleague Komatsu presented at the Conference of the Japanese Society for Surgery of the Hand, several society members were incredulous regarding vascular anastomosis with an outer diameter of 1.0 mm. Prof. Tatsuya Tajima requested that postoperative angiography be conducted to confirm the patency of the anastomosed vessels. Unfortunately, this could not be conducted, as the patient had a contrast media allergy.

In the spring of 1967, I was invited to participate in rat kidney transplantation research by the Department of Pediatric Surgery at the Medical University of South Carolina, Charleston, South Carolina. I contacted Dr. Buncke regarding my experience of replantation of a completely amputated thumb in Nara in July 1965. His reply confirmed that the case was the first digit replantation in the world. He also revealed that Kleinert and Kasdan of Louisville, Kentucky, reported a case of incomplete amputation of the base of the thumb that underwent successful replantation via vascular anastomosis in 1963.[25]

In November 1967, the American Society of Plastic and Reconstructive Surgeons held a conference in New York that included the world's first panel on microsurgery organized by Dr. Buncke, of which I was a participant at the invitation of Dr. Buncke. At the conference, Dr. Buncke presented his research regarding digit replantation and toe transplantation in monkeys and ear replantation in rabbits; Mr. Cobbett presented the detailed procedure for microvascular anastomosis; Dr. Smith presented research regarding peripheral nerve sutures, including his “skewer method of funicular sutures”; and I presented a case report regarding the replantation of a completely amputated thumb. After the conference, Dr. Buncke and I remained close friends for 40 years until he passed in May 2008. This was a valuable friendship in the 1960s as research tools and reference databases were not as available as they are today.

In 1970, the International Microsurgical Society (IMS) was established by Sun Lee, Earl Owen, and others who were conducting experimental microsurgery, and the first conference was held in Rijswijk, Netherlands. I was involved in this Society from the 4th Congress in 1976 and was nominated as an Executive Council Member. In October 1994, I was hosted the 12th conference in Nara City as the Society President and Congress Chairman.

In May 1972, when the 15th Conference of the Japanese Society for Surgery of the Hand was held in Niigata City, Mr. Bernard McC O'Brien of Melbourne gave an invited lecture entitled “Digital Replantation and Revascularization.” His lecture attracted increasing interest of the audience on limb/digit replantation surgery in Japan. Since then, over 150 trainees have visited the Department of Orthopedic Surgery of Nara Medical University to learn replantation and microsurgery techniques under my guidance.

The International Society of Reconstructive Microsurgery (ISRM) was founded in 1972 by Harry J. Buncke, John R. Cobbett, Harld E. Kleinert. Thomas Krizek, Joseph Kutz, Hano Millesi, Jacque Michon, Algimantas Narakas, Bernard McC O'Brien, James W. Smith, Chen Zhong Wei, and others. Dr. Millesi hosted the first conference in Vienna in 1972, where I presented our experimental study on microneurovascular free muscle transplantation in dogs. Later, in July 1985, the 8th ISRM conference was hosted in Paris by chairman Dr. Gilbert and President Tamai.

In 1974, the Japanese Society for Reconstructive Microsurgery (JSRM) was also established jointly by experts in the fields of orthopaedic and plastic surgery, and the first conference was held at Nara Medical University in September 1974 under my presidency. Since then, the orthopaedic surgery and plastic surgery departments alternately host conferences every fall, and the number of society members has increased up to ∼1,500.

The IMS and ISRM each hosted biennial conferences until they merged to become the World Society for Reconstructive Microsurgery (WSRM). The WSRM held its first conference hosted by President Prof. Victor Mayer and Chairman Prof. Fu Chan Wei in Taipei in 2001. In 2011, under the presidency by Prof. Berish Strauch, Profs. Isao Koshima and Kazuteru Doi, as the Chairmen, hosted the fifth academic conference in Ginowan city, Okinawa. Former Prime Minister Shinzo Abe was the special guest of this conference.

In this way, the seeds of microvascular surgery that were sown by Prof. Jacobson in 1960 have greatly blossomed into the fields of neurosurgery, cardiovascular surgery, reconstructive surgery (orthopaedic and plastic), urology, and obstetrics/gynecology. In the field of reconstructive microsurgery, the replantation/transplantation of various composite tissues such as amputated limb and digit replantation, skin flap transplantation, and vascularized bone grafting has become popular worldwide. Moreover, during 1990–2020, reconstructive microsurgery began to include composite tissue or organ allotransplantation of the upper extremities, face, knee joints, penis, and uterus.

Publication History

Article published online:
28 April 2023

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