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The concept that the fetus may be a patient is very recent. Modern ultrasonography can detect fetal abnormalities early in utero, and lead to prenatal correction of such malformations. At present three anatomic defects can benefit from fetal surgery: diaphragmatic hernia, urethral obstructions and obstructive hydrocephalus. The feasibility of fetal surgery has been proved both experimentally and clinically. Microsurgery can be of great help in this type of surgery. At this stage, fetal surgery should be pursued only in very qualified centers.

This survey concerns the years 1989 and 1990. While the number of institutions performing replantations remained constant in Austria and Switzerland, there has been a noticeable trend in Germany from around-the-clock replantation centers to simple replantation services, offering emergency microsurgery by arrangement only. The total number of replantations performed decreased from 975 replanted parts (903 microreplantations and 72 macroreplantations) in 1989 to 875 in 1990, with a micro-/macroreplantation ratio of 12.8:1. Based on the results of questionaire received from 34 university and city hospitals in Austria, Switzerland and former West Germany, an analysis of clinical organization and management of replantation services is presented.

Speculating on the possible advances of microsurgery in the 1990s has encompassed discussion of transplantation technique, biochemistry, monitoring, and nerve and motor reconstruction. This article, however, is by no means exhaustive, and many other discoveries and innovations may come from areas not discussed here. The only clearly incorrect possibility concerning microsurgery in the 1990s is that nothing exciting will happen.

The authors conducted a comparative study of various methods of coronary shunting by means of microsurgical techniques in 240 patients who were operated on for ischemic heart disease. Total myocardial revascularization, including arteries measuring less than 1.5 mm in diameter and vessels in the zones of cardiosclerosis, was found to be more effective than the techniques of shunting of only the affected major branches. The advantages of a mammary-coronary shunt over anauto- logous venous shunt in reconstruction of coronary arteries under unfavourable hemodynamic conditions are demonstrated. It is also shown that multiple bi-mammary-coronary shunting of the branches of the left coronary artery is a promising method.

Vascular surgery, one of the main fundamental parts of angiology, is an important rapidly developing clinical specialty. The author discusses the experience in many thousand operations in injuries, atherosclerosis, and thrombosis of arteries and veins in the light of new advancements in plastic microsurgery and the use of laser, ultrasound, glue, and various types of vascular sutures. He suggests organizing adequately equipped vascular surgery departments and teams of emergency vascular surgery, wider training of vascular surgeons++, and discusses new methods for the reconstruction of vessels and use of vascular prostheses.

Four periods of microsurgery of tubal sterility and present approach to individual operation techniques in respect to assisted reproduction are evaluated. The evaluation concerns 240 operated women, their average was 31.8 years, 68.8 per cent women were operated for the first time. The pregnancy rate arrived at 90 pregnancies (40.8 per cent), 80 women delivered (33.3 per cent), the abortion occurred in 7 cases (2.9 per cent) and ectopic pregnancies occurred in 11 cases (4.6 per cent). By adhesiolysis we achieved 56 per cent pregnancies, by fimbrioplastics 34 per cent pregnancies and by neostomies only 27 per cent pregnancies. Tubal anastomosis (11 operations) and tubal implantations (9 operations) had no significant influence upon evaluation. Deflection from tubal implantations, anastomoses (except refertilizing ones) or neostomies (especially iterative ones) in favour of in-vitro-fertilization is evident.

Until recently, China had been isolated from Western countries for almost 30 years. Surgeons of Western countries, perhaps, are interested to know what is happening in surgery in China. This communication reviews the current interests in Chinese surgery. It is by no means complete, nor is that the intention. The intention is to introduce to our foreign colleagues a general overview of some highlights in Chinese surgery.

The development of extremity replantation and reconstructive microsurgery was initially carried out independently among the pioneering centers throughout the world. The comparative development of these techniques is outlined. With the fast growth of microsurgical procedures, many of the U.S. residency programs have incorporated microsurgery training into the curriculum.

Development and advances in clinical and research work on limb lymphedema in China has progressed rapidly in recent years. The authors first performed successful lymphaticovenous anastomosis using the operating microscope for limb lymphedema in China in May, 1979. By 1983, surgery on 48 lymphedematous limbs in the authors' clinic had given good results in one-third of the cases. By the same year, 185 limbs with lymphedema were treated by lymphaticovenous anastomosis throughout China with excellent results achieved in 72.9% of the cases. Lymphology was investigated using animal models, intraluminal pressure, and venous graft substitution of lymphatics.

On the basis of 2542 cerebro-spinal vascular diseases (933 aneurysms, 689 cerebro-spinal angiomas, 410 spontaneous intracerebral hematomas, 361 vascular bypass operations and 149 endarterectomies of neck vessels) the present situation and problems, as well as the future prospects of cerebral vascular neurosurgery are reviewed. It is expected that the main development will take place in the field of pathophysiology and pathochemistry of vascular diseases through the acquisition of data obtained not in experimental studies but in patients. This will refine the diagnosis and indications. It is not expected that the operative technique will undergo very substantial change. New methods in the application of laser and photosensitization techniques will be probably included in the technical armamentarium. Endovascular methods of treatment will be further developed and will lead to the limitation of the indications for direct operation. It is assumed that mortality and morbidity can be further reduced by improving the diagnosis and establishing the optimal lines of therapy.

In 1963, the successful replantation of an upper extremity amputated at the forearm provided the impetus for great interest in this surgical procedure in the People's Republic of China. In the 16 years since that time, much progress has been made, especially after the introduction of microsurgical techniques. Prior to 1973, replantation of digits was performed 443 times under the naked eye, with a digit survival rate of 51%. Since 1973, 92 replantations have been done under the microscope, with a digit survival rate of 91%. Experience is also recorded for free abdominal skin grafts, toe transplants for thumb and finger reconstruction, free dorsalis pedis flaps, free vascularized fibular transplants, free muscle transplants, jejunal transplants for esophageal defects, combined free grafts of the omentum and skin for repair of scalp, cranial, and extremity defects, and extracranial-intracranial blood flow diversion.

Illustrated by several examples from the past it is demonstrated how difficult it is to predict future developments in neurosurgery. Several determinants can be recognized as exerting a positive or a negative influence in this respect. Careful observation of unexpected events and consequent consideration in combination with a spiritual independency, are aspects which will contribute in a positive way. The reverse will unavoidably lead to abolition of new ideas and concepts. Authority in a personal as well as in an impersonal way, may act as a negative determinant. This aspect is illustrated by some examples regarding the phenomenon of the "medical mandarin" as a personal authority, and the irrational adherence to paradigms as an impersonal one. Based upon recent experiments new ways for neurosurgical activities are indicated, concerning 1st transplantation of fetal central nervous tissue and of adrenal medullary tissue, and 2nd deep long-term stimulation of the beta endorphin-serotonin system for the control of chronic pain.

Five areas of active clinical research development in otolaryngology have been selected to illustrate the specific applications of microsurgical principles and the potential future of associated bioengineering research. These are: (i) biocompatible microelectronic circuitry and cochlear electrode implant in total cochlear deafness, with preservation of auditory nerve function; (ii) microneural surgery of the facial nerve in hemifacial spasm and the techniques available for reinnervation of the paralysed larynx; (iii) laser microsurgery of the larynx--a new surgical modality dependent on high-precision control through the operating microscope; (iv) microvascular free tissue transfer in head and neck reconstruction and its potential value following combined irradiation therapy for carcinoma; and (v) human laryngeal transplantation--its current status.

Replantation of complete or incomplete nonviable amputations of digits, hands, and major limbs along with a number of reconstructive microsurgical procedures reflect the work that has been done in the field of orthopedic microsurgery in Greece during the last ten years. The history of trauma microsurgery in Greece starts in the mid-1970s, when the first attempts were directed toward patients with complete or incomplete nonviable amputations of digits and hands. Few cases of major limb replantations without the aid of an operating microscope or other means of magnification have been reported for the years 1965-1975. The first successful digital replantation was performed in 1979 on a female patient with multiple digit amputations; only the little finger was successfully replanted. More than 310 replantations and revascularization procedures have been performed during the past decade, mainly in two major replantation centers, with an overall success rate of 85% for complete and 90% for incomplete nonviable amputations. Reconstructive microsurgical procedures are mainly related to free skin flaps, vascularized bone grafts, toe-to-thumb transfer, and peripheral nerve microsurgery.

Diagnostic methods to discover a brain tumor and surgical techniques to remove it are steadily advancing. Most well-demarcated tumors can be removed by operation alone. Malignant, invasive tumors, however, will continue to offer a difficult and serious problem except when they are found while still very small in size, by elaborate diagnostic tools and except when they are conveniently located. For those tumors, surgery alone is not enough. Extermination of tumor cells by surgery, radiotherapy, chemotherapy, immunotherapy, etc., or combinations of these has achieved some results but with considerable limitations. We must search for the ways of peaceful coexistence with tumor cells, i.e., living with the tumor cells which are kept non-dividing and non-metastasizing by some means. Recent developments in oncology, such as discovery of c-onc genes, various growth factors, etc., give us some hope in the researches in this direction.

The operating microscope was originally introduced to provide better visualization and illumination for otologic surgery. The successful use of this instrument in the fenestration operation for otosclerosis rapidly led to its application to reconstructive procedures in chronic suppurative otitis media. Later, it became evident that the operating microscope also provided advantages in the treatment of inner ear disorders and in the removal of acoustic Schwannomas; a considerable reduction in morbidity and an improved prognosis have resulted from application of microsurgery to these conditions. In addition, new photographic and television equipment, used in combination with microsurgery, has greatly improved the standards of teaching and the recording of pathologic information.