56.2 Guillotine amputations

If you amputate a severely infected limb, the infection may be spread to the stump, especially if you are amputating for gas gangrene. It will be less likely to do so if you: (1) Cut straight down to the bone all round the limb, and then saw the bone through at the same level, (2) leave the surface unsutured, and (3) revise the amputation later if necessary. A guillotine amputation is quick, and the flaps are less likely to necrose if the blood supply is poor. Some surgeons never use them.

GUILLOTINE AMPUTATIONS Apply a tourniquet. Cut the flaps as far distally as you can, so that you can refashion them later. Cut the patient’s skin down to his deep fascia all round his limb 2 cm distal to the site of bone section. Let it retract. Then cut the muscle all round his limb down to the same site.

Tie and cut all the large vessels you meet. Cut all major nerves at least 2 cm proximal to the end of the stump. Dress the patient’s stump with vaseline gauze and plenty of dry gauze. Bandage it, and let it granulate. When it has healed, or there is no further risk of infection, either: (1) revise the amputation higher up, or (2) graft it, or (3) refer him.