Introduction

Jaloukas have been part of the therapeutic arsenal since ancient times. The first written records of leech therapy in Egypt date back over 3500 years, while evidence of its therapeutic use by Greek, Roman, and Indian civilizations dates back approximately 2000 years. Jaloukavacharana, a method of Raktamokshana, is described in the Sushruta Samhita and Astanga Hridaya. Leeches are indicated for conditions such as Twakroga, Raktajaroga, Dustavrana, Arsha, Vidradhi, Mukhadushika, Indralupta, and others.^[1,2] Jalouka is considered an Anushastra and has been used in parasurgical procedures.^[3,4] Sushruta, the first surgeon, provided a detailed explanation of Sandhanakarma, a term referring to joining, union, restoration, and repair.^[5]

Sandhanakarma is mentioned in various contexts by Acharya Sushruta, such as in wound healing, fractures, Arsha, intestinal anastomosis, and reconstructive procedures for the ear, lip, and nose. The reconstruction of the ear and nose was extensively described by Sushruta^[6], and his procedure for Nasasandhana remains in practice today, forming the foundation for the Indian approach to rhinoplasty. Sandhanakarma can be compared to modern plastic and reconstructive surgery. Today, medicinal leeches (Hirudo medicinalis) are used in a practice known as Hirudotherapy. They are widely applied in plastic and reconstructive surgery. Despite significant advancements in reconstructive surgery, especially microsurgery, venous congestion in transplanted or reimplanted tissues remains a common and challenging complication. Medicinal leeches have been used to salvage free flaps, pedicled flaps, nippleareolar complexes, and in the replantation of fingers, ears, lips, noses, penises, and other organs affected by venous congestion^[7], a condition that occurs when venous outflow cannot keep up with arterial inflow^[8], leading to cell death, tissue necrosis, and flap loss. In 1960, Deganc and Zdravic performed the first leech treatment for a congested flap.^[9]

In July 2004, the FDA approved leeches as a medicinal device for use in plastic and reconstructive surgery.^[10] This review aims to explore the role of Jaloukavacharana in Sandhanakarma.

Venous congestion-related flap necrosis can develop within a mere 3 hours.^[12] To address this complication, all plastic surgeons are familiar with the use of medicinal leeches.

Figure 1: Local flap indicating signs of venous congestion

Application

Leeches should be applied to areas with clinically significant venous congestion. They attach to the skin using a large caudal sucker and create a Y-shaped bite with a smaller cephalic sucker, during which an anesthetic compound is released, often making the procedure painless.^[13] Several techniques for leech application have been described. Traditionally, leeches are placed using a 3 ml syringe with the plunger removed, positioning the open end over the affected tissue and waiting for the leech to securely attach to the skin in the targeted treatment area.^[14] Published studies show significant variation in the number of leeches used, ranging from 1 to 5 per treatment (Fig. 2), or based on the area, 1 leech per 3 cm². Leech therapy is typically maintained until flap neovascularization occurs, requiring an average of 6-10 days.^[15]

Figure 2: Leech applied to the buccal flap

Conclusion

Medicinal leech therapy (Jaloukavacharana) has proven to be an invaluable tool in plastic and reconstructive surgery, especially for managing venous congestion in compromised flaps. The historical use of leeches, as documented in ancient civilizations, provides a strong foundation for their continued application in modern surgical practices. By reducing venous congestion and promoting effective venous drainage, leeches facilitate the survival of flaps and reattached tissues, making them an essential nonsurgical option for tissue salvage. This study highlights the predictable and effective healing outcomes achieved through leech therapy, demonstrating its significant role in improving flap viability and graft acceptance. The biological properties of the medicinal leech, such as blood-letting action, passive oozing, and the release of biologically active substances, contribute to these therapeutic effects, including reduced inflammation, improved circulation, and enhanced tissue metabolism.

Given the benefits, ease of use, and cost-effectiveness of this treatment modality, medicinal leeches represent a valuable addition to the armamentarium of plastic and reconstructive surgeons. As the practice of microsurgery continues to advance, the importance of addressing venous congestion remains critical, and leech therapy provides a reliable and safe solution in the management of this complication. Further research and clinical experience will continue to refine the application and optimal use of leeches in surgical practice, ensuring better outcomes for patients undergoing complex reconstructive procedures.

References