Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps - A Review

Journal of Ayurveda and Integrated Medical Sciences 2025 Volume 10 Number 3 MARCH E-ISSN:2456-3110 Review Article Leech therapy Publisher www.maharshicharaka.in Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps - A Review Manjukumari 1* , Ashok N 2 , Biradar V 3 DOI:10.21760/jaims.10.3.25 1* Manjukumari, Second Year Post Graduate Scholar, Department of Shalyatantra, NK Jabashetty Ayurvedic Medical College and PG Centre, Bidar, Karnataka, India 2 Naikar Ashok, Professor and HOD, Department of Shalyatantra, NK Jabashetty Ayurvedic Medical College and PG Centre, Bidar, Karnataka, India 3 Vijaykumar Biradar, Professor and Dean, Department of Shalyatantra, NK Jabashetty Ayurvedic Medical College and PG Centre, Bidar, Karnataka, India Jaloukas have been used medically for thousands of years dating back to ancient time. Today medicinal leeches are mostly used after Sandhana Karma i.e., in plastic and Reconstructive surgeries for the salvage of free, pedicled and even microvascular anastomosed flaps having venous congestion. The aim of this study is to spotlight on the role of leech therapy after Sandhanakarma. The systemic review of literature was conducted from the online databases and the results obtained in the patients after leech therapy were observed. This study has confirmed the excellent and predictable healing after Jaloukavacharana over the congested flaps. The benefits depend on these main properties of the medicinal leech like bloodletting action during active suction of blood, passive oozing of the wound for 1-2 days and injection of biologically active substances with the saliva into the host. Hence leech therapy is safe, easy to use, beneficial and cost-effective treatment modality to save flaps and reattached body parts in plastic and reconstructive surgery Keywords: Jaloukavacharana, medicinal leech, Sandhanakarma, flaps Corresponding Author How to Cite this Article To Browse Manjukumari, Second Year Post Graduate Scholar, Department of Shalyatantra, NK Jabashetty Ayurvedic Medical College and PG Centre, Bidar, Karnataka, India Email: Manjukumari, Ashok N, Biradar V, Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps - A Review . J Ayu Int Med Sci 2025;10(3):164-168 Available From https://jaims.in/jaims/article/view/4435/ Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted 2025-02-15 2025-02-25 2025-03-05 2025-03-15 2025-03-24 Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note None Nil Not required 10.63 © 2025 by Manjukumari, Ashok N, Biradar V and Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0] J Ayu Int Med Sci 2025 ; 10 ( 3 ) 164

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 Materials and Methods A systematic review of the literature was performed using the PubMed, EmBASE, and ResearchGate platforms. The following keywords were used in the search: "leeches" or " Jaloukavacharana " or "leech therapy" and "flap" or "plastic surgery" or " Sandhanakarma ." Ayurvedic classics and relevant books are also referred. This approach allowed me to preselect relevant articles. The data collected focused on the role of leech therapy in plastic surgery Results In plastic and reconstructive surgery, leeches primarily help alleviate venous congestion in compromised flaps. Postoperatively, the success of the flap depends on careful monitoring for vascular issues, with venous thrombosis being both the most common and rapidly damaging complication. This study confirms that Jaloukavacharana provides excellent and predictable healing for compromised flaps, leading to successful graft acceptance in plastic and reconstructive surgeries. Medicinal leeches offer a non-surgical solution for plastic surgery patients experiencing venous congestion. This is primarily due to the key properties of medicinal leeches, such as their blood-letting action during active blood suction, the passive oozing of the wound for 1-2 days, and the injection of biologically active substances that promote healing Discussion After reconstructive surgery, flaps or reimplanted tissues may experience venous congestion. This occurs when the small, thin-walled veins involved in microsurgical procedures are unable to effectively carry blood away from the surgical site. As a result, blood pools in the veins and cannot return to the heart and lungs for re-oxygenation. Clinical signs of venous congestion include cyanosis or a dusky coloration, increased turgor, a cool touch, brisk capillary refill, and rapid dermal bleeding [11] (Fig 1). If left untreated, stagnant blood leads to the accumulation of carbon dioxide, which can ultimately result in tissue death. In such cases, Jaloukavacharana may be recommended for optimal recovery. Therefore, preventing flap necrosis, the most common complication of venous congestion, becomes a key indication for leech therapy Manjukumari et al. Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps J Ayu Int Med Sci 2025 ; 10 ( 3 ) 165

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 Yshaped 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 Mechanism of action Leech therapy functions by reducing tissue capillary pressure and promoting local anticoagulation through three main mechanisms: active blood suction, the injection of biologically active substances via saliva into the host, and passive blood oozing from the bite wounds after leech removal [16] (Fig. 3) The saliva of the medicinal leech contains a variety of bioactive substances, such as anticoagulants, platelet aggregation inhibitors, vasodilators, anesthetics, antiinflammatory agents, and antimicrobial compounds [17] Hirudin is the important and principal anticoagulant responsible for enhanced bleeding and prevention of coagulation [18] Calin, apyrase, decorsin, saratin, collagenase are platelet function inhibitors accounting for the persistence of bleeding subsequent to biting last for several hours after removal of leech. Hyaluronidase and pyrase are Extracellular matrix degradation, these decreases the viscosity of interstitial fluid and improve the depth wise penetration of nutrients and other substances. Histamine like vasodilators, dilate the vessels. Antistasis, hirustasin, eglin C, carboxypeptidase inhibitor, bdellins, piguamerin, guamerin are anti-inflammatory and analgesic, reduces inflammation and rendering the bite painless [19] Thus, leeches aid in the salvage of compromised tissue by promoting sustained bleeding, which significantly reduces tissue congestion. This process helps lower blood volume, alleviate capillary pressure, decrease venous congestion, and relieve compression on nerve trunks and endings. Additionally, it enhances lymphatic flow, improves local hemodynamics, increases oxygen supply, boosts tissue metabolism, and helps resolve tissue ischemia [20] Figure 3: Passive oozing from the leech bite Manjukumari et al. Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps J Ayu Int Med Sci 2025 ; 10 ( 3 ) 166

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 costeffectiveness 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 1. Singh RN. The Anushastra in Ayurveda Surgery: Clinical Application. World J Pharm Med Res. 2022;8(10):246-50. [Crossref][PubMed][Google Scholar] 2. Shastri AD. Sushruta Samhita with Ayurveda Tatva Sandipika Hindi Commentary. Varanasi: Chaukhambha Sanskrit Sansthan; p. 58. [Crossref] [PubMed][Google Scholar] 3. Singh RN. The Anushastra in Ayurveda Surgery: Clinical Application. World J Pharm Med Res. 2022;8(10):246-50. [Crossref][PubMed][Google Scholar] 4. Shastri AD. Sushruta Samhita with Ayurveda Tatva Sandipika Hindi Commentary. Varanasi: Chaukhambha Sanskrit Sansthan; p. 39. [Crossref] [PubMed][Google Scholar] 5. HR M, D. A critical review on Sandhana Karma. Int Ayur Med J. 2024;:608-18. [Crossref][PubMed] [Google Scholar] 6. Potalia P, Gupta RK, Sharma VD. Sandhana Karma—Base of Ayurveda and Modern Sciences: A Review. Int Res J Ayurveda Yoga. 2021;4(9):151- 61. [Crossref][PubMed][Google Scholar] 7. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open. 2019;E 2555. [Crossref] [PubMed][Google Scholar] 8. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929. doi: 10.1155/2014/205929 [Crossref][PubMed][Google Scholar] 9. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929. doi: 10.1155/2014/205929 [Crossref][PubMed][Google Scholar] 10. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929. doi: 10.1155/2014/205929 [Crossref][PubMed][Google Scholar] 11. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open 2019;E 2555. [Crossref][PubMed][Google Scholar] 12. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open 2019;E 2555. [Crossref][PubMed][Google Scholar] 13. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open 2019;E 2555. [Crossref][PubMed][Google Scholar] 14. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open 2019;E 2555. [Crossref][PubMed][Google Scholar] Manjukumari et al. Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps J Ayu Int Med Sci 2025 ; 10 ( 3 ) 167

15. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open 2019;E 2555. [Crossref][PubMed][Google Scholar] 16. Hackenberger P, Janis J. A comprehensive review of medicinal leeches in plastic and reconstructive surgery. PRS Global Open 2019;E 2555. [Crossref][PubMed][Google Scholar] 17. Potalia P, Gupta RK, Sharma VD. Sandhana Karma—Base of Ayurveda and Modern Sciences: A Review. Int Res J Ayurveda Yoga. 2021;4(9):151- 61. [Crossref][PubMed][Google Scholar] 18. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929. doi: 10.1155/2014/205929 [Crossref][PubMed][Google Scholar] 19. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929. doi: 10.1155/2014/205929 [Crossref][PubMed][Google Scholar] 20. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929. doi: 10.1155/2014/205929 [Crossref][PubMed][Google Scholar] Disclaimer / Publisher's Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of Journals and/or the editor(s). Journals and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content Manjukumari et al. Effect of Jaloukavacharana (Leech therapy) on Reconstructive Flaps J Ayu Int Med Sci 2025 ; 10 ( 3 ) 168

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Sushruta-samhita, Raktamokshana, Rhinoplasty, Indian approach, Leech therapy, Bioactive substances, Hirudotherapy, Medicinal leeches, Clinical experience, Reconstructive surgery, Plastic surgery, Jaloukavacharana, Neovascularization, Venous congestion, Anti-inflammatory agent, Extracellular matrix degradation, Tissue death, Anticoagulant, Microsurgery, Surgical practice, Open Access, Vasodilator, Ischemia, Lymphatic flow, Tissue ischemia, FDA approved, Antimicrobial compound, Venous thrombosis, Tissue metabolism, Platelet aggregation inhibitor, Reconstructive procedures, Anesthetic, Interstitial fluid, Platelet function, Tissue necrosis, Capillary pressure, Open access article, Venous drainage, Capillary refill, Biologically active substance, Bite wound, Venous outflow.