Right lower quadrant tenderness, rebound tenderness and high fever are indeed important diagnostic criteria for appendicitis, but they are not absolute. 【1】
According to the modern diagnostic standards for tertiary-level emergency department, a CT scan must be performed to confirm that there is inflammation in the appendix before a diagnosis can be made. If the next-level hospital is more courageous, perhaps a laparoscopy can be done with only B-ultrasound. Further down the line, small hospitals that do not have surgical operating rooms will choose to transfer patients to other hospitals.
However, in the 19th century, doctors had very limited understanding of intra-abdominal diseases, and any typical symptoms would be immediately diagnosed as appendicitis.
It is said that those who do not know are fearless. Their judgment is not only quick, but also very difficult to change. In Kawei’s impression, Yingenatz made a clear diagnosis of appendicitis with just a simple compression, and made the decision to perform an appendectomy immediately.
Without imaging technology, it would have been impossible for Kawei to see a doctor with more than 50 modern differential diagnoses, nor to supervise the diagnosis given by Ingenac. Because the doctor is also a human being, and time travel did not give him clairvoyance, even Kawei cannot make a 100% accurate judgment.
The only thing that can be done now is to cut open the priest's belly and take a good look at what's going on inside.
As Ingnatz himself said, the trouble with appendectomy is finding it. Other procedures, such as the location of the incision and suturing the intestines, have fixed procedures. As long as you are skilled, you can do it well. Only searching for the appendix will be like opening a blind box, which may surprise, frighten, or...
......Nothing at all.
"We have entered the priest's abdominal cavity. In addition to the thick and greasy fat layers on both sides, everyone should be able to see the bright red intestines. The priest's physical condition is very good, but..."
Ingenac's right hand searched back and forth in the 10cm incision, but he found nothing: "It's just that his appendix is a bit difficult to find."
Ingnatz is almost 40, and years of anatomy and surgery have made it difficult for his waist to maintain the same posture for long periods of time. Kawei very wisely waited for him to take out his hand before choosing to take over: "Teacher, take a rest for a while, I will come and take a look."
"Um."
Ingenac took two steps back to clear the surgical field, then used his toes to hook up a chair and sat down. He raised his hands stained with donated blood and continued quickly:
“Although the anatomical location of the appendix is generally in the ileocecal area of the right lower abdomen, there are still many people whose appendix position is not fixed [2]. There are many cases of appendicitis, and surgical incision is made into the abdominal cavity. The appendix is right in front of you, and it can be cut. Close the abdomen. But some are more difficult to find, and the priest belongs to the latter...
Ingnatz really tried his best.
With the current poor knowledge and experience in abdominal surgery, a surgeon who can recognize the variation in the position of the appendix is already considered a T1 surgeon. If it were other people, once the appendix could not be seen after the abdominal opening, they would choose to close the abdomen after searching twice to no avail.
After all, misdiagnosis and misoperation are common. It is normal to close the abdomen and do nothing. It is better than dying directly on the operating table. As for how to smooth the surgical process after surgery, it depends on the literary skills of those surgeons.
Carvey knows the troubles of acute appendicitis.
The "cheapness" of being able to see the appendix through laparotomy is not something you can always find. Many appendix surgeries often take more than an hour, and most of the time is spent looking for it.
There is no trick to finding the appendix. It all depends on personal experience. The most basic and easiest method is to search along the colonic band of the cecum [3].
Because the root of the appendix is at the junction of the ileocecal part, no matter how it mutates, the root is there. Just follow the cecum to the ileocecal part to find the root of the appendix, and then further to find the inflamed appendix.
So here comes a new question, how to find the cecum?
Ingnatz made the mistake of many young general surgery doctors. He opened the abdomen and saw the winding small intestine. His scalp was numb when he saw it, and he couldn't find the cecum at all. If you can't find the cecum, you can't find the ileocecal part. Without the ileocecal part, searching for the appendix is like finding a needle in a haystack.
"The Sword Comes"
The same mistake is made by modern young residents because of their inexperience, while Yingenatz is limited by the backward anatomy of the abdominal cavity.
Kawei doesn't like to put his whole hand into his abdominal cavity, which is not something worth showing off in general surgery. He first shook the priest's belly back and forth. After the small intestine returned to its position along with the mesentery, he used his fingers to lift out a section of the small intestine. The fingertips followed the mesentery to the lower right and reached its root. The cecum should be there... .
However, surgery is always accompanied by various uncertainties. The length and walking angle of the small intestine exceeded Kawei's expectations.
emmm...it's a bit troublesome...
Seeing the small intestine slowly moving towards the right upper abdomen, even Kawei, who was used to seeing big scenes, was about to choke. His fingers now followed the mesentery to the upper edge of the incision, but the cecum was not where it should be.
Judging from the anatomical position, you have to look higher.
Therefore, in addition to the mutation of the appendix, the human cecum will also mutate, double mutation, double happiness.
"You can't find it either?" Ingnatz sighed, realizing that today's surgery was a tough one. "Let Herman try it."
Kawei gave up his position, but did not let go of the intestines in his hands. He stretched out his index finger and pointed at Schmidt's liver area: "I think the priest's cecum is not in the right lower abdomen, but higher up."
"More above?"
Ingnatz sighed and joked to the audience: "Father Schmidt is indeed a loyal believer of God. Even the appendix in his body is trying his best to get closer to the sanctuary of God. He is admirable and admirable."
Perhaps influenced by Hills' departure, he did not leave his chair and insisted on letting Herman try. Heman had no experience in abdominal surgery. He was sweating while rummaging around in the silent atmosphere of the theater. He gave up within a few minutes: "Teacher, I really can't find it."
Yingnaz knew that it was inevitable that today's operation would fail, and he was going to search it twice more. If he still didn't find it, he would have to find a medical vocabulary as an excuse, and then close the abdomen as soon as possible.
"I think we need to extend the incision upwards."
Kawei would never let them close the abdomen. Since he saw a small amount of yellow-green pus mixed in the intestines after opening the abdomen, he concluded that this must be an infection. Regardless of whether the inflammation comes from the appendix or not, if there is an infection, the infection must be removed. Otherwise, regardless of whether the abdomen is closed or not, the priest will definitely die.
At this time, the significance of large-scale preoperative disinfection is reflected. The 15cm area around the incision can be extended at any time.
"Once the search for the appendix fails, the abdomen should be closed as soon as possible. This is the consensus of surgical colleagues. If you persist, it is likely to cause an surgical accident." Ingnatz advised, "Little Schmidt and the believers of St. Mary's Church are all here The news about the operation is waiting outside the theater. It would be too ugly for the priest to die on the operating table."
"But closing the abdomen cannot remove the lesions, and sooner or later, you will die." Kawei glanced at the dried saliva at the corner of Schmidt's mouth and said, "Give me some more time, I still want to try."
Ingnatz was calm: "We can also think about it from another angle. Maybe we misdiagnosed him. The priest does not have appendicitis."
Kavi:? ? ?
Isn’t this just showing off...
Kawei shook his head, picked up the scalpel, and handed the handle to Ingnatz: "Whether it is appendicitis or not, we have to catch it first before we can make a conclusion, but I firmly believe that the teacher's diagnosis is correct."
These words made Yin Gena feel comfortable for a while.
"I'll just listen to you once." Ingnatz stood up and picked up the scalpel again, "Everyone, since the priest's appendix cannot be found in the entire lower right abdomen, the appendix looks like a prisoner who has escaped without a trace. . We now need to extend the incision upward by about 5cm, cut more muscles, fascia and peritoneum, and then expose more of the small intestine."
Kawei stared at the small intestine in his hand and continued to search upward along the mesentery. At the same time, he did not hang himself from a tree, but used another method to find the cecum, lifting the lateral peritoneum and searching inward along the lateral peritoneum. 【4】
The two directions went hand in hand, and the result soon came: "Teacher, the priest's appendix should be in front of you."
Less than 2 minutes after the incision was expanded, Yingenatz was surprised and delighted by Kawei's discovery: "It's such an unexpected surprise. It seems that my diagnosis is not wrong. The priest has a very typical appendicitis. Here is the cecum, and below it is Back to the cecum, yellow-green pus can also be seen there.”
For a small amount of pus encountered in the abdominal cavity, modern surgery will use a suction device for temporary treatment. If an abscess cavity or perforation is found, the abdomen needs to be cleaned with a large amount of normal saline during the operation.
In the 19th century, it was much simpler. Because there was no suction device, many surgeons would just pretend they didn't see them, let alone deal with them. They would just leave them there naturally and let them flow to various tissue spaces with the peristalsis of the intestines.
The pus accumulated in the body may continue to cause inflammation, or may infect the surgical wound, making the entire operation useless.
Kawei didn't speak, and it wasn't wise to interrupt the operation now, so he took two pieces of clean gauze and quickly wiped away the pus while Yingenatz was looking for the ileocecum. Although simple wiping is not as clean as washing with water, it is still a way to prevent the spread of infection.
Ingnatz did not notice these small movements. His attention was entirely on the ileocecal part he had just found.
Part of the cecum is fixed to the peritoneum, and the free part can be seen connected to the ileum, where the three colonic bands converge, where the root of the appendix is located: the ileocecal part. However, in everyone's eyes, this is just a messy ball of flesh, and the appendix that should be connected to the end of the ileocecal part is missing.
Ingenac was surprised and performed blunt dissection of the cecum. He was speechless: "This... this is really surprising. The priest's appendix is missing!"
After hearing this, there were doubts everywhere in the venue, and the food in their hands suddenly became tasteless. A patient who needed an urgent appendectomy could not find his appendix. And it's not that there is a mutation in the appendix, nor is there a problem with the surgeon's technique, it's that it really can't be found.
Even Varela, who had seen many surgeries abroad, was shocked. He couldn't help but said to himself: "This should be the ileocecal part. There is no reason why I can't find the appendix. What's going on? "
"Did I look in the wrong place?"
Ingnatz smiled and doubted himself for a moment, then compared the intestines in his hands. After confirming that it was the ileocecal part, he unceremoniously expressed his opinion: "The appendix has indeed disappeared. This may be a brand new visceral mutation, congenital absence of the appendix!"
In front of them is Austria's chief surgeon Ingenatz. His explanations and operations are textbooks, and the audience can easily accept them.
Since the appendix was missing, there was no choice but to end the operation. Ether anesthesia is unstable, and no one knows when it will fail.
Half a month ago, Morasso almost ruined the operation due to insufficient anesthesia. He woke up halfway and almost ruined the operation. The chaotic scene was still replaying in Ingnatz's mind. He did not dare to take risks: "It seems that the priest did not have appendicitis."
Herman was already at the side, getting ready to sew and thread: "Do you want to close your abdomen now?"
There is no appendix in an appendectomy, so it is better to end such a ridiculous operation as soon as possible. Closing the abdomen was Yingnaz's original intention, but just when she was about to nod, Kawei suddenly interrupted: "Teacher, I also think this is a mutation, but the appendix did not disappear, but was deliberately hidden. "
"Hide? What does hiding mean? Where to hide?" Yingenatz didn't understand what he meant and pointed to the ileocecal part and said, "The root of the appendix should be in the ileocecal part. There is no way it could go anywhere else."
Kawei knew that it would be useless to say it directly, so he simply pointed to the candle light in the hand of a nurse: "The brighter the place, the easier it is for darkness to accumulate, blocking our sight. I feel that the appendix is attached to a certain point around the cecum. place, camouflaging itself with the serosal layer on the surface of the cecum.”
Posted around the cecum?
Disguise yourself with serosa?
These explanations were far beyond the understanding of everyone present, because no one had ever mentioned: "Dr. Kavey, are you kidding me?"
"You mean the cecum swallowed the appendix?"
"This is so strange. How can there be an appendix in the cecum?"
This is a specific variant of the appendix: the cecal subserosal appendix. 【5】
Not to mention Yingnaz didn't know it, even the top surgeons in the world didn't know it. This is a professional term that only belongs to modern times. Of course, Kawei couldn't say his name directly, because even if he did, no one would believe it.
The audience's trust comes and goes quickly, it's very cheap, and there is no substantial difference. What Kawei wants is the trust of Ingenac, the absolute authority of the entire surgical theater: "I'm sure it's inside the cecum. Just open the It can be found in the serosal layer.”
"Incision of the serosal layer will affect the cecum."
"The lumen of the cecum is very large, so even if it is repaired, there won't be any big problems."
"What about anesthesia?"
"Just the same way as Count Morasso did."
Ingnatz held the scalpel in his hand, still hesitating: "You have to find its exact location first before I can consider whether to dissociate it for further resection."
"It's not difficult to locate."
Kawei tightened the serous membrane on one side of the cecum, touched it back and forth with his fingertips, and quickly found the appendix hidden inside. Even if its appearance has changed, the feeling of the operation that has accumulated over the years is difficult to change: "Teacher, if I guessed correctly, the appendix is right here."
