The part of the uterine wall where the placenta implants is very thin. If it penetrates the muscle layer and enters the outermost serous layer, the uterus will be like a rusted iron pot and there is no need to exist.
Because there is only a layer of skin left in the implantation area, even if it is barely left, it will pose a huge threat to uterine rupture in the future, and it must be cut off entirely. The tension required to cut it off and then sew it up was very high, and the whole process caused serious bleeding, making the operation difficult. It would not be possible to keep it alive in modern times, let alone the 19th century when there was a lack of medical treatment.
Brenda's implant happened to stop in the muscle layer at that time. Kawei's peeling technique was firm but soft. In the end, part of the muscle layer was preserved and the peeling surface could be sutured.
Now this peasant woman's uterine wall can be punctured by her fingers. This is not just as simple as penetrating the muscle layer, but maybe the serosa layer is also almost transparent. In this case, the uterus should be abandoned decisively from the beginning. Now even if the blood flow in the lower uterine segment is blocked, the bleeding is still rapid.
The team, which had been working well together just now, was completely thrown into chaos because of a mistake.
Everyone seemed to have been pressed on the pause button, staring blankly at the hole in the uterus outside the belly. Then all eyes were focused on the "initiator" Orgi, not knowing what to do.
"Gauze! Give me gauze quickly!!!"
Orgi was also startled by the feeling of missing his fingertips, and became a little panicked when he saw the blood pouring out in front of his eyes.
Fortunately, his many years of experience as a surgeon allowed him to react quickly enough. He did not rush to pull out his fingers, but instead clamped the tiger's mouth tightly and clasped the surrounding uterine wall: "The uterine body above is also compressed. Continue to inject oxytocin. Hill Si, you come and sew the blood vessels on both sides of the uterus!"
Pieces of gauze were pressed into the peeling surface of the inner layer. Lockard climbed directly onto the operating table, squatted down, and squeezed the uterine body with both hands.
As long as the arteries on both sides of the uterus can be quickly ligated, the amount of bleeding will decrease sharply like during the Kawei operation. At that time, it will be decided whether to remove the uterus or retain it.
But Hills did not actually perform uterine artery suturing, and all operations were completed on cadavers. He did not slack off in practice, but the organs and tissues of a corpse were completely different from those of a living person, there were many differences between normal human organs and those that were bleeding heavily, and the atmosphere in the autopsy room was even more different from that in the operating theater.
In this case, Hills looked at the blood in front of his eyes, and it was very difficult to even find the uterine artery.
However, under tremendous pressure, Hills still stabilized his mentality. The needle and thread in his hand paused in mid-air, and his other hand touched the elastic tissue on the side of the uterus. Even though he was not sure that this was a blood vessel, he decisively inserted the needle.
Relying on the elasticity and extremely slight pulsation of the arteries, he still guessed the location of the uterine artery correctly.
To suture a blood vessel, the needle tip needs to penetrate the entire tissue, bypass the blood vessel and perform the ligation on the front. As long as the position can be found correctly, the subsequent operations are all basic skills and are not too difficult for Hills. First near his right side, then his left side, both stitches were done beautifully.
Orji finally breathed a sigh of relief: "Just now, because I didn't stop the strength of my hand, a hole appeared in the uterine wall, causing a lot of bleeding. But fortunately, Dr. Hills had already sutured the arteries on both sides of the uterus, and the uterus was There is also a large amount of gauze tamponade inside, and the bleeding has basically stopped now.”
This is true. As soon as the ascending branch of the uterine artery was tied off, the bleeding in the uterus stopped. The wound surface became very clean under the absorption of gauze, and the continuous autologous blood transfusion basically stabilized the farmer's heart rate.
Orji reexamined the condition of her uterus.
Now that the fetus has been removed and the bleeding has stopped, the only trouble is the breach in the uterus. Is it risky to do stitches? Or should we just discard it and perform excision?
Orji definitely hopes to end this cesarean section perfectly, so that he and his hospital can improve their ability to deal with placenta previa in the eyes of the public. Needless to say, Hills came here just to preserve the uterus. Once the uterus was removed, the operation would become meaningless.
"Considering that the mother is still very young, she loses the ability to get pregnant without a uterus, which is a pity." Orji said to the audience, "The uterus has not fully contracted, and the tear is not actually big. I will try to suture the uterine muscle first. Layers. Give me the pliers and the suture needle..."
Kavi was sitting in the audience.
I am very satisfied with the cooperation and decision-making of the three people just now. In this era, there is not even the concept of a surgical team. It is quite good to have such mobility. It can be seen from everyone's movements that every step has the shadow of practice. .
Especially when Hills' artery was sutured just now, except for being a little slow in finding the location, everything went smoothly after that.
It can be said that he handled it well before, and was more skillful than Ignatz who had a cesarean section for the first time. However, Kawei was not satisfied with the final decision.
The uterine tear has reached this point and has lost the basis for suturing.
In modern times, it might be difficult to suture, but in the 19th century, the sutures were not strong, and the sutures that were barely closed would split at some point. Even if the stitches are stitched during the operation, you will have to face multiple abdominal compressions after the operation. Otherwise, serious infection will occur if the lochia is not drained cleanly, and the entire operation will be in vain.
Considering these factors, it is better to just cut it off to save trouble.
However, these considerations are entirely based on Kawei's personal abilities. The person on the operating table is not him now, but Orji.
Kawei's emergency surgery department handles the most trauma to the abdominal cavity and limbs. The pelvic cavity is an important part of the abdominal cavity. Although it does not contain many organs, the anatomical relationship between the tissue spaces is complex, so surgical techniques must be paid attention to. .
Hysterectomy is an important surgery in obstetrics and gynecology, and it is also a surgery that often needs to be faced outside the emergency department.
When encountering a patient with damage to the uterine appendage, Kawei would call an obstetrician to work together to deal with it. Over time, he learned many gynecological pelvic floor surgeries.
Because he understands these surgeries and has seen too many similar surgeries, Kawei knows that hysterectomy is not easy. It cannot be summed up by simply using the words "separation" and "resection". Only those who have experienced it will understand the pitfalls.
Therefore, Orji did not choose a difficult path, but it was difficult no matter which path he chose.
"The line crashed again..."
Orji looked at the broken sutures in his hands, feeling a little desperate: "The incision has been sutured too many times, and the muscle layer can no longer bear the need to insert the needle again. If the incision is trimmed, the tension will only be greater, and the suture line will It’s not strong enough either…it seems like the uterus…”
This was a decision he made after careful consideration, and it was obviously far from the team's original goal.
Everyone's face has lost the luster they had before victory, and you can even hear several sighs if you get closer.
Of course, the one who is most reluctant is Hills: "Teacher Orji, the suture thread is not strong enough, we can choose silver thread. Trim the incision a little and suture it again. She is only 22 years old!"
"It's useless." Olgi took the scalpel from the nurse. "Although the silver thread is strong, it is also easier to cut the uterine wall. Even if it is sutured, letting go will still cause secondary damage."
"How will you know if you don't try?"
"Are you sure there won't be any cracks after the operation?"
Orji ignored his suggestion and asked a question. Seeing what Hills wanted to say, he said directly: "I am the chief surgeon and I have the final say. Let's remove the uterus. Although our operation failed, her own The purpose has been achieved.”
Placenta previa is a very troublesome obstetric problem.
Farm women living in rural areas on the outskirts of the city have no medical concept at all, and they will not pay attention to a small amount of bleeding from the vagina. Even if you really notice that there is a physical problem, you will go to a small local clinic to deal with it. It is impossible to spend a lot of money to go to the city to find an obstetrician.
The travel expenses and hospitalization expenses are enough for a country person to spend for a while.
According to the development of placenta previa, this peasant woman is likely to suffer from uncontrollable heavy bleeding during labor and eventually die in her bed. It is still unknown whether the child will survive.
The sweeping search at Graz Hospital gave her a life-saving straw. Orji not only promised her to keep the child and waived all expenses, but was also willing to pay her family a sum of money as a reward after the operation was completed. Why not do it.
Hills was disappointed but accepted Orji's decision: "Give me the hook."
"Hysterectomy requires the separation of surrounding tissues, which takes some time." Orji first explained his surgical steps, "I will follow the classic removal sequence, cutting off the round ligament of the uterus and cutting off the uterus on both sides. Attachment, processing of remaining uterine blood vessels, and finally diversion of the yd.”
Orji's advantage is in andrology, but his understanding of the uterus is still limited to cesarean section. Although hysterectomy has been performed during repeated practice, due to the limitation of the number of cadavers, I am not familiar with the anatomical structure around the uterus.
"We first search for the round ligaments on both sides of the uterus. Because there are blood vessels in them, we need to clamp them on both sides first, then cut them off and then suture them..."
He talked about the process of removing the round ligament, but his movements were not as quick as before, and it took a lot of time to find the round ligament. 【1】
Next, according to the order of hysterectomy, it is also necessary to find and cut the fallopian tube isthmus and the intrinsic ovarian ligament on both sides of the uterus [2]. But to Orji, it doesn't matter what these areas are called. The most important thing is to grab the eyebrows and beard and cut all the tissue around the uterus.
This crude approach quickly backfired.
"It's bleeding, give me gauze."
When Orgi cut the ovarian ligament, he did not fully mobilize it because there was too much tissue and the crow's beak forceps' clamping ability was further reduced. The closer the proper ovarian ligament is to the uterus, the more sufficient the blood supply will be and the more bleeding will occur. Even if the uterine artery is clamped, the bleeding will not be completely stopped.
"Teacher, the operation has taken a long time."
"I know."
Orgi sutured the ligament in his hand and continued: "Cut the ovarian ligament, and then continue to cut the fallopian tube. It needs to be ligated here. Then we continue to search on the other side and repeat the steps just now... .”
Kawei shook his head as he watched the separation and incision process.
The surrounding tissue above the uterus has clear boundaries, which is easy to see and not difficult to separate. Orgi If you can't do these things well, the complex pelvic floor tissue under the uterus will only be difficult to deal with.
"The upper fixed ligaments have been cut." Orji was not aware of the trouble he was about to encounter. He looked at the half-detached uterus in front of him and breathed a sigh of relief. "Next, let's cut off the ligaments around the uterus first." 【3】
After listening to his words, Kawei immediately realized that the order was obviously wrong, and quickly asked: "Shouldn't the blood vessels on both sides of the uterus be treated first?"
Orji handled the ligaments slowly and said while doing so: "Just now, Dr. Hills has ligated the ascending branches of the arteries on both sides. Most of the blood flow has been blocked. He will only need to bring the remaining tissues with him later." Just disconnect the lateral common artery together, there is no need to rush to deal with it first."
Kawei listened to his nonsense in a daze. After a while, Orji asked for gauze again: "Give me gauze, there is a bleeding point."
It was still an old problem with the previous separation. Orgi did not fully free the tissue around the ligament, the crow's beak forceps were weak, and there was no way to completely block the blood flow before cutting.
"There was not a lot of bleeding during the operation. I have dealt with it one by one." Orji had never seen Kawei's hysterectomy, so he was very satisfied with his performance. "Now most of the uterus has been freed. What we need to deal with next is the lower pelvic floor. But before that, we need to cut off the uterine blood vessels."
The treatment of uterine blood vessels is troublesome because it is easy to damage the surrounding tissue. Kawei also wants to see how he operates.
But the area around the artery was much slender than the ligament just now, and it was easier to block and cut, so before he could see clearly, the blood vessel had already been treated.
"There is no bleeding at the stump, it's perfect." Olgi praised himself and continued to move his hands downward. "We need to completely separate the lower segment of the uterus and cut off the interstitial tissue around the cervix. The main trouble is the bladder in front of the uterus. Give me the scissors."
Taking the scissors, he began to charge towards victory with the help of Lockard and Hills.
However, just after the separation of the bladder and peritoneal reflection [4], Hills suddenly discovered something unusual: "Teacher Orji, there seems to be blood oozing in the abdominal cavity!"
"Bleeding?"
Orji was very confident in his suturing skills and quickly denied it: "It's impossible. My sutures are very strong and there is no possibility of bleeding."
"But there is indeed blood down there..." Hills took a piece of clean gauze from the side and stuffed it inside. A large pool of light red "bloodstains" was quickly printed on the cloth. "This doesn't seem to be blood." , the color is wrong.”
Olgi held the lower part of the uterus in his hand and wanted to lower his head to see what was going on. He didn't expect that his scalpel was still pressed against his bladder.
He turned his body slightly to one side, but with an accidental slip, the scalpel blade cut into the peritoneal reflex of the bladder, and a stream of clear light yellow liquid poured into the bright red abdominal cavity.
Bladder burst!
－－－－－－Digression－－－－－
It's a pity for the patient, but we can't blame these doctors too harshly. Because even in the 21st century, there are many cesarean section accidents in China, and lack of preparation for placenta implantation is very likely to cause serious problems, and these concepts did not even exist at the time.
