Everything has its pros and cons, as well as its limitations of the times.
Orji and his team did make a lot of preparations. After completely disassembling the cesarean section surgery process shown by Carvey, they practiced repeatedly on cadavers. If the placenta accreta was not so serious, this operation should be successful even if it was rough.
Unfortunately, problems caused by the uncertain factor of placenta implantation gradually affected the direction of the surgery. Surgery can make success or failure, and hysterectomy can be declared a failure for this reason.
If he had seen such a hysterectomy two months ago, Kawei might have secretly cursed in his heart for disregarding human life.
But now he has changed his mentality. The "failure" presented from a modern perspective is more like a pioneering of the unknown in the wild and unexplored medical environment of the 19th century.
Surgery cannot spread all over the country instantly because of one person's success. Without the pioneering work of these people and the sacrifice of mothers, there would be no cesarean section in the modern sense, because success is based on thousands of failures.
"The bladder beneath the uterus is ruptured... Maybe not only the bladder is ruptured, but maybe there is something else that was touched while dealing with the separation of other parts just now."
Orji had a lot of excuses, but he still couldn't say them out in the face of failure: "Now the structure in the abdominal cavity has become chaotic, blood and urine are mixed together, and the vision is blurred... I have to The operation was declared a failure.
I know that as a surgeon, you should not give in before the patient dies, but I know my limits and hope to save her life as much as possible. Therefore, if anyone in the audience is confident that this bladder repair can be done well, I am willing to give up my position as the surgeon. "
With Orgi's status, giving up the stage is equivalent to admitting that he is not good at his skills, which is extremely humiliating.
"Orgi, you can't be kidding."
"I'm not kidding, if you can fix it..."
Dr. Corrigor who spoke immediately interrupted him: "No, no, no, no, no, no, no, no, no, no, no, you keep doing urological surgeries and you can't handle it. How can I, a plastic surgeon, handle this kind of surgery?"
There were indeed many doctors in the audience, many of whom had the ability and experience to perform hysterectomies. Three doctors came out and wanted to help, but after looking at the condition of the abdominal cavity, they all shook their heads, said "there is nothing they can do" and left the surgical area.
They did not choose to take over, which made it clear how difficult the operation would be.
"I have never seen such a complicated pelvic surgery. There are too many things to do, and the patient will definitely not be able to survive that long."
"The anatomical structure is a mess. Forgive me for my blindness, I really don't know how to repair it."
"I'm afraid this situation is difficult..."
At this point, Orji could only turn his attention to Kawei again: "Dr. Kawei, you are the best at abdominal surgery, can you..."
"I'll look at it first and then talk about it."
Kawei accepted Orji's invitation and left the auditorium, rarely becoming a callback player.
The situation was much worse than he expected, and the distance from the auditorium did affect his observation of the operation.
Now it is certain that the organ is torn, the knife edge is clearly in front of everyone, and blood can be seen slowly oozing around it. But this position was not like a bladder in the conventional sense. There was so much connective tissue around it that the experienced Kawei couldn't tell the difference between east, west and north for a moment.
Now the field of vision was filled with a mixture of blood and urine. Orji and Hills were at a loss. Only the suction device was still sucking out the liquid in Lockard's hand. Judging from the ripples of liquid in the tissue spaces, urine seemed to be continuously being injected into the abdominal cavity. The amount was not large and the speed was very slow, but Kawei could see it.
In this case, not only the bladder is damaged, but the ureter may also be broken during the separation of the uterine blood vessels. 【1】
Repairing abdominal organs is already very difficult for them. Coupled with unclear vision, severed ureters, and the burden of the uterus, the difficulty of the operation suddenly increases. Orgi's courage to give up the stage is commendable, but it is also a helpless move, because this is a mess, and he cannot directly shut up without conscience.
"Dr. Orji, you did your best."
Kawei put on the cleaned rubber gloves, turned over the messy abdominal cavity, and said something fair: "What I said is the truth, not to comfort you. It is already very good for a mother with such a pelvic condition to reach this point. "
The enlarged uterus during cesarean section visually concealed the peasant woman's severe pelvic adhesions. After the uterus retracted, all the problems caused by the adhesions became apparent. Clusters of connective tissue covered the uterine appendage, and even the ligaments and blood vessels were confused into a pink mass, making it impossible to tell who was who.
The adhesion is so severe that it is difficult to pick up the plate.
Kawei had to do a good job if he wanted to take over. He glanced at the surgery area and found two unfamiliar young people: "Whoever is free, go and get me something."
"Let him go." Orji pointed to a child who was younger than Kawei.
"Go to the preparation room of the surgical theater of the Municipal General Hospital and find the instrument box I just took last week." Kawei said, "Move the whole box over. There is something I need in it. If anyone asks, just say yes I asked you to go."
"good."
...
The patient must be taken over as if he were taking over. Now that the patient is his, Kawei made a simple arrangement in his mind of the risk factors of various areas in the abdominal cavity.
In terms of danger, the most troublesome thing is the uterus, because if this time bomb is not removed, no one knows when bleeding will occur again. When the ureter or bladder is broken, the bleeding is limited. The urine in the ureter is very clean. Although the urine in the bladder is easily contaminated, it is not a big problem in comparison.
So the first problem is the uterus.
"I am the chief surgeon now." Kawei glanced at Orji in front of him, then at Hills and Lockard. Seeing no one objected, he said to the audience, "Considering the possibility of continued bleeding from the uterus, I decided to get the hysterectomy done first.”
After saying that, he took the hook and helped them find the position to press it open one by one, fully exposing the gap between the cervix and the bladder.
"Because there is no peritoneal covering in the lower uterus, a peritoneal depression forms between the bladder and the uterus. There are loose adhesions between the folded peritoneum and the cervix. Only by finding the gap between the bladder fascia and the cervical fascia can the bladder be separated."
Kawei talked about an important knowledge point in obstetrics and gynecology surgery, which is also a key factor in the success or failure of the operation: "Because this woman has severe pelvic adhesions, it is very difficult to find the separation level. At this time, some small skills are needed. You can push down on the bladder. Observe the bleeding on the separation surface to determine whether the position you are looking for is correct.
If the level of separation is correct, there will be little or no bleeding, the surface of the separation will be smooth, and the bladder will move downward easily. If it is wrong, the separation surface will definitely enter the bladder or myometrium, resulting in heavy bleeding and difficulty in pushing the bladder..." [2]
Those in the audience who wanted to truly learn the skills left the table and walked around the surgical area.
Every word he said was a key point, and every operation was enough to make everyone watch attentively.
The broken bladder was slowly separated by Kawei while pushing down. Then he felt the cervix with his fingers and determined the horizontal line for cutting and separation: "Doctor Orji has just processed the ligaments around the uterus, and the cutting was... pretty good."
Kawei checked the entire area around the uterus again. After confirming that everything was correct, he began to make the final incision: "With the scalpel, we will directly cut through the yd fornix and take out the uterus."
Less than 10 minutes after taking the stage, the uterus, which caused great trouble to Orji's team, was removed from the abdominal cavity. Everything seemed so easy. Not only was the treatment clean, but there was very little bleeding. The same operation seemed to be done with ease in Kawei's hands.
The people watching were relieved, but Kawei was not. "Then the heart rate will be reported every three minutes. If there are obvious changes in heart rate or breathing, be sure to notify me as soon as possible."
2k
He placed the nurse next to the patient, wearing a stethoscope and constantly monitoring the two vital signs: "I understand."
After the uterus is removed, the yd stump needs to be sutured. The operation is not difficult. The innermost mucosal layer is sutured first, then the front wall of the stump is sutured, and finally a complete set of continuous sutures is used to finish. Only then did Carvey announce: "The hysterectomy is complete, let's deal with the bladder next." [3]
The tear in the bladder was very obvious and it was not difficult to suture.
But Kawei was not in a hurry to take action: "Why hasn't the child come back yet?"
"The Municipal General Hospital is not far from here, it should be there soon."
"He wouldn't just run away just to save money." Kawei waited for the equipment box and simply went to find the ureters on both sides first. "I just discovered that Dr. Orji didn't do it when he was suturing the uterine artery. Notice the ureter on the side."
"ureter?"
"On both sides of the uterus, the ureters and arteries run parallel and are very susceptible to damage during resection."
Orji looked at the uterus that had long been badly adhered and explained: "Considering the anesthesia time, I did not do too detailed separation. And even if I did separation, it would be easy to damage, after all, the surrounding tissue is sticky. It’s even too serious.”
Kawei also had to admit that he would get a headache if he went on stage. What the abdominal surgery department is afraid of is that the anatomical structures caused by adhesions cannot be clearly displayed.
But in the face of difficulties, there are always ways: "You can use the touch of your fingers to judge the arteries and ureters. Of course, this requires some experience. If you are not sure, you can only do the ligation as close to the uterine isthmus as possible, and if you are far away, you can do it." It’s easy to hit the ureter.”
"Now what?"
Orji's problem is also the problem of everyone present.
Because the severed ureter is softer than the blood vessels, what flows out is not bright red blood but urine. The kidneys produce very little urine, which alone makes it difficult to find the source. Coupled with the severe pelvic adhesion, even Kawei had a hard time finding the ureter in the mess of tissue. 【4】
"That's why I need that equipment box." Kawei looked at the time and said, "It's almost done. Let's add some ether to her."
Just when the nurse was anesthetizing the peasant woman with ether again, the door of the operating theater was pushed open: "Doctor, I brought the things!"
"Did you bring them all?"
"Yes, here it is."
"Open the box. There are three bottles of dye in the box in the lower left corner. Find the blue one, put it in the syringe, and pump out 1ml. I will use it immediately." Kawei said, reaching into the broken bladder and finding the disconnection The ureteral orifice at the site, "Is it healed?"
"I'm coming."
Kawei carefully opened the bladder, took the syringe, and slowly injected a tube of blue dye. I saw blue dye slowly flowing out from the corner of the abdominal cavity, and it was clear where the separation was.
“The gap is right there!!!”
Kawei dropped the syringe and pinched the location where the ureter was severed: "It's easy to find the location. First separate the surrounding adhesions and then suture the ureter. The incision of the bladder will wait first because the ureter is sutured. Finally, you need to inject physiological saline again to judge the quality of the suture.”
The use of dye was beyond everyone's expectations, and the practice of injecting dye in the reverse direction of the ureteral orifice to find the location of the disconnection was unheard of.
The effect will definitely be immediate, because this is also a very good operation method in modern times, simple and labor-saving: "The dyes are all left after I have screened them, and they are harmless to the human body."
"I've never seen it used like this."
"It's really eye-opening."
The suturing of the ureter is a miniature version of intestinal suturing. Direct suturing of such a narrow lumen is definitely not possible. Even if Kawei had that kind of strength, the catgut of the 19th century would not allow it. All he had to do was to make V-shaped incisions at both ends, and then use staggered sutures to ensure that the lumen would not be further narrowed after suturing.
"Find another copper pipe in my box."
"Copper pipes? I didn't see any copper pipes..."
"It's in the little drawer at the bottom. It's a very thin one." Kawei used scissors to trim the ureter. "Do you see it?"
"Saw it!!!"
"Here, I want to use it."
Just when everyone didn't know what the copper tube was used for, Kawei had already used tweezers to carefully insert its two ends into the upper and lower sections of the severed ureter.
"Dr. Carvey, why do you need a tube?"
"I'm just doing support for the ureter," Carvey explained. "The ureter is so narrow that if you just sew it up, it looks perfect from the outside. But after it heals, this scar tissue grows in and blocks the tube. cavity, sometimes even severe adhesions like her abdominal cavity.”
“Once adhesion occurs, will it cause urine blockage?”
"That's why we need to use copper pipes for support!?"
"Yes, this can avoid adhesions." Kawei stuffed the tube in and started suturing with sutures. "If the tube falls downward, it will enter the bladder, and you can use a cystoscope to take it out directly. If it does not fall off, its hollow tube can also allow urine to flow through without affecting urination."
After hearing the explanation, everyone couldn't help but take a breath of oxygen to recharge their brains that were about to shut down. This approach was really wonderful!
