In addition to heavy physical labor immediately after delivery, the loss of pelvic support structures caused by trauma and surgery itself is also a factor in uterine prolapse. In the past, when encountering female abdominal trauma patients, Kawei often asked a gynecologist to perform the same operation, and he also had some knowledge of uterine prolapse.
However, the incidence of uterine prolapse in China is not high, at least after Kawei started working, it has shown a clear downward trend [1]. After the 21st century, prolapse has become very rare, so his experience with this disease comes from the 1980s and 1990s, and his memory is somewhat vague.
But even so, I still remember some surgical methods, at least reducing the broad ligaments on both sides is not one of them.
However, the question now is not at all whether the broad ligament reduction surgery can be successful, let alone whether reducing the broad ligament will have any effect on uterine prolapse, but that both Besim and Denev are stupid about the open abdominal cavity. Eyes, there is no way to start.
Not recognizing the broad ligament was something Carvey didn't expect.
Relying on many years of clinical education experience, he can still remain calm. But the doctors from the same hospital who came to watch the operation were not so easy to talk to, and they would not save their saliva in this situation: "It's better to close the abdomen quickly, the gynecologist is still thinking about the operation."
"This is the funniest thing I have encountered this year. The surgeon couldn't find the surgical site. It's simply ridiculous."
"It's so embarrassing, Dr. Besim. Is this the kind of effort you're proud of?"
"As soon as the abdomen was opened, it was reduced to the point of being invisible. It is indeed the legendary broad ligament reduction surgery..."
Besim didn't expect this result. He thought he had studied anatomy and had done some minor bedside surgeries, but it was the first time he faced a pelvic cavity of the same color and he really couldn't tell the north and the south.
The patient is not underweight, has very thick subcutaneous fat, and very thick visceral fat. In addition, years of uterine prolapse have caused the surrounding tissue to become very loose. Connective tissue, adipose tissue, muscle tissue, and visceral tissue, which are very different in words, are actually similar when looking and touching them.
They memorized the anatomy diagram, and the broad ligament should be on both sides of the uterus.
The uterus that can be lifted into the pelvic cavity is surrounded by messy things. They can be broad ligaments, round ligaments, cardinal ligaments, uterosacral ligaments, proper ovarian ligaments, uterine blood vessels, fallopian tubes, and ureters. .....
The extreme lack of experience and the basic responsible attitude towards the patients were untimely entangled between the two, making neither Bessim nor Denev dare to make judgments easily.
The more they dared not move, the more the doctors in the audience became sarcastic, and some even attributed the incident to the negligence of hospital management:
"I emphasized repeatedly at that time that the hospital's operating theater was too kind to the surgeons who performed the operations. If I wanted to catch up with the National General Hospital and have a stronger surgery department that could attract more patients, I would just stay in my own hospital. Here, how can it be possible to reject reporters and reject other viewers?”
"The Municipal General Hospital also moved the operating theater to its own hospital." Orji felt a little harsh after hearing this. "In my opinion, this professional-oriented and imitating the British and French operating theater system is the general trend. We Instead, the hospital is ahead of the Municipal General Hospital.”
"The general trend is not to make money for profit."
"Yes, there is no charge for surgery at the Municipal General Hospital, so they still allow reporters and spectators to enter the venue just to earn ticket money to fill the gap."
"Although the presence of the audience will infringe on the patient's privacy, it can also urge doctors to make as few mistakes as possible."
"That's what I mean. They are all poor people who can't live anymore. How can they talk about privacy? The most important thing is to find the best doctor in Austria and perform the surgery clearly. If any audience and reporters see this kind of simple surgery, A ridiculous operation that does nothing on the abdomen will probably be on the front page of the daily newspaper the next day.”
"It's good to be in the newspaper, but with the short memory of Vienna citizens, they will soon forget it. But if it disgraces the hospital, it's hard to say whether you can stay in the hospital and continue working..."
This was not the first time that Kawei experienced the power of trolling in the audience. Before, people were gossiping secretly during Orgi's cesarean section. Later, because Waterman was the dean of the College of Surgery, the noise was much less frequent. But if the surgeons were replaced by young surgeons like Hills and Hermann, there would be a lot of discussion in the audience.
In such an environment surrounded by sights from all sides, it is not easy to explain to the audience while performing surgery. After all, it is a paid viewing project, and it is normal to be criticized if you fail.
But now it is an internal operation in the hospital. Although the process is a bit outrageous, these people are too ruthless, which is too far away from modern hospitals full of humane and sophistication.
But if you think about it carefully, those remarks just now are not unreasonable.
In the 19th century, when there were no medical rules and regulations or regulations on diagnosis and treatment procedures, the audience, a regulatory group, did have its rationality for existence. Otherwise, problems such as "amputating the wrong leg", "cutting off a healthy intestinal tube due to intestinal obstruction", "leaving gauze, scissors, and vascular forceps behind", and "removing the spleen and pancreas due to appendicitis" will occur in large numbers.
Of course, the non-professional reactions of the audience will indeed affect the mood and judgment of the surgeon. Which is better or worse can only be judged by benevolent people.
Kawei can't make any comments about the medical system now. What he can struggle with is the surgery itself.
Now that the abdomen is open, the patient does have severe uterine prolapse, and it is very troublesome whether to close the abdomen or not. Of course, according to his own opinion, since the patient has already assumed the risk of abdominal infection, it would be better to go ahead with the operation directly.
Last time, Kawei chose to take over to save his life. This time, the patient was far from that point, and Kawei had no intention of helping. Moreover, the two people beside the operating table said nothing. It was obviously inappropriate to rush in and it was not in line with Kawei's usual style.
Recalling when he was first in the gynecological ward, Besim asked him to provide guidance.
Since it is a guide, try to talk more and do less. First, you have to change their minds: "The broad ligament is on both sides of the uterus. Can't the uterus be found?"
Denev was already in despair, and it was okay for him to be scolded, but he felt really uncomfortable after being scolded along with Besim. Suddenly he heard Kawei's voice. He finally grabbed a life-saving straw and started searching again:
"The uterus has just been pushed and pulled up, and both sides of the uterus...are covered with various soft tissues..."
"Think more about the location covered by the broad ligament, then think about the differences in other tissues, and then use your fingers to feel them one by one."
Denev and Besim followed his instructions and pinched the surrounding tissues, and suddenly they realized: "Could it be these two things that look like butterfly wings?"
"Yes, that's it."
The ligaments in their hands looked and felt completely different from those of dead bodies. In less than five minutes, their anatomy knowledge had already reached a new level: "The broad ligament has been found, let's continue..."
"Go ahead and put down your broad ligaments."
Kawei promptly stopped what they called the broad ligament reduction surgery, and while the audience was still surprised, he revealed his surgical plan: "There are so many uterine ligaments, and the ligaments that can really fix the position of the uterus are not broad ligaments. ligament."
"Not the broad ligament?"
“The broad ligament is so thin that it is only responsible for preventing the uterus from tilting to both sides. What can really fix the uterus is the cardinal ligament underneath it.”[2]
Kawei's suggestions already have some weight. As long as it is pelvic surgery, few people dare to question him, at least the doctors present do not have this ability.
This is the result Besim wants, and completing the operation under the guidance of Kawi will definitely add a lot of convincing. At that time, uterine prolapse will no longer be a single-treatment disease. Compared with inserting a pessary into the vagina [3], many patients still prefer to treat it once and for all.
As chief surgeons and assistants, they will also become celebrities who pioneered surgical treatment in gynecology after ovarian removal [4].
However, Denev seemed to be convinced of his judgment and suddenly said: "The broad ligament is much wider than the main ligament. No matter how you look at it, the broad ligament should be more powerful, right?"
Kawei has always felt that it is a good thing for young people to have their own opinions, but if they cannot see their own level clearly and are blindly opinionated and overconfident, it would be a bit stupid: "Are you so sure?"
"Although you are a great doctor who founded the principle of cesarean section, you are definitely not as familiar with uterine ligaments as I am. I have done many experiments..."
Deneve became bolder and bolder as he spoke, until Besim raised his leg and kicked him in the calf: "What are you talking about? Dr. Kawei is the audience I invited. Can you speak properly?"
"I'm just doing my best..."
Besim raised his leg and kicked him again: "Dr. Kawei has a very deep foundation in pelvic surgery, and this is also a suggestion for us. I think we can try to reduce part of the main ligament first, and then consider the broad ligament. "
"No, the broad ligament is the important anatomy that maintains the position of the uterus."
"We actually didn't recognize the broad ligament at all."
"Those are two different things."
The master and apprentice, who had been helping each other to fight against the ridicule of the outside world just now, now focused their conflict on their surgical goals. Besim knew that his student was stubborn enough, and half of the reason why this operation was carried out was due to this personality.
"Dr. Kavey..."
"It's okay." Kawei didn't care. Since he was so insistent, he couldn't say much as an outsider. "The patient is yours, and the operation is also yours. You should make the decision. Of course, if the operation fails, the responsibility is also yours." .”
...
Although Denev was stubborn and had poor surgical skills, at least he was not too stupid.
After Kawei questioned the function of the broad ligament, he did not rush to do anything to the broad ligament. Instead, he folded the already stretched broad ligament to see the effect of the reduction: "Dr. Kawei, colleagues, everyone You can see where the uterus is after the ligaments are reduced.”
The uterus was between his hands, maintained in the center of the pelvic cavity by the shortened broad ligament.
It seemed that this operation was very reasonable, but soon someone raised a new question: "Although the broad ligament is wide, it is very thin. Can the entire uterus really be maintained only by the reduced broad ligament?"
"I think it's okay, the ligament has very good toughness."
"Ha, if the ligaments were really as perfect as you said, the uterus would not have prolapsed to this extent. Think about how many ligaments there are around the uterus, and it can still be completely separated from the vagina. There is really nothing wrong with it. expected."
"Indeed, with the thickness of the broad ligament, I'm afraid it will relapse not long after the reduction."
"In my opinion, if you want to do it, do a full set, shrink all the loose ligaments around it, and maintain the uterus in its original position."
Kawei shook his head at this idea that had no clinical basis: "Some ligaments have blood vessels running through them. After shrinking, should these blood vessels be sutured or not? Sutures, if not at this level, not sutures, because the short-term blood flow is not smooth. There must be edema in the surrounding soft tissues.
This would be fine in other surgeries. The blood supply would not be a problem with the help of side branches, but now it relies on the reduced ligaments, which are always bearing the weight of the uterus. Once there is a problem with the ligaments, the operation will inevitably fail. "
There are no such blood vessels running through the cardinal ligament, so reduction is not difficult.
Of course, like the broad ligament, although reduction of only the main ligament is more effective and stronger, it is only slightly better than reduction of the broad ligament. Uterine prolapse is easy to relapse, and simple surgery cannot be perfect. It will relapse over time.
Therefore, modern gynecology advocates that surgery should only be considered in severe cases.
According to the situation of this patient with grade III prolapse, in order to achieve complete cure, a complete preoperative evaluation [5] needs to be carried out in advance, and then surgery can be planned.
According to Ekawi's judgment, the patient may need uterine suspension surgery to completely resolve the suffering of prolapse. The uterus is hung at a certain position in the pelvic cavity, such as: transabdominal uterosacral ligament suspension, transyd sacrospinous ligament suspension, transyd main sacrospinous ligament suspension, etc.
According to the current surgical level, these operations are still too troublesome, and because they are not life-threatening, Kawei has no desire to try them for the time being.
In comparison, although cardinal ligament reduction is prone to recurrence, the advantage is that it is simple to operate and the postoperative effect is more obvious. Even if it does relapse, it won't be that serious, and just using a pessary for support is enough.
Denev was a little reluctant, but his hands were not idle and he had already started working: "Isn't there a better way?"
The operation simply deals with the ligaments, does not involve large blood vessels, and does not require suturing organs, so it is very difficult. Even though he had no surgical experience, the many surgical rehearsals and trainings he and Besim had done were not in vain, and there was nothing to complain about in the rest of the surgical operations.
Soon the broad ligaments on both sides were cut in the middle with scissors and then reconnected with sutures.
"Better methods still need to be explored, but this should be the most perfect surgical method imaginable."
De Neve did not take into account the factor of recurrence: "If there is a recurrence, she will continue to use a pessary..."
"It's better than haphazard surgery leading to more serious pelvic damage."
"Do you think it's not good to use a pessary?" Kawei suddenly interrupted and asked.
"After all, a foreign object was inserted," Denev said.
"If it's too troublesome, it's okay not to use a pessary." Kawei glanced at the patient on the bed, "I remember the patient is 53 years old now?"
"right."
"She's about the same age." Kawei calculated the time and continued to ask, "Then is she amenorrhea?"
