From the beginning of more reliable surgical procedures in the 18th century to 1866, when Carvey is now, breast cancer treatment has gone through total mastectomy, total mastectomy when lymph nodes are involved, and combined removal of whole breast and axillary tissue. Doctors have always The question is how to cut and how much to cut.
Because of the high recurrence rate of breast cancer, doctors can only expand the scope of resection as much as possible. This approach of preferring to let go rather than miss is indeed effective. The recurrence rate of surgical treatment for early- and mid-stage tumors was once less than 10%, which also established the status of radical mastectomy in breast cancer resection surgery. 【1】
It must be said that at that time, Austria’s understanding of breast cancer surgery had always been second- or third-rate.
The concept of lymph node dissection existed in the United States as early as 1852, and now German doctors have given the theoretical basis for lymphatic transfer. However, so many Austrian doctors, including the president of the College of Surgery, are still skeptical about axillary lymph node dissection.
To enlighten his colleagues, Carvey chose a staining method based on the sentinel lymph node biopsy technique commonly used in modern breast cancer. 【2】
He believed that the Austrians, who were extremely obsessed with art, would naturally believe in the relationship between lymph and breast tumors after seeing a picture like a blue star sea chart.
"I chose the injection point under the skin, next to the tumor and under the vagina. What is now shown is a lymphatic duct map." Kawei and Damirgang pulled the skin together, revealing a blue duct, "We The concept of sentinel lymph nodes needs to be introduced here."
After saying that, according to the content of the preoperative drill, the nurse opened a black curtain on the wall, revealing a large blackboard behind her. On it was the dependency diagram of the lymph nodes from near to far that Kawei had previously drawn. 【3】
"We can clearly see that lymph node metastasis is like railway transportation. The tumor will first enter the first stop from the cancer tissue through the lymphatic vessels, which is the sentinel lymph node that Mr. Waterman and I just mentioned. After entering the sentinel lymph node, they Then move outward step by step.”
Kawei immersed himself in helping Waterman separate the subcutaneous fat and said: "It can be seen from this simple grid diagram that any distant lymphatic metastasis must pass through the sentinel lymph node, and there is no possibility of 'jumping'."
In the eyes of ordinary people, this seems to be very easy to understand.
But in the eyes of 200 surgeons, before Kawei said this, many people believed that tumor metastasis was jumpy. Many people do not even have the concept of lymphatic metastasis, so much so that they think that tumor metastasis is the recurrence of a new tumor.
"Our principle is"
"Dr. Kavi! Wait!
"
The sentence just now was a bit convoluted, but it was so important that many people had no time to write down the entire content: "Just now you said any 'metastasis' of lymph nodes. It is the 'swelling of lymph nodes that can be reached' as we have been talking about before. ', must we go through the sentinel lymph node first?"
This is a good question.
The main focus is on "swelling of accessible lymph nodes".
"So, does the inaccessible swelling mean that the lymph nodes have not metastasized?"
Kawei raised his head and followed the voice that had just asked: "If there is sentinel lymph node metastasis, we will do the dissection. If not, we will not do it. This can avoid many tumor recurrences caused by misdiagnosis, or excessive growth of surrounding tissues. resection."
Previously it was the concept of sentinel lymph node, but now it is the meaning of sentinel lymph node biopsy.
Kawei completed a teaching on a new knowledge point in just ten minutes:
"Because all the surgeons here are able to do their own thing, I will try my best to describe the sentinel lymph node as concisely as possible. In principle, the resection is strictly based on the rapid pathological examination results of the sentinel lymph node. This requires the help of my teacher: Professor Ingenac, and two pathology assistants to Dean Watermann: Dr. Bergert von Celestin and Dr. Robert Koch.”
Pathology was originally a discipline that assisted surgery in determining tissue types. The examinations were often done after surgery and were only responsible for the final diagnosis and had no guiding significance for the surgical process. No matter how you look at it, it is a subject that is more theoretical and the research content is quite marginal.
Who would have thought that an operation performed by a surgical director would require pathological examination to determine the scope of the operation.
Fortunately, the line of doctors who perform pathological examinations is huge. Yingenatz is the strongest surgeon in Austria. He has ranked first in urology, intestinal surgery, and orthopedic surgery, both in terms of operation speed and postoperative survival rate. .
It was outrageous but reasonable to ask him to do pathological biopsy on the side. Who would let his father and students be on the operating table.
Behind him was the son of Viscount Clichy of the House of Lords. He had just graduated from medical school and was still very young. He was also nominally a student of Ingnatz and had a bright future.
But who was Robert Koch at the end?
Why have I never heard of it?
"Koch. Such a familiar name." Edinson thought of the conversation he had with Professor Lange of the Department of Anatomy when he went to the University of Vienna Medical School. "I remember he was a German who had just arrived in Vienna."
"The Germans who just arrived?"
"When did you come?"
"Looks very powerful."
“I was actually able to perform pathological examinations on the same stage as Dr. Yingenatz.”
These words almost coincidentally popped out of the mouths of the four people around him. Edinson explained: "He is a German doctor of medicine who has not graduated yet. I heard that he came here to study and will have to go back when the time is over. "
Edward thought that the tension between Prussia and Austria was already at war: "Are there any Germans willing to come to Vienna at this time?"
Franz said helplessly: "After all, we haven't broken up yet, some activities must continue."
"It seems that he is just a small person. Otherwise, how could Prussia be willing to let him come over?" Edward seemed to have found another "weapon" to sting the Austrian Emperor: "A small person in Germany actually became the pathology consultant to the chief of surgery in Vienna. This is Too."
As a diplomatic ambassador, he should not compete with Franz everywhere.
But France had won too thoroughly in the Franco-Austrian War, and now that Austria was about to start the war, it was asking for help from itself, which gave Edward considerable courage. But he was in Vienna after all, so he didn't finish his sentence, and the follow-up was nothing more than some sarcastic remarks about the decline of Austrian medical talent.
Franz's face looked a little ugly, but Foreign Minister Karl on the side took over this sentence with a smile and made peace with it: "Yes, being able to become Dean Waterman's pathology consultant must have an extraordinary side. Prussia is too indifferent."
The two of them talked about the same thing, but in the end there was no conclusion.
In fact, Koch at this time was a very ordinary doctor of medicine, and many hospitals in Berlin did not have a place for him to work. If there wasn't someone at the Institute of Chemistry who could help him talk, he might have to pack up and go to the countryside to become a doctor.
Now Kawei is sent to the highest-level surgical theater in Austria. Although he is not able to go to the operating table, doing pathological examinations next to Ingnatz is enough to make everyone remember his name.
The original pathological examination is usually done by the surgeon himself, which is time-consuming and labor-intensive.
Now that Kawei has moved out of the assembly line operation, the dyeing has been completed. Only four steps are required: xylene clearing, sealing wax in the mold, sectioning, and microscopic examination. Although dehydration was not done, it was a quick biopsy after all and there was no way to take care of so much.
"Here it comes, sentinel lymph node!"
With the help of Kavi, Waterman cut out a piece of fat tissue with blue dots [4] from the side of the breast, threw it into the nurse's metal tray, and then put it into Yingenatz's hands: "Wait a minute. Wait, there seems to be more.”
Sometimes there is a single number of sentinel lymph nodes, but sometimes there are several clusters of lymph nodes gathered together. The countess's case fell into the latter.
"Second piece"
"There's a third piece"
"It should be gone."
Kawei looked around and shook his head: "It should be these three pieces."
Waterman breathed a sigh of relief: "According to the original surgical plan, Dr. Carvey and I will first remove the Countess's breast tissue. After the pathological biopsy results of this sentinel lymph node are available, we will decide whether to remove her armpit. "
At this point, the surgical team was divided into two teams, one team led by Yingenatz to do the sectioning, and the other team relied on Waterman and Kawei to perform the mastectomy together.
The name of the operation seems to only have the word "resection", but behind it is "radical cure".
Furthermore, the breast is different from ordinary amputation. It is a three-dimensional and multi-layered structure including skin, fat, glands, fascia, muscles and various blood vessels and lymphatics.
To be honest, Waterman is not good at breast cancer resection and has done it on very few patients. In these three days, he has gained a systematic and comprehensive understanding of breast structure, blood supply and lymphatic drainage. 【5】
In addition to being familiar with various knowledge points, Waterman also deliberately further improved the original operating table that can be bent forward and backward.
The operating table in front of them was now tilted to the left, exposing Giustina's entire right breast and armpit structure, while also reducing the operating distance for the assistant on the other side.
Considering Giustina's high requirements for postoperative quality of life, the surgical incision was an oblique fusiform incision. Starting from the front of the armpit and below the inner side of the costal arch, this type of incision can reduce the impact of scars on the activities of the upper limbs. 【6】
The skin had already been cut when removing the sentinel lymph node, and now Waterman needed to further peel away the skin flap inside the incision.
Damirgaon and Amor each took four tissue forceps, clamped the edge of the skin and then lifted it up, doing reverse confrontation to expose the innermost cutting surface. Waterman used a scalpel to cut, while Carvey took a suture needle and thread to tie up the unstoppable blood vessel bleeding at any time. 【7】
Waterman learned a lot about the key points of mastectomy from Carvey. After several simulations on cadavers, he at least achieved the effect of sharpening his skills in the field.
But Kawei’s reminder is still quite necessary: “Now the director is using a scalpel blade to close to the skin and perform sharp peeling along the superficial layer of adipose tissue so that no adipose tissue remains on the skin on the upper and lower sides. In order to prevent the spread of the tumor Transfer, this high-precision dissection needs to continue to the distal end of the flap, and fat preservation is not an option until the terminal end.”
"Give me warm salt water gauze." Kawei took the wet gauze handed over by the nurse, tested the temperature, and then gently pressed it on the peeling surface with some small bleeding spots. "Generally, the terminal end of the peeling is chosen, up to the clavicle. It goes down to the upper part of the anterior layer of the rectus abdominis sheath, medially to the midline of the sternum, and laterally to the front edge of the latissimus dorsi muscle.”
As soon as the words came out, all the heads that looked up at the operation were buried, and there was another dense sound of writing and recording.
"In case of small bleeding, you can use warm saline gauze to compress and stop the bleeding. If it is large, just suture it directly. As long as you grasp the separation levels like Dean Waterman, there will generally not be too much bleeding."
The peeling of the skin flap was successfully completed, and the next step was to remove the muscle.
Kawei did not want to do early radical surgery for breast cancer, because cutting off the pectoralis major and minor muscles would affect the function of the upper limbs, and the Countess' daily life after surgery would inevitably be affected. But in the 19th century, when there was no chemotherapy and radiotherapy, he did not dare to assert that modified radical surgery could completely solve the recurrence of breast cancer. After much thought, the only option he could do was radical surgery. 【8】
"Next we cut off the Countess's pectoralis major muscle."
Following his previous practice, Waterman first separated the cephalic vein in the deltopectoralis major groove and exposed the entire course of the cephalic vein. Then the fat tissue on the surface of the pectoralis major muscle is separated downward to reveal the lateral edge of the pectoralis major muscle, and the Kawei on the other side is separated upward to reveal the insertion point.
The two used their index fingers to bluntly separate the deep surface of the pectoralis major muscle, preparing to separate the pectoralis major muscle and the cephalic vein along the direction of the fibers, and then cut off near the tendon. 【9】
However, just when Waterman's scalpel blade was pressed against the surface of the muscle and ready to be pushed downward, the vascular forceps in Kawei's hand suddenly moved forward to block the handle of the knife.
Waterman knew very well that Kawei must have done this for a purpose, and he was also shocked. His arm muscles contracted for a while, and he withdrew all the strength to prepare for the knife: "What's wrong?"
"Wait, there seems to be blood vessels here." Kawei removed the blade and the vascular forceps in his hand, and gently stirred his fingers inward, seeming to have fiddled with a piece of soft tissue next to the cephalic vein. "This is so cunning. It actually runs on the inside of the cephalic vein, close to the attachment of the tendon to the clavicle."
Waterman didn't feel anything a second ago, everything had already been trained on the corpse's muscle memory. But the next second, his forehead was covered with sweat beads, and he was only one knife away. If this knife was used to remove the breast cancer, it would probably turn into a fatal rescue.
"This is."
"It's the mutated thoracoacromial artery and vein." Kawei smiled and breathed a sigh of relief, then took the pliers from the nurse on the side, "It doesn't matter, it's not a particularly big blood vessel, it just needs to be separated, ligated, and cut off , and then just cut along the inner side of the pectoralis major muscle as planned." [10]
