[There are a lot of steps, I need to polish them up, I can look at them tomorrow]
The reason why Waterman dared to accept this breast cancer surgery was, firstly, because as the president of the Imperial College of Surgery, he could not avoid political tasks; secondly, there was almost no danger in breast cancer resection. According to the scope of previous surgeries, only incision was needed. Just remove the breast glands and surrounding fat tissue, leaving almost no major blood vessels.
But Justina's identity forced him to agree to Kawei's radical surgery plan. The scope of surgery expanded to the muscles under the breast, and more blood vessels needed to be treated.
Perhaps he had confidence in his skills before and could immerse himself in surgery regardless of the cost. But now, when he was able to avoid the surgical error, an indescribable strange feeling slowly emerged from his mind.
After all, Justina is a French countess, and she is surrounded by Count Carmelin. Although she has no real power, she is a very popular astronomer and writer. He owns the Flammarion Publishing Group and was the first president of the French Astronomical Society.
In the distance sat French Ambassador Edward, and everyone's eyes were watching the operation.
No matter how amazing the sentinel lymph node staining and lymphatic metastasis patterns shown by Kawei were, as long as the operation failed, the radical resection advocated by the two would become a laughing stock throughout Europe. Even if Giustina survives the surgery, the empire is likely to lose France as an ally.
The operation must never fail, or even allow any mistakes to occur. Waterman never thought it would fail at the beginning. Kawei's block just now allowed the operation to proceed smoothly, but it also blocked his confidence in operating the knife quickly.
He stopped what he was doing and turned his face to let the nurse wipe the sweat from his cheeks.
Maybe he is really old...
As the chief surgeon, Waterman is under pressure that others cannot feel. And once this kind of pressure occurs, it is difficult to get rid of it.
He breathed a long sigh of relief, glanced at the newly peeled wound, then turned back to the audience and said: "The countess's body structure is different from ordinary people, and there is a rare vascular mutation. Now Dr. Carvey is isolating this group of After suturing the thoracoacromial artery and vein, the connection between the pectoralis major muscle and the clavicle can be severed." [1]
The appropriate amount of commentary created time for him to buffer his emotions. By the time Waterman leaned down and lowered his head again, the stress just now had been completely hidden in his heart.
Kawei knows that it is not easy to overcome the pressure, and he also knows that it is inevitable that he now proposes to take the position of chief surgeon. But thinking of Waterman's previous care for him and the danger of the operation, Kawei decided to "help" him.
He quickly disconnected the arteries and veins and tied them with silk threads: "The blood vessels are solved."
Waterman nodded, clamped the muscle with pliers in one hand, and cut the pectoralis major muscle along the collarbone with a scalpel in the other hand. His movements were much slower than before. Where he only needed to cut with one knife, he chose two or even three knife cuts to slowly separate them.
Kawei continued to squat toward the arm to separate the greater tubercle of the humerus in the pectoralis major muscle tract, and then took another scalpel to separate the pectoralis major muscle near the tendon.
Waterman put down the scalpel, asked Damirgang to step forward, and continued to explain: "We use three tissue forceps to clamp the pectoralis major muscle and pull it sideways while cutting to expose the pectoralis minor muscle underneath." 【2】
"Give me the scissors." Kawei took the surgical scissors and began to process the fascia on both sides of the pectoralis minor muscle.
Seeing this, Waterman naturally used his hands to create a field of view, trying to expose the fascial position as much as possible: "First cut off the fascia on both sides of the pectoralis minor muscle, bluntly separate it, then lift it up and separate it to the attachment point of the coracoid process, and separate it. The pectoralis minor muscle is severed here...Here, give me wet gauze." [3]
There will be bleeding at the broken end of the muscle, but the amount is not large and can be stopped by simple compression.
To outsiders, the surgery seemed to go smoothly and was not affected by the mutated blood vessels just now. But a discerning person like Edinson still saw some clues: "Why did the two of them change hands?"
"Huh? Doctor Edinson, what did you just say?"
Edinson is not a person who likes to talk. The operation in front of him is not only related to the ability of the surgical college, but also related to the future of the empire, which has long surpassed his personal grudges. Moreover, the exchange of operations between surgeons and assistants is not a big deal, and Kawei’s personal skills can fully cope with it.
"Well, it's nothing." Edinson said with a smile, "I just lamented that Dean Waterman's speed was too fast, and the operation was already halfway through."
"Already halfway through?"
"Yes, the next step is to determine whether the armpit needs to be treated, or to directly remove the muscle."
After incising the pectoralis minor tendon, the structure of the armpit has been revealed in the surgical field. According to the steps of radical mastectomy for breast cancer, it is time to clean up the subaxillary lymph nodes and all surrounding fat tissue.
But Kawei was not in a hurry to take action: "Teacher Yingenatz, are there any results from the pathological examination?"
"We are still sealing wax..."
The three of them had adjusted their speed to the fastest possible speed, but still could not catch up with the progress of the operation. Considering the top-down process of the surgery, Carvey decided to re-examine the flaps on both sides that Waterman had just done. 【4】
Because it is close to the breast and fat tissue, the flap should not leave any other tissue. The flap needs to be thinned, leaving only the capillary layer supplying the flap: "The operation needs to come to an end, and Dean Waterman can take a break. . I will carefully check the thickness of the surrounding skin flap to ensure that no tumor tissue remains."
The ideal thickness of the skin flap is such that it will not cause necrosis after surgery, and there will be no cancer cells remaining under the skin. To truly achieve this goal requires a very high level of operational skill.
What Kawei can do now is to quietly solve the problems left by Waterman, and at the same time give a warning to colleagues in the audience who are preparing to challenge the radical surgery: "Skin flap incision is an important first step in the operation. I Here we need to give a supplementary explanation to Dean Waterman’s operation just now.
When separating the skin flap, the tip of the scalpel needs to be pointed slightly upward and cannot be cut flat. Once it is cut flat, a lot of tissue will remain. "
While Kawei was thinning the skin flap and cutting out a lot of tissue with a scalpel, he explained to the director: "We are human hands, so there will definitely be unevenness, so we need to confirm it repeatedly during the operation to prevent uneven thickness. situation. This not only affects the aesthetics of the final suture, but also affects the chance of recurrence after surgery..."
"Three lymph nodes, one has tumor tissue."
Ingnatz never liked procrastination, so he reported the inspection results simply: "I think I need to clean my armpits."
Kawei put down the scalpel, looked at the skin flap carefully, and nodded: "Damirgang and Amor will clamp the broken ends of the pectoralis major and minor muscles and pull them downward to fully expose the clavicle muscles covering the axillary cavity. membrane and the axillary sheath surrounding the axillary artery and vein [5]... Come, someone help me adjust the operating table."
The nurse knelt down and looked at the audience's angle: "It's reached its limit."
"Then bring me a soft cushion."
The angle of the patient's arms and torso was readjusted, the field of view was fully exposed, and the surgery continued.
The armpit has a complex anatomical structure, with blood vessels and nerves running here, mixed with fat and lymph nodes. Therefore, dissection is the key and difficult point in the entire operation, which requires extremely detailed anatomical skills. According to the previous plan, as long as there were no problems along the way, Waterman should be the one in charge.
But now things have changed. The incident just now made his pressure rise sharply. Although he can continue the operation, his confidence has been lost. In addition, breast cancer removal is not his strong point, and the operation is easy to deform and make mistakes.
If it was an ordinary surgery, Waterman would still have a chance to adjust his mentality, but now the situation around him was completely different, and the gazes from two hundred pairs of eyes made him breathless.
Kawei looked at Waterman's somewhat stiff hands, understood what he meant, and gently tapped the back of his hand with the tissue forceps in his hand. At this point, the roles of the two have been completely reversed. In the armpit, which has more blood vessels and nerves, Kawei has become the chief surgeon, while Waterman has become the assistant and commentator:
“We first clean the axillary vein, use a camera to lift the clavopectoral fascia and axillary sheath, and cut it open from the subclavicle to expose the axillary vein inside.”[6]
"Then, we will remove the surrounding fat tissue one by one. When peeling off the lower part of the axillary blood vessel, we will ligate the small venous branches coming from the chest wall and the arteries entering the chest wall, especially the pectoralis major and minor muscles, close to the main trunk. ."【7】
Kawei followed his explanation and operated step by step, trying to be as careful as possible while maintaining hand speed with each step, carefully clearing the fat and lymph nodes around the blood vessels.
"Then we started to deal with the fat and lymph nodes on the top of the armpit..."
Kawei held the hemostatic forceps and continued the separation without injuring the axillary artery, vein and brachial plexus during the process.
This separation continues to the outside of the chest wall, where there are the long thoracic nerve and the thoracodorsal nerve. Generally, the long thoracic nerve is located 2cm behind the lateral thoracic artery, while the thoracodorsal nerve is located outside the long thoracic nerve. It separates the surrounding fat tissue and lymph nodes. Clear it clean. 【8】
"The armpits are basically cleaned."
Kawei looked at the armpit tissue again and again, and after confirming that it was correct, he took two balls of wet gauze from the nurse and covered the newly cleaned area: "After treating the armpit, we will then cut the pectoralis major and pectoralis minor muscles. First find the sternum attachment point, then slowly separate the muscles and merge towards the center...
Here you need to pay attention to the chest wall below. When separating the muscles of the chest wall, all the blood vessels passing through the chest wall should be ligated one by one. Compression can be used for minor bleeding. "【9】
Waterman's suture ligation speed was far less rapid than that of Kawei. The silk thread that Kawei had just proposed for clinical use was thinner and stronger than the previous catgut. For this reason, Kawei gradually slowed down the speed of cutting and separation. At the same time, in order to let Waterman concentrate, he also took over the right to explain:
"Our movements here must be standardized and gentle. It doesn't matter if we prefer to go slower. We must not injure the pleura. And when separating the outer sides, we must not cut the fibers of the serratus anterior muscle."
The operation entered a repetitive stage. In the next twenty minutes, Kawei kept cutting the muscles, while Waterman kept suturing the small blood vessels until the pectoral muscles, subcutaneous fat, breast tissue, and armpits were removed. Cavalal lymph nodes were removed en bloc.
The entire piece of tissue, along with the blue lymphatic vessels and lymph nodes and the tumor, entered the nurse's tissue metal tray.
Waterman had completed all his work and left the surgical area completely. His forehead was covered with sweat, and he felt that his whole body was soaked. His slightly trembling legs could not even keep him standing. He could only find a baffle in front of the auditorium to lean on and take a simple rest.
He didn't know why he was like this. He always felt that the whole operation had completely drained his energy.
Maybe it's the pressure on my body, or maybe there's something else...
what is it then?
The operation had completely entered its final stage, and Kawei was still standing by the operating table, doing the final work: "Get warm saline and prepare the rubber drainage tube."
The nurse who passed the equipment had already prepared the equipment for the final stage and handed it to the other two assistants immediately: "Here."
"Considering the possible metastasis of the tumor, we must flush the wound with saline before ending the operation to remove the clots and fat particles produced by the operation just now."
Kawi made room for Damirgang and Amor, allowing them to rinse, suction and drain, while he walked aside and started looking for the opening of the underarm drainage tube: "The underarm tissue is very easy to accumulate leaked fluid, so We make a cut at the top of the axillary cavity, put in a rubber tube for drainage, and then suture it intermittently with sutures." [10]
At this step, he gave Waterman a lot of rest time, because the final skin suturing had to be completed by the plastic surgery master.
"Dean Waterman..."
"Is the drainage tube ready?"
"Um."
Waterman took a deep breath again, stood up straight, and then slowly walked to the operating table step by step. At the same time, he gave a summary of the previous operation: "The operation was more complicated than expected, but the results of the operation were amazing." People are quite satisfied. The breast tumor was completely removed, and if nothing else happens, the countess’ chance of recurrence after surgery will be less than 10%.”
The audience burst into warm applause, and Kami Yin on the side also shed tears as before the operation started: "Thank you, thank you so much, thank you for everything you have done for Justina!"
The pressure disappeared in the applause, and Waterman gradually regained his strength: "This is only the first phase of surgery, and there will be a second phase of your breast reconstruction surgery after that. So while trying to ensure the beauty of the skin suturing, we also need to prevent subcutaneous Infection of tissue.”
Preventing infection is a very general statement, but actually putting it into practice is what Kawei is doing now.
"I will gently squeeze the axillary cavity to drain out the residual air and liquid. Then, while the assistant is bandaging, I will use a large amount of gauze to fill the axilla, subclavian and anterior chest wall, so that the skin flap and chest wall are close to promote healing. Reduce the accumulation of fluid at the incision. But at the same time, we must also ensure that the pressure is not too strong. Too much pressure will also cause insufficient blood supply to the skin flap, leading to necrosis..."
The operation is complete.
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