The question caught Kawei a little off guard, but he had always claimed that his adoptive father was dead and never revealed his name, so it wasn't too much trouble and he could get over it with just a few words.
"Dead? How did you die?"
"I accidentally cut my finger during the autopsy, and the wound became infected..." Kawei made a joke about the most common cause of death among surgeons. "This is why I have been calling for gloves to be worn during surgery. No matter how you look at it, this approach protects both patients and doctors."
Massimov seemed even more sad than Kawei: "How could such a skilled surgical master have fallen like this?"
"He is just a surgeon in a small place. He stays in his own clinic all his life. Even if he has some bright ideas from time to time, he is not famous." Carvey drilled hard into Mrs. Santini's skull and shook his head helplessly. "At first I was expected to inherit the clinic, but unfortunately he died, so I sold the clinic and came to Vienna."
"What a good choice. It's a pity to stay in the countryside without writing a book or biography." Massimov sighed after hearing this: "Oh... If possible, I really hope to have a good chat with him."
"Teacher, let's focus on the surgery first." Kawei pulled out the bone drill in his hand and wiped away the bone powder around it. "I have drilled open Mrs. Santini's skull."
This should be the first neurosurgery performed by Massimov and the two surgeons around him. The operating table is still the same as before, but the position has changed a lot. Because the brain is not like the abdominal cavity and cannot withstand the slightest infection, only one second assistant is allowed to stand around the head besides Kawei and Massimov to pass the equipment. 【1】
The cranial drill was taken away, leaving a layer of dura mater on Cavite without continuing. 【2】
Just like marching and fighting, the operation must be carried out before the soldiers and horses use food and grass. The conditions in the operating room were poor, the assistants were incompetent, and the anti-infection ability was also poor. In order to minimize the exposure time of brain tissue, he temporarily put the puncture aside and first completed the subsequent shunt path, that is, the work of burying the tube to connect to the abdominal cavity. 【3】
"Give me the scalpel."
Kawei used a knife to make a shallow incision below the puncture point, only reaching the fat layer. After the bleeding was stopped, he used tissue forceps to clamp the front end of the hose and push forward. Then he opened the forceps to expand a certain area, then clamped the hose and pushed forward. , and then expand.
An obvious tunnel appeared under the skin under this blunt dissection, but the length of the tunnel was related to the length of the forceps. It reached the limit just after crossing the back of the head, and the exit was set at the side of the neck.
After all, it was a conclusion drawn from decades of clinical practice. It was difficult for Massimov to see the significance of this operation at the first time.
Carvey explained: "This is for Mrs. Santini's continued daily life, and the hose needs to be buried under the skin in sections as much as possible."
The sterilized hose pokes out of the neck outlet, exposes a small section, and then enters the subcutaneous area above the clavicle again. The same routine and the same distance, the second exit was set by Kawei in front of his chest. Then came the third section, which stretched out from the chest to the upper abdomen, and the work of burying the tube in the middle came to an end.
Finally, as long as the puncture of the upper ventricle is completed and the rubber tube is connected, a new incision can be made in the abdomen to formally enter the abdominal cavity.
This kind of work similar to digging a tunnel may seem easy, but in fact there are many details to consider.
"You must control the depth of the skin. If you want to perform the same operation in the future, please practice more on cadavers." Kawei put down the tissue forceps and switched to a scalpel. "If the separation is too deep, bleeding and infection will occur. If it is too shallow, it will cause bleeding and infection." If the nutrient supply is destroyed, the skin will easily die. The best depth is the fat layer under the skin, and the movements must be gentle..."
Watching the process of digging tunnels and threading hoses, not to mention the second assistant who handed over surgical instruments, even Massimov was amazed by Kawei's basic skills.
VP shunt surgery is just about punching two holes in the body and connecting them with tubes. It sounds simple, but in practice it is full of details. Now it was just general preparations, and Massimov no longer had much confidence.
But Kawei's operation further aroused his desire to learn new techniques: "Will I have to do ventriculocentesis next?"
"right."
If it were in modern times, what the instrument nurse would hand over at this time would be a ventricular puncture needle with a metal guide core [4]. However, current conditions are limited. This kind of thin hollow metal pipe is difficult to make, and it is impossible to have it ready-made. When I temporarily opened the surgical instrument box of St. Mary's Hospital, all I saw were thicker suction heads.
The suction head inserted into the abdominal cavity is too thick and long, and the ordinary needle is too thin and short.
The Municipal General Hospital does have a silver tube of similar thickness, which Kawi asked Laszlo to make for the purpose of catheterizing patients. However, this kind of pipeline only has two front and rear openings, which is too simple for the shunt and drainage of cerebral crest fluid with high protein content, which may lead to poor drainage or even obstruction.
Faced with this difficulty, Kawei could only find another way before the operation: "Where are the quills I asked you to collect?"
"It's all soaked in carbolic acid."
"The length should be about 10cm and the diameter should be 3mm." This was the piercing substitute that Kawei had previously requested. "It doesn't matter if it floats up and down. The key is that I have to clean the surrounding feathers."
"There are a total of 55 pens in the hospital, and we selected 3 of them. In order to remove the feathers, we also chipped off a layer of the tube wall."
"Is it slippery?"
"Very smooth."
The second assistant who delivered the instrument delivered three "puncture tubes", the length and diameter of which met Kawei's requirements. Although the material is not as strong as metal, compared to other patients who need shunting, Mrs. Santini actually uses it not long. 【5】
"The front end of this one is too thin and cannot be used; the middle of this one has too many cracks and cannot be used; this one...this one is not bad, but it needs to be reprocessed."
Kawei carefully poked several small holes in the wall of the tube with a thin needle, and soon made a crude version of the 19th century ventricular puncture needle. Under the premise of ensuring that the outer wall is basically smooth, Kawei holds the pen tube in his hand and prepares to insert it directly into the brain ventricle from the drilled hole. 【6】
This is the key to determining the success of the operation. The depth, angle and strength of the puncture need to be considered. If anything goes wrong, it can range from coma to death on the operating table: "The puncture position has been determined, and the angle is aligned with the eyebrow arch in front. The depth of the needle..."【7】
As Kavi explained, he began to use force to insert the puncture needle.
In the entire surgical theater, no one spoke, and the two assistants did not perform any other operations. All attention was focused on Mrs. Santini's head.
1cm...3cm...5cm...【8】
The distance from the scalp to the ventricle of the brain is not long. In this short 5cm distance, the surgeon must endure tremendous psychological pressure. Especially when there is still no cerebral crest fluid after the puncture needle has penetrated 5cm, the surgeon who puts aside his distracting thoughts needs to consider many factors and battle with the patient's brain structure, himself, and even the air.
For a novice neurosurgeon, the whole process from the time the needle enters the brain until it penetrates 5cm into the scalp without seeing the cerebral crest fluid is very irritating. The level of nausea increases as they go deeper, finally forcing them to make a choice.
There are generally two possibilities at this time.
One possibility is that the puncture depth is not enough, so you need to continue moving forward. Maybe you can enter the brain ventricle by moving 1-2 mm further forward. But if the direction is really incorrect, then no matter how far it goes, it will damage other brain tissues.
The deeper you go, the more damage there is and the more severe it is.
It may be that the ventricular veins are blocked, causing intracerebral hemorrhage [9].
It may be the diencephalon, causing sensory impairment and emotional abnormalities; it may also be the brainstem, affecting spontaneous breathing and heart rate regulation. 【10】
If the doctor is "cowardly", he may judge the lack of cerebral crest fluid as a problem with his puncture angle. At this time, you must not change the puncture direction halfway. You can only withdraw the puncture needle along the original path and choose a suitable angle for puncture again.
However, re-puncture does not mean that the situation has improved. The problem of puncture angle still exists. If cerebral crest fluid appears at the nozzle after entering 5cm, everyone in the operating room will be happy, but what if it still doesn't appear?
At this time, should we continue to delve deeper, or should we quit and start again?
If you choose to go deeper, it means there is something wrong with your judgment just now. So is the angle correct this time, or is the angle you just chose to quit from just now correct?
If you choose to quit again, even if the re-puncture is successful, a total of three punctures have caused considerable brain damage, and the patient may have lost considerable neurological function. To the doctor, it was a complete failure.
Such immediate surgical failure can easily create a psychological shadow on the surgeon, which will further affect other subsequent surgeries.
And this is based on the success of the operation. What if it fails even the third time?
Of course, these are all questions that newbies who are just starting to do puncture surgery need to worry about. A veteran like Kawei will not have any problem judging the puncture angle even if his hands are rusty.
After entering almost 5cm, Kawei did not hesitate and confidently continued to explore a distance of 3-4mm. Suddenly, he felt an extremely slight vibration on the pads of his fingers, and then a clear liquid with a lot of blood streaks spurted out from the outer mouth of the tube.
"The tip of the needle has entered the brain ventricle, and it still needs to go deeper."
Massimov and his students looked at the brain crest fluid spurting out and breathed a sigh of relief: "Do you want to go deeper?"
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"Of course." Kawei explained, "Why else would I have made so many small holes around the drainage tube? It would be easy to block it just in front."
As soon as he finished speaking, he inserted the entire pen tube into Mrs. Santini's brain, with only a short section exposed, "Give me the infusion valve."
This valve can control the flow rate of cerebral crest fluid drainage outside the body. Although it is much worse than the multi-functional shunt valve used in modern medicine, it is still better than connecting nothing at all. 【11】
The hose on the front and back of the valve connects the puncture needle and the lowered hose. What Kawi can use is common surgical tape for sealing. The connection was sealed directly under the skin, and the incised skin was re-sewn with needles and threads, and the side of the brain was finally closed. 【12】
"That's pretty much it, right?"
"Connect the valve and the drainage tube below. We will make a hole in the stomach and put the other end into the abdominal cavity." Carvey drained some more bloody cerebral crest fluid and lowered Mrs. Santini's head. After applying pressure, he closed the valve according to experience and began to process the abdominal incision. "Here, give me the scalpel."
Now that there is no minimally invasive technology or qualified puncture needles, he can only make a slightly larger incision in the abdomen, follow the steps of abdominal surgery, separate the muscles and peritoneum layer by layer, and put the other end of the tube into the omentum. .
The reason why cerebral crest fluid can be drained into the abdominal cavity depends on the strong absorptive capacity of the greater omentum, which can reabsorb the cerebral crest fluid into the circulation and re-form a new closed loop while isolating external invasion.
This is the theoretical core of the success of this type of surgery. For this reason, in addition to abdominal drainage, ventriculocentesis can also perform atrial drainage through the cervical veins. 【13】
"So, everything must be completely closed. Not only the skull opening must be completely closed, but also the lower abdominal cavity opening must be closed, as well as the part where the subcutaneous tube is buried in the middle..." Kawei still has some regrets about the operation, " It would be great if all the hoses in the middle could be buried under the skin, now we can only hope that there will be no infection."
"Dr. Kawei, you have done a great job!"
It was an eye-opener for Massimov. This was more exciting than the modified breast cancer resection, and every step seemed so fresh and exciting: "If this kind of surgery can really reduce the pressure on the brain and relieve headaches for a long time, then what? Does it also apply to children with cerebral crest fluid syndrome?"
"Children have to grow after all." Kawei hit the point. "Height growth is a very troublesome problem."
"If it is really successful, frequent replacement of hoses is actually acceptable. After all, these children will die soon and there is no other way."
"That's the problem of infection. This kind of surgery is very easy to get infected. You must be careful during the operation..." Ka maintained a pessimistic attitude, but still praised him with a smile, "Teacher Massimov also has a good idea." Not bad, you can try it.”
The operation was completed under Kawei's operation. What followed was some routine postoperative observation. At the same time, it was necessary to repeatedly adjust the flow rate of the cerebral crest fluid after Mrs. Santini woke up.
As for how to deal with the incision and dressing changes after surgery, and how to take methylene blue orally to fight infection, Kawei does not need to do it himself. What he and Massimov had to do was to inform Ed Nelson, who had been waiting outside the Handwriting Theater for a long time, to postpone tomorrow's electrotherapy schedule.
But at this time, there were not only Ed Nelson and Jenny outside the theater, but also Mr. Santini and another man in a black coat.
The man was pacing back and forth with a cigarette in his mouth, looking more nervous than anyone else: "Why hasn't he come out yet?"
"Logically speaking, it should be soon." Ed Nelson was still thinking about what he had just said with Jenny, and he became less and less optimistic about the results of Kawei's surgery. "If the Sheriff doesn't mind, I can do it for him. After all, Kawei The doctor's operation is very difficult, so accidents are the least surprising."
"I know you have superb medical skills, but..." Werther was in trouble: "But that guy only recognizes him, and other doctors are useless."
