To be honest, without the anatomy foundation mentioned in the previous chapter, and without the pictures in this chapter, it is a bit suffocating to look at it directly. If you feel bored, just wait until this chapter is finished, and it will be easier to understand with the addition of pictures.
Anyway, just remember to subscribe]
The short gastric artery, as the most dangerous anatomical structure when the retractor exposes the field of vision, has always been an anatomical term that intern medical students must learn when going to the general surgery operating table. 1】
It is not difficult to see the characteristics of this artery from the literal meaning, it is short.
Because it is short, it is not conspicuous. When performing gastric surgery on the side and back, interns who do not understand it can easily break it due to excessive pulling. It would be fine if it were a vein, but it is an artery, which maintains the blood supply to the entire stomach wall. Once broken, it will cause a large amount of blood loss, and it is not easy to repair.
Kawei didn't go into detail when doing the autopsy practice, because his previous emergency surgery department often performed emergency surgeries for upper gastrointestinal bleeding, and the practice was just to go through the process and get a feel for it.
But it's different when you actually go to the operating table. You can't make mistakes in every step.
"Did you see the artery?"
"I saw it..."
"Remember, once the short gastric artery is severed, it will not mean that the operation will be unsuccessful, but will directly result in the patient's life." Kawei slowly let go of his hand, "Now that the lesser omental sac has been opened, We slowly explored downward to reveal the anatomy next to the spleen, the posterior wall of the stomach and the pancreas and stomach..."
This is the splenic hilum area, and inside is the splenic pedicle, which contains the splenic artery and vein, lymphatic vessels, nerves and surrounding peritoneum.
At this point in the surgery, what we actually have to do is not only remove the spleen, but also prepare for the measurement of the subsequent splenic vein shunt. Since it is a shunt, it is to reroute the remaining veins to other blood vessels, and this modification of the original anatomical structure requires some prerequisites.
Kawei took some measurements and spoke to the loudspeaker next to him: "From the anatomical position, the patient's splenic vein has a certain length, so there is no need to trouble the renal vein. We can consider changing it to the inferior cavity later. Vein. Although the distance is longer, the blood pressure lowering effect is much better. Before that, we first cut off the blood supply of the spleen."
The two of them had no chance to take action here, and Kavi had to take the lead from now on.
"We first use arterial pulsation to find the splenic artery located at the upper edge of the pancreas, incise the retroperitoneum on the splenic pedicle, incise the arterial sheath, and then slowly and bluntly free the artery..." Kawei said slowly Doing meticulous dissection work, the arteries and veins are tightly attached to each other. Because the splenic vein needs to be shunted, it must not be damaged. "Give me the right-angle forceps."
The splenic artery was gently lifted from the sheath with right-angle forceps, and then a thick silk thread was passed inward by Hermann and ligated. 2】
The occlusion of the splenic artery itself can relieve a considerable part of the portal pressure, but in order to prevent excessive damage to the greater omentum vein, Kawei decided to wait until the operation is completed before testing again: "After the artery is blocked, the vein will not be moved first. Dissociate the spleen downward.”
Below the spleen are the splenocolic ligament and splenorenal ligament that are connected to the colon. After blunt separation of adhesions, they are clamped with simple hemostats and then cut and ligated. 3]
Because it is easy for novices to damage the blood vessels of the colon and mesocolon, Kawei performed the entire process: "After the lower part is solved, we start to deal with the loose tissue between the spleen, diaphragm and peritoneum. Although it sounds very simple, it can be done with your fingers. Separate, but everyone must pay attention!
! "
Kawei put his hand between the spleen and diaphragm, and then raised his voice: "The spleen, especially the giant spleen that has suffered a lot of inflammation, has already developed a large number of collateral blood vessels around it due to adhesion and congestion. You must not blindly use your fingers. Exploration, let alone forced blunt separation." 4]
Although Hermann did not know the short gastric artery, he was already quite proficient in handling the spleen. Using a retractor and fully exposing the field of view were the assistant's top priorities.
In this way, Kawei cut and tied the splenophrenic ligament, lateral peritoneum and adhesion tissue under direct vision.
There will definitely be bleeding again when the adhesion tissue is separated. Without an electric knife, it is impossible to suture all the small bleeding. I can only rely on Bergert to use warm saline gauze to apply pressure one by one to stop the bleeding. 5]
The surroundings had just been separated, and the two retractors in Bergt's and Damirgang's hands exerted force respectively. After removing the last trace of resistance, the spleen was able to be lifted out of the incision, and Herman immediately filled the location where the spleen was, the spleen fossa, with the prepared warm saline gauze.
"This piece of gauze can effectively prevent the protruded spleen from sliding back into the abdominal cavity. It can also compress the bleeding points on the retroperitoneum and diaphragm surface." Kawei briefly explained the reason for this, and then took it from Herman. Hemostatic forceps, "We continue to separate the remaining upper part of the spleen and gastric ligament, which contains the short gastric artery just now."
The operation method is still the same, bilateral clamping, central cutting, and unilateral ligation. 6]
The spleen does not need to be ligated, only the stomach side really needs to be ligated. The ligation of the side of the stomach is more difficult than before, because the short gastric artery is very short, and the distance of the stump that can be used for ligation is very short. It needs to be firmly ligated within a limited distance without any slippage.
Kawei has made many optimizations to the originally rough splenectomy, and it has become basically a bleeding-free operation.
But this also shows that the surgical procedure is very serious, and every step is followed according to the procedure. Fernan's heart rate and blood pressure were stable, and the surgical scene that was supposed to involve massive bleeding became very "boring."
"The chrome catgut made by Mr. Laszlo is actually extremely tough, and the sutures have never slipped or broken." Carvey gave a brief introduction, "One piece only costs 50 Hellers, which is very cheap. "
"Is it Laszlo's equipment factory in Nancheng District?" I don't know which vendor started selling speakers. A man sitting in the doctor's area suddenly asked loudly, "Are there any wholesale discounts?"
"Yes, you can find out the details by asking at the instrument factory. In addition to the sutures, there are also a full set of surgical instruments I used this time."
Kawei finished the suturing, and gently opened the spleen to the right with his left hand. His right hand pointed at the posterior edge of the splenic hilum: "Now let's go back to the operation. After freeing the ligaments and loose tissue around the spleen, we turned the spleen to expose the remaining part." The splenic pedicle. This is where the splenic pedicle and the pancreas are connected. We can gently push open this loose tissue with our fingers." 7]
As if hearing a preset alarm, Damirgang reflexively held onto the inverted spleen, letting Kawi's two fingers of his left hand pass behind the splenic pedicle and gently hook it. Then use three long hemostats with your right hand to clamp the splenic pedicle, and finally cut the splenic pedicle between the middle and splenic side hemostatic forceps close to the spleen side, and remove the spleen. 8】
"You need to pay attention here..."
Kawei's suturing was very selective, starting with the blood vessels in the pancreas. He only ligated the stump of the splenic artery, not the veins.
"If it is just a simple splenectomy, we need to ligate both blood vessels here. Not just a simple silk ligation, but also a through ligation. However, in order to prevent accidents, I personally still think that the two blood vessels should be ligated far away from each other. It is safe to tie both ends together. But..." 9]
Kawei left the vein: "But we will need to do a venous shunt later, so this vein will not move. Let's deal with the spleen first."
He did not suture the broken end of the spleen pedicle on the other side. This was actually normal. After all, it was an organ that was to be discarded, and ligation was meaningless. But Kavi’s intention was not just abandonment, but reuse.
Just as the spleen left Fernan's body, the third assistant Berget left the operating table again, and then a metal basin with a scale quickly appeared in front of everyone. 50ml of 2.5% sodium citrate + 20ml of 50% glucose preservation solution was placed in it for bleeding the spleen.
At this time, Damirgang also left the operating table, took out four large pieces of sterilized gauze from the instrument table on the side, folded them and wrapped them around the spleen. 10】
"There is a large amount of fresh blood in the giant spleen, which is not a pity for surgery." Kawei and Herman worked together to stop the bleeding of the remaining bleeding points in the spleen fossa. "Relying on the anticoagulant effect of sodium citrate, this The spleen piece should be able to supply nearly 500ml of blood to the patient again..."
On the side was the sound of bleeding after releasing the hemostatic forceps. Bergert was bleeding, and Damirgang was shaking the container evenly to mix the spleen blood and the preservation solution evenly to prevent blood clots.
On the side, two people were cleaning up the bleeding location. This strange scene lasted for a total of two minutes, and finally the blood scale in the metal basin stopped at 540ml.
Berget roughly calculated the dosage, then took sodium citrate and 50% glucose from the equipment box, and poured 40ml and 12ml respectively into them. 11】
Then he chose a filtering funnel and started the long process of filtering the blood bowl by bowl. After the filtration is completed, the blood needs to pass through the hanging bottle and enter the secondary filtering dropper, and finally it can enter Fernan's body. 12】
At this time, Damirgaon had returned to the operation side, and Kawei used forceps to loosely insert the greater omentum into the wound in the spleen area.
"Because the patient has portal hypertension, unlike ordinary traumatic splenectomy patients, it is necessary to create collateral circulation as much as possible to help shunt. Therefore, we stuff the greater omentum with rich blood supply into the vacant splenic fossa, without the need for fixed sutures. , just leave it."
The splenectomy was completed. After completing the clean-up work, the three-person team began to move towards the shunt.
Before the shunt is performed, the splenic vein left just now becomes the protagonist of the operation. Kawei needed to fully mobilize it. Not only did he cut off part of the pancreatic tail, but he also needed to create a 23cm free area for the distal vein to facilitate anastomosis.
"We first incise the capsule at the upper and lower edges of the pancreas, and free the body and tail of the pancreas. The upper edge reaches the root of the splenic artery, and the lower edge reaches the termination of the inferior mesenteric vein, so that the splenic vein can move downward to the right along with the body and tail of the pancreas.
Here I have cut off the tail of the pancreas and separated the upper and lower edges of the body and tail of the pancreas. Then the avascular area of the transverse mesocolon on the left side of the suspensory ligament of the duodenum is incised. Through this mesangial incision, the splenic vein and the body and tail of the pancreas are lifted to the left of the inferior vena cava. "13]
Three simple sentences contain a lot of anatomical nouns. Although the technique is not too difficult and the sentences are not long, it is much faster than the detailed and slow splenectomy just now. These anatomical terms are like submachine gun bullets, constantly impacting everyone's brain.
The general audience has given up long ago, but those surgeons who have persisted until now have been filtered out for the most part in this section.
The only people left who could keep up with Kawei's thoughts were the two assistants beside the operating table, and only Yingenatz, Waterman, Orji, Massimov and another person who had not been in the audience were left. Five doctors spoke.
"How about it, Bill Rotter, you have seen it now, why don't you even say a word?"
Waterman asked his old friend with a hint of relief. His face looked very relaxed, but his eyes and ears did not dare to rest for a moment, for fear that he would accidentally miss some key process.
He knew very well that in this fast-paced critical moment of surgery, once a link is missed, it will be difficult to catch up.
"Is this person really only 17 years old?" This is the answer Bill Rotter wants to know most. "The surgical skills are no different from those of you and me..."
To be honest, I have been reading books recently to catch up on updates, switch sources, read aloud with many sounds, and it can be used on both Android and Apple. 】
He wanted to say that his skills had long been surpassed, but for the sake of each other's face, he chose a conservative statement.
"If it's fake, it can be written clearly on the identity certificate." Waterman's smile became even brighter, "You have been saying that abdominal surgery is difficult when you were in Switzerland. There are not many people in the world who can do it well except you. Yes, but now it seems it’s not difficult at all.”
"Pooh!
! "
Billroth snorted lightly, but it was still not enough, so he couldn't help but added a few more times: "Bah! Bah! Bah!
! You touch your chest and swear to God, try saying that sentence again? "
Waterman smiled and stopped talking.
Because Kawei's shunt surgery has reached the final stage of suturing.
"Because the patient's splenic vein is very long, there is no need to use a renal vein shunt, because the renal vein is not strong, and suturing will cause lumen stenosis." Kawei said, "At this time, because the splenic vein is long enough to touch the superior and inferior vena cava, then Let’s just suture the inferior vena cava.”
What follows is a series of dissociation, revelation, dissociation, and re-revelation...
After a simple separation of the inferior vena cava, Hermann lifted the transverse colon and cut the duodenal suspensory ligament.
Kawei carefully cut the retroperitoneum in front of the abdominal aorta, separated the ascending part of the duodenum, exposed the inferior vena cava located on the right side of the abdominal aorta and below the branches of the renal vein, and freed the inferior vena cava below the left renal vein. 2/3 of the vein circumference, approximately 67cm long.
Use curved hemostats to clamp part of the inferior vena cava lumen, block part of the inferior vena cava, and cut an oval orifice consistent with the caliber of the splenic vein on its anteromedial wall. Pass the splenic vein together with the pancreatic tail through the transverse mesocolon incision, turn clockwise to the inferior vena cava side, and anastomose the splenic vein to the end-to-side posterior wall of the inferior vena cava.
"The preparation work is over, and the next step is the stage of blood vessel suturing." 14]
