[I’m afraid I will have to wait until November to resume the discussion and comments on this chapter, which is painful...]
The key points of intra-abdominal surgery are nothing more than freeing anatomical structures, clamping and blocking, cutting and separation, suturing and anastomosis.
A few seemingly simple words, but each step embodies the sweat of repeated practice, and also embodies the health and life of the patient after the operation failed. The difference between Kawei and all the doctors present was not only more than 150 years of medical development history, but also thirty years of experience in emergency treatment.
It is impossible for a doctor who has only done surface tumor resection, lithotripsy and amputation to follow Kawei's ideas, nor understand the anatomy of the area he is currently operating on, let alone the anastomosis of the stumps after the rectal mass is removed. Gold content.
They only know that rectal anastomosis is not easy, but they do not know how difficult it is.
Among the many doctors in the audience, probably only a few surgeons who have ever challenged abdominal gastrointestinal surgery have a certain say. Among these people, there is only one Bill Rotter who has actually been exposed to and publicly performed rectal surgery.
Ever since he took up the position of chief surgeon, he decided that his future surgical path would never be a waste of time on epidermal tumors and plastic surgery.
Billroth's target has always been the digestive tract, and during the years he worked in Switzerland, he specialized in rectal cancer. Although only four cases were performed in total, two died within one month after surgery and one died a year later, but one case is still alive to this day. 【1】
He chose rectal cancer surgery not because rectal cancer surgery is simple and easy, but because the symptoms of rectal cancer are typical and obvious enough, with blood in the stool and intestinal obstruction being the most direct evidence.
At the same time, rectal cancer is the only digestive tract tumor that can be diagnosed clearly through non-invasive examination so far. It only needs a rectal dilatation examination or a simple digital examination to confirm the diagnosis.
The surgical method, whether it was originally in the early 18th century or now in the mid-19th century, has always been transanal resection of rectal tumors.
While everyone was shocked by Kawei's superb abdominal surgery skills, Bill Rotter's shock stopped at the method of surgery. Because only he knows how much anatomy goes through from the abdominal skin into the abdominal cavity and then around the rectum.
"Dean, you should know how difficult it is to operate from the abdominal cavity to the rectum. Let alone a living person, even a dead body may not be able to do it."
"I'm not familiar with celiac..."
Billroth was holding a notebook with several pages of writing in his hand, and was staring blankly at the operating table not far away. The only thing he wanted to do was to rush to the operating table and see the situation in the patient's abdominal cavity: " Tell me, if I go to the operating table now, will Dr. Kawei give me the opportunity to be an assistant?"
"The operation should be over soon." Waterman didn't expect him to have this idea. "Anyway, he has been in Vienna. There will be plenty of opportunities in the future."
"The key issue is not the doctor. Of course Dr. Carvey is also very important, but..." Bill Rotter sighed, "Alas... the point is, the next rectal cancer patient who is willing to operate Patients don’t know how long they have to wait.”
...
The reason why Kawei chose transabdominal surgery was because he did not deliberately prepare the leg frame in advance and could not create a lithotomy position. Secondly, because there is not much difference between transabdominal and transanal surgery for him, in order to fit the theme of this operation, it would be better to choose transabdominal surgery.
Abdominal and pelvic floor surgery is also an important foundation for general surgery and obstetrics and gynecology. In Vienna, where cesarean sections are increasing day by day, there is no harm in showing these doctors pelvic floor surgery.
Simple mass resection is indeed simpler than rectal cancer resection, eliminating the need for resection of the descending colon and sigmoid colon, and less peripheral lymphatic dissection. But other than that, there is not much difference. The intestinal segment where the mass is located still needs to be cut off, and the disconnected intestinal tubes still need to be anastomotic.
What really reflects the difference between modern times and the 19th century is the stapler. 【2】
Fortunately, Kawei is someone who has experienced the era of sewing intestines by hand. If it were those young doctors who would require staplers for almost every operation, many of them might have forgotten how to perform manual anastomosis of the intestines.
Of course, the existence of the stapler definitely outweighs the disadvantages because it makes up for many of the technical shortcomings caused by manual suturing and reduces postoperative complications. 【3】
It is certainly true to transfer part of the doctor's skills to the machine, allowing doctors to pursue more advanced surgical techniques and ideas. But in Kawei's eyes, there is no conflict between using staplers and practicing original suturing techniques.
Because staplers are commodities, they have value since they are commodities, and often the value of medical commodities is not low. Even with insurance and reimbursement, the patient still needs to pay a sum of money in the end.
For those poor people, the cost of equipment that others think they can afford is likely to be their living expenses for several months. At this time, forcibly using a stapler is causing discomfort for the patient and yourself. The best way is to give up the expensive stapler and choose to perform the anastomosis manually.
The rectum is different from the small intestine. Anastomosis not only means connecting the two sections of intestine together, but also ensuring that the underlying rectal sphincter is not damaged.
This is why it is necessary to determine the distance from the dentate line as soon as possible after seeing the lump.
"This is the mass on Mr. Fernand's rectum." Carvey opened this section of the rectum, revealing the rupture of the mass inside. "The mass has grown to such an extent that surgical removal is really the only way to treat it."
The audience burst into warm applause, and the operation, which lasted for nearly 4 hours, finally came to the end of the second stage.
But for Kawei, the beginning and end of the operation are the same, and nothing can be careless: "How is his blood pressure and heart rate now?"
"It's back to around 120/70, heart rate 95."
"Okay, continue to monitor..."
Kawei was surprised by Fernan's body, but also relieved.
Open-air surgery inherently carries various risks. The light source alone is a big problem. Not only is air disinfection useless, but you also have to deal with the constant falling dust. Repeated use of ether will cause unimaginable consequences. It is a miracle that Fernand can persist until now.
"Next we need to anastomose the intestines, which requires some skills."
Kawei used a needle holder to bring silk thread and said: "I made traction and fixed sutures on both sides of the intestinal tube to make the two broken ends close together. Then I used silk thread to make inversion continuous sutures on the posterior wall, each stitch The thread must be tightened when stitching. This is related to the sealing of the anastomosis, and no gaps can be left." [4]
After saying that, he quickly completed the suturing of the back wall, and then tied the suture with the traction silk thread: "The technique for the front wall is the same as that for the back wall. It also requires continuous varus sutures, and finally the traction sutures on the other side. The silk thread is knotted. This is done to prevent the continuous suture from shrinking too much, causing lumen stenosis."
In fact, the stitching technique is as simple as before, and there is nothing particularly outstanding about it. What really deserves Kawei's "skills" is actually after the stitching.
"The rectal segment lacks serosal wrapping, and anastomotic leakage can easily occur when the stump is anastomotic."
Kawei put down the suture needle and thread, carefully inspected the anastomosis, and said, "Everyone knows what the rectum is used for. Once an anastomotic leak occurs, the patient has no other treatment except for another operation for a secondary anastomosis. So here In addition to suturing, technique also refers to an experiment to check whether the anastomosis is tight. Bring me a basin of normal saline..."
While Berget prepared the salt water, Kavi chose an enema.
"Pour the water into your belly."
"Pour it all in?"
"Pour 200ml first, and I'll see if I can bury the anastomosis."
Berget nodded and poured saline into Fernan's abdominal cavity. He did not stop until the rectal anastomosis was completely submerged in water.
Kawi asked Damirgaon to put a tube of air into Fernand's rectum while he was pouring in the salt water. More than 100 ml of air entered Fernand's rectum. Due to the internal pressure, some of the fine air penetrated into the abdominal cavity through the gap in the anastomosis.
"Did you see the bubbles?"
"I saw it."
Kawei leaned into the speaker and said loudly: "Please remember to do an air enema experiment when performing the final anastomosis in rectal surgery. No matter who is doing the surgery, we are all human beings, and it is difficult to escape the possibility of making mistakes. For example, now, A small string of bubbles entered the saline pool in the abdominal cavity, which is the sign of a missed needle."
After that, he asked Herman to use a metal suction tube to suck out the saline solution from his stomach.
"Suture problems are common, as long as remedial measures are taken in time."
Kawei gently reached into the rectum, exposing the surgical site to his eyes again. He gently kneaded the sutures on both sides of the broken end, and then discovered that there was a stitch missing in the corner of the suture... maybe just half a stitch.
"There is indeed a leak, but it's not difficult to remedy. All you need is to hang a stitch." Kawei said while suturing: "If you give me some more water, I have to do it again..."
After the second successful inflation test, the operation entered the final stage.
Before this time, Kawei would summarize the gains and losses of today's surgery: "First of all, I have to thank Mr. Fernand's body. Although his soul was sold to the devil, this body allowed me to fully demonstrate the two surgeries. The whole process. The second thing I want to talk about is the medicine in the infusion bottle."
What was in the No. 1 infusion bottle was adrenal gland extract, which was the invisible protagonist of today’s surgery.
Without it, the entire operation might have ended when the spleen was removed, because Fernand had consumed most of his energy in the first hour or so. It is precisely because the adrenal gland extract contains not only epinephrine and those messy other hormone products that the surgery has been demonstrated to this day.
What’s in infusion bottle No. 2 is pituitary gland extract.
Compared with adrenaline, the pituitary gland is less overbearing, but for Fernan's upper gastrointestinal bleeding, the pituitary gland extract can quickly solve his bleeding problem. Because pituitaryin has always been a very easy to use and very common hemostatic drug in hospitals.
"The 4-hour operation relied not on my skills, but on these two drugs."
Kawi once again advertised for himself: "As mentioned before, the price of these two medicines is 10 crowns, which is very cheap. If you want to choose a package of two bottles, the Karachi Pharmaceutical Factory will give a special price. At the same time , we will also launch a sphygmomanometer + adrenaline + pituitary surgery gift package together with Mr. Laszlo’s steel factory. You can consult the Karachi Pharmaceutical Factory for specific prices.”
Promotion is also a feature of Kawei's surgery. Since he got the patent, he will insert some advertisements between surgeries.
The original intention was not only to increase my own income, but also to help doctors develop good habits in using drugs and equipment while making money.
In order to ensure the popularity of these drugs, the patent period is not long-lasting, and he will announce the preparation method after one year. This is not giving away money. You can make money by doing anything you want, and Kavey is not short of money. The ventricular shunt surgery he performed at St. Mary's Hospital alone brought Kavey 400 crowns in income.
In this case, if we still cling to patents, the situation will be small.
After suturing the peritoneum, re-examine the various organs in the abdominal cavity. After confirming that no gauze instruments are left behind, rinse the abdominal cavity twice, and then start closing the abdomen.
This complex abdominal surgery, which lasted from 1 p.m. to 5 p.m., finally came to an end with Kawei's "The operation is over!"
Kawei took off his leather skirt and gloves and left the center of the surgical square without looking back. But what was waiting for Fernand was not the post-operative care ward, but Edward's sentencing. After all, he is just a death row prisoner used to show off the surgery, and there is no room for bargaining with his life.
But unlike Kavi, the hands-off shopkeeper, Edward is now in a very difficult situation.
The operation was a great success, and the audience was excited. At this time, it seemed very embarrassing to announce that the patient who had just been rescued was sent to the gallows: "...Congratulations to Dr. Carvey on a successful operation. This is really unexpected." Exceeded my expectations. For such a death row prisoner, a devil with more than a dozen lives on his back, I feel there is no need to show him any mercy."
However, except for the two executioners, there were no tools for execution in the square, no guillotine, no gallows, not even a noose.
Everyone, including Edward, was convinced that the operation would fail, even Kavi.
But who could have known that there would be such a big change during the operation, the diagnosis was constantly changing, and the surgical plan was also changing. The operation in Edward's mouth was a revelation from God. Since God arranged it this way, the people had no hesitation.
Before Edward could speak, the whole audience began to shout "Live, live, live..." one after another.
82 Chinese website
