Hills was a peripheral figure in the entire operation, passing instruments and tools and other chores, often leaving the operating table. Everyone else's attention was also on the surgery area, and they wouldn't look at him unless there was something particularly important.
If Hills was dumber and didn't realize that dropping would carry bacteria, or was selfish, or wanted to save face, and chose not to say anything, then the accidental drop of a small piece of iliac bone flap would not have attracted anyone's attention at all.
By simply squatting down and picking it up, you can act like an outsider without even noticing.
At that time, the bone flaps that touch the dirty towel will bring dense bacteria into the old marshal's intervertebral disc, and the original chance of infection, which may be only 20 to 30%, will be magnified to 100%. As for whether Ludwig can survive the disc infection, everything will remain unknown.
Surgery is not afraid of encountering problems, but it is afraid of not being bored when encountering problems.
Now that Hills has spoken out about his mistakes very bluntly and without escaping, there is still room for maneuver.
Kawei has taught countless students and knows that although swearing at someone at this time is useful, it can easily damage their self-confidence, but not saying a few words will make the other party think that the problem is not serious, so the tone, attitude and subsequent operation methods are very important: " Why did it fall to the ground?"
Hills knew he was wrong and explained: "My hand slipped when I took it."
"Where did it fall? On the ground?"
"It didn't touch the ground, it fell on the towel."
"Skeletal surgery has very high requirements for sterility." Kawei just looked up at the bone flap in his hand and continued the bone scraping operation in his hand, "I have repeatedly emphasized this in the previous cadaver dissection exercises. , If you cannot perform aseptic operation well, you are not qualified to operate on the marshal."
Compared with the treatment of interns on the modern surgical operating table, this sentence is very soft.
But after all, Hills was also the chief surgeon at Graz Hospital. It was equivalent to speaking to a senior surgeon as a resident, so his words were naturally very serious. Fortunately, this place was not an operating theater but the marshal's bedroom. There was no one else around, so his most basic self-esteem was preserved.
"It's my problem. My vision and movements were misaligned just now." Hills admitted the mistake, "What should I do now?" [1]
Regarding the bones, the four people present had done three types of treatments: one was amputation, the other was drilling the skull, and the third was fracture and bone resetting. There is no bone surgery in the strict sense, let alone such a delicate and complicated spinal surgery.
In their eyes, the surgery itself is a blind spot.
After all, Hills has many years of clinical experience, and it is impossible for Kawei to pursue his mistake: "First rinse with normal saline. It is a rinse, not soaking in it, otherwise the whole basin of water will have to be poured out."
"Then what?" Hills guessed the beginning.
"Then take diluted methylene blue," Kawei said. "It's in my toolbox. Put half a bottle in one liter of water. Mix it and soak it for half an hour."
When he heard it would take so long, Hills sped up his hands: "You guys do other things first, I'll get it done as soon as possible."
Kawei was not happy that the surgical procedure was forcibly changed, but this was also an established fact. At least Hills did not hide it: "Before disinfecting and soaking, help me get a small leather bag from the suitcase."
Hills saw the long leather bag in the box at a glance: "Is it this?"
"right."
Kawei handed the fascia-skin suture of the posterior superior iliac spine to Massimov. After changing his position, he spread out a piece of clean gauze: "Open it carefully, and then take out the white cloth bag inside."
Hills untied the rope on the leather bag and slowly took out a white cloth bag inside: "Whatever it is, it needs to be wrapped in two layers."
Kawei didn't reply, just said: "Open it carefully as before, and then slowly pour the contents onto the gauze. Be careful not to touch the contents with your fingers."
Hills nodded.
Simple posterior lumbar interbody fusion destroys the posterior bone structure and affects stability, so the long-term effect of the surgery was not ideal in the years when it first appeared. It was not until later that the Department of Orthopedics pointed out the skill tree of internal fixation, and the addition of internal fixation on the basis of interbody fusion led to various types of LIF that are widely used in modern times. 【2】
The bag contains the screws needed for internal fixation. Because there is no stainless steel and pure silver is too soft, Kawei can only choose silver alloy. 【3】
"The worries of all the teachers before were indeed necessary, so I chose to use screws to fix the lumbosacral area after filling the intervertebral disc." Kawei briefly demonstrated, "The injection site."
As soon as the words started, Orgi felt something was wrong: "You mean to drive nails into the marshal's bones?"
"Yes, I measured the size before and it's just right." Kawei said as he found the opening cone from inside. "As soon as possible, the longer it takes, the greater the risk of infection."
The previous abdominal surgery on Fernand had already revealed Kawei's unique surgical ideas. He did not follow the routine at all and was very willing to take risks and perform some complicated operations. The current vertebral body fusion surgery alone has opened their eyes. They have seen skin flap removal, but they have never seen bone flap removal.
Fusion surgery is seventy or eighty years ahead of its time, but relying on clinical foundation, these are still within the scope of their understanding.
But the bone nail implantation was incredible. This kind of bold surgical idea was something they had never seen before, and they didn't even dare to think about it.
Wouldn't this destroy the stability of the bones?
Will the bones break over time?
Is there any harm to the body if implanted?
Do you want to take it out again later?
There are so many problems that need to be solved. Their minds are blank. They dare not imagine what will happen after the silver nails enter the body: "Kavi, do you want to discuss it again?"
"No need." Kawei pointed to the signed consent form on the table in the distance. "The old marshal has given me the power to decide on the surgery. There is nothing to discuss."
"But if you penetrate the pedicle like this, will it damage the surrounding bones?"
"As long as the angle is okay, there won't be any problem." Kawei said while choosing the nail entry point.
"The pedicle is so thin that it won't be damaged?"
"Don't worry, this is the strongest part of the entire spine. I've tried it on cadavers and it's no problem."
"What if it's been a long time?"
"No, because for three months after the operation, the old marshal will be restricted from moving. Even if he can really move later, the curvature of his waist will be affected. He cannot exercise vigorously, cannot bear weight, and needs to squat down to pick up things, and cannot bend directly. waist"
Kawei did not hide the trouble caused by internal fixation: "But you should know that this is much more comfortable than the pain in the waist and legs before."
"Wouldn't it affect the body if the implant was inserted into the body like this?"
"As long as you don't have allergies. As for whether to take it out in the future, I don't think it should be taken out as long as there are no special circumstances." Kawei answered the last two questions, picked up the opening awl, and started to drill the nail entry point that had been determined. Li [4], "Oh, by the way, just take a look at this surgical method. Don't use it easily, as it may cause accidents."
Four people: "."
"I'm not saying you are incompetent, it's just that the angle is not easy to grasp and needs practice." Kawei said, "When I was a child, I felt that fractures should be solved with surgery, so I often used an awl to drill into the bones, and there would be no problem in judging the angle. .”
The structure of the vertebrae of the spine is different. Although they are all called vertebrae, the selection of nail entry points, inclination angle, and penetration length are all different.
The opening awl only drills an opening in the bone cortex. After entering the cancellous bone, a probe is needed to determine the entry direction of the screw.
In fact, the old marshal's posterior lamina has been completely removed, and the pedicle screws can be inserted under direct vision, which is much better than those cases of complex traumatic fractures. Kawei has a lot of experience in spinal trauma surgery, and he is not only strong in modern surgical concepts, but also in touch.
The angle of nail insertion is not fixed. For the lumbar spine, it is possible from 5 to 30°. It just depends on the differences between people.
Modern surgery may be able to use imaging image navigation to increase accuracy, but using image navigation will increase surgical costs, navigation learning costs, and instrument costs. For the surgical team, image navigation means taking rays.
Kawei doesn't like this. Setting nails with bare hands has always been something he emphasizes must be learned and practiced thoroughly. Even if optical navigation, electromagnetic navigation, and robot navigation appeared later, blind penetration is still one of the items he often emphasizes when teaching newcomers. 【5】
Since it is blindly penetrated with bare hands, the feel is particularly important. When the probe is inserted into the cancellous bone of the vertebral pedicle, it will feel like gritty friction. As you continue to insert the needle, you will feel a "pinched" inhalation sensation.
"It's like a stick inserted into the sand. In fact, you will know it after you become familiar with it."
Kawei quickly found the nail path on both sides of the pedicles of the lumbar vertebrae 4 and 5. He was as fast as an old carpenter who knows his way: "Next, two more are needed on the sacrum S1."
The shape of the sacrum is completely different from that of other vertebrae. Coupled with the complex anatomical structure in front of the sacrum, the position of the sacrum nail insertion is very particular, and the angle of the nail insertion also needs to be severely inward tilted. 【6】
Unknowingly, more than three hours had passed since the operation, and Kawei had dug out the holes from waist 4 to sac 1. Hills, who was carefully disinfecting the bone flap, also brought the results of the disinfection: "It's time to disinfect."
"Rinse twice more with saline."
"OK"
The surgery had reached this stage and he no longer cared about the situation in the bedroom. Because there is no wash basin, the saline flushing work can only be done on the floor, supported only by a few absorbent towels. Hills asked the housekeeper several times for it, but in the end it was no longer enough and he had to rely on carpets to absorb water.
Splattered blood, leftover gauze, bone fragments, and carelessly dropped surgical instruments made this place no less neat and tidy than an operating theatre.
"I now cut the bone flap into three pieces and place them flatly into the intervertebral disc space."[7]
Kawei calculated the height, removed the reamer, and stuffed the bone flaps in piece by piece.
In fact, the iliac bone was Kawei’s choice out of desperation, and the better choice was the intervertebral disc filling block [8]. As long as it is filled with bone, there is no need to worry about the height and the risk of postoperative deformation. Now, the filling height of the intervertebral disc has become the most troublesome problem before them.
"The height is not high enough." Even Waterman, who has no experience in spinal surgery, can tell that the intervertebral disc between lumbar 4 and 5 is thinner than other places. "Not only the lumbar spine, I also see that the intervertebral disc above sacrum 1 is not enough."
"What should I do? Do I need to make another incision and then take out the bone flap?"
"Or you can choose other metals, and the bone nails are already drilled, so that's not bad."
Kawei was also using a reamer to measure the gap height of the intervertebral disc, and suddenly opened a pile of clean gauze on the side. Inside was placed the freshly cut lamina fragments: "It doesn't matter, you can use these useless laminae. "
From a shape perspective, they lack sufficient thickness to be suitable as the main material for filling. But if you cut off the bone cortex and scrape off the spongy bone inside, the discarded bones can be reused.
The disadvantage of the original ecology is probably that it is a waste of time.
"Come on, let's each use an osteotome to separate these bones."
Downstairs, the pattern of sometimes caring about the operation and sometimes gossiping continued. When the clock officially passed 12 o'clock, lunch was silently brought up on the topic column by some people: "It's so late, why isn't the operation over yet?"
"Just wait a little longer. If there is no news now, it means the operation went well."
"After all, it's a brand new spinal surgery."
Everyone was chatting about the surgery, but their eyes were on the servants around them. They all have rich service experience, and the meal times are engraved in their biological clocks. Someone immediately reminded: "Everyone, if anyone is hungry, you can go to the restaurant first. The kitchen has prepared a sumptuous lunch."
With these words, everyone turned to Franz and sought the king's opinion. Because in the palace, even eating must be done under the orders of His Majesty the Emperor.
"I want to say a few words to Mr. Edward. You go and eat first."
Just when Franz waved his hand and was about to continue waiting for the results of the operation, there were rapid footsteps in the corridor.
The voice sounded from far away to near, and finally the old housekeeper who had been waiting upstairs came into view: "The operation, the operation is over!"
[Write this chapter while I take a shower]
(End of chapter)
