Cardiac decompression was first used in the 17th century, when a surgeon named Riolanas chose to cut the pericardium from the front. To do this, he not only needs to use a knife to cut the patient's skin, but also needs to drill a hole in the sternum, which is an extremely cumbersome step.
But since there was no anesthesia, the procedure was completed quickly.
The outcome is unknown. The only thing that is clear is that the operation to decompress the heart has been passed down. Even with the emergence of less invasive percutaneous puncture, incisional decompression can still appear in the surgical treatment items as the last resort for cardiac tamponade.
Even in the early 20th century, pericardiotomy and drainage were safer than blind percutaneous pericardiocentesis due to problems such as comprehensive visual field exposure. This situation was not improved until imaging emerged and became an important support for surgery.
But such an effective pericardiotomy and drainage is not a routine surgery, and very few surgeons are actually willing to perform it.
The main reasons are two points.
The first point lies in the blood coagulation mechanism during trauma that few people understand.
When blood overflows into the pericardial cavity through a break in the heart, the coagulation process is immediately initiated, and it does not take long to form a coagulated blood clot. The discovery and determination of this process is a rather long process.
Since the discovery of platelets in 1842, physiologists have spent hundreds of years successively discovering fibrin, fibrinogen, thrombin, and prothrombin [1]
Medicine is a discipline composed of a variety of knowledge accumulations. There seems to be a big difference between medicine and surgery, but the development of any branch is limited by the development level of the overall knowledge.
Of course, no one in Austria in 1866 understood why blood coagulated, and no one knew when blood would coagulate. There are doctors who understand the symptoms and diagnose pericardial effusion, but they are extremely limited, and even fewer have the courage to perform a paracentesis after diagnosis.
If after the puncture it is found that the blood cannot be withdrawn, everyone will choose to give up.
They will question their judgment, like those surgeons just did, thinking that the casualty did not have cardiac tamponade. Even if the diagnosis is clear, they will question their puncture skills, thinking that the failure to puncture blood is due to the wrong location.
The second point is the contraindication of cardiac surgery.
Even the most authoritative surgeons have to admit that the probability of survival after cardiac trauma is very small. Even if heart surgery is performed reluctantly, it will cause a series of problems, such as intraoperative bleeding and serious postoperative complications that are difficult to prevent.
The postoperative bleeding itself may also form new pericardial effusion, making the operation useless.
Therefore, for a long time, pericardiotomy was considered a foolish choice, and this mainstream view dominated surgeons' decisions. Kavi doesn't need to go back to Vienna now, and similar objections can be heard in the operating room.
"You want to drain the pericardium? Is this really appropriate?"
"The heart is not the abdominal cavity, and cutting the pericardium will bring unpredictable risks."
These are just small fights, what really troubles Kawei is Bill Rotter.
This devout Austrian Catholic, like the royal family of the Holy Roman Empire, has a very special belief in the heart: "The heart is the residence of the human soul. Operating on the heart is a blasphemy to the art of surgery!"
Kavi:? ? ?
"I am not the first surgeon to cut the pericardial cavity. Doctors have been doing this since the 16th and 17th centuries." Kawei stood beside the operating table, confirming vital signs and looking for the location of the surgical incision. "Be blasphemous, as long as the wounded can survive."
"No! You don't understand!" Bill Rotter advised. "Those surgeons who tried to operate on the heart ended up in ruins. You can go through the history of medicine. Many of them failed to survive." Name it.”
"I'm not interested in being able to leave my name," Kawei said. "The surgery is well-established and beneficial to the wounded, so naturally I want to give it a try!"
Billroth sighed, feeling helpless. Four months ago, he might have used his status as the vice president of the College of Surgery and his confidence in surgery to argue with Kawei, but now he has lost the confidence to do so and can only stand aside. He shook his head.
His retreat did not change the attitude of the surrounding doctors. Led by Bill Rotter, other opposing voices gradually emerged. However, they did not think about it from a metaphysical perspective, but thought about the problem from a more rational perspective:
"Even if there are traces, it's still very dangerous!"
"The injured person's vital signs are not critical now, and he was still conscious before anesthesia. This shouldn't be an indication for heart surgery, right?"
"But the diagnosis of cardiac tamponade is okay." Kawei was still explaining, "Anyway, I need to open his pericardium and remove the blood clot accumulated in the pericardial cavity."
"Is it possible, and I'm just saying possible, that cardiac tamponade can be relieved on its own? The blood clot may be absorbed by itself. Physiologists have explained it before. Thinking about it from another perspective, those patients or injured people who have undergone surgery are all If there is no good result, it is better to choose conservative treatment from the direction of internal medicine.”
"The result of their operation was not good because the patient's condition was too serious. Moreover, the operation was not sterilized. The cause of death was not the operation itself, but the severe suppurative pericarditis caused after the operation."
"But once the operation fails."
Kawei looked back at the doctors who were still trying to persuade him to stop: "I have decided."
He has never been a person who likes to explain, especially after making a decision. The explanation is nothing more than to help the other party accept the facts further. But if the other party insists on not accepting it, then Kawi will choose to give up the explanation.
He has become more stubborn since he became the emergency director. Unless a family member comes forward to stop it, no one can stop the planned operation.
Now that his power is at an all-time high, he has long since lost patience with such advice. Moreover, Rogelini's situation is inherently special. It is extremely rare for people with cardiac firearm injuries to persist to this day, and luck plays a large part in it. If you give up, you don't know how long it will take to encounter such a wounded person next time.
The diagnosis was clear. The wound should be located in the left ventricle. Judging from the speed of the development of the injury, the wound was not large. The symptoms of the wounded were becoming more and more obvious, but the vital signs were relatively stable. Moreover, they were in Olmitz Fortress General Hospital, which had the best logistics preparation. .
According to the practice of modern military medicine, such wounded patients should undergo thoracotomy and pericardiotomy + cardiac repair as soon as possible.
Kawei thought so too.
but.
Kawei is also a human being, and no matter how powerful he is, he cannot exceed the limits of a normal surgeon. As human beings, it is impossible to make every decision right.
Therefore, in order to pursue perfection, he would consider all conditions twice before formally deciding on the surgical plan. Although Kawei himself felt that he re-examined the correctness and success rate of the surgical plan for safety reasons, in fact, the voices around him had already subtly changed his mind.
Before leading the operation with more than a hundred years of advanced surgical techniques, Carvey had to consider many other factors. For example, the current operating room environment is terrible, I am not very skilled in cardiothoracic surgery, and the assistants around me have no cardiothoracic experience.
In addition, unstable anesthesia during the operation, the last location of the bullet trajectory, whether the heart rupture is serious, etc. are also important considerations.
It is very difficult to sew a wound in the heart, but it is not impossible to do it. However, for safety reasons, it still needs to be carefully considered whether it is really necessary to forcefully open the chest for suturing. What troubled him the most was the size of the heart hole.
Judging from various current factors, the heart break should not be large, it may be just a tangential injury of less than 1cm, and the location is in the thicker ventricle of the myocardium. The amount of bleeding may not be large, and it may even coagulate to stop the bleeding on its own.
Although such a small wound does not require conservative treatment, Kawei needs to put a question mark on whether dangerous sutures need to be performed directly in the case of cardiac tamponade.
The opposition voices around him were suppressed, but the opposition voices in Kawei's own heart slowly rose up.
Is it really too risky to just do heart suturing as others say?
Is it possible to perform palliative care, which only deals with the current cardiac tamponade and puts the gap in the heart that has been blocked by the blood clot away? After the cardiac tamponade is relieved, the patient's condition should be closely observed. If tamponade recurs after surgery, dangerous cardiac repair surgery should be performed.
Or you can carefully observe the situation after the heart beats when the blood clot in the pericardial cavity is clear. If there is an overflow of fresh blood, it is not too late to consider cardiac suturing.
In the eyes of outsiders, less than half a minute passed between the time Kawei verbally made it clear that surgery would be used to treat cardiac tamponade and when he took the scalpel and prepared to perform the operation. However, Kawei has already rehearsed many possible situations in his mind, and even the rare pseudocardiac tamponade is within the scope of his consideration. 【2】
These combined circumstances finally changed Kawei's previous decision.
He changed the original pericardiotomy and drainage + cardiac repair to simple pericardiotomy and drainage, and he placed the remaining cardiac repair after the pericardiotomy. This is a sign of stability, because Kawei is not too sure about the success rate of heart repair.
It's not that he thinks failure will affect his status and identity. What he cares about is that if this operation fails, the number of doctors who dare to perform similar operations in the future will drop significantly.
Since simple pericardiotomy and drainage were chosen, the surgical location also needed to be changed.
The fifth and sixth intercostal space incisions used for cardiac suturing may cause various complications. If only the pericardium is to be incised, it is safer and more reliable to choose the subxiphoid incision.
Subxiphoid pericardial window is a very common method of pericardial drainage, and its indication is severe cardiac tamponade like this.
In order to save the life of the injured, this operation does not even have absolute contraindications. That is, no matter what special circumstances the injured person has, as long as the doctor determines that cardiac tamponade threatens life, he can choose to perform this operation immediately.
Demonstrating the entire surgery process in front of so many surgeons is to hope that they can master this kind of surgery, because similar patients will appear on the battlefield at any time in the future.
Carvey asked Lucius and Goram to come on stage, and used a scalpel to gently open the lower edge of Rogerini's xiphoid process: "I remember that in 1810, a French surgeon named Larry risked losing his job. , bravely drained pericardial effusion in a patient with mediastinal tumors. The location he incised at that time was the fourth costal cartilage, vertically downward along this anatomical position."
"I have the impression." Lucius suddenly said, "The patient lived for 23 days and finally died of severe pericarditis."
"So disinfection before and after surgery is very important."
Carvey's scalpel entered the 5cm longitudinal incision under Rogerini's xiphoid process, continued downward, incised the abdominal white line, and separated the xiphoid process: "I chose to avoid the xiphoid process of the chest. The incision ensures the integrity of the bear's ribs and has far fewer complications. Give me the rongeur."
What he wanted to do was to cut off the xiphoid process that affects the surgical approach downward to expose the surgical field. Regardless of whether the indications for surgery were clear or whether the surgery was really suitable for Rogelini, at least Carvey's technical skills were enough to convince these objections.
After a few clicks, the xiphoid process was removed.
"Here, wash away the broken bones." Kawei continued downward, separated the pleura on both sides, and then found the diaphragm below. "Each person can pull it open with a hook, and give me a needle and thread and four hemostats." [3]
The role of the needle and thread is not in suturing, but in the subsequent pericardial window opening.
Kawei retracted the broken end of the sternum and soon saw the pericardium. Unlike a normal heart, the pericardium does not beat with the heart at this time, but appears very full, like a plastic bag filled with water.
"The tamponade situation is already serious. If the drainage is not opened, something will definitely happen."
Kawei used a scalpel and scissors to make a small incision in the pericardium. After separating the four corners, he used four sutures and four hemostats to pull the four corners of the pericardium window to create space for himself to remove the blood clot. 【4】
"Have you seen these black jelly-like things?" Kawei took the suction device handed over by Goram, "I think you guys who often do dissections should know what these are."
"Blood clot."
"Because these blood clots fill the pericardial cavity and seriously affect the beating of the heart, a series of symptoms will occur." The suction device in Kawei's hand began to work. "What we have to do is to remove the obstructive blood clots."
Perhaps due to the improvement of the Laszlo Foundry, the suction power of the suction device has reached a higher level. When a large semi-solid blood clot penetrates into the suction pipe, a dark red viscous liquid flows out like a waterfall. It infiltrated into the upper pericardial space.
"gauze!"
Kawei immediately realized that the blood clot on the heart break had fallen off, and it was impossible to stop the bleeding with just a small window. He gave the suture needle and thread to Ichisuke Lucius, and the suction device to Goram: "The suction device and gauze stop the bleeding, and then quickly sew the pericardium."
The two assistants didn't follow his train of thought at all, and they still didn't react when they saw the scene just now: "Shall I suture it?"
"The heart is leaking. I need to have a heart repair right now." As soon as he finished speaking, Carvey's scalpel had already landed on the skin above Rogelini's fifth rib.
(End of chapter)
