No one except Kavi knew why Rogaro had the surgery.
Surgery requires surgical indications and technical support to complete the operation. Cholecystectomy has gone through the process of "cannot be cut, but can be cut. If not cut, just remove the stone. If there are stones, cut them. If there are symptoms, cut them. If you can do it endoscopically, The bumpy process of laparoscopic resection.
Nowadays, the indications for cholecystectomy are patients with symptomatic gallbladder stones (resection is performed only when symptoms are present), rather than in the past (resection is performed only if stones are present).
However, there are exceptions. For example, if a patient lives in a remote area with poor medical conditions and has gallbladder stones, preventive cholecystectomy may be considered. Medical conditions in the 19th century were definitely not good, and patients like Rogaro did have to have their gallbladder surgically removed as soon as possible.
Rogaro is a typical symptomatic patient. He has severe pain in the right upper quadrant, obvious tenderness and rebound tenderness, and Murphy's sign. His body temperature was just measured at 39°C. It is basically certain that he has cholecystitis.
Even if Kawei's diagnosis was wrong, he still needed to undergo an exploratory laparotomy as soon as possible due to high fever and abdominal pain for three days, so no matter how he performed the surgery, it would not be wrong.
"Gallbladder surgery is basically based on removal, because there are a large number of stones inside, and acute inflammation can easily become chronic. Preserving the gallbladder is unwise and may even be counterproductive."
Kawei originally wanted to make a midline incision on the upper abdomen, but his confidence in the diagnosis still led him to make a right subcostal incision, which is most commonly used for gallbladder surgery: "I have already talked about the symptoms of cholecystitis and surgical indications on the way, and now it is Incision selection for cholecystectomy.”
Hermann divided the retractors between Damirgang and Beckett, one pulled the skin and subcutaneous tissue, the other pulled the costal margin of the right upper abdomen, and he and Kavi cut down the skin and tissue.
While he was doing his assistant's work, he was thinking about this brand-new operation, and soon came up with a question that came to him after thinking independently: "If it's just a stone, can you cut open the gallbladder and remove the stone inside? Maybe Rinse again, wait until it’s clean, and then sew the gallbladder shut?”
This is a good proposition, at least in the early days of modern general surgery. Even by the end of the 20th century, surgical technology had developed to a certain height, and some people put forward similar views.
Unfortunately, the evidence-based medicine followed by modern medicine uses large sample data to resolve disputes.
"It's not necessary, just cut it off." Kawei changed his usual surgical attitude of focusing on precise operations and directly rejected this view.
Hermann’s idea was limited to abdominal anatomy in the 19th century, which was very similar to that of Donilson and Yingenatz: “But the anatomical structure around the gallbladder is very messy, and resection can easily lead to operational errors. Incision and stone removal do not have this problem. Perhaps ..."
Kawei tapped the tissue forceps in his hand with his own needle holder and reminded: "The proposal is good, but this is my surgery, so I have the final say."
"......yes."
"If you feel that gallbladder removal is not good, you can handle this type of patient yourself." Kawei did not mean to blame him, "but I think you will give up such thoughts after entering the abdominal cavity."
Herman didn't understand what he meant. He didn't realize the seriousness of the problem until he cut open the abdomen all the way down and saw and gently turned over the liver.
"Give me a retractor for my organs." Kawei took the hook given by the nurse, helped to press the liver, lifted it up slightly, and said, "Have you seen the tissue structure under the liver?"
"I saw it."
"Can you see clearly?"
"cannot......"
"I have said before when performing appendicitis resection that inflammation will stimulate adhesions in surrounding tissues. It is very difficult to distinguish adhesions. There is no possibility that simply incising the gallbladder is more convenient than removing the gallbladder. And... .”
Kawei looked at the chaotic gallbladder triangle and the surrounding purulent fluid, and felt bad: "The greater omentum is wrapped up, and yellow-green fluid can be seen around it."
"Is this pus?"
"Maybe."
Kawei used tissue forceps to slowly separate these adhesions, and his movements became more and more careful: "The adhesion site we have to deal with first is not the liver and gallbladder, but the hepatic flexure of the colon below the liver and gallbladder. You need to be extra careful when separating this kind of adhesion. It is necessary to achieve careful separation without damaging the surrounding tissue while ensuring basic hand speed."
The tissue above the hepatic flexure of the colon is separated to free the hepatic flexure of the colon, usually to the second segment of the duodenum and the head of the pancreas. Then put a moist gauze pad between the gallbladder, transverse colon, and duodenum, and then pull the transverse colon downward to expose the gallbladder neck well. 【1】
However, just exposing part of the gallbladder scared them. It was completely different from the gallbladder they usually saw during autopsies.
Kawei gently touched the gallbladder wall with tissue forceps and said: "The adhesions are severe, the epidermal tension is high, the shape is enlarged, and the texture is very brittle. It is typical of gangrenous cholecystitis and will break if you are not careful. If there is If it breaks, the pus inside will pour out, and the consequences will be disastrous.”
"What will happen?"
"Similar to acute peritonitis, you end up with shock."
The gallbladder is visibly blackened and enlarged, and the surrounding tissue is tightly packed. Even the simplest tissue around the gallbladder cannot be separated cleanly, and the most important gallbladder triangle is even more troublesome. The anatomical structures there are all mixed together, including blood vessels and bile ducts. Damage to anyone would be fatal and would greatly affect the prognosis of the operation.
In ordinary cholecystectomy, the gallbladder itself will be simply stretched.
For example, the ampulla of the gallbladder can be clamped, pulled toward the head and side, and then the serosal layer of the hepatoduodenum can be opened, so that the anatomical relationship within the porta hepatis can be clarified. 【2】
But now the texture of the gallbladder cannot withstand clamping. It would be a blessing if it is not broken. How to separate it?
Kawei put down the tissue forceps, postponed the scheduled cholecystectomy, and thought differently. Since the gallbladder is severely swollen and adherent, and we are afraid that it will burst and leak fluid, we simply solve these troubles before doing the surgery: "Nurse, give me a syringe."
The syringe was inserted into the bottom of the gallbladder [3], and 4ml of pus was slowly withdrawn. The surface tension of the gallbladder became smaller. Kawei also discovered two key points from the puncture.
First, during the puncture, it was found that the gallbladder wall was very thick, probably more than 4mm. This was caused by the proliferation of the gallbladder after inflammation. Second, there is not much pus, but more gallstones, especially silt-like gallstones.
Based on these two points, Kawei became bold in his separation action: "If it is an ordinary gallbladder stone and the gallbladder volume does not increase significantly, we may be able to dissect the gallbladder triangle first.
However, the anatomy of the gallbladder triangle is currently in chaos. It is more reliable to separate the gallbladder first, and it will also provide more visual fields for the subsequent dissection of the gallbladder triangle. "
Speaking of vision, he changed the position of the candle holder in Berget's hand: "Now we continue to separate the tissue around the gallbladder and separate the gallbladder from the liver gallbladder bed as soon as possible. The nurse will prepare the stove and wire, and may need to cauterize the wound."
Kawei's preparation was very timely.
Because the enlarged gallbladder in gangrenous cholecystitis will be in close contact with the liver, bleeding from the separation wound will often occur when the gallbladder is separated. Moreover, this kind of bleeding is often very large, and ordinary needles and threads will not work.
Modern surgeries will choose medical hemostatic glue and hemostatic gauze, but the only thing Kawei can use is the backward combination of posterior pituitary lobe extract + gauze + cauterizing wire.
Peel off, bleed, cauterize to stop bleeding.
Peel off again, bleed, and stop bleeding again...
It took him more than 20 minutes to separate the gallbladder, which was basically the same speed as before when he came on stage. Considering the current conditions, it can be said that his performance was extraordinary. But this is not enough. The ideal operation time should be no more than 50 minutes, which means it will end with the first ether anesthesia.
"The separation of the gallbladder is complete. Let's put it aside temporarily and start to separate the gallbladder triangle downward."
Because the gallbladder has been decompressed just now, and the gallbladder wall is very thick, as long as you protect it and be careful that the pulling will not cause gallbladder rupture: "Herman gently pulled the tissue forceps, right, outward, then outward, don't use too much force. , Okay! Just keep it like this!"
During separation, it is first necessary to open the serosal layer of the hepatoduodenal ligament and clarify the anatomical relationship within the hepatic hilus. 【4】
Kawei quickly spotted the cystic duct, used a silk thread to perform a double ligation, and then said: "The double ligation is to prevent small sand-like stones in the gallbladder from being squeezed into the common bile duct through the cystic duct during surgery. Causing unnecessary obstruction.”
"Where is the gallbladder artery?" Herman's eyes were a bit dazzled, and he really couldn't figure out the internal position of the gallbladder triangle.
"We have to continue to dissect slowly..." Kawei carefully turned over the surrounding connective tissue and said, "The cystic artery originates from the common hepatic artery, or it may originate from the right hepatic artery. The anatomical variation here It is very common, so the structures of the biliary tract and arteries should be carefully identified to avoid unnecessary damage to the tissue structures."
In fact, in addition to these two categories, there are many special variations, which are also an important factor in the troublesome triangular anatomy of the gallbladder.
For example, it originates from the left hepatic artery, or there are two cystic arteries originating from the left and right hepatic arteries respectively. 【5】
Fortunately, Rogaro's cystic artery is not troublesome, and the starting position is the very standard right hepatic artery. But this does not mean that dissection is easy. Before the right hepatic artery tortuously enters the liver parenchyma, it will accompany the cystic duct and gallbladder. It can easily be mistaken for the cystic artery, leading to ligation errors.
"So, no matter what the situation is, the cystic artery should be clearly dissected out, and it must be clear that it has indeed entered the gallbladder before ligation can be performed."
Kawei's dissection is very detailed, but his hand speed is not slow at all. The triangular anatomical structure of the gallbladder gradually became clear before everyone's eyes, and the path of the gallbladder artery slowly emerged.
"Generally, the cystic artery runs on the surface of the cystic duct and then enters the gallbladder vertically."
Kawei changed the direction of the gallbladder pulling, exposing more of the anatomical area of the gallbladder triangle, and the course of the cystic artery became clearer: "First give me a set of suture needles and silk threads, and then prepare two sets of the same ones. I want Get a triple ligation.”
Cholecystectomy is not a particularly troublesome operation, and it is one of the surgeries that Carvey hopes to give them as soon as possible.
The difficulty and popularity should be comparable to cesarean section and appendicectomy.
But a troublesome part of this kind of cramming teaching is that many details are difficult to grasp and must be emphasized repeatedly to strengthen their memory. Therefore, during the interval between ligation, Kawei once again emphasized the key points of dissecting the gallbladder triangle and ligating the cystic artery.
"What I want to emphasize repeatedly is that it is very, very, very important to dissect the gallbladder triangle. The course of the cystic artery must be completely exposed, otherwise the cystic artery should not be ligated and cut off. In this case, repeated confirmation is required before making a judgment. Don't be irritable, be sure to patience."
After dissecting the blood vessels, Kawe performed clamp dissection of the cystic duct, and the huge gallbladder was removed from Rogaro's abdominal cavity.
"Saline solution, rinse the abdominal cavity quickly."
"How many times?"
"First come three times and rinse carefully, especially since there was a lot of pus and bleeding in the area where the surgery was just now."
"I understand this."
Bergert poured the saline solution from the metal basin in his hand into the abdominal cavity. Damirgang shook his abdomen and sucked out the liquid through the suction device: "There is not much bleeding, and there is some purulent residue, but not much."
"Well, after cleaning, put two drainage tubes under the liver."
"OK"
After Kawei put the black and swollen gallbladder into the tray, he gently cut it open with scissors and used forceps to separate the gallbladder wall, revealing a large number of gallbladder stones inside: "For a record, remove the huge gangrenous gallbladder, size 9*8 *3cm. After incision, there were a large number of silt-like stones in the gallbladder, the largest of which was 3cm in diameter."
[My mother-in-law passed away, suffering from pulmonary hypertension and right heart failure for nearly 20 years. It has been delayed long enough. I’ve been a little busy lately, so I suggest you try some fattening up.]
