[This thing has a bit of stamina. I’ve been on duty all the time and haven’t had a break these days, so the words haven’t been coded. I’m sorry. 】
Kawei's previous choice was a midline incision in the lower abdomen, with the lower edge just enough to be pulled 2cm below the right common iliac branch. Now the blood vessels are severely broken and the length of the incision is limited. If you want to do the next step, you have to expand the incision downward. 【1】
"The right common iliac artery is seriously ruptured, and there is a considerable distance between the external and internal iliac arteries. If you were to handle it, what should you do on the premise of limb preservation?" Kawei followed the original incision downwards. The dilation was extended by 5cm. Seeing that they didn't respond, he continued, "If you want to be a surgeon, you have to learn to think independently."
They also want to think independently, but the current situation is completely beyond the scope of the three assistants. The blood vessel separation defect reaches 4cm. No matter how strong the elasticity is, it is impossible to tighten it and continue suturing. It can be said that there is no room for operation.
If Kawi hadn't been there, the leg would have been amputated long ago, and so much time wouldn't have been wasted.
Compared with this wounded soldier's leg, the lives of other wounded soldiers are more important. But now seeing Kawei's determined look, they all wanted to see how this operation would develop.
The right lower limb is severely ischemic, and half an hour has passed, so we need to speed up.
With the help of Damirgang, Kawei quickly separated the skin and muscles and continued to ask: "Then let me change the question, which parts of the internal iliac artery and external iliac artery are responsible for the blood supply?"
This was not difficult for the three of them, and they quickly gave the answer: "The external iliac is responsible for the lower limbs, and the internal iliac is responsible for the lower abdomen and pelvic cavity."
After incising the skin and muscles, Kawei changed the position of the retractor and expanded the surgical area from the right side to the left side: "In order to provide blood supply to the right lower limb, the blood pumped by the heart needs to be perfused into the right external iliac artery. So the question is, which blood vessel is the right external iliac artery closest to now? Is it the right common iliac artery that has been cut off?"
"Obviously not......"
The three of them were confused again. This was not a problem, because there was only one major artery in the surrounding area, and there was no possibility of connecting to it.
But while he was talking, Kawei had already started dissecting the left area. From the questions to the operation, they were reminded that the next operation area was on the left side, and what he was going to do was a kind of blood vessel grafting that no one had ever tried before.
Does it need to be connected to the left iliac blood vessel?
This route is indeed a bold choice, but the problem is that the cut-off position of the right external iliac artery is fixed. Even if you turn around to connect to the left internal iliac artery, it is completely out of reach. There is such a gap in the middle... ..
emmmm...it doesn't seem right!
The three of them seemed to have caught something extraordinary. After looking at each other twice and then at the surgical incision, they came to their senses.
"Is it necessary to connect it to the left internal iliac artery?" Damirgang tried to answer, "Let the blood from the abdominal aorta pass through the left common iliac artery to the left internal iliac artery and then flow into the right external iliac artery, thereby saving the patient's limb."
Kawei nodded slightly, but gently played with the external iliac stump clamped by the hemostat in his hand, and asked: "The left iliac inner part is here, the stump is here, how do you plan to connect it?"
Seeing that Kawei had already begun to separate the left common iliac, external iliac, and internal iliac arteries, Damirgang tried to answer again: "There is a long distance between the stump and the left internal iliac artery. It is definitely impossible to graft with a hole." , we can only cut off the left internal iliac artery, leaving enough length to actively connect the right external iliac artery." [2]
"That's a pretty good answer."
The answer was correct, but the three of them did not know the underlying logic that supported this answer.
As the saying goes, the more you know, the more questions you will have. When you suddenly understand the surgical plan, you will find many logical inconsistencies after calming down and thinking about it: "But if you do this, both internal iliac arteries will be damaged." Will ligation affect the pelvic blood supply?"
"Yes, yes, it's very good to think of this step." Kawei finally separated the left internal iliac artery, but still didn't want to give a direct answer, "Do you remember the cesarean section?"
The three of them said in unison: "Remember."
"How do I deal with heavy bleeding when I expect it?"
"Tie the cervix."
"Um."
"Compression of the uterus."
"Um."
"Gauze packing?"
"Well, what then?"
Herman was deeply impressed because he and Kavi had undergone several cesarean sections. He immediately related the current situation and replied: "Ligate the uterine artery."
"Yes, if heavy bleeding is expected, I will definitely ligate both uterine arteries." Kawei said, "Does ligating both uterine arteries mean that the entire blood supply to the uterus is destroyed? Is the uterus useless? What?"
"No! In addition to the uterine artery, there are many collateral circulations that deliver blood to the uterus. They only deliver very little blood under the premise of compressing the uterine body and binding the cervix." Herman brought the topic to the current surgery, " Is this also true for the bilateral internal iliac arteries?”
"In addition to the bilateral internal iliac arteries, the blood supply to the pelvis and buttocks is also supported by the inferior mesenteric artery. Normally, these three blood vessels have abundant interconnected side branches. As long as the blood supply of the three blood vessels is good and the side branches are abundant, Any two of them can be ligated without causing ischemia of the pelvic organs and buttocks." [3]
"I see."
"Prepare two hemostats, and then prepare the sutures, and we will perform the anastomosis again." Kawei said, "You should continue the same as before, hold the hemostats in place, and use sodium citrate to expose the field of view."
"OK."
"OK."
Kawei sutured the stumps of the right common iliac artery and the right internal iliac artery, kept the stump of the right external iliac artery, calculated the length from the left side, and then found the position to cut off the left internal iliac artery: "A hemostat at the proximal end, One at the distal end, split in the middle with a razor blade...sew the distal end closed..."
After repeated inspections showed no bleeding in the three stumps, Kawei safely returned them to their original positions, leaving only the left proximal internal iliac stump and the right external iliac stump.
The second anastomosis took a lot of time, and the suture tension was also very subtle because part of the suture distance was reserved in advance: "Damirgang, it's your turn this time, please help bring the last gaps together, and wait for me Release the hemostat once the suturing is complete.”
"Um."
It seems that Kawei is so determined that he still delegates this operation to his assistant. But if you look closely, you can still see the traces of the lesson he has learned. At least the tone of the command and the vocabulary used are different: "The movements must be very, very gentle to bring the blood vessels together. They must be very gentle...very !Qingrou! Do you understand?"
"OK......"
Damirgaon's hands were similar to Herman's. It would be good if the strength gained from years of orthopedic surgery on the limbs could adapt to the environment in the abdominal cavity. Now he must be more careful when dealing with tender blood vessels.
"Slowly, must be slowly..."
Damirgang held two hemostats, and the force in his hands was transmitted to the blood vessels through the handles of the forceps. The stump of the blood vessel gradually moved closer to the center under his guidance, and Kawei followed this force and slowly tightened the suture: "Well done, just keep the tension like this and get ready to tie the knot. Come on, nurse, put it in my hand Pour some warm water on it to soften the clotted blood around the thread."
The next knot-tying was Damirgaon's forte, so as long as he performed it with the same strength as before, there would be no problem.
"The suturing is complete." He performed it carefully to the last moment, even removing the needle holder with great care, for fear of disrupting the operation again, "The hemostat must be completely loosened next."
"Well, loosen the distal end first...then loosen the proximal end..." Kawei briefly checked the suture quality, "Okay, the anastomosis is successful!"
The two loosened blood vessel clamps were like the gates of a dam opened, and the gushing blood was like the rushing river water, instantly flowing into the blood vessels of the injured person's lower limbs from the newly anastomotic passage. The right external iliac artery, which had been lifeless just now, began to pulse evenly and powerfully with the heartbeat.
Kawei asked them all to reach out and feel the pulse of the right external iliac artery. He did not want to rely on this to judge the success of the blood vessel suturing, because they could see the blood vessel pulsing just by looking at it: "Remember this feeling, and do what you want in the future." Stopping bleeding from large blood vessels is very important.”
"The dorsalis pedis artery is also pulsing!"
“My blood pressure and heart rate are both good!”
The nurses and Amor came forward with good news, but it was still not time to declare the operation a success. The bullet entered the blood vessel in the front through the lower lumbar spine. It has not been found so far. It may have entered the abdominal cavity.
Whether the bullet itself can be found is secondary. The main thing is to prevent the intestinal fistula from forming in the intestine that was shot, so the abdomen cannot be closed for the time being.
"First suture the retroperitoneum, and then we have to carefully check whether there is any leakage in the intestines." Kawei handed the suture to Damirgang, and he and Bergt began to check the intestines step by step with their fingers, "Wait a minute Rinse the abdominal cavity after suturing..."
If there is no problem after repeatedly rinsing the abdominal cavity and checking the intestines with fingers 2-3 times, Kawei can be sure that there is no problem with the intestines, and there is no need to look for bullets. After all, the danger of a metal slug floating outside the organs is far less than that of a long-term laparotomy.
As for the lumbar spine surgery just performed, since it has been simply sutured, let's leave it alone for now and choose further treatment options based on the recovery of the injured soldier.
So for Kawei's team, checking the abdominal cavity became the last step of the entire operation.
However, this last step required much more time than the grafting of the right external iliac artery just now, so much so that the Prussian army outside Gablenz could not hold back and launched a new round of attacks.
...
Kavi has said before that large military hospitals are not suitable to be built in forward areas like Gablenz. Although there are many residential buildings, buildings, churches and warehouses suitable for use as wards, considering the previous war situation, they were attacked. It's only a matter of time.
The most reliable way is to only perform simple first aid here, and transport the remaining wounded soldiers as far back as possible, so that they can be safely treated in the rear areas away from the chaos of the front lines. An important city that meets these conditions and is some distance away from Gablenz is Kissin.
It's a pity that almost no 19th century army could do this after a heavy defeat.
In particular, the troops on the Western Front have not received long-term escort drills, and there are also big loopholes in the reserves of carriages and medical equipment. In comparison, sending good surgeons to the front lines seems like an easier alternative.
According to the division of labor of the Military Medical Department, Kawei is only responsible for the affairs of the Omilz Fortress General Hospital on the Northern Front, and several first aid teams are also active on the Northern Front.
However, the war on the Western Front is tight, and medical resources must be tilted compared to the lukewarm Northern Front. The "tactful" request given by Archduke Brecht made it difficult for Kawei to refuse. Considering that there were not many people at hand who could be of great use, Kawei could only come to the Western Front to support himself.
Of course, what supported him in coming to the Western Front was not just courage or the aristocratic complex of serving the empire, but more importantly the escort given to him by Franz.
"Dr. Kawei, it's too dangerous here!" The captain of the escort team who had been following Kawei was now rushing into the operating room with his team members. "Please evacuate immediately!"
"What's going on outside?" Kawei was still checking his intestines, and the sound of artillery fire in his ears seemed to have hit the Gablenz Central Hospital that had just besieged the city. "Have the Prussians already invaded?"
"The specific situation is unclear, but the sound of artillery fire has reached here, it must be not far from the city center!" After the captain said this, he stepped forward and tried to pull Kawei's arm. "Now that we are leaving the operating room, we can retreat in the direction of Kisschin. , where you can..."
However, Kawei didn't want to listen to his command. He threw away his arm and looked back at the captain: "Don't affect my operation."
"Dr. Kawei, now is not the time to worry about surgery!" The captain and Kawei have been living together in the past few months. Knowing his temper, he is really anxious this time. "Other doctors and wounded soldiers have begun to evacuate. No more, we can’t stay any longer!”
"I'll finish it right here!"
The captain couldn't understand the operation. He only knew that he had been tinkering with the intestines and didn't know when it was over: "You assistants didn't help to persuade me!"
The four of them knew that the surgeon on the operating table was the most powerful, and they looked at each other for a few times, not daring to persuade. Kawei was accelerating in his hands, but he still had to calm everyone down. After all, the operation was about to end: "What did His Majesty the King say when he asked you to be the captain of my escort team?"
Come and try it quickly. 】
"Protect your life at all costs!"
Kawei nodded: "So stay outside the operating room and obey the orders!"
"The Prussian cannonballs don't have eyes, and the next one might hit the operating room!" The guard captain gritted his teeth and exchanged glances with his men. He stepped forward and hugged Kawei, carried him on his shoulders, and walked away. He ran out of the operating room and said, "Hurry up and pack up and leave together! Evacuate quickly!!"
Kawei had never been treated like this before. He looked at the ground and used his hands and feet to still be unable to break free from his iron-like arms: "Hey, what are you doing?! Put me down quickly!!!"
"I am obeying His Majesty the King's order! Because this is the most direct way to protect your life!"
