Mendelstein followed Carvey into the operating room.
This time he was not doing surveillance. There were two company soldiers watching in the temporary operating room that the confessional had turned into. If something went wrong, they would tell him immediately. I came to the operating room mainly because I was worried about the safety of my subordinates, and secondly because of my own curiosity.
In war, maxillofacial injuries like Opal's are not uncommon. After all, the head is the most important part of the human body. Bayonets, bullets and gun butts all like to greet this place, and stones are not unheard of.
But he always felt that Kawei's handling method was different from the military doctors he had seen.
He definitely doesn't understand surgery, but that doesn't mean he hasn't seen it. As a soldier who has served for so many years, I have helped surgeons to some extent and have also nursed injuries in field hospitals. He was not blind, and he had never seen a Prussian military surgeon perform a tracheotomy on a soldier.
In fact, Mendelstein has always been skeptical about tracheostomy.
He still doesn't know why he made an incision in his neck or why he inserted that strange tube inside. It was only because of his big heart that he always gave orders to his subordinates that he made this decision. Now that Opal said his breathing was much smoother, he felt relieved.
After Opper stabilized, his most important concern now was naturally the wounded soldier who had just been sent to the operating room.
Different from Opal's friendship, this is more of an officer's desire to protect his subordinates, but unfortunately it is not allowed in Kawei's operating room. Considering that the other party was an absolutely powerful party, his expression was a little tactful: "Sir, the operating room is a place that needs to be kept clean. Outsiders should not come in."
Mendelstein didn't understand: "Where do you start with this? Aren't surgeries all performances? The operating rooms in Berlin hospitals are all open."
"That's an operating room in a big city, with ventilation facilities and clean water for disinfection and cleaning." Kawei explained, "Today's temporary operating rooms are small and have poor ventilation. There are too many people. After the operation, the The incision will definitely fester.”
"But."
"If you don't want him to die, please take those two soldiers out as well." With the "actual performance" of dealing with Opal before, Kawei's attitude gradually became tougher, "Sir, please believe in my professionalism. And please don’t insult my profession.”
Mendelstein was overwhelmed by him for a moment, and he didn't know where to start if he wanted to refute.
Looking at the busy figures in the confession room, he could only do as he was told and called two soldiers out to guard the door: "I have done what you asked. I believe in your professionalism and respect you. Professional ethics. Again, please cure him."
These words were much less threatening than before, but Kawei still did not dare to be careless and asked: "How are the vital signs?"
"not too good."
"How much fluid did you need?"
"500ml costs 200."
Kawei roughly understood the situation, and turned back to Mendelstein and said: "I will try my best to cure him, but I need a favor from the commander."
"What's the deal?"
"A few drops of blood need to be given to all your soldiers."
The confessional is indeed very small. In the middle is a long table that was moved from the house next door, a makeshift operating table. Ignatz, Hermann and Bergt stood on both sides. The nurse pretended to be a patient in order to hide her identity, so she had to be replaced by another doctor.
The room was occupied by them, and with the equipment boxes, medicine boxes, and water basins on display, there was not much free space around.
The young soldier lying on the operating table was called Craig. He was injured in his right leg. The bullet directly severed his right femoral artery and vein. The blood vessels were not completely severed, but there was a large defect, and the entire lower limb was ischemic for more than 3 hours.
The right lower limb is now pale and cold, and neither the dorsalis pedis artery nor the posterior tibial artery can feel the pulse.
The bullet hit the root of his thigh, and Ignatz chose the most common surgical approach.
Starting from about 3cm above the inguinal ligament, a longitudinal incision about 15cm long was made along the outer edge of the femoral artery pulse. 【1】
"The middle of the blood vessel has been completely broken. Fortunately, it is partially connected and the broken end has not rebounded. I can only do a simple debridement first, but the surgical field is too blurry." Ignatz is a novice in vascular surgery. , "You still have to suture the remaining blood vessels."
Previously in Gablenz, Kawei had undergone an operation to rupture and then suture the iliac artery.
The bleeding was severe at that time and was even more critical than it is now, and the subsequent sutures also encountered a lot of trouble. In comparison, the leg in front of me was much cleaner, but it was a little scary.
"The bleeding stopped without applying a hemostat?"
"It seems a little strange for you to say that." Ignatz finally reacted, "I just opened the wound, and there were blood clots inside, so the bleeding was not too much."
"This shows that there are quite a lot of blood clots blocked in the blood vessels." Kawei simply washed his hands, put on gloves and inserted his fingers into the leg incision to find the defect. "The blood flow is completely blocked at the top. .”
"Can it be done?"
"Clamp the distal end, cut off the blood vessel and then flush it." Carvey briefly introduced the process, but quickly denied, "But it doesn't work. The middle defect of the femoral artery exceeds 2cm, and the venous defect is even larger. Even if you do this, it will not work. It makes no sense. Moreover, the sodium citrate we have for anticoagulation is very limited, and we may not be able to clean it."
Ignatz sighed: "It seems the only option is amputation. Give me the bone saw."
"Wait a minute." Kawei didn't want to do an amputation easily. "The damage only lasted three hours. It would be a pity to do an amputation."
"How can the blood vessels be connected without amputation?" Ignatz asked, "This is not the iliac artery. The femoral artery is the thickest blood vessel. There are so many large blood vessels around it for you to graft."
"Don't worry."
If we were in the 21st century, such injuries would usually be anastomotic with artificial blood vessels, but for poor families with low incomes, autologous great saphenous veins could be used as substitutes. The main reason why artificial blood vessels can replace the great saphenous vein is that the caliber of the great saphenous vein does not match the large blood vessels.
The previous case of Gablenz explained this well, but now Kawei has no other way.
"Let's do an autologous transplant."
"Autologous transplantation?" Ignatz was a little confused. "Is it the interception of a section of the great saphenous vein for transplantation that you mentioned before?"
"right."
Kawei did not rush to take action, but stood by the operating table and considered how to solve the problem of mismatched tube diameters.
The blood vessel wall has a certain degree of elasticity, and the elasticity of veins is less than that of arteries. If there is a problem with the blood vessels of the upper limbs, the great saphenous vein can complete the task of autologous transplantation very well. But the defect occurs in the lower limbs. The diameter of the common iliac artery alone reaches 9mm, and the great saphenous vein, which is only 3mm, cannot be transplanted.
The injured location is in the thigh, where the caliber of the femoral artery is not smaller than that of the common iliac artery, so forced transplantation is likely to cause major problems.
The strength of surgeons is not only their dexterous hands, but also their imagination.
Kawei has previously demonstrated how to perform blood vessel grafting to solve the problem of large defects that cannot be anastomotic. Grafting is now impossible. All that can be done is graft anastomosis. However, there are many types of graft anastomoses. A simple graft of the great saphenous vein is a graft. If there is a slight change in the middle, it is a graft.
Kawei seemed to have thought of a good idea: "Give me the hemostatic forceps, and let's cut off a section of the femoral vein first."
"Cut off the femoral vein?" Everyone, including Ignatz, expressed doubts about his sudden idea. "Aren't the femoral veins going to be anastomotic? Why do we need to cut it off?"
"The arterial blood flow is turbulent, and the lumen of the great saphenous vein is much thinner than the femoral artery. Direct transplantation may cause blood supply problems after surgery."
Kawei took the hemostatic forceps, blocked the femoral artery and femoral vein, and then trimmed the two blood vessels appropriately: "But the femoral vein is different. Although the femoral vein is a vein, its diameter is almost the same as that of the femoral artery. It must be Tassels that can cope with arterial blood. So I chose to transplant each other. First, the femoral vein was cut and grafted to anastomose the upper femoral artery, while the great saphenous vein was only transplanted to the femoral vein." [2]
This is a relatively safe approach and avoids the problem of excessive diameter differences affecting arterial blood flow.
Because the femoral vein is the venous blood returning to the heart, the blood flow rate is obviously much slower, so if the diameter is narrower, it should not be a big problem.
Kawei cut off the broken walls at both ends of the femoral artery, peeled off the outer membrane, and then cut a section of the femoral vein less than 4cm long: "Clean the blood clots inside."
"good."
While Berget was cleaning, Kawei and Ignatz were not idle and continued to intercept the great saphenous vein. The interception of the great saphenous vein and the femoral vein have certain length requirements, so the location selection is very important.
"Continue to extend the incision downward to the position above the knee." Kawei said, "The defect of the femoral vein has now reached 8cm, and the great saphenous vein must at least be cut."
Before he finished speaking, he thought of a huge hidden danger that made him want to overturn all the decisions he had just made.
The anastomotic blood vessels will cause the blood to form vortices. Large arteries such as the femoral artery may not be a big problem, but the blood flow in the veins is slow, and if the vortices are generated, it is easy to form thrombus. After modern vascular surgery, patients are generally given anticoagulants for a certain period of time to reduce postoperative thrombosis.
But there is no such thing now, and sodium citrate cannot anticoagulate in the body. 【3】
Even if the wall of the slender great saphenous vein is expanded, it is only about 4-5mm, which is less than half of the femoral vein. If a blood clot occurs, it will not only damage the leg. The blood clot may also break off and return to the heart, and then enter the lungs through the pulmonary artery, causing pulmonary embolism.
If a pulmonary embolism occurs, even God cannot save it.
what to do? ? ?
"What's wrong with you?" Seeing him suddenly stop, Ignatz couldn't help but ask.
"It's a bit troublesome." Kawei stared at the defective femoral vein and said, "Even if the defective femoral vein is replaced with the great saphenous vein, the flow rate of the return blood may still not be enough."
The other doctors on the same stage didn't know where all this knowledge about blood flow in blood vessels came from, but listening to Kawei say it always gave people a convincing feeling.
Of course, while you are convinced, you still have to speak out your doubts boldly, so that you can improve your medical skills. At this point, Ignatz has always done a very good job: "You said before that the vein branches are very rich. If you ignore the femoral vein and just suture all the upper and lower ends of it, is it okay?"
"No, the reflux of the lower limbs relies on the femoral vein." Kawei explained, "If the femoral vein is sutured and tied, although it will not completely block the blood flow back to the heart, it will still cause swelling of the lower limbs. Blood accumulates in the lower limbs, and sooner or later there will be bleeding. If the problem is serious, compartment syndrome may appear the next day.”
Hermann on the side also asked: "Is it possible to use the great saphenous vein for reflux or not?"
"No, otherwise why would I dare to intercept the great saphenous vein? Because of the existence of the femoral vein, the great saphenous vein is unimportant."
"I see."
"If you can't find any other way, I think it's better to do it first." Berget said while cleaning the femoral vein in his hand. "After all, it has been ischemic for such a long time. If it continues to be used up, even if the blood vessel is connected, His right leg may not recover either.”
Ignatz sighed: "I think amputation is safer."
"The captain outside the door will not let us go." Kawei pointed at the door and said.
"Amputations are too common, limb salvage in this case is abnormal!" Ignatz lowered his voice and cursed lightly, "If there weren't so many of them, I wouldn't have operated on the Prussians!"
"Shh~~~ don't talk nonsense, he is still at the door."
"It's so frustrating."
Strictly speaking, Ignatz is also a soldier, and he will definitely have feelings for him after getting along with the soldiers for a long time. Thinking of the convoy soldiers who had been eliminated by the opponent before, he felt bad: "Don't think about it, just do the transplant. If it really doesn't succeed, just amputation."
"There will be no anesthesia for the next amputation."
"Yes, if the amputation is done without anesthesia, the problem will be serious."
There are so many factors that Kawi needs to consider. The best result is to solve all the problems once and for all in this operation: "Amor, how much anesthesia is left?"
"Only enough for two hours."
"No amputation, absolutely no amputation!" Kawei looked at the femoral vein and suddenly looked back at Berget, "By the way, how many silk threads do I still have in the box?"
"Silk thread?" Berget stood up and handed the cleaned blood vessels to Kawei's hand, and replied, "There are probably two more bundles, you brought quite a lot."
"Two bundles, that's enough! You go prepare the silk thread!" Kawei took the blood vessel and said to another assistant on the side, "Give me the scalpel, I have to continue to extend the incision downward."
The assistant who passed the equipment handed the thing to Kawei, with a look of surprise on his face: "Extension to where?"
"To below the knees."【4】
(End of chapter)
