Edem is an old man over sixty years old and has a lot of fat on his lower abdomen. It is very troublesome to make incisions and tractions. In addition, the field tubes are also piled up here. If he wants to explore carefully, he needs to further expand the surgical field.
Kawei raised his foot and kicked the table leg on his left: "Put your head down a little further."
"good."
Damirgang, who was preparing the infusion bottle, freed his hand, held the handle on the side of the table, and continued to lower the mattress on the side of his head for a certain distance. The descending body can pull the skin and also allow the organs to move toward the head with the help of gravity, freeing the tight and complex structure of the lower abdomen and giving more space to the bladder.
Kawei explained in detail the reason for choosing the head-down and foot-height position, and then changed the topic and said while exploring the bladder: "I heard that some people recently reported that this movable operating table will cause damage to the arm function, and then questioned the operating table. Changes, and even feel that the changes themselves are insignificant and will do more harm than good.”
This is one of the many myths surrounding his medicinal products.
Many people on the stage began to talk in low voices, and soon a surgeon stood up: "Dr. Kawei, this is indeed the case. The two surgeries I performed were based on the principle of lowering the head and keeping the feet high to reduce the amount of bleeding, but the surgery Later, they all developed symptoms of reduced arm function.”
Kawei listened to his complaints and nodded slightly, seeming to agree with what he said, but what he was talking about was the bladder: "The previous cystoscopy failed to see the tumor, so I first put my hands into the back and sides of the bladder to explore The location of the tumor... By the way, the one who spoke just now was Teacher Musa, right?"
"Yes, it's me." Musa sat on his seat solemnly, with a stern look on his face, "I don't dare to be a teacher. I can only be regarded as your colleague at most."
Kawei doesn't care about this. As long as everyone is younger than him, he will call the teacher at the beginning: "Why can the teacher be sure that if the patient's arm function decreases, it must be a problem with the operating table?"
"This... I have never had such a problem in previous surgeries." Moussa gave a reason that he thought was difficult to refute. "Doesn't this prove that it was caused by the new operating table? Because the surgery is related to The only difference between surgeries is the operating table.”
Musa was the unlucky doctor who had been squeezed out of the surgery report at the College of Surgery by Kavi. There were two other doctors who were also squeezed out, one named Paisher and the other named Sergey. They received letters of dissuasion from Dean Waterman, and they never got a seat at the report meeting.
After all, the time for the surgical report meeting was limited, and nearly half of it was reserved for Kawei.
Not to mention ordinary surgeons like them, even director-level doctors like Orgi and Massimov are in danger. Because if the evaluation is really based on the difficulty and completion of the operation, the report meeting will become a one-man show for Kawei.
Communication becomes a professor.
However, they have no hostility towards Kawei, they are just inferior to others in terms of skills. They accept their own mediocrity, don't struggle with it as much as Hills did, and come to see Carvey perform surgeries from time to time in the hope of improving their skills.
Now Sergei goes out with the army, and it is Musa and Paisher who appear in the operating theater.
The former is proficient in amputation of various parts, and the success rate has increased from the original 40% to more than 65%. He is very skilled in how to carefully debridement, how to choose the cutting plane, how to ligate blood vessels, and how to embed myocutaneous flaps.
The latter has blocked his future in the resection of hemangioma. From simple resection to blood vessel suturing, he is now required courses.
In the context of increasingly sophisticated surgeries, both surgeries need to improve their respective hemostasis methods to reduce the risk of death by reducing bleeding. Kawei's position-changing operating table can exactly achieve the purpose of reducing the amount of bleeding in the lower body, so they all customized one from Laszlo's equipment factory.
The hemostasis effect was indeed good, and at least it added a touch of calmness to their hectic surgery, but complaints from patients followed one after another.
"I also have this problem. Patients will have paralysis and sensory impairment at the most severe stage after surgery. Some people still feel soreness and fatigue in their arms after more than a month." Paisher said, "This is undoubtedly arm dysfunction."
Kawei nodded: "Has anyone else encountered this kind of thing?"
Many people raised their hands on the stage.
"It seems quite a lot."
As a product salesman, Kawei will receive a share of each operating table. Now that feedback has been collected, explanations need to be given in a timely manner.
But after the previous exploration, he had figured out the location of the tumor. Compared with product after-sales service, surgery must be more important: "Mr. Edem's tumor is located close to the left side, which happens to avoid cystoscopy. If we can provide Maybe you can see it if you bend the right side 15-20°, but it's a pity..."
In the absence of imaging examinations, the abdominal cavity exploration is far from over. Kawei previously extended the incision upward to 4cm above the umbilicus in order to fully explore the abdominal cavity.
In addition to clarifying the location of the tumor, he also needs to rely on exploration to confirm that there is no metastasis to surrounding organs and lymph nodes, and that there is no adhesion to the iliac blood vessels behind the bladder. He even had to touch his liver upward to make sure there was no mass on the surface of the liver, and then he felt relieved.
Because once distant metastasis is discovered, the surgery itself is of little significance. 【1】
"I hope there will be no metastasis..." Kawei's right hand was still rummaging in Edem's stomach, and the topic returned to the adjustment operating table. "I didn't expect that the doctors would fall on this operating table." Come on, haven’t you considered other issues?”
"Other questions? How can other questions have such a high degree of overlap?"
"Yes, Dr. Kawei, it's not that we want to embarrass you. We are really upset by the complaints."
Kawei repeatedly judged the touch that came back to his mind from his fingertips, and finally breathed a sigh of relief after confirming that everything was normal: "The tumor is single, with no adhesion to surrounding tissues, and no peripheral metastasis."
He removed his right hand and asked Hermann and Damirgon to return to the operating table together and pull open the skin on both sides of the abdominal wall incision. The intestines and omentum are then pushed to the upper abdomen and protected with gauze pads to expose the pelvic organs.
"The heart will experience some pressure now, so remember to monitor your vital signs at all times."
"knew."
"Give me the scalpel and let's cut off the blood supply to the bladder and ureter first."
Kawei took the scalpel and asked Berget, who was unable to go to the operating table, to stand next to Edem's head and control the light of the candlestick: "Everyone, the loss of function of the arm means that the nerves that control the arm are damaged. Think about the arm. The function is controlled by those nerves, where are these nerves, and is there anything compressing them during the operation?"
This is an extremely simple question in modern times. Considering the structure of the operating table, medical students who have studied anatomy can answer it.
But in the 19th century, when neurology had hardly developed much, it was not so easy to immediately remember the cause of the injury and find out the key to the problem. Instead, they will think wildly about the details of their surgery, and may even classify the injury as the careless stacking of instruments on the patient's body.
Seeing that many people on the stage were still whispering, Kawei hit the hemostatic forceps with the handle of the scalpel and reminded: "Everyone, it is time for the operation, and I will not answer any questions that are not related to the operation.
If you still can't find the answer after the operation, I will be responsible for answering it. But now, I hope you can focus on Mr. Edem's pelvic cavity and watch the operation while looking at the atlas. "
Everyone knew about Kawei's temper, so they all stopped talking, and his voice was the only one left in the theater.
The operation is divided into two parts. The first part is the radical cure of bladder cancer. For radical cure, the bladder must be removed first.
Resection sounds simple in theory, but is very cumbersome in practice. Separation and ligation are all basic skills. If you want to cut the bladder well and wonderfully, you need a lot of practice.
The bladder is located in the pelvic cavity and has an extremely rich blood supply. The main blood supply comes from the anterior branch of the internal iliac artery. Now the operation time is quite long and the conditions are limited. Kawei needs to reduce the bleeding as much as possible.
Similar to the original hysterectomy, ligation of the internal iliac artery does not affect the blood supply of the pelvic floor, but the removal of the bladder itself can greatly reduce bleeding.
Kawe gently incised the retroperitoneum at the bifurcation of the common iliac artery, freed one side of the internal iliac artery [2], covered it with a silk thread and lifted it up to block it. At this time, a nurse standing by the operating table ready to help cooperated tacitly and reached out to touch his dorsalis pedis artery: "The dorsalis pedis artery is still there."
"Very good, it's definitely the internal iliac artery." Kawei explained. "The external iliac artery is responsible for the lower limbs. Cutting off the blood flow will cause the lower limbs to lose their pulse. The internal iliac artery is responsible for the pelvic cavity. You need to deal with the iliac artery when performing pelvic floor surgery. If you cannot distinguish between the two when detecting an internal artery, you can make a judgment according to the process I demonstrated."
After that, both internal iliac arteries were ligated.
"Next to the internal iliac artery, we can also see the ureter [3]." Kawei used vascular forceps to slowly separate it. "After we found the ureter, we slowly and bluntly dissected it down to the bladder. When we reached the bladder wall, Cut it off and use silk thread to ligate the bladder side.”
Kawei's technique of dissociating surrounding tissue was extremely proficient, which was not obvious during the autopsy. At that time, it was just for practice and to help several assistants become familiar with the operation.
Now that he is in a living person's body, there is pressure on time. He strives to do his best every step of the way, so he has no reservations. After cutting off the ureter and ligating it, Kawei looked at the diameter of the ureter and said, "Take the thinnest catheter."
"Give."
"This is a temporary catheter for draining urine. It is produced by Mr. Laszlo's vulcanized rubber factory and is just suitable for this operation." Carvey said, "The catheter is inserted into the ureter to temporarily drain the urine that continues to flow out of the kidneys. Urine. The size is just right, even the anti-slip fixing is omitted.”
Just when everyone thought the operation was about to begin to remove the bladder, Kawei returned to the common iliac vessel to deal with the retroperitoneal lymph nodes.
It ranges from the bifurcation of the common iliac vessels to the opening of the femoral canal, including various lymph node connective tissues lateral to the external iliac artery, around the external iliac vein, around the internal iliac vessels, and around the obturator nerve.
Lymph node dissection is a big project, and Kawei didn't dare to do it when it came to Fernan. Suddenly, the "boring" time started right next to the operating table.
However, Kawei could clearly feel the attention of the audience on the two urinary catheters in the stands, and explained: "These are the first medical rubber catheters in Austria. Compared with the silver tubes used before, they are very soft. There are many in the stadium. Urological surgeons should know that the physiological curvature of the male urethra is not suitable for the insertion of silver tubes, which often causes great pain.
Nowadays, with rubber tubes, it is easy to enter the bladder for catheterization as long as it is done correctly. It has a very good effect on urine retention caused by prostatic hyperplasia and bladder stones. "
He continues to play the role of "carrying goods". While introducing products, he also needs to answer everyone's questions one by one.
"Can the rubber tube really enter the bladder smoothly? What should I do if it encounters resistance?"
"Don't worry, they won't just have soft bodies."
"Then how to fix it after entering the bladder?" Another doctor said, "There is a bulge in the front section of the silver tube. Although the insertion process is extremely painful, after entering the bladder, it can be stuck in place by the bulge in the front section to prevent the tube from falling off."
"That's a good question."
Kawei explained: "What I use now is only a single-lumen tube, but in fact, the rubber factory is already studying double-lumen tubes. One tube is used for urination, and the other tube is used to inflate the rubber balloon in the front section. .”
"Double chamber? Balloon???"
"Let's ask Dr. Mosier to introduce us here."
Kawei casually threw it away and regarded Mosier as a salesman: "Actually, when I was undergoing prostate expansion surgery, I chose to use an expandable rubber balloon to forcefully open the enlarged prostate. In the past few days, I have been with Kawei. During the communication, Dr. Wei found that it seems that this expanded rubber balloon can also be used to fix the urinary catheter in the bladder." [4]
"Like a balloon?"
"Yes, it's a relatively small balloon." Mosier formed a circle with his fingers. "You only need to fill it with water to expand it."
"Sounds like a good thing."
"The finished product will be available in the next few days, and there will be a brief introduction meeting at that time." Kawei said, "The cost should be 10 crowns a piece, which is not too expensive. But because it is a consumable, there is a quantity requirement when purchasing. , please also pay attention to the instruction manual and don’t make the same mistakes on the operating table again.”
The two of them cleaned the lymph nodes and easily sold something that had not yet left the factory.
"Beget."
"exist."
"Give the candle to the nurse, and you go and do pathological sections on these lymph nodes," Kavey said. "Koch and Savarin should be here soon."
"good."
After two rinses with normal saline, the two conducted two carpet searches of the retroperitoneal lymph.
Kawei looked at the "clean" retroperitoneal tissues, and changed his gloves with Mosier: "Others came to help. The instruments used just now need to be rinsed, and a brand new set has to be brought up."
"The cleaning started ten minutes ago."
"How is your heart rate and blood pressure?"
"Stablize."
It took more than half an hour to ligate the blood vessels, cut off the ureters, and clean the lymph nodes. This was only the first step of the entire operation, because they didn't even see the surface of the bladder.
"Next we start working on the bladder."
