[The surgical process is the core of this book, especially the content that is closely related to the patient. I have to write it down. I will simplify it at most, but it is impossible to omit it. 】
[Warning for multiple pictures, please skip if you are indifferent]
To perform the surgery well, the doctor not only needs to have solid surgical skills, but also needs to do adequate preoperative assessment and preparation.
The core of these modern tasks is the doctor's preoperative examination, and all the patient has to do is spend money and cooperate. The powerful hospital management system will help patients arrange everything. As long as the patient is obedient and the doctor is serious and responsible, the risk of most surgeries is already very low.
But in the 19th century, doctors had limited abilities. The only thing they could do was to help patients manage their bodies and create conditions for successful operations.
Over the past week, Edem has been cooperating with preparations. This includes no smoking and alcohol restriction, as well as collecting some autologous blood for backup two days before surgery. Of course, the most important thing is intestinal preparation. After all, urinary diversion requires a long intestinal tube, and cleaning the intestines is of great help to the operation.
This is the benefit brought by modern medical theory and practical experience, which allows Kawei to easily perform operations that other doctors cannot perform.
But if you want to make the operation exciting enough, you need to consider various details.
Radical cystectomy itself does not require a large incision, usually as far as the belly button. If a urethral diversion is performed simultaneously, especially if this intestinal replacement diversion is used, the scope of the incision needs to be expanded.
Taking into account the operation time, abdominal contents, the patient's slightly obese body and the series of tasks that the assistant has to undertake, it is really a huge waste of manpower to leave the mindless work of continuous hook retraction to the second and third assistants.
In fact, Kawei had sent a design drawing to Laszlo Equipment Factory a few months ago, which contained several sketches of retractors for abdominal surgery.
However, military orders were more important at that time, and Kawei had very few abdominal surgeries, which were basically focused on cesarean section, appendix, and hernia that only required simple retractors. In addition, he was also devoted to the trauma surgery performed by military doctors, so he did not rush it.
Even when Kawei asked them to hurry up with the cystoscopy a few days ago, he never thought about rushing to make a retractor.
However, as Edem's requirements escalate and the surgical procedure changes, the time may be extended to 4-5 hours, and the retractor becomes very important. 【1】
"Remove the retractor and apply the retractor." [2]
Kawi asked the nurse to take out the bladder retractor from the clean surgical instrument bag, allowing both Herman and Damirgon to free their hands to participate in the operation. At the same time, he did not forget to introduce:
"If you want to go down the path of precision surgery, you can try to use the automatic retractors I developed. They can save manpower. There are several models, and the average price is about 50-100 crowns each."
Intuitive surgical operation is the best demonstration [3]. Compared with the cystoscope and urinary catheter mentioned before, retractors, which save a lot of labor expenses, are easier to accept.
Moreover, Kawei asked the factory to prepare not only abdominal retractors, but also smaller forceps-like retractors that are more suitable for maxillofacial and eye surgeries. 【4】
"Eyelid surgery too?"
"Yes, you can go to the equipment factory to ask for details. They also support returns within three days without any reason. But if you want...hehe, I don't think you will do anything that goes against the decency of a gentleman for such a small amount of money. After all, Mr. Felix has submitted a patent application for me in this regard.”
Kawei stabilized the distance between the retractor hooks and brought the topic back to the surgery: "Just now, Mr. Mosier and I have roughly cleaned the retroperitoneal lymph, only stopping the bleeding and not dealing with the lymphatic vessels [5]. What's next? Officially free bladder..."
Enlarging the incision, maintaining a good surgical field, performing lymphatic dissection and sufficient dissection of the lesion are all important components of a successful surgery.
However, for radical cystectomy, if you want to meet the "wonderful" standard, you may have to do more and be more difficult than other tumor resections.
Because of the specific location of the lesion, the bladder is close to many important male organs and tissues. For quite some time after the creation of this operation, male patients had more or less post-operative ejaculation dysfunction that could hardly be improved. 【6】
And Edem comes from romantic France, which is different from conservative Britain and Austria. Even in his sixties, he still has very high requirements in that regard.
If this was not taken into consideration, the surgery that was supposed to save his life would easily kill off the rest of his life, and the surgery would no longer be exciting. The patient might even be labeled as "killing the hope of life."
This is one of the important reasons why Kawei postponed the operation.
"You must have thought before why I had to change the date of surgery. The newspapers and media publicized this matter to great effect, but in fact the reason is very simple..." Kawei carefully separated the structure between the bladder and peritoneum, " That was because my abilities at the time were not up to par with Mr. Edem’s expectations for the surgery.”
Anyone with a discerning eye can see that Kawei is fully capable of directly performing a cystectomy and is fully capable of getting the patient to agree to the original surgical plan.
The reason why it was delayed for so many days was simply because of Edem's identity. His identity determines that he must be satisfied with the choice of surgery, so that he can have a chance to have a good relationship with the French.
Although the vast majority of Austrians on the stage are still trapped in the war seven years ago, they feel that France is the enemy, and they also feel that the French man lying on the operating table is too greedy for "health". But now that Austria suffered a loss in the Prussian-Austrian War, it should also win over France based on the principle of Franco-Austrian friendship and relying on Prussia.
This surgery put Kawei under heavy pressure, but for the audience, what is more important is what Kawei practiced.
"The diagnosis is a tumor. It's good to be alive. I wonder what else Mr. Edem wants?"
"Before I say this, I still want to talk about a wounded soldier I met on the battlefield before." Considering that everyone knew very little about the X function, Kawei did not directly talk about the theory, but made up an example, "That person The wounded soldier was shot in the butt, and the bullet passed through the skin, fat, muscle and rectum, and came to rest below the bladder, close to the prostate."
"Is this wounded soldier related to today's surgery?"
"It's related." Kawei briefly skipped the treatment process and quickly told the result, "We spent more than two hours to help him remove the bullet and suture the rectal rupture. The operation was successful, at least in my opinion. Overall, he was satisfied. But after the operation, he encountered a quite troublesome problem."
"what is the problem?"
Kawei nodded: "Unfortunately, this is what Mr. Edem wants, otherwise he wouldn't be able to survive even a moment."
"As expected of a Frenchman..."
"This is the School of Surgery, not the Hofburg Palace. We should still focus on surgery, not those annoying political topics."
"Yes, Dr. Moussa is right. Let's talk about the injured soldier. If there are any obstacles after the operation, could it have been like this before the operation?"
"Obviously not. He's very familiar with Hoyntz Street."
"Maybe the bullet wound damaged something important?"
"The bullet traveled to the rectum behind the bladder and did not injure the front."
"The trauma of the surgery itself affected his function."
"I also thought it was surgery, so I reviewed the pelvic neuroanatomy again in the past few days, and I discovered something interesting." Kawei slowly peeled off the peritoneum on the top of the bladder, and Mosier looked slightly surprised. He looked down and said, "The normal process of ejaculation, ejaculation, and orgasm has nothing to do with the existence of the bladder, prostate, semen, or even the urethra." [7]
The amount of information in this sentence was so huge that the audience on the stage opened their mouths in disbelief and could not utter a single sentence.
"What does that have to do with?"
"The corpus cavernosum, to be precise, is the nerve that controls it."
Not long after the operation started, Kawei came up with several new ideas, each of which was an update, improvement and major breakthrough in the existing medical theory. The most surprised person in the audience was not them, but Mosier who stood opposite Kawi.
For the past five days, he had been virtually inseparable from the young man. The two assistants sometimes go home to rest, but they basically live in the hospital, even sleeping in the same room, just so that they can communicate with each other about the details of the operation at any time.
Mosier was confused: When did he come up with this theory?
On the front lines?
Or five days ago?
He had many questions, but now that the operation was in progress, it was not easy to ask questions suddenly. He could only follow Kawei to continue to deal with the bladder.
After separating the superior bladder blood vessels and the umbilical ligament that wraps the umbilical artery, the two men slowly completed the separation of the top of the bladder. The free surface is then moved downward along the bladder surface, gradually exposing the posterior bladder recess and incising the peritoneum here. 【8】
"This is the gap between the bladder and the rectum." Carvey used a scalpel and scissors to separate here [9]. "What really affects the entire process is the nerve bundle, not a certain organ. So the injured person Although the soldier only damaged his rectum, he still lost his rectal function due to the bullet and scalpel."
"Dr. Carvey thinks that as long as those nerves are preserved, he can prevent breast dysfunction?"
"right."
"Do you have any evidence?"
"No."
"Where's the experiment?"
"nor."
"Is this too arbitrary?"
Kawei answered quite simply, with an attitude that it doesn't matter whether you believe it or not: "You can leave your doubts to be verified after the operation. According to the previous agreement, Mr. Edem will recuperate in Vienna for a month before leaving for home. You have plenty of time.”
This is not the first time that Kawei has put forward a new point of view. After more than half a year of information shock, everyone is more accepting of it than Mosier.
But this also raises a new question. Since the function of stimulation is related to nerves, how to protect those nerves?
"First of all, we need to know where the nerves are." Kawei said, "The nerves that control the bouncing come from the pelvic nerve plexus and are distributed in large numbers in the retroperitoneum, anterolateral rectum and posterolateral seminal glands, forming a flat network [10 ]."
After saying that, he gently pressed his bladder and exposed the side anatomy:
“Before doing lateral separation, let’s take a look at the nang [11]. The nang is an important anatomical landmark for identifying the pelvic plexus nerves. In the previous extensive practice, Teacher Mosier and I have been able to skillfully distinguish this place. of nerves and blood vessels.
The shape of the nerve should be more lateral. You only need to free the blood vessel branches and do a small area of separation and ligation near the side of the spermatozoa to avoid the nerve..."
Mosier was completely bewildered.
I have never worked with him to identify nerves and blood vessels. As a first assistant, what he needs to do is to fight against the surgeon when he separates the tissue, stop the bleeding in time when he sees it, and hold the thread when it needs to be ligated. Sometimes he is also needed to do it. Suture ligation.
He just passively accepted the tasks given by Kawei and tried his best to do his best.
In the past few days, I have learned how to use a needle to perform deep abdominal suturing, and also learned to use red-hot wire to perform point-shaped cauterization to stop bleeding. As for the subjective treatment of where the organization should separate, he does not participate at all and cannot participate, because just keeping up with Kawei's rhythm has already exhausted him.
"Hey, when did I separate blood vessels and nerves with you?" Mosier asked in a suppressed voice.
Kawei smiled, did not explain, and continued to separate the sides: "...In addition to the accompanying blood vessels and nerves, we also need to separate the sperm cells on both sides of the bladder. As long as the boundaries of the tumor Without infringing on them, considering Mr. Edem's energy, we still have to try to stay..."
Suddenly, his hands and throat stopped at the same time, and his eyes fell silent as he looked at Mosier in front of him.
Some audience members on the stage had not noticed Kawei's strangeness, and kept asking: "What then? What is left behind?"
Mosier, who had practiced together for a long time, understood his current mood better. Kawei, who devoted himself wholeheartedly to the operation, was most worried about the growth of the tumor.
As cautious as he is, he will definitely consider various variables during practice and will also make plans to deal with these variables in advance. But there are many variables, and the one that is most difficult for Kawei to accept is the spread of the tumor.
Mosier also stopped the hemostatic forceps in his hand and asked, "Is there any adhesion on the left side?"
Kawei nodded, touched the outside of the tumor with his hand and then moved along the bulge to the side: "Maybe there is also a prostate."
Mosier frowned: "This... won't go together..."
"As I told you before, I'm afraid this situation cannot stay."
Kawei sighed, took out his right hand for exploration, and said to everyone on the stage: "As the bladder becomes more and more free, the scope of my exploration also expands. Mr. Edem's tumor does not grow backwards, but completely." It's biased towards the left outer side where it is located, and has already affected the sperm. I'm afraid the scope of the surgery that was scheduled before will have to be changed."
