Chapter 285 281. Three-in-one
Like most surgeries before it, Erdem's bladder cancer was still something of a blind box.
Even if the nature of the tumor has been clarified through prior microscopic examination, even if the exact location of the tumor can be seen during the cystoscopy a week ago, the full picture of the tumor will not be visible due to the wanton growth pattern of the tumor.
The lack of imaging localization is ultimately a flaw in surgery.
The bladder is a pouch organ, and tumors often penetrate the inner wall and spread outward, often affecting adjacent tissues.
The most common ones are the peritoneum above, the rectum behind, the spermatids on the side, the prostate and urethra below, and of course the ureters, blood vessels and nerves connected to the bladder. The dissociation work is still in progress. There is nothing in the rear, and the right side is safe. For the time being, it is confirmed that the left spermatozoa is affected.
"It's a mixed blessing."
Kawei said: "The worry is that as the scope of resection increases, the trauma will increase, and postoperative recovery will become more difficult. The good news is that resection of unilateral sperm nodules does not affect any function. If the prostate is also removed, The prostate hyperplasia that is unique to older men will also go away from him. Although Mr. Edem urinates smoothly, it is a precaution. "
Everyone on the stage knew about Kawei’s surgical skills and innovation ability, but unlike other surgeries that were more innovative, this surgery had too many revolutionary things.
Just hearing that the patient's bladder was to be cut off had already made many doctors shocked, and the subsequent reconstruction filled their heads with questions.
Can the bladder be cut off?
Can it be rebuilt after being cut?
What to rebuild with?
Do you use cow or pig bladders as a substitute, or do you use new rubber bags?
I don’t know how many doctors said it was impossible when they learned that Kawei wanted to use intestines to rebuild his bladder. But as they thought more deeply and calmed down, they found that this might actually be a good idea. .
However, one wave came after another, and now Kawei also wanted to remove the sperm and prostate around the bladder, without giving them a chance to digest.
The prostate is wrapped around the urethra. Can this be removed?
How to cut this thing?
Will cutting it affect urinary function?
What if it's broken?
These questions are still at a high-end level. Most people who can think of these questions have a good understanding of the prostate.
In fact, at least half of the doctors on the stage don’t even understand the anatomy of the prostate itself. They also gave up thinking early, or already knew that instead of thinking by themselves, it would be more straightforward to listen to Kawei's dictation with confidence.
Benign prostatic hyperplasia is a very common disease in modern times and can be treated with long-term medication or simple surgery.
But before the 19th century, this disease was rare. The reason is naturally that the average life span of a person is only in his early 30s, and it is not yet serious enough to develop the disease. However, with the gradual development of medical treatment and the increase in the average life span of Europeans, prostates have begun to bloom among older men.
Mosier's 30 years of medical practice were 30 years of watching these old men suffer.
He has tried many methods to help these patients. Simply dilating the urethra is the most common and cheapest method, but the effect is very limited.
He also tried directly incising the urethra, and even chose to use cautery to burn some obstructed areas in the urethra, exchanging pain for urinary obstruction. There is definitely an effect of physical expansion, but patients who survive these treatments can often only maintain unobstructed urination for a short period of time, and the old problems return over time.
Later, Mosier also read many books and articles by other doctors and found that Gao pills seemed to be inextricably linked to prostate hyperplasia, so he also tried cutting off Gao pills to combat prostate hyperplasia.
Castration is generally very effective, but that kind of change requires a certain amount of time and requires the sacrifice of the most precious thing in a man.
No matter how much he tried, the behavioral restrictions brought about by the solidification of medical thinking and the human instinct of fear of damaging the surrounding tissue and causing the patient to endure further torture after surgery made him never think of forcibly cutting it off through surgery. That ever-expanding prostate.
Even if I did think about it, it was just a fleeting inspiration.
Unfortunately, this sudden flash of inspiration naturally lacked enough energy to drive him step by step to eliminate all the unknown risks caused by the surgery.
As a result, after thirty years of working day after day, he became more and more skilled in catheterization and urethral dilation, and he became a doctor loved by all the old men in Paris. But Mosier was not happy. The pain caused by the urinary disorder never completely disappeared, and he never really defeated the disease.
Or looking at it from another angle, he may be the "loser" left behind after fighting the disease.
Listening to Kawei's casual talk about the new concept of rubber catheter hoses, Mosier felt the technological changes brought about by vulcanized rubber. The subsequent abdominal wall stoma and bladder remodeling completely changed his understanding of surgery, and he increasingly denied his thirty years of work.
And now, it's his turn for the prostate treatment that he's most proud of.
In fact, during the five days of practice, Mosier had heard from Kavi more than once that surgery might involve removing the prostate. After all, the growth pattern of the tumor dictated that several surgical records must be made in advance.
But when he heard that the prostate was to be removed as planned, he still looked at Kawei in surprise and couldn't help but ask: "Are you really going to remove the prostate?"
"Although it is not visible to the naked eye, it is very likely that the tumor has touched the prostate." Kawei had no worries at all and just said, "Teacher Mosier and I have practiced together so many times just to cope with this situation. Well, we should be more confident."
So many times?
When is three times too many?
"Whether the semen is incised or not, dissociation work needs to be done, because the autonomic nerve of the cavernous body is behind it." Kawei repeated this knowledge point again, "If you are considering doing this surgery in the future, please do so. Protect the patient’s neurovascular bundles.”
The surgery has entered the first difficult point. Many doctors have to get up from their seats and lean forward as much as possible to see the anatomy and operation steps clearly.
The fares are divided according to the seats. As long as one or two people do not follow the rules, others will follow suit. For a moment, the whole theater was in uproar, and the audience moved forward one after another.
"What are you doing?"
The first person to disagree was Waterman, who was standing next to the operating table. He occupied the VIP position and did not want to break the rules: "Who allowed you to move?"
"Dean, we are too far away to see clearly."
"The price determines the seats. If you guys are so messy, then the theater will have a unified ticket price from now on."
Massimov, who was sitting next to him and had just digested the autonomic nervous system function of the cavernous body, also joined in: "Yeah, thanks to the fact that it is the operating theater of the Municipal General Hospital. If it were replaced by the old Theater on the River Wien, don't even think about it if you don't follow the rules. Looking for surgery."
After hearing these words, everyone did not dare to speak. No matter their position or status, they had no capital to disobey. In the end, they could only mutter a few words to return to their original positions.
"It's not that I won't let you come forward. After all, this is not the theater of the School of Surgery. I don't care."
Waterman stood behind Kawei and watched his operation carefully. Just as he was about to get angry, he saw Kawei looking back at him, and quickly changed his words: "The surgical area of the School of Surgery is large enough, and it is more suitable for everyone to get closer. Study. Here, forget it. Keeping distance is also a way to protect the incision."
"The director is right, the number of people in the surgery area should not be too large."
Kawei took the forceps, asked the nurse to wipe the sweat on his forehead, and continued: "When I have the opportunity in the future, I will go to the surgical college to give a demonstration."
In fact, for other people, the transition from ordinary tissue tracheal resection to fine neurovascular dissection is a bit too long. It is obviously not enough and unrealistic to want to learn by observing an operation.
What's more important is repeated anatomy practice.
"When separating the sperm duct, it is necessary to free the vas deferens [1]."
Kawei used tissue forceps to gently lift up the newly separated left vas deferens: "Clamp and cut off, and then continue to separate along the distal end toward the spermatine fascia until the prostate spermatogen fascia, which is Denonvilliers fascia." [ 2】
Waterman squinted at the dense layer of fibrous smooth muscle tissue, and couldn't think of it for a while: "This name is so familiar."
"Charles-Pierre Dinonville." Mosier must know this term better than these Austrian doctors. "This was discovered by him in 1837. It is the fascia tissue between the peritoneum and the vagina. On both sides are the neurovascular bundles.”[3]
"Mr. Mosier is right," Kawei said. "This layer separates the rectum from the prostate. It also covers the posterior surface of the sperm and the neurovascular bundle. It plays a very important role in this operation."
The posterior fascia has almost been separated, and now the two sides are further separated, and the bladder is gradually becoming looser.
"We try our best to protect the neurovascular bundle, but the nerves are invisible to the naked eye. I can only distinguish them by the accompanying blood vessels. [4]" Kawei gently separated the levator ani muscle and fascia on the side, revealing Several tiny arteries, "you can see the blood vessels when you separate them to this extent, try to avoid them."
"The location is just outside the fascia, right?"
"Yes." Kawei slowly completed the separation work and continued, "But the neurovascular bundles are very scattered. The only one that can serve as a landmark is probably the sperm. When you see it, you should be careful when dealing with the subsequent anatomical separation. "
The operation took more than half an hour to separate the bladder and prostate. It seemed that the neurovascular bundle was hindering the operation, but in fact, there would only be more troubles to follow.
"We pull the bladder forward to expose the spermatic triangle at the rear, lift Di's fascia at the base of the prostate, and then... give me the scissors and we will cut it carefully."
Kawe made a small incision in the fascia and then used his fingers to perform a blunt dissection, which required a complete separation of the prostate and rectum, all the way to the tip of the prostate. 【5】
Maybe it's a long-term chronic inflammatory reaction, or the adhesion is already severe and separation is not optimistic. This is also a common situation encountered when separating the prostate and rectum, and Carvey has encountered it a few times on cadavers.
"There are a lot of adhesions below." Kawei fiddled with his fingers a few times and then withdrew. "We should start from the prostatic lateral ligament, remove the vascular pedicles on both sides, and then slowly move closer to the middle."
Compared with other abdominal operations that Carvey has demonstrated, this radical cystectomy is more complex than many doctors imagined.
Although many doctors know the position and relationship of those anatomical structures, surgery on a living person is completely different from anatomy on a cadaver. The messy fascia, blood vessels, nerves, and ligaments in the pelvic cavity are densely arranged, making it difficult to start.
Even Kawei, who has a strong background in pelvic floor surgery, will inevitably make some small mistakes.
From the beginning of the operation until now, small blood vessel rupture has become a common occurrence.
There is no blood loss of hundreds or thousands of milliliters here. Every time a blood vessel ruptures, it seems very slight, and Damirgaon and Heman can stop the bleeding immediately. The amount of bleeding does not seem to be much, but it is very frequent, and because it is close to the blood vessel and nerve bundles, sutures can easily affect surrounding structures, and the bleeding can often only be stopped by compression.
This seemingly simple task has been repeated more than a dozen times since the beginning of the operation, and will continue as time goes by. They will impact the tense nerves of the four people on the stage again and again, and once a mistake is made, it may cause unpredictable results.
The atmosphere in the surgical theater was solemn, and it was not peaceful outside the theater either.
The impact of Kawei's postponement of the operation was far greater than he imagined. Not only was Edward trapped in Vienna, but even the secret negotiations planned by Franz and Brecht had to be temporarily shelved.
The meeting to negotiate an armistice could not be handled by minions, and any important person leaving Vienna was likely to make Edward suspicious.
Even if this possibility is not high, they are not willing to take risks, so they keep suppressing the news and keep it secret.
"Mr. Edward, why are you here again?" Franz looked at him upset, "It's so strange that you go to the Hofburg Palace every day."
"I'm worried." Edward had a lot of worries in his mind. Whether it was the Prussian-Austrian front or the operation in Vienna, they were tormenting him. "I just received a tip last night. It seems that the front has been calm for several days."
Franz looked at the document in his hand and said with a smile: "Yes, the Prussian attack has been suspended, and we can take a breather."
Edward frowned, always feeling that the man in front of him was hiding something from him: "The Prussian army's attack at the end of September was very fast and violent, and it was overwhelming. But now the attack has suddenly stopped. Is there any other intention?"
"Other intentions?" Franz closed the document and asked, "What is Mr. Edward's opinion?"
Edward doesn't have any high opinions, all he has is some unrealistic guesses: "I just find it strange."
Franz laughed and opened another document: "They just blocked the attack. Maybe they want to adjust their strategy. It's not a big deal. But Mr. Edem's operation should have already started. Your trip to Paris Are you ready?"
"We've been waiting for a whole week." Edward sighed, "Everything is ready. As soon as the operation is successful, Mr. Carvey and I will leave for Paris immediately."
"It seems everything is going well." Franz seemed very calm, far less nervous than before about the success or failure of the operation. "I wish you and Dr. Kawei a happy trip in advance. Oh, by the way, I also wish Edem Sir, the operation will be successful."
(End of chapter)
