During surgery, distinguishing the location of each tissue relies on the touch of fingers and the difference in color and texture brought about by vision. Compared with subjective touch, the difference in color is much more intuitive and objective. Unfortunately, this objective difference is easily undermined by other factors.
The light source is a variable.
One of the important reasons for the slow development of abdominal surgery in the mid-nineteenth century was the insufficient brightness of light. Coupled with a lack of understanding of the anatomy, very few people dare to perform abdominal surgery and do it well.
The bladder and prostate are located very low on the pelvic floor. In the absence of electric light, it is a luxury to maintain a clear surgical field at all times.
In a sense, it has only been an hour since the operation. The most tiring person is definitely not Mosier, who is following in Kawei's footsteps but still has some strength, nor is it the nervous but experienced Kawei, but the one who has never done any surgery before. Berget of the instrument.
Bergert needed to constantly change the position and angle according to the progress of the operation, repeatedly switching between candles, a huge candlestick on the top, and a brighter kerosene lamp. A single slender candle can be closer to the incision to help illuminate the deep anatomy. The ceiling candlestick is like a weakened version of a shadowless lamp, and the flame of the kerosene lamp can ensure sufficient brightness.
At the same time, he had to adjust the angle of the light to prevent wax oil from dripping, stand in a position that would not affect the four surgeons, and avoid relatively sterile surgical instruments.
In order to maintain the light, he had to lie on top of Edem.
Of course, due to limited external conditions, it would be unrealistic to rely on Bergert alone to maintain the clarity of the surgical field. As the chief surgeon, Kawei also needed to make adjustments.
In the past, intra-abdominal surgery often did not pay much attention to small blood vessel bleeding. If it is a radical surgery on the limbs, this kind of bleeding is even less important. But now the light is limited. Not only is the surgery location low, but the operable range is also small. In addition, the four hands of the surgeon and an assistant are constantly blocking the field of view. It is obviously unrealistic to rely on tossing the light back and forth.
In addition to the light source, the most important variable that affects color is the bleeding of the tissue itself.
The blood will adhere to the mucosal surface, staining the tissues that were previously distinguishable by vision uniformly red.
Although the color can be restored by rinsing with saline, once the rinsing is done, the liquid must be sucked out with a suction device, which wastes time. It would be okay if the frequency is small, but the pelvic floor is covered with various blood vessels, and almost immediately after flushing, it will be covered again by the blood that emerges from behind.
Therefore, Kawei tried to be as "clean" as possible when dealing with the dorsal vein complex.
"When treating the pelvic floor, you need to be as clean as possible, that is, to lock the blood in the blood vessels." Kawei picked up the suture needle just left on the perichondrium of the pubic symphysis, clamped the needle holder and said, "Dissolve the back After the vein complex is formed, use this thread to continue suturing the distal broken edge to achieve complete hemostasis." [1]
"Second anesthesia."
Amor put a mask on Edem, listened to the nurse around him reporting his vital signs, and watched his body's reaction: "The reaction is normal, the anesthesia is over, and the vital signs are normal."
"good."
Kawei nodded and asked: "There is also a urinary catheter in the equipment box. Go and insert it for him. The urethra must be propped up before cutting off the prostate."
"knew."
In fact, inserting a urinary catheter before surgery is a routine procedure.
An open incision during the operation will cause a large amount of body fluid loss, and bleeding will require a bottle of fluid to be rehydrated throughout the operation. Under the premise of long-term rehydration, urine will naturally continue to be produced. During general anesthesia, the sphincter is tightly closed and cannot urinate smoothly. Without a urinary catheter, the bladder will soon become full.
This will not only cause damage to the bladder, but sometimes it can cause diarrhea due to excessive pressure.
However, there are currently no rubber tubes with air bags, making it difficult to self-fix, and the number of urinary tubes themselves is also limited. In addition, the nature of the operation determines that the ureter will be severed at the beginning, so the situation of urine pigs no longer exists.
So at first Kawei only asked to empty his bladder and did not place a urinary catheter.
Now that the surgery is about to separate the prostate and the urethra, it is still necessary to insert a urinary catheter for support. This can add a reference object to the urethra and clearly see the relationship between the internal and external structures of the urethra.
"The catheter was put in," Armor said.
"Okay." Kawei said, pointing to the compressed dorsal vein complex covered with gauze. "The suture used before the disconnection was not enough to stop the venous complex. The bleeding is serious now, and compression is obviously not enough. We need more Use sutures to stop this wound and give me the needle holder..."
He quickly made continuous "V"-shaped sutures on the wound. 【2】
"Press back on the prostate." Kawei moved the pressure plate in Damirgang's hand downwards. "Don't use too much force. Just expose the junction of the prostate and the urethra. What we need to do next is to separate the outside of the urethra. of the striated sphincter, exposing the internal urethra."
Mosier took a pair of right-angled forceps and inserted them near the tip of the prostate just behind the smooth muscle of the urethra. Then the forceps teeth are expanded outward to create a cavity under the urethral smooth muscle, so as to avoid the neurovascular bundles close to the urethra and prevent accidental injuries caused by the scissors in Carvey's hand. 【3】
This is a very basic but practical assistant operation. After five days of practice, the two have developed a tacit understanding, and Waterman and Massimov nodded repeatedly as they watched.
"When cutting the urethra, be careful not to cut it off at once, and not to damage the internal urethra." Kawei tilted his head and carefully distinguished the urethra and the urethra inside. "This is not an amputation. It needs to be done first. Cut off 2/3 and keep the rest for now.”
The scissors were quickly replaced with three needle holders.
The first one passes through the 12 o'clock position of the urethra: "It is easy to distinguish the inner urethral mucosa by leaning on the urethra, and also see the outer urethral smooth muscle. Do not damage the smooth muscle when suturing, otherwise the urinary control function will not be restored after surgery. It’s going to be difficult.”
Leave the sutures unknotted, lift up the 12 o'clock position, pass the second and third handles from the outside inward, and pass through the 7 and 10 o'clock positions of the urethra respectively.
Then there are the fourth and fifth hands, passing through 2 o'clock and 5 o'clock respectively. 【4】
"Give me gauze." Kawei laid a total of 10 threads in five places on the surgical towel, then covered it with gauze and a hemostat to hold down the threads. "Amor, remove the catheter."
"good."
"After removing the urethra, the sixth needle holder left a suture...scissors." Kawei pulled out the thread again and used scissors to cut off the back 1/3 of the urethral wall. "Then further down is the urethra. The posterior part of the striated muscle continues to be cut downward. When cutting off, we still have to pay attention to the most important point, the neurovascular bundle." [5]
This anatomical structure has been repeated a dozen or even dozens of times. It seems very nagging, but Kawei still has to say that only repeated reminders can deepen their impression.
However, they are almost completely attached to the outside of the prostate fascia and are in the blind area of the top-down field of vision, so care must be taken during resection.
To use an analogy, removing the prostate is like peeling a single piece of grapefruit. You need to take out the tender grapefruit flesh inside.
The levator ani fascia on the outside is the outer skin on both sides of the grapefruit, the denonvilliers fascia is the albuginea below, the prostate fascia wraps the grapefruit flesh and cannot be broken, and the neurovascular bundles are some meridians-like things that need to be severed below. . 【6】
However, when handling, it is not only the grapefruit meat that needs to be protected, but also the meridians that must be stripped off.
The nerve runs on the posterolateral surface of the prostate, and branches are constantly extending into the prostate. It is necessary to cut off those small branches while retaining the trunk branches, and then peel off the neurovascular bundles little by little.
Mosier still did the same operation as before.
The right-angle forceps expand the surrounding tissue, exposing the space under the smooth muscle, giving enough room for the Kawei scissors to operate.
But this is not enough for Kawei: "Don't open the scissors too wide. When cutting off the last 1/3 of the urethra, you cannot cut it all at once. You need to cut half of it first and then switch to the other side for separation. Because the scissors are There are no eyes, and the front teeth of the right-angle pliers are not long either. If you just rely on feeling, you may be able to find countermeasures."
The next thing to do is to process the lateral edge of the dorsal vein complex of the prostate, separate the levator ani fascia, and slowly peel off the outer skin of the grapefruit.
The urethra is transected, urethral sutures are placed, the posterior part of the striated sphincter is cut, and then the underlying denonvilliers fascia is completely freed. The lowest part of the prostate was finally cut open, and it could be said that only the last part was left in the radical mastectomy.
"Lifting the severed prostate tip, we can see that there are still many adhesions on the left and right sides that need to be dealt with." Kawei used tissue forceps to mark several locations on the back of the prostate. "We need to slowly work on the tendons. Separate the membrane, carefully expose and cut off those small nerve and blood vessel branches, and be sure not to damage the part that remains in the body."
Mosier used tissue forceps to clamp the pelvic fascia covering the prostate. Carvey used a knife to make a small incision, and then Mosier inserted right-angle forceps into it and expanded it to expose the cutting space.
The superficial fascia is incised along the bladder neck to the tip of the prostate. 【7】
After both sides were opened separately, the degree of freedom of the prostate was further increased, and because of Kawei's excellent hemostasis work, the location of the neurovascular bundle was completely exposed. 【8】
"Do the final separation work."
Kawei took Mosier's right-angle forceps and gently separated the neurovascular bundle. He could even see some of the small branches that are closely connected to the prostate: "I was lucky, I kept most of the branches. Before the separation, if you are interested, you can come down and have a look."
In fact, when the prostate is removed during surgery, many people no longer understand it. Those anatomical tissues that they had barely touched upon popped into their ears one after another, and their brains had no time to process them, let alone integrate them into a spatial model.
Even if they could actually come forward and take a look now, it wouldn't be of much help to them.
"I see many people are almost falling asleep." Waterman looked around and joked, "The surgery is so exciting, probably less than 20% can understand it."
"They should have done their homework," Massimov said.
"Maybe the prostate is not within the scope." Kawei quickly tried to smooth things over, "Medicine is a process of accumulation. It doesn't matter if you don't understand or understand it the first time. If you read and listen more, you will slowly understand."
"The cost is not low..."
With the chief surgeon's permission, Waterman couldn't say much and could only let the other doctors come down and observe.
Everyone wore masks and circled around the operating table in a clockwise direction, poking their heads forward one by one, trying to take a closer look at the fascia layer and neurovascular bundle left by Kawei's separation. Some people also sketched this anatomical scene, and questions continued.
“Is the next step going to be to untie the relationship between the prostate and the rectum?”
"To be precise, it's the relationship between the denonvilliers fascia and the rectum." Carvey used a right-angle forceps to lift up a layer of dense structure and cut it with scissors. "Then the prostate can be turned over. The neurovascular bundle here will meet the blood vessels supplying the tip of the prostate. In parallel, it is necessary to separate them one by one, clamp and cut off the blood vessels, and then continue to repeat the previous method of treating the neurovascular bundles." [9]
With the previous processing techniques, the next step is very procedural work.
Lift, dissociate, expose small branches, suture and cut...【10】
"Don't be too quick here. You must keep the pace and take your time." Kawei said while doing it, "until the entire prostate is freed and the neurovascular bundles are no longer connected to the prostate... .Take it!"
With the bladder and prostate completely thrown into the metal bend, the first part of the surgery ended successfully.
Next, this piece of tissue will be divided into several small pieces under the scalpel of Koch and Savarin, just like the lymph node just removed, and then dozens of pathological slices will be made.
But before that, Mr. Edem needs to give an explanation.
"Mr. Hans!"
"I'm here." Hans stood up gently, with a smile on his face that could make half the beauties in the city fall in love. "What are your orders from Dr. Kawei?"
Carvey asked, "Mr. Edem didn't ask for his bladder to be drawn?"
"Emmm...it doesn't seem like it." Hans put the drawing paper he had just drafted aside and replaced it with another one. "But, according to Dr. Ikawi, this should be a very important thing." .”
Kawei did not dare to give a definite answer, but asked Xiang Savarin: "How is the pathological examination of the lymph nodes?"
Savarin used a pen to draw a mark on the small piece of paper next to the slide and replied: "Not all the tests have been completed, but tumor cells have been found."
Pathology results are the best diagnostic report, and the diagnosis of bladder cancer is clear.
Kawei nodded after hearing this and looked at Hans: "This is indeed very important. This is the world's first radical bladder cancer surgery. What is on the plate is the world's first bladder and prostate tumor to be removed. It is very important." Memorial significance.”
