For the bladder-replacing bladder, in principle, there are certain physiological indications for choosing the location of the intestinal segment. But in clinical practice, the surgeon's preference is more dominant.
The reason is that no matter where the intestinal segment is, it will not have much impact on the patient after being lost, and the most important urinary control mechanism has nothing to do with the location of the intestinal segment. In addition to the nerves and urethral smooth muscles that must be protected during the operation, what needs to be paid attention to is the handling of the intestinal tube. After all, it is the surgeon's technique rather than which section of intestinal tube is removed.
In the development history of making the intestine into an urinary bladder, surgeons used a lot of spatial imagination.
The reconstructed urinary bladder needs to maintain three important characteristics: high volume, low pressure, no reflux, and reabsorption.
These three points determined Kawei’s choice.
"First we need to understand the characteristics of the bladder." Kawei found the ileocecal part, lifted a section of ileum, and said, "Why is there 3*4*5l of urine?"
"It's because there are many folds in the bladder wall, which increases its compliance." Waterman replied.
"Yes, compliance." Kawei said, "The intestine itself is not a bladder, and its compliance is not great, but its rebound and contraction performance after expansion is much stronger. The same volume of urine enters the bladder and the intestinal urinary bladder, so The pressure they bring is different. So we need to increase the capacity, otherwise the patient will suffer from frequent urination after surgery."
"It seems that a colon that is not very elastic is not good." Massimov said, "And you also mentioned the problem of cleanliness before."
"Yes, based on what I just said, the ileum has the greatest compliance among all intestinal segments, but its contractility is much smaller. As long as enough intestinal tubes are selected, a high-volume and low-pressure environment can be created."
Before Kawei appeared, cutting off the intestines and then suturing them was an absolutely imaginative thing.
It has been more than half a year since Kawei appeared, and half of the people present have learned how to anastomose the intestines.
Although not many people have actually performed the operation, it doesn't seem too outrageous to hear that it is a weird operation that should not have occurred at this time. In their eyes, the requirements for intercepting intestinal tubes are not too high, but the shape of the intestines used as the material is fixed, and how to expand the volume is the key.
"These are just intestinal tubes, only a small section can be used."
"Yes, even if it is made into a long tunnel, the compliance is not great, probably only about 100, which is far less useful than a bladder."
"If we really switch to this kind of replacement bladder, then the usual urination once every 2-3 hours will become once every half an hour..." Musa shook his head, filled with doubts, "Dr. Kawi, don't be so pretentious. Now, tell us directly, how to do it?"
"To increase the volume of the urinary bladder, all we need to do is change the original shape of the intestinal segment." Kawei made a few simple folds of the intestinal tube in his hand and said, "Remove the tube shape, re-sew it and change it to S Shape, shape, or more similar to an oval or spherical appearance."
Finding the most suitable shape requires long-term clinical practice, from cadavers to patients, everything is indispensable.
In fact, the development and maturity of this surgery took more than 20 years of efforts by urological surgeons around the world. The final shape chosen depends on the surgeon's proficiency and is not static.
….
In addition to the establishment of external volume, Kawei also needs to establish an adequate anti-reflux mechanism.
Modern urology may not be interested in reflux. After all, there are powerful enough antibiotics, a large number of advanced surgical instruments, and a mature enough postoperative medical system to support it.
Postoperative upper urinary tract injury actually takes a long time to settle, ranging from a few years to decades. Patients undergoing urinary diversion and neobladder surgery are basically elderly people with limited life span, so anti-reflux is necessary but not the first priority.
But in the 19th century, what Carvey did was a one-shot deal.
Once the surgery is over, the treatment is over. Even if there is a problem with the surgery itself, the opportunity to correct it is basically lost. Not many people can endure two consecutive surgeries. Without complex and efficient postoperative support, all he could do was to try to squeeze all the problems into the surgery to solve them.
But Kawi is also a human being, not a god.
It is unrealistic to solve all problems with your hands.
Even after many anatomy exercises, even though all the hospital's cadaver resources were delivered to him, and even though Mosier and he had already cooperated very well, he still felt that the success rate of the operation would not be too high.
At most, it is only 70%. If you are more conservative, the probability may be only half.
Who makes Edem not the previous Prussian soldier, let alone Fernand, old age + tumor have taken away the health of this French gentleman.
Cutting open the intestine to make a large number of shape changes will greatly extend the operation time, and postoperative recovery will also take a certain amount of time. Moreover, a large number of incisions and sutures are required during the operation, and the technical requirements are also very high.
In the past, this was definitely a major surgery that required several department directors to be consulted and handled together.
Now, the pressure is all on Kawei alone.
He didn't dare to change the shape of the intestine too much, he didn't dare to operate on Edem like Fernand, and he didn't dare to take a gamble.
The original intention of the surgery is not to show off one's skills, but to accomplish the purpose of the surgery as much as possible with the lowest health cost. Therefore, after repeated practice, he chose a surgical method that was relatively simple and could also minimize the impact on urinary function.
"In the past few days, I have tried many intestinal reconstruction methods, and I have used the intestines of almost every corpse for reconstruction."
Kawei took the tissue forceps and gauze sent by the nurse and said: "I have tried all the bending, S-shaped twisting, V-shaped and T-shaped anastomosis mentioned before. Just cut the tube wall lengthwise and remove By removing their original tubular structure, and then anastomosis and connecting the sides, they can be made into the shape of a pouch."
After what he said, the doctors who were still a little confused finally caught up with the idea, and the discussion started gradually: "So that's it, it's a good idea."
"But complete dissection requires very high anastomosis skills..."
"There is also blood supply, and the most important thing is blood supply! If the incision and suturing of the intestines are not handled properly, the blood supply will definitely be affected. Even if the anastomosis is well sealed, problems will occur over time."
"Yes, intestinal fistula, that's the most troublesome thing."
"According to Dr. Kawei, the mesentery does not actually need to be cut off. As long as the suturing is done carefully, the blood supply should not be a problem."
….
"No, your statement is a bit taken for granted. Such a large-scale incision and anastomosis will definitely cause blood supply problems. This cannot be avoided by saying 'be careful'. Think about why we were still anastomosing intestinal tubes half a year ago. Are you worried? Isn’t it just because of carelessness in operation? Isn’t this carelessness easy to avoid?”
"Indeed... there are still many cases of intestinal fistulas caused by intestinal anastomosis."
"Don't forget, in addition to the blood supply, there are also infections caused by surgery, which will also affect the intestinal anastomosis."
"Yeah, intestinal anastomosis doesn't look difficult, but I'm just worried about what might happen. It would be too troublesome if something goes wrong after the operation..."
What weighed on Kawei's heart was the eventuality they mentioned.
Of course, the eventuality he had in mind was not the intestinal anastomosis. After all, intestinal anastomosis was a common skill in emergency surgery and he was already familiar with it.
What he is afraid of is the burden that the excessive operation time will bring to Edem: "According to the original plan, the operation requires the reconstruction of four intestinal tubes, and the suture distance exceeds 1 meter. The time spent on the reconstruction alone will be An hour and a half."
In front of everyone is a very simple math problem, 1.5+1.5=3 hours
This does not include the final anastomosis of the ureter and the neobladder, and the anastomosis of the urethra and the neobladder. In addition, the hand speed difference caused by the need for stability during the operation, the four-hour operation time is definitely considered conservative.
"In this case, the operation may take five hours...which is too long."
"I've never seen an operation take that long."
Kawei began to free the ascending colon, found the hepatocolic ligament, and prepared to cut it: "So two days ago, I gave up the so-called complex reconstruction. Instead, I wanted to change the position of the colon and ileum to form a bladder."
This was a very ambiguous statement. Many people present could not understand it, including Massimov and Waterman who were standing aside and watching: "What do you mean by this? What does changing position mean?"
"You just made such grandiose remarks, but now you want to give up on reconstruction?"
"Mr. Massimov, this is actually a kind of reconstruction, but it's different from changing the shape. What I'm doing is a change in position." Kawei thought for a moment and explained, "If I have to make a comparison, it's Remove the cadavers in the anatomy room and add a few seats, and it will feel like an operating theater."
What a mess!
Waterman was confused and couldn't help but look at Massimov beside him, trying to get some useful information from him so that he would not look so embarrassed. But Massimov was even more confused and didn't understand what Kavi meant.
"I'll understand when I keep doing it."
Kawei cut off the hepatocolic ligament. After measuring the length, Kawei chose 2 liters of colon and 1 terminal ileum [1]: "First of all, I have to explain the anti-reflux mechanism of reconstructing the bladder, which is closely related to urinary tract infection."
Anti-reflux, as the name suggests, prevents urine that enters the bladder bag from returning to the ureter due to pressure, body posture, etc.
"You must be well aware of urinary tract inflammation, which can bring a series of symptoms and bladder stones..." Kawei asked Berget to put down the candle in his hand and use only the light on the ceiling to perform ileocolic dissection. "Go and prepare disinfectant cleaning solution with Damirgaon."
….
"good."
Kawe separated the peritoneum of the ascending colon and cut it with scissors [2]: "... Bladder stones are caused by inflammation, but inflammation of the lower urinary tract rarely moves up into the kidneys. This is because Top-down flushing of urine and anti-reflux mechanism at the ureterovesical orifice.
This is originally an important landmark in vesicoureteral anatomy.
There will definitely be infection during surgery, whether it is inside the urinary tract or outside the urinary tract. Given Mr. Edem's age and physical condition, infection is certain. Under the premise that infection is almost certain, the reflux mechanism can effectively protect the upper urinary tract. Even if the lower urinary tract infection is severe, the kidneys are safe. "
After that, he pointed to the ileocecal part, which is still connected to the abdominal cavity by the mesentery: "There are two anti-reflux mechanisms I have set up. The first one is the interface between the ureter and the intestine, and the second one is the interface between the ureter and the intestine. It depends on the special anatomical structure of the human body."
"Ileocecal valve...you mean ileocecal valve???"
"right."
"I never thought there was such a way... the idea is so clear!"
"But Dr. Kawei, choosing the ileocecal valve means that the ileocecal valve in the intestine disappears. Then how to prevent small intestine food from entering the large intestine too quickly? What about the reflux of feces in the colon?"
Kawi nodded and looked at Moussa who asked the question: "That's a good question."
"so?"
"So...it doesn't matter." Kawei smiled helplessly, "If this thing is gone, it is gone. Let it go."
A very neat answer, not like Kawei who always comes up with wonderful ideas for everything.
"Is there no way to rebuild?"
"Yes, there is, but it's not necessary." Kawei wrapped his fingers in wet gauze to separate the loose mesh tissue under the peritoneum [3]. "The absence of the ileocecal valve will only cause some diarrhea, but if it takes more time, To reconstruct it may cause unnecessary damage."
He explained the anti-reflux structure while working on the mobilization of the ascending colon.
However, this dissociation was different from the previous ones. Kawei removed most of the loose tissue, but specially retained a part of it, and only pulled out a part of the intestine: "Give me wet gauze, it needs to be hot."
"coming."
Damirgang twisted out two pieces of gauze from the disinfectant cleaning solution, loosened them, and carefully covered the intestines.
"When dealing with the ascending colon, that is, the right half of the colon, you must be particularly careful about the duodenum below the colon [4]." Kawei used dissecting scissors to carefully handle the tissue here, and said, "First explore with your fingers, and then exposed, then
separation. Berget, is the cleaning fluid ready? "
"almost done!"
"Come over and help me soon. The light is not bright enough!"
"yes!"
Kawei loosened the tissue around the hepatic flexure and turned the intestine over to expose a large amount of mesentery on the medial side: "We need to distinguish the colic artery and the branches of the hepatic flexure, and then determine the location of the colon cutoff. Mr. Edem's right colon is not long. We cut it all at once." [5]
After distinguishing the blood vessels, Mosier used two tissue forceps to clamp the colon tube horizontally, leaving a gap in the middle for Kawei's scalpel to cut it.
"Be careful to protect the transverse colon incision. We will perform end-to-end anastomosis later." Kawei asked Damirgan in the distance, "Is the cleaning solution ready?"
"Already prepared, methylene blue saline solution at around 30 degrees Celsius."
"Okay, after we cut out the ileum, you can do the flushing."
"yes."
The procedure for resection of the terminal ileum was the same as for the right colon, so Carvey left this step to Mosier and Hermann. He himself carefully dragged the newly removed right colon and said, "Next, in order to reconstruct the intestine without incising it, I need to loosen the bandage of the colon."
"Relax?"
"I'm going to remove the colonic band around the intestines and free up the colon."
West wind
