godfather of surgery

Chapter 646 Ceiling

There are many people, and everyone is very motivated to learn.

Professor Liang can tell you a lot of things every time, so everyone likes to listen to Professor Liang's class very much.

Professor Liang's attainments in spine are very high. His academic achievements not only occupy a leading position in China, but also have world-class academic achievements, which makes Concord's spinal surgery have a place in the world.

Therefore, the supreme reputation of Xiehe is created by the efforts of generations of people.

After Song Yun reported the medical records, everyone was thinking about it, and Professor Liang began to speak.

"Total spinal en bloc resection, also called total vertebra resection, is a very complicated operation. There are not many articles at home and abroad, only a dozen, and even fewer hospitals can do it."

"Due to the complex anatomy of the spine, which is adjacent to spinal nerves, large blood vessels and important organs, surgical resection is very difficult and the risk is very high. In the past, subtotal resection was used for such cases, which led to incomplete tumor resection. It is very easy to relapse, and the relapsed tumor is difficult to treat, and finally the treatment effect of this kind of tumor is very poor."

"In the 90s of the last century, Tomita, a professor at Kanazawa University in Japan, proposed the posterior total spondylectomy, which is now the total spondylectomy. With this technology, not only for such tumors, but also for all The complex tumors of the spine have improved the surgical effect. In this case, I would like to ask everyone, how to do the total vertebra resection, Song Yun, please give me the answer.”

Professor Liang would like to use this case to tell you about the difficult and high-risk surgery of total vertebral resection, so that everyone can thoroughly grasp the relevant knowledge based on the case.

Song Yun once graduated from the Concorde Eight-Year Program. Both basic knowledge and learning ability are outstanding. The college entrance examination scores of the Concorde Eight-Year Program are at the same level as Tsinghua University, but because of the small enrollment scale, it is more difficult than Tsinghua University.

This kind of high starting point, high standard, and high demand cultivated talents are all the elites in the industry.

Think about Su Nanchen entering the Concorde eight-year system, and his college entrance examination score that year was the top scorer in the science department.

Song Yun took his time and answered clearly:

"Dr. Tomita's operation method is also the current mainstream operation method. The operation is performed from the posterior approach. The vertebrae are cut off from the pedicle with a wire saw, and the vertebrae are divided into two parts: the vertebral body and the appendages, and then the two parts are cut separately. Of course, it takes Safely detach all structures surrounding the vertebrae."

"Combined with the specific situation of this patient, the tumor has invaded the large blood vessels in front and adhered to them. A simple posterior surgery cannot solve the problem. Anterior surgery must be combined to remove the tumor."

"The choice of the anterior approach should also take into account the growth pattern of the tumor. The aorta and inferior vena cava cannot be fully stripped through the anterior lateral approach, so it is best to choose the anterior approach, which facilitates the aorta and inferior vena cava. At the same time, pay attention to the Protection of internal and external veins."

"The segmental arteries should be handled carefully. The psoas muscle is attached to the vertebral body. Be very careful when separating it to prevent damage to the nerve roots that go out of shape inside the psoas muscle."

Song Yun briefly explained the operation process and precautions, which shows that he has a very thorough understanding of the operation and can make such a summary.

"Very good! Not only have I read the papers in this area, but I also have some experience in surgery, and I have a good understanding of the precautions." Professor Liang praised.

Although Professor Liang has strict requirements, he never hesitates to praise his students. He believes that only criticism is not enough, and students should be praised and encouraged in a timely manner.

"So, when this operation cuts the vertebrae from the pedicle, it needs a special tool. Why is this tool special? What's so special? Raise your hand and answer."

Professor Liang continued to ask, since this case has been discussed, he wants to check whether the young doctor has grasped it.

Many people in the conference room raised their hands. Everyone was very active and the atmosphere was very active.

Professor Liang ordered a young doctor at random. The young doctor had a good appearance and temperament, and he answered confidently and calmly: "The structure of the vertebrae is complex, so a special guide is needed to guide the wire saw under the pedicle, because the direction of the wire saw It is impossible to follow the standard route like the usual long bones, so a special redirector is needed to change the direction of the wire saw so that it can go around the pedicle to form an effective cut."

"This special instrument is difficult to buy on the market. Hospitals that can perform this type of operation either bring back tools from abroad or use existing tools to adapt to this type of surgery."

"We need to redesign the surgical tools for this patient. Let's look at the [-]D reconstruction of the spine and tumor. The normal wire saw penetrates between the laminae and exits through the intervertebral foramen. Then the wire saw diverters the vertebral arch After the rhizome is cut, there is a space-occupying lesion in the spinal canal, and there is no gap to thread the wire saw. If the thread is threaded forcibly, it is easy to cause the tumor to spread and cause tumor bleeding. Some personalized changes need to be made to the equipment to adapt to this special situation. "

The ceiling of Chinese hospitals is well-deserved. Any one picked out is the elite of the elite, and these doctors all have a kind of temperament: calm and confident.

Yang Ping has been quietly listening to their speeches, thinking about the uniqueness and shortcomings of these speeches.

"Very good! Every case should be treated as a classic. This is the responsibility to the patient as well as to oneself. A lot of things can be learned from one case. Who is responsible for 3D printing?" Professor Liang was very angry.

"Me!" A young doctor raised his hand.

The doctor immediately walked to the computer and projected a 3D model of the artificial spine onto the screen.

Because of the importance of 3D printing technology, almost every doctor in Xiehe Orthopedics is proficient in this technology, and they use this technology as a basic skill for training.

The 3D printed artificial spinal prosthesis is placed on the screen and rotated 360 degrees.

"This is the 3D artificial spinal prosthesis we designed to replace the three vertebrae that will be resected during the operation. In order to achieve effective reconstruction of the vertebral body, we make a personalized design based on the patient's anatomical structure and biomechanical characteristics. This is the upper and lower parts of the prosthesis. , perfectly fits the connecting surface of the upper and lower normal vertebral bodies. This is the screw implantation hole specially designed by us, which can connect the artificial vertebral body with the rear screw-rod system to form a unique truss structure. The truss structure combines the porous titanium alloy we adopt. The design allows the artificial vertebral body to have sufficient biomechanical strength, and postoperative patients can get out of bed as soon as possible for rehabilitation training, and realize life and work like normal people."

Yang Ping thinks that the design of this artificial vertebral body is very good and meets the requirements of biology and biomechanics. The designer must have received relevant systematic training.

After sorting it out in this way, the preparations for the entire operation have been very sufficient, and there are no mistakes.

"I have a question!"

Among the crowd without seats, a young doctor raised his hand to ask a question.

Because there are too many people, some people have seats, and many young doctors are standing.

"you say!"

Professor Hu Guolin asked him to stand up.

The doctor in his early thirties said loudly: "The operation preparation just mentioned is based on the assumption that everything is going well. If things don't go well and there are extremely bad situations, such as rupture of the aorta or inferior vena cava, what should we do? ?Especially in cases of extensive tearing."

The doctor walked up to the podium with his chest out, and continued confidently:
"You can see that the adhesion between the tumor and the large blood vessels is as long as 10 cm. In this case, it is very easy to tear the aorta and inferior vena cava. Even if there is no tear, the tumor and the large blood vessels can be successfully separated. Such large blood vessels Can it still be used? Is there a potential safety hazard? Like aortic dissection, it is like a time bomb. I saw an article mentioning a case, which belongs to the abdominal tumor specialty. The tumor was adhered to the large blood vessels in the abdominal cavity. It was separated from the large blood vessels, and the operation went smoothly, but the patient died suddenly on the fifth day after the operation. Later, the autopsy found that the reason was that the aorta was invaded by the tumor, and the blood vessel wall had changed. The patient developed an aortic aneurysm, the aorta was torn in a large area, and the patient died of internal hemorrhage and shock. Have we ever thought about what to do in the worst case? Do we rely on blood transfusion?"

The young doctor sounded sharp like a critic, as if he was questioning his colleagues, Professor Liang and Director Hu in the front row.

Yang Ping found that almost none of the doctors in Xiehe were hunchbacked, but all of them held their heads high and their backs straight.

Even Professor Liang, who is the oldest, holds his head high, his back straight and energetic, whether he is sitting, standing or walking.

"very good!"

Professor Liang applauded the questioner, and everyone applauded.

"This is what I always tell you, what about us as doctors?"

Everyone replied in unison: "Do your best and prepare for the worst!"

"Yes! We are working towards the best goal, but we must prepare for the worst. Who will answer the doctor's question?" Professor Liang was very satisfied with the doctor's question.

Those who are academics must have the spirit of questioning, not copying what others say, and lacking the ability to think independently.

Director Hu stood up: "Let me answer. We have considered this situation and have measured the blood vessel wall on the images. Indeed, there is such a risk in the blood vessel wall, and the risk is still very high. For this reason, we have prepared For the artificial blood vessel, we invited the assistance of vascular surgery to detect the condition of the blood vessel during the operation, and if necessary, implant the artificial blood vessel in advance to prevent the worst case mentioned by the doctor.”

Those who raised the question were very satisfied, and it seemed that the director was very considerate.

"Are you satisfied with my answer? During the case discussion, you must have left early, and I mentioned this issue at the end." Director Hu didn't mean to blame, but told the doubter gently.

Indeed, the doctor's medical team was on duty at the time, and he left temporarily because of emergency surgery.

Yang Ping was sitting in the first row, and the enhanced [-]D reconstruction of the tumor was displayed on the screen. He saw the extent of tumor invasion, the spinal canal was already crowded, it invaded the spinal cord and nerve roots, and the anterior side was adhered to the aortic inferior vena cava. The difficulty is indeed very high, especially the wall of the vena cava is thin, and if the separation is a little bit worse, the wall of the vessel will rupture.

The tumor is intertwined with the spinal nerves in the spinal canal, which can easily damage the nerves. This operation is well-deserved world-class.

The implantation of artificial blood vessels in advance is very clever, which minimizes the risk of rupture of large blood vessels during and after surgery.

There is another problem. Although it is not fatal, if it is not handled properly, it will easily cause the tumor to spread. That is, the tumors of L2 and L3 have invaded the pedicles on both sides. In this case, use a wire saw to cut off the pedicles. Either way, the tumor is damaged, leading to dissemination of tumor cells.

In order to reduce the possibility of spreading, only through careful operation.

If the tumor can be carefully peeled off to expose a part of the pedicle, this problem can be solved, but it is very difficult.

Yang Ping thought about this problem in his heart, trying to handle every step perfectly.

"Anyone else have any questions?"

Director Hu asked everyone, because the discussion cannot go on indefinitely, so there is no way to end it for three days and three nights.

"I just mentioned that the tumor and the pedicle are intertwined. How to insert a wire saw to avoid damage to the tumor and reduce the spread of the tumor." A doctor was also thinking about this issue and proposed it.

"To remove the vertebra, it must be divided into two parts, and it cannot be cut in one piece, so this problem cannot be avoided. We can only use a special guide for bone-bonding puncture to guide the insertion of the wire saw, and we have improved the instrument and added a A protective cover when placed, which can minimize the risk of spreading." Director Hu introduced the solution.

The questioner nodded, very satisfied, this is already the best way, it is impossible to take out the whole vertebra at once, it cannot be done.

"Are there any questions? Time is limited, and there are still questions that can be communicated in private."

No one was asking questions, Director Hu said to Professor Liang: "Shall we go see the patient?"

Professor Liang nodded, turned to Yang Ping and said, "Let's go see the patient together."

Professor Liang did not let Yang Ping speak. After all, Yang Ping came to Xiehe for the first time. Professor Liang regarded him as a student or as a professor, and this meeting was of a learning nature.

Under the leadership of the general manager Song Yun, everyone came to the ward. Jing Yunsong was obese, especially the abdominal distension was very obvious. He was chatting with the patients in the same ward, and when he saw the professor coming to make rounds, he immediately sat back on his bed.

When encountering this kind of ward round, most patients are a little confused and do not understand the situation, but Jing Yunsong is very relaxed. He should be a patient who has been to many hospitals and seen big scenes.

"Professor Liang, hello, I finally see you." Jing Yunsong recognized Professor Liang.

Before coming to Xiehe, Jing Yunsong had already searched all the orthopedic surgeons on the Xiehe official website.

"We are going to operate on you. This operation is very complicated and the risk is high, so let's come to see you again." Professor Liang was very kind.

Jing Yunsong smiled and said: "If it is not complicated and difficult, I will not come to Xiehe. I heard that other hospitals will recommend patients to transfer to higher-level hospitals when they encounter difficult and miscellaneous diseases. Only Xiehe does not have this sentence. If you don’t perform surgery on me at the higher-level hospital, I can only travel around the world.”

It's rare for a patient to be so relaxed. Whether it's really relaxed or pretending, at least he can face it optimistically.

"Professor Liang, I heard that this kind of surgery is done most by Xiehe in China. I came here just because of the reputation. Anyway, I have no place to go here anyway. There is a saying in the legend that Xiehe can stay until the third night of the king of hell. Fifth watch." The patient was very funny.

It is very rare for cancer patients to be so optimistic.

(End of this chapter)