godfather of surgery

Chapter 806 Innovation begins with boldness and absurdity

Academician Wang began to tell everyone about Fontan surgery.

"It's a bit complicated to talk about it in three steps. I'll talk about it in flashback. Let's talk about the result first, which is the goal to be achieved in the three steps. Why can't it be achieved in one step? Because after the heart is modified, there is an adaptation process. One step Once the heart can't bear it, serious complications will occur, so you can only take it step by step so that the heart can slowly adapt."

"Look at this case. The left ventricle is very small and underdeveloped. What should we do? We don't want this left ventricle and should be discarded. Doesn't the heart also have a right ventricle? It can also pump blood, so we connect the aorta to the right ventricle. Let the right ventricle replace the left ventricle. It turns out that the right ventricle is connected to the pulmonary artery and is the driving force of the pulmonary circulation. Since the right ventricle is connected to the aorta, what about the pulmonary circulation? The soul of Fontan surgery is here, didn’t I say that before? , the core of this surgery is to directly short-circuit the pulmonary artery and the superior and inferior vena cava, without going through the heart. The power source of the heart is kicked off, and their pressure difference provides the driving force. Finally, the partition wall between the left and right atria is knocked down. Let them become a room, so the three points are the results we want, but this result can be achieved in three steps."

"What will the heart look like after the surgery?"

"Look, everyone!"

Academician Wang drew a picture on the electronic blackboard: "My drawing skills are not as high as Professor Yang's, so I'll make do with it."

In fact, as a medical drawing, Academician Wang is already at a very high level.

"The systemic circulation becomes like this - oxygen-rich arterial blood returns from the pulmonary veins back to the left atrium, then enters the right atrium through the surgically created opening between the two atria, and then into the right ventricle, where it is pumped by the aorta throughout the body as the heart beats. Finally, it is collected back by the superior and inferior vena cava.

"As for the pulmonary circulation, it goes like this - oxygen-poor blood flows directly from the superior and inferior vena cava into the pulmonary artery. After gas exchange in the lungs, it becomes oxygen-rich blood and returns to the left atrium through the pulmonary veins.

As you can see, an artificially modified circulation has been successfully established and the goal has been achieved: oxygen-rich blood and oxygen-poor blood are separated, and the heart is only responsible for the systemic circulation. This kind of modification uses unqualified factory parts to reorganize to achieve normal functions.

"Isn't it interesting for everyone to compare the normal systemic circulation and pulmonary circulation? What an imaginative method this is."

Next, Academician Wang explained in detail the specific stages of the surgery. The first stage is usually completed within one month, the second stage at half a year old, and the third stage at one to one and a half years old.

"The first step is to enlarge the aorta, because the left ventricle is connected to the aorta. Since the left ventricle is underdeveloped, the aorta is often underdeveloped and very thin. We need to enlarge the aorta, and then connect the pulmonary artery to the right ventricle. Cut off and then connect the aorta to the right ventricle, allowing the right ventricle to replace the left ventricle to complete the systemic circulation. So what to do with the abandoned pulmonary circulation? We bridge the pulmonary artery and the aorta, and this bridge is temporary. In this way, the circulation is still chaotic. Yes, oxygen-rich and oxygen-poor blood are mixed, which means the goal has not been achieved yet. However, this is only the first step. Although the final goal has not been achieved, it can ensure that the child lives until the second step of surgery. Of course, we still have to do this step To open the gap between the left and right atria.”

"After the heart adapts, we started the second step when he was half a year old. It turned out that we built a bridge between the aorta and pulmonary artery. This bridge was only temporary. Now it needs to be removed to connect the superior vena cava to the pulmonary artery. This way The pulmonary artery receives oxygen-poor venous blood and is one step closer to the goal, but the blood from the inferior vena cava still enters the right atrium, left atrium, and right ventricle, which acts as the left ventricle, so in the second step, the venous blood and arterial blood still mix. "

"When we are one to one and a half years old, we take the final step and connect the inferior vena cava to the pulmonary artery. Let's see, have we achieved the goal we set out to achieve?"

Academician Wang clearly explained the three steps of Fontan surgery in plain and simple language, and combined with drawings, young students have completely understood it.

"During the entire operation and postoperative monitoring, we focus on monitoring the pulmonary artery pressure. Because the entire operation is based on the pressure difference between the aorta and the pulmonary artery, once pulmonary artery hypertension occurs, the entire operation effect will collapse and the patient will be in danger, so we Once a problem is identified, surgery is needed to regulate the pulmonary artery pressure."

"To summarize, our goal is - because the left ventricle is disabled, we will reconnect the aorta that originally connected the left ventricle to the right ventricle, connect the pulmonary artery that originally connected to the right ventricle with the superior and inferior vena cava, and open up the separation between the left and right atria. "

"Just to allow the heart to adapt, we took our time and completed the goal in three steps - first, reconnect the aorta to the right ventricle. At this time, the pulmonary artery has not yet been connected to the superior and inferior vena cava, so we temporarily built a channel with the aorta; Connect the aorta to the superior vena cava; finally connect the aorta to the inferior vena cava, and you’re done!”

"Is there anything you don't understand about Fontan surgery or have any questions?" Academician Wang asked.

One student raised his hand: "Teacher Wang, apart from heart transplantation, will there be any new methods to cure this disease in the future?"

Academician Wang said: "I'm not sure. At the current medical level, apart from heart transplantation, there is no way to cure it. But this only refers to the existing ones. It is only within the scope of my knowledge. In the past, tricuspid atresia was not and could not be cured. Isn’t it true that Fontan surgery can save lives? I think the next step for radical surgery should be among you."

After Academician Wang finished speaking, everyone was silent and did not think of asking any questions for a while.

In order to prevent the situation from getting colder, Yang Ping said at this time: "Everyone, think about it, is there any good way, think boldly, no matter what ridiculous ideas it is, for example, isn't this case of left ventricular dysplasia? Can we bury a dilator in the left ventricle and slowly expand it to normal size? We first perform a temporary Fontan operation while burying the dilator in the left ventricle. When the left ventricle completes dilation, we remove the Fontan Surgery to return each blood vessel to its correct position."

When Academician Wang heard this, he was immediately shocked by Yang Ping's idea. This idea was indeed called "bold and absurd", and no one had thought about it yet.

Everyone has always believed that the left ventricle is underdeveloped and very small, so it cannot be used. Apart from heart transplantation, there is only Fontan surgery. Fontan surgery is only a palliative surgery, which only uses the disabled heart to work normally.

No one had ever tried to take the underdeveloped left ventricle and turn it back to normal.

yes!Can we get a dilator, bury it in the left ventricle, and slowly expand it? Everyone was immediately activated by the topic raised by Yang Ping.

The idea of ​​a real genius is different in the brain of a genius. Both Li Zehui and Professor Chen were confused by this unbridled idea.

One student began to speak:
"The left ventricle is originally small. If it is artificially enlarged, will the myocardial wall be stretched thinner, and the heartbeat will become weak or burst?"

Everyone saw that this classmate's idea did not arouse ridicule, so many people became bold. "Yes, when doing expanded skin flaps, the bigger the spreader is, the thinner the skin will be. It's like a pancake. If you want to enlarge the area, the thickness will become thinner."

Students are active thinkers and very imaginative. Once their self-confidence increases, they become bolder and dare to speak. Regardless of whether they are reliable or not, they dare to express their thoughts anyway.

"Children are still growing and developing, and the heart is also growing and developing. It is not an unchangeable thing. According to Ilizalov's principle, stretched tissues will grow faster." Li Guodong said excitedly.

"Wouldn't placing such a large dilator in the left ventricle cause blood clots?" a girl asked.

"I didn't just say that the left ventricle has been abandoned in this case because it is too small and useless. We just happened to completely seal the left ventricle and the left atrium, and then there will be no blood in the left ventricle. In this way, there will be no problem of blood clots when inserting the dilator, etc. Once the left ventricle has developed, we will take out the dilator and then open the closed septum between the left atrium and ventricle." Another boy immediately took over.

Unexpectedly, these students had such rich imaginations. Yang Ping was very happy. He just liked this kind of atmosphere. Everyone dared to speak. It was great.

Academician Wang was also surprised that these children's ideas were quite bold and novel.

"If a dilator is buried in the underdeveloped left ventricle, how to perform the dilation? When we usually do skin dilation, a water bladder is buried in the skin dilator, and then a tube connected to the water bladder is exposed to the outside, and the tube is regularly used to inflate the dilator. How does the heart achieve gradual expansion by filling the water bag with water?"

Li Guodong asked.

"Yes, how to achieve expansion?"

Young doctors are scratching their heads, yes, how to perform dilation? It can't be like dilating the skin and leading a tube out from the heart.

The idea is absurd, but the progress of medicine is to realize some seemingly absurd ideas.

"Can a small tube be led from the blood vessel, like a dialysis fistula, and water can be filled into it when needed, and then closed again after filling."

"The blood vessels are not good. There are tubes in the blood vessels, and thrombus will form quickly. The entire blood vessel will be blocked, and the left ventricle will no longer participate in the circulation and cannot guide it into the blood vessels."

Song Zimo also participated in the discussion at this time: "If the left ventricle does not participate in the circulation, things will be easier to handle. Refer to the ventricular drainage of neurosurgery, directly fix the left ventricular tube, and design a route to lead it out."

"It cannot come out from the chest cavity. The chest cavity has negative pressure. Even if it is buried under the skin, if the tunnel leaks, after surgery or when the skin is incised in the future, the air will follow the tube and enter the chest cavity through the gap between the tube and the tunnel. A pneumothorax forms." Professor Chen also became excited.

"Refer to the ventricular shunt, after the drainage tube is led from the left ventricle, it is introduced from the chest cavity through the diaphragm hiatus into the abdominal cavity, and then led out of the abdominal cavity to the subcutaneous place, buried in the skin folds next to the belly button. When needed, incision is made and water is injected when not needed. Sewn shut, safe and convenient.”

At this point in the discussion, Academician Wang discovered that the plan to bury the expander actually took shape. There were specific implementation plans on how to bury the expander, how to route the pipeline, and how to expand it.

This comprehensive surgery department is amazing and will be a gathering place for geniuses in the future. The reference ventricular shunt proposed by Dr. Song just now opened up my mind.

"After the left ventricle is dilated, the biggest problem is how to restore the separation between the left ventricle and the left atrium, that is, the mitral valve. I think this is the biggest problem!"

Xu Zhiliang’s speech.

This guy actually used this method to put his stuttering between reasonable sentences. Although he spoke slowly, everyone could understand easily.

Yes, is it difficult to reopen the mitral valve?
Song Zimo thought for a while and said, "It's not difficult. The valve exists and there is a basis for suturing. Mitral valve replacement surgery can be performed."

"There is another problem. We know that - when we use Ilizarov's theory to carry out - bone lengthening - the bottleneck that limits bone lengthening is the nerve - the lengthening of the nerve has a certain limit - beyond a certain The limit will be ineffective - during the expansion process - will there be conduction block - that is, the conductive bundle of the heart will be ineffective due to stretch."

The discussion became more and more in-depth, and Academician Wang sat down and listened carefully.

"This possibility exists or does not exist. We can accumulate some data through animal experiments, and then gradually collect data in clinical practice and gradually optimize it. What is certain is that if this possibility exists, then there must be something between apraxia and normality. A critical value.”

"I think this idea is really good. It can be used as a subject to study. It is very promising. No matter whether it succeeds or fails in the future, at least we will explore a new way." Academician Wang became excited and he recognized this idea more and more.

Although it is absurd and unrealistic, many innovations begin with boldness and absurdity, and many innovations come from being absurd and unrealistic.

PS: Two chapters and more than 8000 words, it’s a small update!Thank you everyone for your encouragement and vote!Thanks! ! !
(End of this chapter)