godfather of surgery

Soon, Nong Zhiwen came to Sanbo Hospital to find Director Fang again. Because he couldn't find so much money, he could only accept Director Fang's cheapest plan.

According to Director Fang, the total cost is only about 20,000 yuan. Excluding the medical insurance reimbursement, the self-pay part is several thousand yuan, which Nong Zhiwen can completely afford.

Nong Zhiwen came to see Director Fang this time. Nong Zhiwen was fully prepared. Nong Zhiwen took his father to review several hospitals he had visited before. This time the focus was not on seeing a doctor, but on asking about the situation. He asked the doctor, In a situation like his father's, if he now went to Professor Yang and Director Fang of Sanbo Hospital for surgery, he would still go to Director Qian of the Fourth Auxiliary Hospital.

These doctors all said without exception: "Go to Sanbo Hospital, especially Professor Yang. His medical skills and character are the most trustworthy."

Every doctor's evaluation of Yang Ping had one last word. One of the doctors finally warned repeatedly: "Go directly to Professor Yang at Sanbo Hospital! Don't go anywhere else. You absolutely can't go to Director Qian's place. Listen to me." .”

The doctor who said this sounded very sincere, and Nong Zhiwen could feel it, so he came to Sanbo Hospital again.

Seeing Nong Zhiwen and his father Nong Tiesheng, Director Fang breathed a sigh of relief and finally pulled the patient out of the fire pit. However, what happened to Director Qian was just a rumor with no real evidence, and Director Fang couldn't say anything behind his back.

This time Nong Zhiwen still did not bring the pathology report, because the medical record room said that there was no pathology report in the medical record, and the doctor said that there must be a pathology report in the medical record. Nong Zhiwen didn't know much about it, and it was impossible to go there for a pathology report. It takes too much time.

There is another way, that is to ask Nong Zhiwen to get the pathological slides, and let the pathologists from Sanbo Hospital help to look at the pathological slides, and then issue a verbal pathology report. In this way, at least Nong Zhiwen can grasp the thyroid gland. Cancer classification and staging.

However, this method is very unrealistic. Without the internal relationship of the hospital, the hospital cannot allow patients to take pathological slides out. This is not allowed by hospital management regulations.

It’s really okay if there is no pathology report. Why don’t we do the surgery without the pathology report? Is this disease still not cured?

Yang Ping also meant the same thing. The surgery to repair the recurrent laryngeal nerve should be done first. As for the treatment of the tumor, some basic examinations can be done again. During the operation, multiple tissue points should be taken for pathological examination, combined with the latest imaging examination and the results obtained during the operation. Pathological examination of the tissue can be used to make a basic judgment on the tumor, and then decide whether to perform other treatments.

Judging from all the current imaging data, the patient does not need any further treatment for the tumor after surgery, and only needs lifelong thyroid hormone replacement therapy.

Director Fang admitted Nong Tiesheng to the hospital and stayed in the General Surgery Department, because the number of beds in the surgical institute was very tight, and many more complicated and serious patients than Nong Tiesheng were waiting for beds.

Nong Tiesheng used to have a strong body and was a good hand at farm work. Since he got the disease, he has undergone two surgeries, multiple rounds of radiotherapy and chemotherapy, targeted therapy and other treatments. Now he is very weak and can't even breathe. They all seemed strenuous, and I felt uncomfortable even after walking for more than a dozen steps.

In addition to the devastation of the disease, radiotherapy and chemotherapy are also a double-edged sword. While treating the disease, they will cause damage to the body's immune system. The right recurrent laryngeal nerve may be damaged, and the left recurrent laryngeal nerve may be compressed, resulting in bilateral recurrent laryngeal nerves. Nerve damage can also affect breathing. Taking these factors together, Nong Tiesheng's current state can be easily explained.

After being admitted to the hospital, Director Fang ordered the doctor in charge to save costs as much as possible. In addition to some routine examinations on admission, such as blood routine, biochemistry, liver and kidney function, four infectious diseases, four thyroid function tests, electrocardiogram, chest X-ray, etc., there are also some A check-up is a check-up for tumors.

No way, he didn't have a pathology report, so he had to rely on some of the latest imaging tests to judge the current status of the tumor.

As for the recurrent laryngeal nerve, everything will be clear when the bilateral recurrent laryngeal nerve exploration is performed during the operation. Intraoperative exploration is more accurate and reliable than any imaging examination.

In the past few days, Director Fang has checked a lot of literature. Regarding the repair of the recurrent laryngeal nerve, Professor Yang's plan is really original. It is much better than the traditional method. It not only solves the problem of nerve defect, but also does not require nerve repair. Transplantation and translocation, in fact, nerve transplantation and translocation are rogue actions, because there are too many nerve defects and cannot be sutured directly, so they are a last resort.

If the nerve can be sutured directly without tension, the effect will be much better than nerve transplantation or transposition.

Professor Yang combined the basic principle of "the shortest line segment between two points" with the anatomical course of the recurrent laryngeal nerve and came up with such a wonderful method. Director Fang couldn't help but marvel.

I have been a general surgeon for more than ten years, but I never thought that I could perform this procedure. Why didn't other doctors think of it? There are so many doctors in the world, from general surgery, thyroid surgery, head and neck surgery, how come no one thinks of it?

Why do people keep using three types of surgery? If it cannot be sutured directly, it is nerve transplantation or nerve transposition. Why don't you apply this elementary school mathematics knowledge to surgery?

If it doesn’t exist, it means it doesn’t exist. This thing cannot be understood.

If another twenty or thirty cases of this surgical method are accumulated, the postoperative observation effect is indeed very good, and a paper will be published by then. This will be a heavyweight academic achievement. Director Fang feels itchy just thinking about it, and Professor Yang casually leaks it in his hand. Something is absolutely priceless to Director Fang.

Professor Yang probably doesn't have much interest in this kind of surgery, Director Fang thinks so.
-

This technique was designed by Yang Ping. It was the first time Director Fang did it, and he would definitely need Yang Ping's guidance.

Still following the old routine, let Yang Ping "lead" Director Fang to perform the surgery. This model was a huge success last time.

The patient is under general anesthesia and is placed in a supine position with a pillow under his shoulders. This allows the patient's surgical area to be well stretched and the surgical field to be more fully exposed.

With Yang Ping standing opposite, Director Fang now dares to perform any surgery, and his confidence is completely different. Now it is equivalent to turning on the "invincible mode".

The original incision is extended to a suitable length on both sides, and the skin, subcutaneous tissue and platysma muscle are incised layer by layer, and the target of the operation - the recurrent laryngeal nerve - is penetrated step by step.

Director Fang originally wanted to show off the "One-Sword Style", but unfortunately he didn't learn how to do it. After one stroke of the knife, it was either deeper or shallower, and the skin in the shallower parts was not even penetrated.

I had no choice but to add a few more cuts. This thing looked easy, but it was very difficult to do.

After incising the platysma muscle, Director Fang separated the strap muscles on both sides of the cervical linea alba and freed the front edge of the right sternocleidomastoid muscle.

At this time, the assistant used a double-toothed hook to rotate and pull the larynx. The director was very skilled in this kind of surgery. Although there were a lot of adhesions inside, with Professor Yang here, any adhesions were not a problem.

With the help of Professor Yang, Director Fang's anatomy was very clear. Step by step, after the larynx was retracted, Director Fang cut off the pharyngeal constrictor muscle attached to the edge of the left thyroid cartilage, and then separated the paraglottic space. How to completely It was adhesions, what exactly was the situation at that time.

Yang Ping couldn't help frowning when he saw the severe adhesions inside. Based on his rich experience, he judged that this adhesion was not caused by radiotherapy at all, but was caused by the rough surgery at that time. After Director Fang clearly separated the paraglottic space, he found that the left cricoarytenoid muscle had significantly atrophied. He performed retrograde separation of the left recurrent laryngeal nerve from behind the left cricothyroid joint. Retrograde separation means separation against the direction of the nerve's movement.

After a period of separation, it was found that the recurrent laryngeal nerve was obviously thinner, and 2.5 cm away from the cricothyroid joint, the recurrent laryngeal nerve was compressed by scars, and the compression was very serious.

No wonder the patient's symptoms are much more severe than those caused by unilateral recurrent laryngeal nerve injury, which has significantly affected breathing, and can now be explained clearly.

A rupture of the recurrent laryngeal nerve on one side and entrapment of the recurrent laryngeal nerve on the other side means that the recurrent laryngeal nerves on both sides are damaged. The entrapment of the left recurrent laryngeal nerve is so serious that if not treated in time, after a period of time, the left recurrent laryngeal nerve will There will also be complete loss of use of the nerves.

If the right side is really defective by 8 centimeters, this operation is really difficult to perform. No wonder Qian himself is unwilling to take over the surgery and keeps pushing back.

"Is it okay to release it on the left side?"

Director Fang asked Yang Ping for his opinion. At critical moments, he still had to ask for instructions.

''If you cut open the epineurium and take a look, it should not be degenerated yet, and it can be restored after release. "

Yang Ping directed Director Fang.

Director Fang carefully cut open the outer membrane of the nerve. Well, the structure of the peritoneal membrane inside was quite good and relatively clear, which showed that the nerve had not degenerated. It only needed to be released, and there was no need to perform resection and then anastomosis.

After the nerve on the left side is treated in this way, part of the operation is completed.

Director Fang studied Yang Ping's hemostasis technique and did not forget to use bipolar electrocoagulation to accurately stop the bleeding. Of course, he was very careful that bipolar electrocoagulation would never get close to the nerves.

The left recurrent laryngeal nerve has been treated, and Director Fang began to expose the right recurrent laryngeal nerve. Because it was not Yang Ping and Director Fang who performed the surgery, we don’t know where the nerve end is now. If the surgeon had any intention at that time, , in order to facilitate subsequent nerve repair, it would be better to mark the right recurrent laryngeal nerve, which will make it much easier to find.

Bad adhesions again!

Yang Ping was a little confused as to how the surgery was performed at that time. Logically speaking, the level of the fourth-level surgeon should be good, but looking at the current situation and relying on experience, the surgery at that time felt like it was done by a novice, and it was a complete mess.

"Both surgeries were performed with Da Vinci robot surgery. Not counting other treatment costs, one surgery alone costs hundreds of thousands." Director Fang explained.

Yang Ping was puzzled: "This kind of surgery is done with the Da Vinci robot? Will it be better than traditional surgery?"

"Who knows? You may not know that the General Surgery Department of the Fourth Affiliated Hospital can use robots instead of traditional methods, so their da Vinci robot has a very high usage rate." Director Fang couldn't help but sneer.

Director Fang finally dug out the severed end of the nerve from the adhesions. Not only was it not marked, but the location of the nerve was also randomly placed. If the surgeon was inexperienced and careless, it might snap off with one cut.

The right recurrent laryngeal nerve defect was actually a full 8 centimeters. Director Fang thought carefully, if Professor Yang hadn't given him a plan in advance, what would he have done if he suddenly encountered this situation on the operating table?

It’s not just a matter of hastily finding a nerve to bridge. As for the effect, who knows.

According to the surgical procedure prepared by Yang Ping in advance, Director Fang directly dissected the severed end of the right recurrent laryngeal nerve retrogradely from the brachiocephalic trunk to the vagus nerve, and anastomosed it with the recurrent laryngeal nerve in the larynx behind the carotid artery.

Since the patient's pathology report has not been seen, Yang Ping, out of caution, ordered Director Fang to take tissue from different parts of the surgical area for post-operative pathological examination. PETCT did not show any metastasis anywhere in the body. Now take this Perform pathological examination on multiple tissues. If no tumor tissue is found, it can be determined that no treatment for the tumor is required after surgery, and only replacement therapy for the thyroid is required.

With Yang Ping's help, Director Fang completed the operation seriously.

After the operation, Director Fang tentatively asked Yang Ping: "Professor Yang, you can write a paper on this case by then."

How could Yang Ping have time to write these papers? He still had many topics to do, so the other director said: "I don't have time. If you are interested, just write articles. Don't worry, I won't ask you for knowledge." property."

At this time, Director Fang was very excited. This was something that could not be found in a lantern. It might not matter to Yang Ping, but to Director Fang, this was a major innovation. If this paper can be published in an international journal, then the director can be said to be number one in the country and world leader in the field of recurrent laryngeal nerve repair.

World leader! How's that not exciting?

After Yang Ping left, Director Fang calmed down in the dressing room for half an hour before he came back to his senses. He immediately called the fruit shop downstairs of the hospital, bought two boxes of the best cherries and sent them to the Institute of Surgery immediately. No, how could two boxes show sincerity? He immediately changed the two boxes to ten boxes.

Where is this article published? Director Fang began to think about this matter and must send it to top international journals.

After working as a doctor for more than ten years, I have never had such a sense of accomplishment. Not only did I solve a problem that others could not solve, but I also published articles in international journals. In my circle of classmates, I should be the best in this situation.

Director Fang couldn't help but take out a cigarette and light it. Life is really wonderful sometimes!

After solving the problem of the recurrent laryngeal nerve, Yang Ping did not stop. He began to think about Nong Tiesheng's condition. What was the classification and staging of thyroid cancer at that time? There was no pathology report, and there was no specific classification and staging in the medical records. , this is extremely irregular, especially since radical surgery has been performed, how could it not be classified and staged?

Judging from the analysis of a large number of images, this patient does not look like thyroid cancer at all, but more like a benign thyroid tumor. If this is the case, how can radical surgery be performed? This is completely contradictory and does not make sense in any case. , let’s wait until the pathology report comes out.

Regardless of the previous surgery, if the pathology report is really okay, the patient will be temporarily cured, which is also a good thing.

As for any subsequent targeted treatment, it is completely unnecessary.