Nineteenth Century Medical Guide

Chapter 138. 135. The Recipient (1)

The part of the uterus where the placenta implants is very thin. If it penetrates the muscle layer and enters the outermost serosal layer, the uterus is like a rusted iron pot, and there is no need for it to exist.

Because there is only a layer of skin left in the implanted area, even if it is barely kept, it will be a huge threat of uterine rupture in the future, and the whole piece must be cut off.But after cutting it off, the tension of suturing is very high, and the whole process bleeding is serious, and the operation is difficult. It is impossible to keep it in modern times, let alone in the 19th century when there was a lack of medical treatment.

Brenda's implantation happened to stop in the muscular layer at that time, and Kavey's stripping technique was firm but soft, and finally part of the muscular layer was retained and sutured on the stripped surface.

Now the peasant woman's uterine wall can be punctured by fingers. This is not just as simple as penetrating the muscle layer, maybe the serosa layer is also almost penetrated.In this case, the uterus should be abandoned decisively from the very beginning. Now even if the blood flow in the lower uterus is blocked, the bleeding is as rapid as it is.

The team that cooperated very well just now was completely messed up because of a mistake.

Everyone stared blankly at the holed uterus outside their stomachs as if the pause button had been pressed.Then all eyes were focused on the "instigator" Olgi, not knowing what to do.

"Gauze! Give me the gauze!!!"

Olgi was also taken aback by the sense of loss at his fingertips, and was a little flustered seeing the blood gushing out in front of his eyes.

Fortunately, his many years of experience as a surgeon allowed him to react quickly enough. Instead of pulling out his fingers in a hurry, he clamped the tiger's mouth tightly and killed the surrounding uterine wall: "The upper uterine body is also compressed, continue to take oxytocin, Hill Si, you come to suture the blood vessels on both sides of the uterus!"

Pieces of gauze were pressed into the peeling surface of the inner layer. Locard climbed directly onto the operating table, squatted down, and squeezed the uterine body with both hands.

As long as the arteries on both sides of the uterus can be ligated quickly, the amount of bleeding will be reduced as sharply as in Carvey's operation, and then it will be judged whether to cut off the uterus or keep it.

But Hills did not actually perform uterine artery suturing, and all operations were done on cadavers.He didn't slacken his practice, but the organs and tissues of a dead body are completely different from those of a living person, and there are many differences between normal human organs and those that are bleeding profusely, and the atmosphere in the dissection room is even more different from that in the surgical theater.

In this situation, Hills saw the blood red in front of his eyes, and it was very difficult to even find the uterine artery.

However, under tremendous pressure, Hills still stabilized his mind.The needle and thread in his hand paused in mid-air, and the other hand touched the elastic tissue on the side of the uterus. Without being sure that it was a blood vessel, he decisively inserted the needle into it.

Relying on the elasticity and extremely slight pulsation of the arteries, he guessed the location of the uterine arteries correctly.

Suturing the blood vessel requires the tip of the needle to penetrate the entire tissue, bypass the blood vessel and then ligate the front side. As long as the position can be found, the subsequent operations are basic skills, which is not too difficult for Sears.First near his right side, then his left side, both stitches are beautifully done.

Olgi finally breathed a sigh of relief: "Because I didn't hold back the strength in my hand just now, a breach occurred in the uterine wall, causing a lot of bleeding. But fortunately, Dr. Hills has continuously sutured the arteries on both sides of the uterus. There is also a large amount of gauze stuffed inside, and now the bleeding has basically stopped."

This is true, as soon as the ascending branch of the uterine artery was ligated, the bleeding in the uterus stopped.The wound became very clean after being absorbed by the gauze, and the continuous autologous blood transfusion basically stabilized the peasant woman's heart rate.

Olgi takes a second look at the womb.

Now that the fetus has been taken out and the bleeding has stopped, the only trouble is the tear in the uterus.Is it a risk to do stitches?Or just discard it and do a resection?

Olgi definitely hopes to end this cesarean section perfectly, so that he and his hospital can improve their ability to deal with placenta previa in the eyes of the public.Needless to say, Hills, he came here to preserve the uterus. Once the uterus is removed, this operation will become meaningless.

"Considering that the mother is still very young, it is a pity that she will lose the ability to conceive without a uterus." Orgi said to the audience, "The uterus has not fully contracted, and the breach is actually not that big. I will try to suture the uterine muscle first. layer. Give me the pliers and the sewing needle."

Carvey was sitting in the audience.

I am very satisfied with the cooperation and decision-making of the three people just now. There is no concept of a surgical team in this era. It is quite good to have their mobility. From the movements of all the people, it can be seen that every step has the shadow of practice. .

Especially for Sears' arterial suturing just now, except for finding the location a little slower, everything went smoothly afterwards.

It can be said that he handled it properly before, and he was more proficient than Ignatz, who had a cesarean section for the first time, but Carvey was not satisfied with the final decision.

The uterine breach has lost the basis for suturing at this point.

It may be difficult to suture in modern times, but in the 19th century, the sutures were not strong, and the sutures that were barely closed would split at any time.Even if the sutures are stitched up during the operation, you will have to face multiple abdominal compressions after the operation. Otherwise, if the lochia is not drained cleanly, severe infection will follow, and the whole operation will become useless.

Taking these factors into consideration, it is better to cut it directly to save trouble.

However, these considerations are entirely based on the conclusions drawn by Kavey's personal ability. It is not him who is on the operating table now, but Olgi.

The emergency surgery where Carvey works mostly deals with trauma to the abdominal cavity and extremities. The pelvic cavity is an important part of the abdominal cavity. Although it does not contain many organs, the anatomical relationship between the various tissue spaces is complicated, so you must pay attention to various small skills in surgery. .

Hysterectomy is an important operation in obstetrics and gynecology, and it is also a surgery that often needs to be faced outside the emergency department.

When encountering a patient with a damaged uterine appendage, Carvey would ask the obstetrician to cooperate with him to deal with it. Over time, he learned many gynecological pelvic floor operations.

Because he understands these operations and has seen too many similar operations, Carvey knows that hysterectomy is not easy.It cannot be summed up simply by using the words "separation" and "removal". Only those who have experienced it can understand the pitfalls.

Therefore, Olgi did not choose a difficult path, but that no matter which path he chose, it was difficult to walk.

"Crash line again."

Olgi looked at the broken suture in his hand, feeling a little desperate: "The incision has been sutured too many times, and the muscle layer can no longer bear the needling again. If the incision is trimmed, the tension will only be greater, and the suture Not firm enough, it seems the uterus"

This is a decision he made after careful consideration, which is obviously far from the team's original goal.

Everyone's face lost the brilliance before the victory, and when they got closer, they could even hear several sighs.

Of course, it was Sears who was most reluctant: "Mr. Olgi, the suture is not strong enough, we can choose silver thread. Trim the incision a little, and do another suture, she is only 22 years old!"

"It's useless." Olgi took the scalpel from the nurse. "Although the silver thread is strong, it is also easier to cut the uterine wall. Even if it is sutured, it will still cause secondary damage if you let go."

"How do you know if you don't try?"

"Are you sure it won't crack after surgery?"

Olgi ignored his suggestion, and after asking a question, seeing what Hills wanted to say, he said directly: "I am the chief surgeon and I have the final say, let's remove the hysterus. Although our operation failed, her own The purpose has been achieved."

Placenta previa is a very troublesome obstetrical problem.

Peasant women living in rural areas on the outskirts of the city have no medical concept at all, and they don't care about the small amount of bleeding from the vagina.Even if I really noticed something wrong with my body, I would go to a small local clinic for treatment. It was impossible to spend a lot of money to go to the city to find an obstetrician.

The travel expenses and hospitalization expenses on the road are enough for the rural people to spend for a long time.

According to the development of placenta previa, this peasant woman may have unstoppable hemorrhage during labor, and finally died in her own bed. Whether the child will survive is also unknown.

Graze Hospital's blanket search was a life-saving straw for her.Olgi not only promised that she would keep the child and waive all expenses, but also willing to pay her family a sum of money after the operation was completed, so why not do it.

Sears was disappointed, but accepted Olgi's decision: "Give me the hook."

"Hysterectomy requires the separation of surrounding tissues, which will take some time." Olgi first explained his surgical steps, "I will cut off the round ligament of the uterus in turn according to the classic order of resection, and cut off the uterus on both sides. Attachment, deal with the rest of the uterine blood vessels, and finally cut off the yd."

Olgi's advantage is in andrology, and his understanding of the uterus is still limited to cesarean section.Although hysterectomies have been performed in repeated practice, due to the limitation of the number of corpses, I am not familiar with the anatomical structure around the uterus.

"We first searched for the round ligaments on both sides of the uterus. Because there are blood vessels in it, we need to clamp on both sides first, then cut off and suture."

He was talking about the process of removing the round ligament, but his movements were not as swift as before. It took a lot of time to find the round ligament. 【1】

Next, in accordance with the order of hysterectomy, it is necessary to find and cut the isthmus of the fallopian tube and the proper ovarian ligament on both sides of the uterus【2】.But for Olgi, it doesn't matter what these areas are called. The most important thing is to grab the eyebrows and beard and cut off all the tissues around the uterus.

This crude approach quickly backfired.

"Bleeding, give me gauze."

When Olgi cut the ovarian ligament, he did not fully dissociate it, because there was too much tissue, and the clamping ability of the crow's beak forceps further decreased.The closer the proper ovarian ligament is to the uterus, the more abundant the blood supply and the more bleeding, even if the uterine artery is clamped, the bleeding cannot be completely stopped.

"Teacher, it's been a while since the operation."

"I know."

Olgi stitched the ligament in his hand, and continued: "Cut the ovarian ligament, and then continue to cut the fallopian tube. Here we need to do a ligation. Then we continue to rummage to the other side and repeat the steps just now."

Kavi watched the process of separation and cutting and shook his head.

The surrounding tissues above the uterus are clearly demarcated, easy to see, and not difficult to separate.If Olgi can't do these things well, the complex pelvic floor tissue under the uterus will only be difficult to deal with.

"The upper fixed ligament has been cut." Olgi didn't realize the trouble he was about to encounter, and he was relieved to see the half-detached uterus in front of him. "Next, let's cut off the ligament around the uterus." 【3】

After hearing what he said, Carvey immediately realized that the order was obviously wrong, and quickly asked, "Shouldn't the blood vessels on both sides of the uterus be dealt with first?"

Olgi handled the ligaments unhurriedly, and said while doing it: "Just now, Dr. Hills has ligated the ascending branches of the arteries on both sides, and most of the blood flow has been blocked. You only need to take the rest of the tissue later. Just cut off the lateral common artery together, there is no need to rush to deal with it first.”

Carvey listened to his nonsense in a daze. After a while, Olgi asked for gauze again: "Give me the gauze, there is bleeding."

It was still the old problem of the previous separation. Orgi did not fully free the tissue around the ligament, and the crow's beak forceps were weak, so there was no way to completely block the blood flow before cutting.

"There wasn't much bleeding during the operation, and I've dealt with it one by one." Olgi had never seen Kavey's hysterectomy, so he was still very satisfied with his performance. "Most of the uterus has freed up now. The next step is to deal with the lower part of the pelvic floor. But before that, we need to cut off the uterine blood vessels."

The treatment of uterine blood vessels is troublesome, because it is easy to damage the surrounding tissues, and Carvey also wants to see how he operates.

But the area around the artery is much thinner than the ligament just now, and it is easier to block and cut, so before he can see clearly, the blood vessel has been processed.

"The stump is perfect without bleeding." Olgi praised himself, and continued to lower his hands, "We need to completely separate the lower uterine segment and cut off the space around the cervix. The main trouble lies in the bladder in front of the uterus. Give me the scissors."

Taking the scissors, he began to charge towards victory with the help of Lockard and Sears.

However, just beginning to separate the bladder-peritoneal reflex [4], Hills suddenly noticed something unusual: "Mr. Olgi, there seems to be blood oozing in the abdominal cavity!"

"Bleeding?"

Olgi was very confident in his suturing skills, and quickly denied it: "Impossible, my suturing is very firm, and there is no possibility of bleeding."

"But there is indeed blood underneath." Sears took a piece of clean gauze from the side and stuffed it in. A large pool of light red "blood" was printed on the cloth quickly. "It doesn't seem to be blood, the color is wrong."

Olgi was pinching the lower part of the uterus in his hands, and wanted to lower his head to see what happened, but he had no idea that his scalpel was still pressed against his bladder.

He turned slightly to one side, but accidentally slipped, the blade of the scalpel cut into the retroperitoneum of the bladder, and a clear light yellow liquid poured into the bright red abdominal cavity.

Bladder burst!
　It's a pity for the patients, but we can't be too harsh on these doctors.Because even in the 21st century, there are still many cesarean section accidents in China, and the lack of preparation for placenta accreta may cause major accidents, and there were no such concepts at that time.

　　
　
(End of this chapter)