Nineteenth Century Medical Guide

Chapter 139. 136. The Recipient (2)

Everything has pros and cons, and it also has its limitations of the times.

Olgi and his team did make a lot of preparations. After dismantling the cesarean section process shown by Carvey, they practiced repeatedly on the corpse.If there is no such serious placenta accreta, this operation, even if it is rough, should be successful.

It is a pity that the problems caused by the uncertain factor of placenta accreta affect the operation direction step by step.Surgery wins and loses, and hysterectomy can already be declared a failure for this sake.

Had he seen such a hysterectomy two months ago, Carvey might have cursed inwardly in his heart.

But now he has changed his mentality. The "failure" presented from a modern perspective is more like a kind of pioneering of the unknown in the wild medical environment of the 19th century.

It is impossible for surgery to blossom everywhere instantly because of the success of one person. Without the pioneering work of these people and the sacrifice of the mother, there would be no cesarean section in the modern sense, because success is based on thousands of failures.

"The bladder below the uterus is ruptured. Maybe it's not just the bladder that's ruptured, maybe something else was touched just now while dealing with the separation of other parts."

Olgi had a lot of excuses, but he still couldn't say it in the face of the failure: "Now the structure in the abdominal cavity has become chaotic, blood and urine are mixed together, and the vision is blurred. I have to declare the operation failed.

I know that as a surgeon, you shouldn't admit defeat until the patient dies, but I know my limits and I want to try to save her life as much as possible.Therefore, if anyone in the audience is sure that he can do this bladder repair well, I am willing to give up the position of the chief surgeon. "

With Olgi's status, giving up the stage is tantamount to admitting that he is not skilled, which is extremely embarrassing.

"Olgi, you're not joking, are you?"

"I'm not kidding, if you can fix it"

Dr. Colrigo who spoke interrupted him immediately: "Don't, don't, you can't handle the urological surgery all the time. How could I, a plastic surgeon, be able to handle this kind of surgery."

There were indeed quite a few doctors in the auditorium, and some of them had hysterectomy ability and experience.There were three doctors who wanted to help, but after seeing the condition of the abdominal cavity, they all shook their heads in unison, said "there is nothing they can do" and left the operation area.

They did not choose to take over, and they have clearly indicated the difficulty of the operation.

"I have never seen such a complicated pelvic surgery. There are too many things to do, and the patient must not last that long."

"The anatomical structure is messed up. Forgive me for my poor eyesight. I really don't know how to fix it."

"I'm afraid this situation will be difficult."

So far, Olgi can only turn his attention to Carvey again: "Doctor Carvey, you are the best at abdominal surgery, okay?"

"I'll watch it first and then I'll talk about it."

Carvey accepted Olgi's invitation and got out of the auditorium.

The situation was much worse than he expected, and the distance from the auditorium did affect his observation of the operation.

Now the tearing of the organs is a certainty, the incision is clearly displayed in front of everyone's eyes, and blood is slowly oozing around.But this location is not like a bladder in the conventional sense, and there are many connective tissues around it, making it difficult for the experienced Karvey to tell the difference between east, west, and north for a moment.

Now the field of vision is full of a mixture of blood and urine, Olgi and Hills are a little at a loss, only the suction device is still sucking out the liquid in Lockard's hand.Judging from the liquid level ripples in the interstitial space, it seems that the urine is still pouring into the abdominal cavity continuously, the amount is not much, and the speed is also very slow, but Carvey can see it.

In this case, the bladder is not only damaged, the ureter may also be broken during the separation of the uterine blood vessels. 【1】

The repair of abdominal viscera was already very difficult for them. In addition to the blurred vision, severed ureter, and the cumbersome uterus next to it, the difficulty of the operation rose sharply.Olgi's courage to give way to Taiwan is commendable, but it is also a helpless move, because this is a mess, and it is impossible for him to directly shut his stomach against his conscience.

"Doctor Orgi, you did your best."

Carvey put on the cleaned rubber gloves, flipped through the messy abdominal cavity, and said something fair: "What I said is the truth, not to comfort you, it is already very good that the pelvic cavity of a pregnant woman can achieve this level. "

The swollen uterus during the cesarean section visually concealed the serious pelvic adhesions of the peasant woman. After the uterus retracted, all the problems caused by the adhesions appeared.Clumps of connective tissue covered the uterine appendages, and even the ligaments and blood vessels were blurred into a pink mass, making it impossible to tell who was who.

The adhesion is too serious, and the plate is not easy to pick up.

If Carvey wants to take over, he must do it beautifully. He scanned the operation area and found two strange young people: "Whoever is free, go and get me something."

"Let him go." Olgi pointed to a kid younger than Carvey.

"Go to the prep room of the City General Hospital's surgical theater and find the equipment box I just took last week," Carvey said. "Bring the whole box. It has everything I need. If anyone asks, say yes." I let you go."

"it is good."

If you take over, you have to look like you are taking over. Now that the patient is his own, Carvey made a simple arrangement of the risk factors in each area of ​​the abdominal cavity in his mind.

In terms of danger, the most troublesome thing is the uterus, because if this time bomb is not taken away, no one knows when it will bleed again.However, if the ureter or bladder is ruptured, the bleeding is limited, and the urine in the ureter is very clean. Although the urine in the bladder is easily polluted, it is not a big problem in comparison.

So the first problem is the uterus.

"Now I'm the chief surgeon." Carvey glanced at Olgi in front of him, then at Hills and Lockard, and seeing no one refuted, he said to the audience, "Considering the possibility of continued bleeding from the uterus, I decided to get the hysterectomy done first."

After speaking, he took the hook and helped them find the position to press it one by one, fully exposing the gap between the cervix and bladder.

"Because the lower uterine segment is not covered by peritoneum, a peritoneal depression is formed between the bladder and the uterus. There is loose adhesion between the folded peritoneum and the cervix. Only when the gap between the bladder fascia and cervical fascia is identified can the bladder be separated."

Carvey talked about an important knowledge point in obstetrics and gynecology surgery, which is also a key factor in the success of the operation: "Because this woman has severe pelvic adhesions, it is very difficult to find the separation level. At this time, some small skills are needed. Observe the bleeding on the separation surface to judge whether the location you are looking for is correct.

If the separation is at the correct level, there will be little or no bleeding, the surface of the separation is smooth, and the bladder can be pushed down easily.If it is wrong, the separation surface will definitely enter the bladder or myometrium, the amount of bleeding will be large, and the bladder will be difficult to push.”【2】

Those spectators who wanted to really learn the skills left their seats and walked around the operation area.

Every word of his is the key point, and every operation is enough to make everyone watch intently.

The bladder with a crack was pushed down by Kawei while separating, and slowly separated.Immediately afterwards, he touched the cervix with his fingers, and determined the horizontal line of cutting and separation: "Dr. Olgi has already processed the ligaments around the uterus, and the cutting is not bad."

Carvey checked the entire uterus again, and after confirming that it was correct, he began to make the final cut: "Scalpel, let's cut the vaginal vault directly and take out the uterus."

Less than 10 minutes after taking the stage, the uterus, which caused great trouble to Olgi's team, was taken out of the abdominal cavity.Everything seemed so easy, not only the treatment was clean, but also very little bleeding, the same operation seemed to be very familiar in Kawei's hands.

The people watching are relaxed, but Kawei can't relax: "From now on, the heart rate will be reported every 3 minutes. If there are obvious changes in heart rate and breathing, you must notify me as soon as possible."

The nurse was placed next to the patient by him, wearing a stethoscope to monitor these two vital signs: "Got it."

After the uterus is removed, the yd stump needs to be sutured.The operation is not difficult. First, the innermost mucosal layer is sutured, then the anterior wall of the stump is sutured, and finally a complete set of continuous sutures is used to finish.Until then, Carvey announced: "The hysterectomy is complete, and we will deal with the bladder next."【3】

The tear in the bladder was very obvious, and it was not difficult to suture.

But Carvey was not in a hurry: "Why hasn't the kid come back?"

"The Municipal General Hospital is not far from here, it should be soon."

"He won't just run away to save money." Carvey waited for the equipment box, and simply went to find the ureters on both sides first, "I just found out that Dr. Olgi did not suture the uterine artery." Notice the ureters to the side."

"ureter?"

"On both sides of the uterus, the ureters run side-by-side with the arteries, which are very vulnerable to damage during resection."

Olgi looked at the uterus that had long been stuck together, and explained: "Considering the time of anesthesia, I didn't do too fine a separation. And even if I did a separation, it would be easy to damage, after all, the surrounding tissues are sticky. It's too serious."

Carvey also had to admit that if he came on stage by himself, he would have a headache. The fear of abdominal surgery is that the anatomical structure caused by adhesions cannot be displayed clearly.

But in the face of difficulties, there is always a way: "You can judge the arteries and ureters with the touch of your fingers. Of course, this requires some experience. If you are not sure, you can only do the ligation as close to the isthmus of the uterus as possible. It's easy to touch the ureter."

"What now?"

Olgi's problem is also a problem for everyone present.

Because the severed ureter is softer than the blood vessel, what flows out is not bright red blood but urine.The urine produced by the kidneys is very small, and it is difficult to find the source based on this alone.Coupled with severe pelvic adhesions, even Carvey had difficulty finding the ureter in the messy tissue. 【4】

"That's why I need that equipment box." Carvey glanced at the time, "It's almost there, add some ether to her."

Just as the nurse administered ether anesthesia to the peasant woman again, the door of the operation theater was pushed open: "Doctor, I brought the things!"

"Have you brought them all?"

"Well, here it is."

"Open the box, there are three bottles of dye in the box in the lower left corner. Find the blue one, put it in the syringe, draw 1ml, I will use it right away." Carvey said, reaching into the broken bladder and finding the broken one. at the ureteral orifice, "Is it all right?"

"I'm coming."

Carvey carefully opened the bladder, took the syringe, and slowly injected a tube of blue dye into it.I saw azure blue dye slowly flowing out from the corner of the abdominal cavity, and it was clear at a glance where the disconnection was.

"The gap is there!!!"

Carvey dropped the syringe and pinched the severed ureter: "It's easy to find the location, first separate the surrounding adhesions, and then suture the ureter. Wait for the incision of the bladder, because the ureter is sutured. Afterwards, another injection of normal saline is needed to judge the suture quality."

The use of the dye was beyond everyone's expectations, and this method of injecting the dye in reverse through the ureteral orifice to find the location of the disconnection is even more unheard of.

The effect must be immediate, because this is also a very good operation method in modern times, which is simple and labor-saving: "The dyes are all left after I have screened them, and they are harmless to the human body."

"I've never seen it used like this before."

"It really opened my eyes."

The suturing of the ureter is a miniature version of intestinal suturing. It is definitely not possible to suture such a narrow lumen directly. Even if Carvey had that kind of strength, the gut in the 19th century would not agree.All he had to do was to make V-shaped incisions at both ends, and then staggered the sutures, so as to ensure that the lumen would not be further narrowed after suturing.

"Find another copper pipe in my box."

"Copper pipes? Didn't see any copper pipes?"

"It's in the bottom drawer, the very thin one." Carvey trimmed the ureter with scissors, "See it?"

"I saw it!!!"

"Bring it, I want to use it."

When everyone didn't know what this copper tube was used for, Carvey had carefully inserted both ends of it into the severed upper and lower ureters with tweezers.

"Dr. Carvey, why are you using a tube?"

"I'm just supporting the ureter," Carvey explained. "The ureter is so narrow that if you just sew it up, it looks perfect from the outside. But after it heals, the scar tissue grows in and seals off the tube." cavities, sometimes with severe adhesions like her abdominal cavity.”

"Once it sticks, it will cause urine blockage?"

"That's why you need copper pipes for support!?"

"Yes, this way we can avoid adhesions." Carvey stuffed the tube in and began to suture with sutures, "If the tube falls off downwards, it will enter the bladder, and it can be taken out directly with a cystoscope at that time. If it doesn't fall off, its hollow channel can also allow urine to flow through without affecting urination."

After listening to the explanation, everyone couldn't help but take a breath of oxygen to recharge the brain that was about to shut down. This approach is really wonderful!
(End of this chapter)