Nineteenth Century Medical Guide

Chapter 150 147. Limited Guidance

In addition to heavy physical labor immediately after delivery, the loss of pelvic support structures caused by trauma and surgery itself is also one of the factors for uterine prolapse.In the past, when meeting female patients with abdominal trauma, Carvey often asked a gynecologist to operate on the same stage, and he also knew something about uterine prolapse.

However, the incidence of uterine prolapse in China is not high, at least it has shown a clear downward trend after Kavey started work [1]. After the 21st century, prolapse has become very rare, so his experience of this disease also comes from the 20s and 90s of the [-]th century, and his memory is a bit vague.

But even so, I still remember the surgical methods, at least the reduction of the broad ligaments on both sides is not one of them.

However, the problem now is not at all whether the broad ligament reduction surgery can be successful, nor whether the reduction of the broad ligament is effective for uterine prolapse, but that both Besim and Denever are stupid about the opened abdominal cavity Eyes, there is no way to start.

The failure to recognize the broad ligament was unexpected for Carvey.

Relying on years of experience in clinical education, he can still hold his breath.But the doctors from the same hospital who came to watch the operation were not so easy to talk about, and they would not save their saliva under such circumstances: "It's better to shut down the abdomen quickly, the gynecologist is still thinking about the operation."

"This is the funniest thing I've ever encountered this year. The surgeon couldn't find the surgical site. It's ridiculous."

"It's too embarrassing, Dr. Bessim, is this the effort you are proud of?"

"It was reduced to invisible after the abdomen was opened. It is indeed the legendary broad ligament reduction."

Besim didn't expect this result either. He thought he had learned anatomy and had done some minor bedside operations, but it was the first time he faced a pelvic cavity of similar color and really couldn't tell the north from the south.

The patient is not light in weight, has thick subcutaneous fat and visceral fat, and the surrounding tissue has become very loose due to years of uterine prolapse.Connective tissue, adipose tissue, muscle tissue, and visceral tissue, which are completely different in words, look and feel the same now.

They memorized the anatomy diagram, and the broad ligament should be on both sides of the uterus.

There are messy things around the uterus that can be pulled into the pelvic cavity. They can be broad ligaments, round ligaments, cardinal ligaments, uterosacral ligaments, ovarian proper ligaments, uterine blood vessels, fallopian tubes, and ureters
The extreme lack of experience and the basic responsible attitude towards patients were untimely entangled in the two of them, so that neither Besim nor Denever dared to judge easily.

The more they dared not move, the more excited the doctors in the auditorium were to ridicule, and what's more, they classified the incident as a negligence of hospital management:

"At that time, I repeatedly emphasized that the hospital's surgical theater was too kind to the surgeons who used the knife. If you want to follow in the footsteps of the Municipal General Hospital, if you want to have a stronger surgery that can attract the source of disease, you just stay in your own hospital. Here, how can it be possible to refuse reporters and reject other audiences?"

"The Municipal General Hospital has also moved the operating theater to its own hospital." Olgi always felt a little harsh when he heard this, "In my opinion, this kind of professional-oriented and following the British and French operating theater system is the general trend. Instead, the hospital is ahead of the Municipal General Hospital."

"What is the trend of the times, is not to make money for profit."

"That's right, the City General Hospital doesn't charge for surgery, so they still allow reporters and spectators to enter the arena just to fill the vacancy by earning ticket money."

"Although the existence of the audience will violate the privacy of patients, it can also urge doctors to make as few mistakes as possible."

"That's what I mean. They are all poor people who can't live happily. What's the point of talking about privacy? The most important thing is to find the best doctor in Austria to perform the operation clearly. If there are audiences and reporters who see this simple open A ridiculous operation that does nothing on the stomach, I am afraid it will be on the front page of the daily newspaper the next day."

"It's not bad to be in the newspaper, but the citizens of Vienna quickly forget it. But if the hospital loses face, it's up to me whether I can stay in the hospital and continue working."

It wasn't the first time for Carvey to experience the power of the audience. Before Olgi's cesarean section, some people were secretly gossiping. Since Watman was the dean of the School of Surgery, this kind of voice was much less.But if the surgeons were replaced by young surgeons like Sears and Herman, there would definitely be discussions in the audience.

In such an environment surrounded by sight from all sides, it is not easy to explain to the audience while performing surgery to satisfy the audience. After all, it is a paid viewing program, and it is normal to be sprayed if it is messed up.

But now it is an internal surgery in the hospital. Although the process is a bit outrageous, these people are too merciless, and it is too far from the modern hospital full of sophistication.

But thinking about it, those remarks just now are not unreasonable.

In the 19th century, when there were no medical regulations and procedures for diagnosis and treatment, the audience, a regulatory group, did have its rationality for existence.Otherwise, problems such as "amputation of the wrong leg", "intestinal obstruction cutting off a section of healthy bowel", "gauze, scissors, and vascular forceps left over", "appendicitis but the spleen and pancreas were cut off" will appear in large numbers.

Of course, the unprofessional reaction of the audience will indeed affect the mood and judgment of the surgeon. It is only a matter of opinion.

Carvey still has no way to make irresponsible remarks on the medical system. What can be tangled up is the operation itself.

Now the abdomen is opened, and the patient does have severe uterine prolapse, and it is very troublesome to close the abdomen.Of course, according to his own opinion, since the patient has already assumed the risk of abdominal infection, it is better to proceed with the operation directly.

The last time I chose to take over the order to save Kavey's life, this time the patient is far from this point, and Kavey didn't intend to help.Besides, the two people beside the operating table didn't say anything, it was obviously inappropriate to enter the arena rashly, and it didn't conform to Kavey's usual style.

Recalling that when he was in the gynecological ward, Besim asked him to be a guide.

Since it is a guide, try to talk as much as possible and do less. First of all, you have to change the concept of the two people: "The broad ligament is on both sides of the uterus. Could it be that the uterus can't find it?"

Denever was already in despair, and it was fine for him to be scolded, but Besim was scolded together, and he felt really uncomfortable.He suddenly heard Kavey's voice, he finally caught a life-saving straw, and rummaged again:
"The uterus has just been pushed and pulled up, and both sides of the uterus are full of various soft tissues."

"Think more about the position covered by the broad ligament, and then think about the differences in other tissues, and then use your fingers to feel them one by one."

Denever and Besim squeezed the surrounding tissue according to his intention, and suddenly realized: "Could it be these two butterfly wings?"

"Yes, this is it."

The ligaments in the hands of the two men were completely different from those of dead bodies in terms of appearance and feel. Just less than 5 minutes of experience had raised their anatomical knowledge to a higher level: "The broad ligament has been found, let's move on."

"Next, put down the broad ligament in your hands."

Carvey stopped what they called the broad ligament reduction surgery in time, and while the audience was still surprised, he revealed his operation plan: "There are so many uterine ligaments, the ligaments that can really fix the position of the uterus are not broad ligaments." ligament."

"Not the broad ligament?"

"The broad ligament is so thin, it is only responsible for preventing the uterus from tilting to both sides. What can really fix the uterus is the main ligament below it."【2】

Carvey's suggestion already has some weight. As long as it is a pelvic surgery, few people dare to question him, at least the doctors present are not capable of this.

This is the result that Besim wanted, and completing the operation under the guidance of Carvey would definitely add a lot of persuasiveness.At that time, uterine prolapse will no longer be a single treatment disease. Compared with putting a pessary in the yd【3】, many patients still prefer once and for all.

As chief surgeons and assistants, they will also become celebrities who pioneered surgical treatment for gynecology after oophorectomy [4].

However, Denever seemed to be convinced of his own judgment, and suddenly said: "The broad ligament is much larger than the main ligament, no matter how you look at it, the broad ligament should be stronger."

Carvey has always believed that it is a good thing for young people to have their own opinions, but if they cannot see their own level, blindly have their own opinions and be overconfident, they are a bit stupid: "Are you so sure?"

"Although you are a great doctor who established the principle of cesarean section, you are certainly not familiar with the uterine ligament. I have done many experiments."

Denever spoke more and more boldly, until he was kicked in the calf by Besim: "What are you talking about? Dr. Carvey is the audience I invited, can you speak well?"

"I'm just doing well."

Besim raised his leg and kicked him again: "Dr. Carvey has a very deep knowledge of pelvic surgery, and this is also a suggestion for us. I think we can try to reduce part of the main ligament first, and then consider the broad ligament. "

"No, the broad ligament is the important anatomy for maintaining the position of the uterus."

"We actually didn't recognize where the broad ligament was at all."

"It's two different things."

The two masters and apprentices who were helping each other against the ridicule of the outside world just now put the focus of their conflict on their surgical goals.Besim knew that his student was stubborn enough, and half of the reason why this operation was carried out was actually due to this personality.

"Doctor Carvey."

"It's okay." Kavi didn't care. Since he insisted so much, he couldn't say much as an outsider, "The patient is yours, and the operation is also yours. It should be up to you. Of course, if the operation fails, the responsibility is also yours." .”

Denever was stubborn and a bad surgeon, but at least he wasn't too stupid.

After Carvey questioned the function of the broad ligament, he did not rush to do it, but first folded the stretched broad ligament to see how it would be reduced: "Dr. Carvey, colleagues, everyone You can see where the uterus is after the ligaments are reduced."

The uterus is between his hands, and it is maintained in the center of the pelvis by the shortened broad ligament.

It seems that this operation is reasonable, but someone soon raised a new question: "Although the broad ligament is wide, it is very thin. Is it really possible to maintain the entire uterus with only the reduced broad ligament?"

"I think it's okay, the ligament has very good toughness."

"Ha, if the ligaments were really as perfect as you said, the uterus wouldn't prolapse to such an extent. Thinking about how many ligaments there are around the uterus, it's really nothing to be able to completely separate from the vagina just like this expected."

"Indeed, given the thickness of the broad ligament, I'm afraid it will recur soon after the reduction."

"In my opinion, if you want to do it, do the whole set, reduce the loose ligaments around it, and maintain the uterus in its original position."

Carvey shook his head at this unfounded idea: "Some ligaments have blood vessels running through them. After the reduction, should these blood vessels be sewed or not? Sew, there is no such level, do not sew, because the short-term blood flow is not smooth, The surrounding soft tissue must be edematous.

It’s okay if it’s in other surgeries, as the blood supply can be helped by side branches, but now it’s relying on the reduced ligaments, which bear the weight of the uterus all the time, and if the ligaments go wrong, the surgery will inevitably fail. "

There is no such blood vessel in the main ligament, so it is not difficult to do reduction.

Of course, like the broad ligament, only the main ligament reduction is more effective and stronger, but it is only better than the broad ligament reduction.Uterine prolapse is easy to recur, and surgery alone cannot be perfect, and it will recur after a long time.

Therefore, modern gynecology advocates that surgery should only be considered in severe cases.

According to the situation of this third-degree prolapse patient, in order to achieve a complete cure, a complete preoperative evaluation should be done in advance [5], and then the operation should be planned.

According to Kawi's judgment, the patient may need uterine suspension surgery to completely solve the torture of prolapse.That is to hang the uterus at a certain position in the pelvic cavity, such as: abdominal uterosacral ligament suspension, yd sacrospinous ligament suspension, yd main sacrospinous ligament suspension and so on.

With the current surgical level, these operations are still too troublesome, because they are not life-threatening, and Karvey has no desire to try them for the time being.

In comparison, although the reduction of the main ligament is prone to recurrence, the advantage is that the operation is simple and the postoperative effect is more obvious.Even if it does recur, the degree will not be that serious, and it is enough to use the pessary for support.

Denever was a little reconciled, but his hands were not idle, and he had already started to work: "Is there no better way?"

The operation is just a simple treatment of the ligament, no large blood vessels are involved, and there is no need to suture the viscera, so the difficulty is very small.Even if he had no surgical experience, he and Besim had done so many surgical rehearsals and trainings for nothing, and there was nothing to complain about the rest of the surgical operations.

Soon the broad ligaments on both sides were cut off in the middle by scissors, and then reattached with sutures.

"Better methods still need to be explored, but this should be the most perfect surgical method that can be thought of."

Denever does not factor in relapse: "If there is a relapse, she will continue to use the pessary"

"It's better than random surgery and more serious pelvic damage."

"You don't think it's good to use a pessary?" Carvey interrupted suddenly.

"After all, it was stuffed with a foreign object." Denever said.

"If it's troublesome, it's okay to not use a pessary." Carvey glanced at the patient on the bed, "I remember that the patient is 53 years old now?"

"Correct."

"The age is almost the same." Carvey calculated the time and continued to ask, "Is she amenorrhea?"

(End of this chapter)