Nineteenth Century Medical Guide

Chapter 166 163. The first radical mastectomy for breast cancer was successfully completed

The reason why Watman dared to accept this breast cancer surgery was that, as the dean of the Imperial College of Surgeons, he could not avoid political tasks; It is enough to remove the mammary glands and surrounding fat tissue, and hardly touch the large blood vessels.

But Giustina's identity and fear of tumor recurrence forced him to agree to Carvey's radical operation plan. The scope of the operation was expanded to the muscles below the breast, and more blood vessels needed to be treated.

Maybe he still had confidence in his skills before, and he could devote himself to the operation regardless.But now, when Kankan avoided the surgical error, an indescribable strange feeling slowly drilled out of his mind.

After all, Justina is the Countess of France, and Count Camille is by her side. Although she has no real power, she is a very popular astronomer and writer.He has the Framarion Publishing Group under his name and is the first president of the French Astronomical Society.

In the distance, Edward, the French diplomatic ambassador, was sitting, and everyone's eyes were on the operation.

No matter how amazing the sentinel lymph node staining and lymphatic metastasis pattern that Kavey showed before, as long as the operation fails, the radical surgery advocated by the two will become the laughing stock of the whole of Europe.Even if Giustina survived the operation, the empire would most likely lose its ally, France.

The operation must never fail, not even allowing any mistakes to occur, and Watman never thought it would fail at the beginning.Carvey's block just now allowed the operation to proceed smoothly, but it also blocked his confidence in quickly moving the knife.

He stopped what he was doing, and turned his face to let the nurse wipe the sweat off his cheeks.

may be really old
As the chief surgeon, Waterman is under pressure that others cannot feel.And once this kind of pressure appears, it is difficult to get rid of it.

He breathed a long sigh of relief, glanced at the freshly peeled wound, then turned to the audience and said, "The Countess's body structure is different from ordinary people, and there are rare blood vessel variations. Now Dr. Carvey is separating this group The thoracoacromial artery and vein can cut off the connection between the pectoralis major muscle and the clavicle after suturing.”【1】

The right amount of commentary created time for him to buffer his emotions. By the time Watman bent down again, the pressure just now had been completely hidden in his heart.

Carvey knows that it is not easy to overcome the pressure, and he also knows that it is okay for him to suggest taking the position of the chief surgeon.Thinking of Watman's care for him before and the slightly lower risk of the operation, Carvey decided to "help" him.

He quickly cut off the arteries and veins, and sutured them with silk thread: "The blood vessels are resolved."

Watman nodded, gripping the muscle with pliers with one hand, and cutting the pectoralis major with a scalpel along the collarbone with the other.His movements were much slower than before, and he chose two or even three cuts where he only needed to cut with one blow, and slowly separated.

Carvey continued to bluntly dissect the pectoralis major muscle at the greater tuberosity of the humerus toward the arm, and then took another scalpel to dissect the pectoralis major near the tendon.

Watman put down the scalpel, asked Damirgang to step forward, and continued to explain: "We use three tissue forceps to clamp the pectoralis major, and pull it sideways while cutting, so as to expose the pectoralis minor underneath." 【2】

"Give me the scissors." Carvey took the scissors and began to work on the fascia on both sides of the pectoralis minor.

Seeing this, Watman naturally made a visual field with both hands to expose the fascia as much as possible: "First cut off the fascia on both sides of the pectoralis minor muscle, bluntly separate it, and then lift it up to the attachment point of the coracoid process. The pectoralis minor muscle is severed here. Come, give me wet gauze."【3】

There will be bleeding from the muscle stump, but the amount is not large, and the bleeding can be stopped by simple compression.

From an outsider's point of view, the operation seemed to be going smoothly without being affected by the mutated blood vessels just now.But a discerning person like Edinson still saw some clues: "Why did the two change hands?"

"Huh? Dr. Addinson, what did you just say?"

Edinson is not a person who likes to chew his tongue. The operation in front of him is not only related to the ability of the School of Surgery, but also to the future of the empire, which has long surpassed his personal grievances.Besides, it's not a big deal for the chief surgeon and assistant to swap operations, and Kawei's personal level can handle it completely.

"Um, it's nothing." Edinson said with a smile, "I just lament that Dean Waterman's speed is too fast, and the operation is already halfway through."

"Halfway already?"

"Yes, the next step is to judge whether it is necessary to deal with the armpits, or directly perform muscle resection."

After incision of the pectoralis minor tendon, the structure of the armpit has been revealed in the surgical field of view. According to the steps of radical mastectomy, it is time to remove the lymph nodes under the armpit and all the surrounding fatty tissue.

But Carvey was not in a hurry: "Mr. Ignatz, is there any result from the pathological microscope?"

"We're still sealing the wax."

The three of them had adjusted their speed to the fastest, but they still hadn't caught up with the progress of the operation.Considering the top-down process of the operation, Carvey decided to re-examine the two side flaps that Watman had just made. 【4】

Because it is close to the breast and fatty tissue, the flap should not leave any other tissue, and the flap needs to be thinned, leaving only the capillary layer that supplies the flap: "The operation needs to come to an end, and Dean Watman can rest for a while I will check the thickness of the surrounding skin flap carefully to ensure that there is no residual tumor tissue."

The ideal thickness of the skin flap is that it will not cause necrosis after surgery, and there are no cancer cells left under the skin. To really achieve this goal, it is very challenging to operate.

What Carvey can do now is to calmly solve the problems left by Watman, and at the same time give a wake-up call to colleagues in the audience who are about to challenge the radical surgery: "Skin flap cutting is an important first step in surgery. Here we need to make a supplementary explanation to Dean Waterman's operation just now.

When separating the skin flap, the tip of the scalpel needs to be slightly upward, and it cannot be cut flat. Once cut flat, a lot of tissue will remain. "

While thinning the skin flap and cutting off many tissues with a scalpel, Kavey excused the dean: "We are human hands, and there will definitely be unevenness, so we need to confirm repeatedly during the operation to prevent uneven thickness. situation. This not only affects the aesthetics of the final suture, but also affects the chance of recurrence after surgery”

"Three lymph nodes, one with tumor tissue."

Ignatz never liked to procrastinate, and the report of the inspection results was simple and straightforward: "It's time to clean the armpits."

Carvey put down the scalpel, looked at the skin flap carefully, and nodded: "Damirgan and Amor will clamp the stumps of the pectoralis major and minor muscles and pull them down, fully revealing the locked pectoralis muscles covering the axillary cavity." membrane and the axillary sheath surrounding the axillary artery and vein【5】Come, someone help me adjust the operating table."

The nurse squatted down and looked at the angle of the audience: "It's reached the limit."

"Then bring a cushion here."

The angle of the patient's arms and torso was readjusted, the field of view was fully exposed, and the operation continued.

The armpit has a complex anatomical structure, where blood vessels and nerves run, mixed with fat and lymph nodes.Therefore, cleaning is the key and difficult point in the whole operation, which requires extremely detailed anatomical skills.According to the previous plan, as long as there is no problem in the middle, it should be Watman who will take the lead.

But things have changed now. The accident just now has caused him a sharp increase in pressure. Although he can continue the operation, his confidence has been lost. In addition, breast cancer resection is not his strong point, and the operation is easy to deform and make mistakes.

If it was an ordinary operation, Watman still had a chance to adjust his mentality, but the surrounding situation is completely different now, and the gaze cast by two hundred pairs of eyes made him breathless.

Carvey looked at Watman's stiff hands, understood what he meant, and gently tapped the back of his hand with the tissue forceps in his hand.So far, the roles of the two have been completely reversed. In the armpit with more blood vessels and nerves, Carvey has become the chief surgeon, while Watman has become the assistant and commentator:

"We first cleaned the axillary vein, lifted the cleavage pleural fascia and axillary sheath with a tweezer, and cut it open from the subclavian to reveal the axillary vein inside."【6】

"Then, we will remove the surrounding fatty tissue one by one. When we strip the lower part of the axillary vessels, we will ligate the small veins coming from the chest wall and the arteries entering the chest wall, especially the pectoralis major and minor muscles, one by one close to the main trunk. ”【7】

According to his explanation, Carvey proceeded step by step. Every step was as careful as possible on the basis of maintaining hand speed, and the fat and lymph nodes around the blood vessels were carefully removed.

"Then we start working on the fat on top of the axilla, the lymph nodes"

Carvey took the hemostat and continued to make the separation without injuring the axillary artery, vein and brachial plexus during the process.

In the previous surgical plan, Watman could only avoid vascular damage, and the neurological aspect could only depend on luck.Now that he has taken over, the nerves have to be avoided, so as to leave a good postoperative experience for the Countess.

Especially when the separation continues to the outside of the chest wall, there will be the long thoracic nerve and the thoracodorsal nerve.

Generally, the long thoracic nerve is located 2 cm behind the lateral thoracic artery, while the thoracodorsal nerve is located outside the long thoracic nerve. It is necessary to carefully remove the fatty tissue and lymph nodes around it that may be invaded by the tumor. 【8】

This stage lasted about 20 minutes, and Amor even asked Giustina to refill some ether in the middle.

"The armpits are basically cleaned."

Carvey cut off the last piece of fatty tissue, checked the clean armpit again and again, and after confirming that it was correct, he took two balls of wet gauze from the nurse and covered the area that had just been cleaned: "After treating the armpit, we will continue Cut the pectoralis major and pectoralis minor. Find the sternal attachment first, then slowly separate the muscles, converging towards the center
It is necessary to pay attention to the lower chest wall. When performing muscle chest wall separation, all blood vessels passing through the chest wall should be ligated one by one, and small bleeding can be oppressed. "【9】

Watman's suturing and ligation speed is not as fast as Kavey's. The silk thread proposed by Kavey for clinical use is thinner and tougher than the previous catgut.For this reason, Carvey gradually slowed down the speed of cutting and separation. At the same time, in order to let Watman concentrate, he also deliberately took over the right to explain:
"Here our movements must be standardized and gentle. It doesn't matter if you prefer to be slower, and the pleura must not be injured. And when separating the outer side, the fibers of the serratus anterior muscle cannot be cut."

The operation entered the stage of repeated operations. In the next 20 minutes, Carvey kept cutting muscles, while Watman kept suturing those small blood vessels until the pectoralis major muscle, subcutaneous fat, breast tissue, and axillary cavity En bloc resection of lymph nodes. 【10】

The whole piece of tissue went into the nurse's tissue metal tray along with the blue lymphatic vessels and nodes and the tumor.

Watman has also completed all his work and left the operating area completely.His forehead was covered with beads of sweat, and he felt that his whole body was soaked. His slightly trembling legs couldn't even stand upright. He could only find a baffle in front of the auditorium to lean on his body and take a simple rest.

He didn't know why he was like this, he always felt that the whole operation completely drained his energy.

Maybe it's the pressure you're carrying, or maybe there's something else.
what is it then?

Watman looked at the 17-year-old child, and inexplicably came up with a thought in his heart: Could it be that he was leading the pace faster, and his hand speed could not keep up?
Just when the old dean doubted his ability, the operation completely entered the final stage.

Carvey is still standing by the operating table, maintaining the final work: "Take warm saline, and then prepare the rubber drainage tube."

The nurse who passed the equipment had already prepared the equipment for the final stage, and handed it to the other two assistants immediately: "Here."

"Considering the possible metastasis of the tumor, we must rinse the wound with saline before finishing the operation to remove the blood clots and fat particles generated during the operation just now."

Kavi made room for Damirgaon and Amor to do irrigation, suction and drainage, while he walked aside and began to look for the opening of the underarm drainage tube: "Axillary tissue is very easy to accumulate exuded fluid, so We made an incision at the top of the axillary cavity, put in a rubber tube for drainage, and then closed it with intermittent sutures." [11]

In this step, he reserved a lot of rest time for Waterman, because the final skin suturing must be done by him, a plastic surgery master.

"Dean Waterman"

"The drainage tube is ready?"

"Ah."

Watman took a deep breath again, stood up straight, and then slowly walked towards the operating table step by step, and at the same time made a summary of the previous operation: "The complexity of the operation exceeded expectations, but the result of the operation made me feel ashamed. I am quite satisfied. The breast tumor has been completely removed, and if there is no accident, the probability of recurrence of the countess after surgery will be less than 10%."

The auditorium burst into applause, and Kamiyi on the side also shed tears like before the operation began: "Thank you, thank you so much, thank you for everything you have done for Justina!"

The pressure melted into nothingness in the applause, and Watman gradually regained his strength: "This is only the first-stage operation, and there will be a second-stage breast remodeling operation after that. Therefore, on the premise of ensuring the beauty of the skin sutures as much as possible, we also need to prevent subcutaneous sutures. tissue infection."

Preventing infection is a very general statement, and it really comes down to what Carvey is doing now.

"I will gently squeeze the axillary cavity to drain the residual air and fluid. Then, when the assistant is bandaging, I choose to use a large amount of gauze to pack the armpit, under the clavicle and the front chest wall, so that the skin flap and the chest wall are close to promote healing. Reduce the effusion at the incision. But at the same time, it is also necessary to ensure that the pressure is not too strong, too much pressure will cause insufficient blood supply to the skin flap, and then necrosis."

The surgery is done.

　There are a little more steps, and I have deleted a lot of details, so let's take a look.I'm a bit tired from summarizing, I have to go to bed as soon as possible, I will correct any typos tomorrow.

　　
　
(End of this chapter)