Nineteenth Century Medical Guide

To be honest, without the anatomical basis mentioned in the previous chapter, and without the pictures in this chapter, it is a bit suffocating to look at it directly.If you feel bored, you can wait until this chapter is out and then read it. Adding pictures will make it easy to understand.

Anyway, just remember to subscribe]

The short gastric artery, as the most dangerous anatomical structure when the retractor exposes the field of view, has always been an anatomical term that intern medical students must learn when they go to the general surgery operating table. 1】

It is not difficult to see the characteristics of this artery from the literal meaning, short.

Because it is short, it is inconspicuous. When doing stomach surgery to deal with the side and back, interns who don't know it can easily break it due to excessive stretching.It’s fine if it’s a vein, but it happens to be an artery, which maintains the blood supply to the entire stomach wall. Once it breaks, it will cause a lot of blood loss, and it’s not easy to repair.

When doing autopsy exercises, Carvey didn't go into so much detail, because his previous emergency surgery often performed emergency operations for massive upper gastrointestinal bleeding, and the exercises were just to go through the process to find out the feeling.

But it's different when you're on the operating table, and you can't make mistakes in every step.

"See the arteries?"

"saw"

"Remember, once the short gastric artery is broken, it's not a matter of success or failure of the operation, but a direct result of the patient's life." Carvey slowly let go of his hand, "Now that the lesser omental sac has been opened, We slowly probed down and revealed the anatomy next to the spleen, the back wall of the stomach and the pancreas"

Here is the splenic hilum area, and inside is the splenic pedicle, which wraps the splenic artery and vein, lymphatic vessels, nerves and peritoneum.

When the operation comes here, what needs to be done is not only to remove the spleen, but also to prepare for the measurement of the subsequent splenic vein shunt.Since it is a shunt, it is to divert the remaining veins to other blood vessels, and this modification of the original anatomical structure requires some prerequisites.

Carvey made a little measurement, and said to the loudspeaker beside him: "From the perspective of anatomical position, the patient's splenic vein has a certain length, so there is no need to trouble the renal vein. We can consider changing it to the inferior vena cava later. Vein. Although the distance is relatively long, the blood pressure reduction effect is much better. Before that, we cut off the blood supply to the spleen."

Here, the two of them have no chance to make a mobile phone, and the next step will be led by Kawei.

"We first find the splenic artery located on the upper edge of the pancreas by the pulse of the artery, cut the retroperitoneum on the splenic pedicle, cut the arterial sheath, and then slowly free the artery bluntly." Carvey slowly freed the artery Work, the arteries and veins are tightly attached together, because the splenic vein needs to be shunted, so it must not be damaged, "Give me the right-angle forceps."

The splenic artery was gently lifted from the sheath with right-angle forceps, and then a thick silk thread was passed inward by Hermann to ligate. 2】

Blocking the splenic artery itself can relieve a considerable part of the portal pressure, but in order to prevent excessive damage to the omental vein, Carvey decided to wait until the operation is complete before testing: "After the artery is sealed, the vein is not moved first. Detach the spleen downward."

Below the spleen is the splenocolic ligament and splenorenal ligament connected to the colon. After blunt separation and adhesion, it is clamped with a simple hemostat and then cut off and ligated. 3]...

Because novices can easily damage the blood vessels of the colon and mesoclonus, Carvey will operate the whole process: "After the lower part is settled, we start to deal with the loose tissue between the spleen, the diaphragm and the peritoneum. Although it sounds simple, you can do it with your fingers." Separate, but everyone must pay attention!

"

Carvey put his hand between the spleen and diaphragm, and then raised his voice: "The spleen, especially the giant spleen that has suffered a lot of inflammatory stimulation, has already grown a large number of collateral blood vessels around it due to adhesion and congestion. You must not use your fingers blindly. Exploration, not to mention forced blunt separation." 4】

Although Herman didn't know the short gastric artery, he was quite skilled in handling the spleen, and using the retractor and fully exposing the field of view were the first tasks of the assistant.

In this way, Carvey cut and sutured the splenophrenic ligament, lateral peritoneum and adhesion tissue under direct vision.

When the adhesive tissue was separated, it would definitely bleed again. Without an electric knife, it would be impossible to suture all the small bleeding. We could only rely on Bergert to use warm saline gauze to stop the bleeding one by one. 5】

The surrounding area had just been separated, and the two pull hooks in the hands of Bergett and Damirgang used force respectively.After the last trace of resistance was removed, the spleen was lifted out of the incision, and Herman immediately stuffed the prepared warm saline gauze into the position where the spleen was just now, the splenic fossa.

"This piece of gauze can effectively prevent the protruding spleen from sliding into the abdominal cavity again, and at the same time, it can also compress the bleeding point on the retroperitoneum and diaphragm." Carvey briefly explained the reason for doing so, and then took it from Herman's hand Hemostatic forceps, "We continue to separate the remaining upper part of the spleen and stomach ligament, which contains the short gastric artery just now."

The operation method is still the same, bilateral clamping, central cutting, and unilateral ligation. 6]

The spleen side does not need to be ligated, and only the stomach side side really needs to be ligated.The ligation of the side of the stomach is more difficult than before, because the short gastric artery is very short, and the distance of the stump that can be used for ligation is very short. It needs to be ligated firmly within a limited distance without any slippage.

Carvey has made many optimizations to the original rough splenectomy, and has basically been able to achieve bleeding-free surgery.

But doing so also shows that the procedure of surgery is very serious, and every step is carried out according to the procedure.Fernand's heart rate was stable, his blood pressure was stable, and the surgical scene, which was supposed to have a lot of bleeding, became very "boring".

"The chrome gut made by Mr. Laszlo is extremely tough, and the sutures have never slipped or broken." Carvey still gave a brief introduction, "One piece only costs 50 Helles, which is very cheap. "

"It's Laszlo's equipment factory in Nancheng District?" I don't know which vendor started selling speakers. A man sitting in the doctor's area suddenly asked loudly, "Is there any discount for wholesale?"

"Yes, you will know the details when you go to the instrument factory and ask. Apart from the sutures, there are also a complete set of surgical instruments I used this time."

After finishing the suturing, Carvey gently opened the spleen to the right with his left hand, and pointed to the posterior edge of the splenic hilum with his right hand: "Now let's go back to the operation. After freeing the ligaments and loose tissues around the spleen, we turn the spleen over to expose the remaining The pedicle of the spleen. This is where the pedicle of the spleen connects with the pancreas, and we can gently push this piece of loose tissue away with our fingers.” 7]

As if hearing a pre-set alarm, Damirgang dragged the flipped spleen reflexively, allowing Kawei's left two fingers to go around behind the spleen pedicle and gently hook it.Then clamp the splenic pedicle with three long hemostatic forceps in the right hand, and finally cut off the splenic pedicle between the middle and splenic side hemostatic forceps near the spleen side to remove the spleen. 8】…

"Attention is needed here."

Carvey's suturing was very selective. First, he ligated the blood vessels at the pancreas. He only ligated the stump of the splenic artery, not the veins.

"If it's just a simple splenectomy, we need to ligate the two blood vessels together. Not only a simple silk ligation, but also a through ligation. However, in order to prevent accidents, I personally still think that the two blood vessels are far away. It is safe enough to ligate each end. However.” 9]

Carvey left the vein: "But we will do a venous shunt later, so this vein will not move, and the spleen will be dealt with first."

He also did not suture the stump of the spleen pedicle on the other side, which is actually quite normal, after all, it is an organ to be discarded, and ligation is meaningless.But Carvey's intention is not just to discard, but to reuse.

Just as the spleen left Fernand's body, Sansuke Bergett left the operating table again, and then a metal basin with scales appeared in front of everyone's eyes.50ml of 2.5% sodium citrate and 20ml of 50% glucose preservation solution were put in it to bleed the spleen.

At this time, Damirgang also left the operating table, took four pieces of sterilized gauze from the instrument table beside him, folded them and wrapped them around the spleen. 10]

"There is a lot of fresh blood in the giant spleen, so it's not a pity for the surgeon." Carvey and Herman were doing the hemostasis work on the remaining bleeding points in the spleen fossa, and said, "Relying on the anticoagulant effect of sodium citrate, this A spleen should be able to resupply nearly 500ml of blood to the patient"

On the side was the sound of bloodletting after the hemostat was released, Bergett was bleeding, and Damirgon was shaking the container evenly to mix the spleen blood and preservation solution evenly to prevent blood clots.

On the side, the two were cleaning up the bleeding site. This strange scene lasted for a total of 2 minutes, and finally the blood scale in the metal basin stayed at 540ml.

Bergett roughly calculated the dosage, took sodium citrate and 50% glucose from the equipment box, and poured 40ml and 12ml into it respectively. 11]

Then he chose a filter funnel and started the long re-filtering of the blood bowl by bowl.After the filtration is over, the blood still needs to pass through the hanging bottle and enter the dropper of the secondary filtration, before finally entering Fernan's body. 12]

At this time, Damirgang had returned to the side of the operation, and Carvey used tweezers to loosely stuff the greater omentum into the wound in the splenic area.

"Because the patient has portal hypertension, unlike patients with ordinary traumatic splenectomy, collateral circulation needs to be made as much as possible to help shunt. Therefore, we stuff the omentum rich in blood supply into the vacant splenic fossa without fixed sutures , just leave it alone."

The splenectomy ended here, and after the sweeping work was thoroughly completed, the three-person team began to move towards the shunt operation.

Before the shunt was performed, the splenic vein left just now became the protagonist of the operation.Carvey needs to fully free it, not only cut off part of the tail of the pancreas, but also need to make a 23cm free area for the distal vein to facilitate anastomosis.

“We first incised the capsule of the upper and lower borders of the pancreas, and freed the tail of the pancreatic body, from the upper border to the root of the splenic artery, and from the lower border to the termination of the inferior mesenteric vein, so that the splenic vein could move down to the right along with the tail of the pancreatic body.

Here I have cut off the tail of the pancreas and separated the upper and lower borders of the body and tail of the pancreas.Then cut the avascular area of ​​the left transverse mesocolon of the suspensory ligament of the duodenum, and lift the splenic vein and the tail of the pancreatic body to the left of the inferior vena cava through the mesenteric incision. "13】…

The simple three sentences contained a large number of anatomical nouns. Although the technique was not too difficult and the sentences were not long, it was much faster than the detailed and slow splenectomy just now.These anatomical nouns are like submachine gun bullets, constantly impacting everyone's brains.

Ordinary audiences have long since given up, and those surgeons who have persisted until now have been filtered out by more than half in this paragraph.

The rest who can keep up with Kavey's train of thought, except for the two assistants beside the operating table, are Ingnacz, Watman, Olgi, Massimov and another in the auditorium who have never been there. Talking Doctor Five.

"How about it, Billrot, you have seen the present, why don't you even have a word."

Watman greeted his old friend with a hint of relief, his face looked very relaxed, but his eyes and ears dared not rest for a moment, for fear that he would accidentally miss some critical process.

He is very clear that once a certain link is missed at the critical moment of this tight-paced operation, it will be difficult to catch up again.

"Is this person really only 17 years old?" This is the answer Bill Roth wants to know the most. "Is there no difference in surgical skills between you and me?"

To tell you the truth, I have been using reading books to catch up, change sources, read aloud with many timbres, and both Android and Apple can be used. 】

He wanted to say that the skills had already been surpassed, but for the sake of the mutual face of the two, he chose a conservative statement.

"If it's fake, it can be written clearly on the identity certificate." Watman smiled brighter, "When you were in Switzerland, you kept saying that abdominal surgery is difficult, and there are not many people in the world who can do it well except you. But now it seems that it is not difficult at all."

"Pooh!

"

Billrot snorted lightly, but he still didn't think it was enough, so he couldn't help adding a few more: "Bah! Bah! Bah!

You touch your chest and swear to God, try saying that sentence again? "

Watman smiled and said no more.

Because Carvey's shunt has reached the final stage of suturing.

"Because the patient's splenic vein is very long, there is no need to take the renal vein shunt, because the renal vein is not thick, suturing will cause the lumen to narrow." Carvey said, "At this time, because the length of the splenic vein is long enough to touch the inferior vena cava, then Let's do the suturing of the inferior vena cava."

What follows is a series of dissociation, exposure, dissociation, and re-revealing
After a simple separation of the inferior vena cava, Hermann lifted the transverse colon and cut the suspensory ligament of the duodenum.

Carvey carefully cut the retroperitoneum in front of the abdominal aorta, separated the ascending part of the duodenum, exposed the inferior vena cava located on the right side of the abdominal aorta and below the branch of the renal vein, and freed the inferior vena cava below the left renal vein 2/3 of the circumference of the vein, approximately 67 cm long.

Part of the lumen of the inferior vena cava was clamped with curved hemostatic forceps, part of the inferior vena cava was blocked, and an oval opening with the same diameter as the splenic vein was cut on the anteromedial wall.Pass the splenic vein together with the tail of pancreas through the incision opening of the transverse mesocolon, turn clockwise to the side of the inferior vena cava, and anastomose the splenic vein with the end-side posterior wall of the inferior vena cava.

"The preparatory work is over, and the next step is the stage of blood vessel suturing." 14]