Nineteenth Century Medical Guide

[The words and comments in this chapter may have to wait until November to resume, painful]

The key points of intra-abdominal surgery are nothing more than free anatomy, clamp blocking, cutting and separation, suturing and anastomosis.

The seemingly simple words, every step embodies the sweat of repeated practice, and embodies the health and life of the patient after the operation failed.The difference between Carvey and all the doctors present is not only the 150-year history of medical development, but also the 30-year experience in emergency treatment.

It is impossible for a doctor who has only performed surface tumor resection, lithotripsy and amputation to keep up with Carvey's thinking, nor can he understand the anatomical structure of his current surgical area, let alone the anastomosis of the stumps after rectal mass resection. Gold content.

They only know that rectal anastomosis is not easy, but they don't know how difficult it is.

Among so many doctors in the auditorium, I am afraid that only a few surgeons who have challenged abdominal gastrointestinal surgery have a certain right to speak.Among these people, there is only one Bill Roth who has really come into contact with and publicly performed rectal surgery.

Since he took the position of chief doctor, he has determined that his future surgical path will never waste time on epidermal tumors and plastic surgery.

Bill Roth has always focused on the digestive tract, and during his years working in Switzerland he specialized in rectal cancer.Although only four cases were done in total, two cases died within one month after the operation and one case died a year later, but one case has survived to this day. 【1】

He chose rectal cancer not because rectal cancer surgery is simple and easy to do, but because the symptoms of rectal cancer are typical and obvious enough. Blood in the stool and intestinal obstruction are the most direct evidence.

At the same time, rectal cancer is so far the only gastrointestinal tumor that can be diagnosed by non-invasive examination, which can be confirmed only by rectal dilation microscope or simple digital examination.

Regardless of the method of surgery in the early 18th century or the current middle of the 19th century, rectal tumor resection has always been done through the anus.

When everyone was shocked by Carvey's superb abdominal surgery skills, Bill Roth's shock stopped at the operation method.Because only he knows how many anatomical structures he has to go through from the abdominal skin into the abdominal cavity and then around the rectum.

"Dean, you should know how difficult the surgical path from the abdominal cavity to the rectum is. Let alone a living person, even a dead body may not be able to do it well."

"I'm not familiar with celiac"

Billroth held a notebook with several pages in his hand, and stared blankly at the operating table not far away. The only thing he wanted to do was to rush to the operating table to see the situation in the patient's abdominal cavity: " You said, if I am on the operating table now, will Dr. Carvey give me a chance to be an assistant?"

"The operation should be over soon." Watman didn't expect him to think this way. "Anyway, he has been in Vienna all the time. There will be opportunities in the future."

"The key issue is not the doctor. Of course, Dr. Carvey is also very important, but" Bill Roth sighed. "The point is that the next patient with rectal cancer who is willing to undergo surgery does not know when he will have to wait."

The reason why Kavey chose the abdomen is because he did not deliberately prepare the leg frame in advance, and there was no way to make a lithotomy position.The second reason is that there is not much difference between transabdominal and transanal for him. In order to fit the theme of this operation, it is better to choose transabdominal. …

Abdominal and pelvic floor surgery is also an important basis for general surgery and obstetrics and gynecology. In Vienna, where cesarean sections are increasing, it is not harmful to show these doctors pelvic floor surgery.

Simple mass resection is indeed simpler than rectal cancer resection, eliminating the need for resection of the descending colon and sigmoid colon, and less dissection of surrounding lymph nodes.But other than that, there is not much difference. The intestinal segment where the tumor is located still needs to be cut off, and the disconnected intestinal tube still needs to be anastomosed.

And what can really reflect the difference between modern times and the 19th century is the stapler. 【2】

Fortunately, Carvey is a person who has experienced the era of hand-sewed bowel tubes.If you were replaced by those young doctors, you would need to use a stapler for almost every operation, and many people may have forgotten how to perform manual anastomosis of the intestines.

Of course, the existence of the stapler definitely has more advantages than disadvantages, because it makes up for many technical defects caused by manual suturing and reduces postoperative complications. 【3】

It is definitely true to transfer part of the doctor's technology to the machine, so that the doctor can pursue more advanced surgical techniques and ideas.But in Carvey's eyes, there is no conflict between using a stapler and practicing the original suturing technique.

Because the stapler is a commodity, since it is a commodity, it will have value, and often the value of medical commodities is not low. Even if there is insurance and reimbursement, the patient still needs to pay a sum of money in the end.

For those poor people, the cost of equipment that others can afford is likely to be their living expenses for several months.At this time, forcibly using the stapler is making the patient uncomfortable and making himself uncomfortable. The best way is to give up the expensive stapler and choose to do the anastomosis manually.

The rectum is different from the small intestine. Anastomosis not only means joining two sections of intestinal tube together, but also needs to ensure that the rectal sphincter below is not damaged.

This is why it is necessary to determine the distance from the dentate line immediately after seeing the mass.

"This is the lump on Mr. Fernand's rectum." Carvey opened this section of rectum, revealing the appearance of a ruptured internal lump. "The lump has grown to such an extent that surgical removal is indeed the only way to treat it."

The audience burst into applause, and the surgery, which lasted nearly 4 hours, finally ushered in the end of the second stage.

But for Carvey, the beginning and end of the operation are the same, and there can be no sloppy: "How is his blood pressure and heart rate now?"

"Back to around 120/70, heart rate 95."

"Okay, keep monitoring"

Carvey was surprised by Fernan's body, but at the same time he was relieved.

There are various risks in open-air surgery. The light source alone is a big problem. Not only is the air disinfection useless, but it also needs to face the constantly falling dust.Repeated use of ether will cause unimaginable consequences, and it is a miracle that Fernan can persist until now.

"Next we need to anastomose the bowel, which takes some skill."

Carvey used the needle holder to bring the silk thread, and said: "I perform traction and fixation sutures on both sides of the intestinal tube respectively, so that the two ends are close together. Then use the silk thread to perform continuous inversion sutures on the posterior wall, each suture is one The thread must be tightened when the needle is used. This is related to the sealing of the anastomosis, and no gaps can be left.”【4】…

After finishing speaking, he quickly completed the suture of the back wall, and then tied the suture with the silk thread for traction: "The technique of the front wall is the same as that of the back wall, and continuous inversion suture is required, and finally the traction suture on the other side is done. The silk thread is knotted. This is done to prevent the successive sutures from constricting too much and narrowing the lumen."

In fact, the stitching technique is as simple as before, and there is nothing special about it. The place that is really worthy of Kavey's "skills" is actually after the stitching.

"The rectal segment lacks serosa wrapping, and the anastomosis of the broken ends is prone to anastomotic leakage."

Carvey put down the suture needle and thread, checked the anastomosis carefully, and said, "Everyone knows what the rectum is for. Once an anastomotic leak occurs, the patient has no other way to deal with it except for a second anastomosis. So here In addition to suturing, technique also refers to an experiment to check whether the anastomosis is tight. Bring me a basin of normal saline."

While Bergett prepared the brine, Carvey selected an enema.

"Pour water into your belly."

"Pour it all in?"

"Pour 200ml first, and I'll see if I can bury the anastomosis."

Bergett nodded, and poured the normal saline solution into Fernand's abdominal cavity, and didn't stop until the rectal anastomosis was completely submerged by water.

Carvey asked Damirgon to inject a tube of air into Fernand's rectum while he was pouring the salt water. More than 100 ml of air entered Fernand's rectum, and due to the internal pressure, some of the tiny air penetrated into the abdominal cavity through the gap of the anastomosis.

"See the bubbles?"

"I saw it."

Carvey stepped up to the loudspeaker and said loudly: "When performing the final anastomosis in rectal surgery, please remember to do an air enema experiment. No matter who performs the surgery, we are all human, and it is difficult to get rid of the possibility of making mistakes. For example, now, There is a small string of air bubbles entering the saline pool in the abdominal cavity, which is the performance of a missed needle."

After all, he asked Herman to use the metal suction tube to suck out the normal saline in his stomach.

"Sewing problems are common, as long as the remedial measures are taken in time."

Carvey gently reached into the position where the rectum was, exposing the operation site again.He gently kneaded the sutures on both sides of the broken end, only to find that there was a stitch missing at the corner of the suture. Maybe it was only half a stitch.

"There is indeed a leak, but it's not difficult to remedy. You only need to hang a stitch." Carvey said while doing the stitching: "Add some water, I have to do it again."

After the success of the second inflation test, the operation entered the final finishing stage.

Before this time, Carvey will summarize the gains and losses in today's surgery: "First of all, I have to thank Mr. Fernan's body. Although my soul was sold to the devil, this body allowed me to fully demonstrate the two operations. The whole process. The second thing I want to talk about is the medicine in the infusion bottle."

The No. 1 infusion bottle contains adrenal gland extract, which is the invisible protagonist of today's surgery.

Without it, the entire operation might have ended when the spleen was removed, because Fernan had exhausted most of his energy in the first hour or so.It is precisely because the adrenal gland extract contains not only adrenaline and those other messy hormone products that the operation can be shown until now. …

In the No. 2 infusion bottle is pituitary extract.

Compared with adrenaline, the effect of the pituitary gland is not so overbearing, but for Fernan's upper gastrointestinal bleeding, the pituitary gland extract can quickly solve his bleeding problem.Because pituitary hormone has always been a very useful and common hemostatic drug in hospitals.

"The 4-hour operation did not depend on my technique, but on these two drugs."

Kavi once again advertised himself: "As I mentioned before, the price of these two medicines is 10 crowns, which is very cheap. If you want to choose a package of two bottles, the Karachi Pharmaceutical Factory will give you a special price. At the same time , we will also launch a blood pressure monitor adrenal pituitary surgical gift package together with Mr. Laszlo’s steel factory, and the specific price can be consulted at the Karachi Pharmaceutical Factory.”

Sales promotion is also a feature of Carvey's operation. Since he got the patent, he will intersperse some advertisements between operations.

The original intention is not only to increase income for myself, but also to let those doctors develop good habits of using drugs and equipment while making money.

In order to ensure the popularity of these drugs, the patent period is not long, and he will announce the preparation method after one year.This is not giving away money. You can earn money by doing whatever you want, and Kavey is not short of money. The ventricular shunt performed at St. Mary’s Hospital alone brought Kavey an income of 400 crowns.

In this case, the pattern of holding on to patents is small.

After the peritoneum was sutured, the various organs in the abdominal cavity were checked again. After confirming that there were no gauze instruments left, the abdominal cavity was washed twice, and then the abdomen was closed.

This complex abdominal surgery, which lasted from [-]:[-] p.m. to [-]:[-] p.m., finally came to an end with Carvey's voice, "The operation is over!"

Carvey took off his leather skirt and gloves, and left the center of the surgery plaza without looking back, but what awaited Fernan was not the postoperative care ward, but Edward's sentence.After all, he is just a death row prisoner used to perform surgery, and there is no room for bargaining over his own life.

But unlike Kavi, the hands-off shopkeeper, Edward is very embarrassed now.

The operation was a great success, and the audience was in high spirits, so it seemed embarrassing to announce that the newly saved patient was hanged: "Congratulations to Dr. Carvey for the successful operation, which was beyond my expectation. For such a death row prisoner, a demon with more than a dozen lives, I don't think it is necessary to show him any more mercy."

However, except for the two executioners, there were no tools for execution in the square, no guillotine, no gallows, not even a noose.

Everyone, including Edward, believed that the operation would fail, even Carvey.

But who knew that there would be such a big change during the operation, the diagnosis was constantly changing, and the operation plan was also changing.The operation that Edward said was inspired by God. Since God arranged it in this way, the people did not hesitate.

Before Edward could speak, voices of "Live, live, live" began to be heard in the audience.