Nineteenth Century Medical Guide

Chapter 235 231. Pericardiotomy and Drainage
Cardiac decompression was first described in the 17th century, when a surgeon named Rio Lanas chose to cut the pericardium from the front.For this reason, he not only needs to cut the patient's skin with a knife, but also needs to punch a hole in the sternum, which is extremely cumbersome.

But because there was no anesthesia, the operation process was completed quickly.

It is impossible to test the outcome, the only thing that is clear is that the operation to decompress the heart has been passed down.Even with the advent of less invasive percutaneous puncture, incision and decompression can also appear in the surgical treatment program as the last resort for pericardial tamponade.

Even in the early 20th century, pericardiotomy and drainage were safer than blind percutaneous pericardiocentesis because of problems such as comprehensive visual field exposure.This situation was not improved until the rise of imaging and became an important support for surgery.

But such an effective pericardiotomy and drainage is not a routine operation, and very few surgeons are really willing to perform this operation.

The main reason is two points.

The first lies in the little understood mechanism of blood clotting during trauma.

The blood spills into the pericardial cavity through the opening of the heart, and the blood coagulation process will start immediately, and it will not take long to form a solidified blood clot.The discovery and determination of this process is a rather lengthy process.

Since the discovery of platelets in 1842, physiologists have continued to discover fibrin, fibrinogen, thrombin, and prothrombin for a hundred years [1]

Medicine is a discipline formed by the accumulation of various knowledge. It seems that there is a big difference between medicine and surgery, but the development of any branch is limited by the development level of the overall knowledge.

Austria in 1866 Of course no one understood why blood clots or when it clotted.Although there are doctors who can understand the symptoms and diagnose pericardial effusion, the number is extremely limited, and even fewer people dare to perform puncture after diagnosis.

If it is found that the blood cannot be withdrawn after the puncture, everyone will choose to give up.

They will question their own judgment, as the surgeons did just now, thinking that the casualty did not have a tamponade.Even if the diagnosis is clear, they will question their puncture technique, thinking that the failure to puncture blood is due to the wrong position of the puncture.

The second point is the contraindication of cardiac surgery.

Even the most authoritative surgeons have to admit that the possibility of surviving cardiac trauma is very small.Even if the heart is barely operated, it will cause a series of problems, such as intraoperative bleeding and serious postoperative complications that are difficult to prevent.

The postoperative bleeding itself may also form a new pericardial effusion, making the operation useless.

Therefore, for a long time, it was considered a foolish choice to open the pericardium, and this mainstream view dominated the surgeon's decision.Carvey doesn't need to go back to Vienna now, and similar objections can be heard in the operating room.

"You're going to drain the pericardium? Is that really appropriate?"

"The heart is not the abdominal cavity, and cutting the pericardium will bring unpredictable risks."

These are just small troubles, and it is Bill Roth who really troubles Carvey.

This devout Austrian Catholic, like the royal family of the Holy Roman Empire, has a very special belief in the heart: "The heart is the residence of the human soul, and operating the operating room on the heart is a blasphemy of surgical art!"

Carvey:? ? ?
"I'm not the first surgeon to cut the pericardial cavity. From the 16th to the 17th century, doctors have done it one after another." Carvey stood by the operating table, looking for the location of the surgical incision while confirming the vital signs. "Let's blaspheme, as long as the wounded can survive."

"No! You don't understand!" Bill Roth persuaded. "Those surgeons who tried to operate on the heart ended up ruined. You can look up the history of medicine, and many of them failed to survive." Name down."

"I'm not interested in whether I can leave my name." Carvey said, "There are traces of surgery and it is beneficial to the wounded. Of course I want to give it a try!"

Billrot sighed long, feeling helpless in his heart.If it was placed four months ago, he might still be able to use his identity as the deputy dean of the School of Surgery and his confidence in surgery to argue with Carvey, but now he has lost the confidence to do so and can only stand aside Shake your head straight.

His retreat did not change the attitudes of the doctors around him. Led by Bill Roth, other voices of opposition gradually arose.However, they did not consider it from a metaphysical point of view, but from a more rational point of view:
"Even if there are traces, it is very dangerous!"

"The vital signs of the wounded are not critical now, and he was conscious before the anesthesia. Isn't this an indication for heart surgery?"

"But the diagnosis of tamponade is fine," Carvey was still explaining. "Anyway, I need to open his pericardium and remove the blood clot that has accumulated in the pericardial cavity."

"Is it possible, I just said possible, that the cardiac tamponade can be relieved by itself? The blood clot may be absorbed by itself, which has been explained by physiologists before. Thinking about it from another angle, those patients or wounded who have undergone surgery, all If there is no good result, it is better to choose conservative treatment in the direction of internal medicine."

"The results of their surgery were not good. That's because the patient's condition was too serious. Moreover, the operation was not properly disinfected. The cause of death was not the operation itself, but the severe suppurative pericarditis caused by the operation."

"But once the operation fails."

Carvey looked back at the doctors who were still trying to persuade him to stop: "I've already decided."

He has never been a person who likes to explain, especially after making a decision, explaining is nothing more than helping the other party to further accept the facts.But if the other party insists on not accepting it, Kavey will also choose to give up the explanation.

He has become more and more stubborn since he became the emergency director. Unless a family member comes forward to stop it, no one can stop the operation that has been decided.

Now at an all-time high in power, he has long since lost patience with such suggestions.Moreover, Roserini's situation is inherently special. The heart firearm injuries that can persist until now are extremely rare, and luck accounts for a large proportion of them. If you give up, you don't know when you want to meet such wounded next time.

The diagnosis is clear. The wound should be located in the left ventricle. Judging from the speed of the injury, the wound is not large. The symptoms of the wounded are becoming more and more obvious, but the vital signs are relatively stable. The hospital is located in the Olmitz Fortress General Hospital with the best logistical preparations. .
According to the practice of modern military medicine, such wounded patients should have their chests opened for pericardiotomy + heart repair as soon as possible.

Carvey thought so too.

but.
Carvey is also a human being, no matter how powerful he is, he cannot exceed the limit of a normal surgeon.As a human being, it is impossible to make every decision right.

Therefore, in order to pursue perfection, he will consider all the conditions carefully every time before formally determining the operation plan.Although Carvey himself felt that he re-examined the correctness and success rate of the surgical plan out of safety considerations, in fact, the surrounding voices had already subtly changed his mind.

Carvey needed to consider many other factors before leading the operation with more than 100 years of advanced surgical techniques.For example, the current bad operating room environment, the cardiothoracic technique that I am not very skilled in, and the assistants around me who have no cardiothoracic experience.

In addition, unstable anesthesia during the operation, the last position of the bullet trajectory, whether the heart rupture is serious, etc. are also important considerations.

It is very difficult to sew up a hole in the heart, but it is not impossible. It is just for safety reasons. Whether it is really necessary to forcibly open the chest cavity for suturing now needs to be carefully considered.Among them, what troubled him the most was the size of the hole in his heart.

Judging from various factors today, the heart breach should not be large, it may be a tangential injury of less than 1cm, and the location is in the thicker ventricle of the myocardium.

Although this kind of small wound is not suitable for conservative treatment, whether it needs to be directly sutured in the case of pericardial tamponade, Kavey needs to put a question mark.

The voices of opposition around him were suppressed, but the voices of opposition in Kawei's heart slowly rose.

Is going straight to heart stitches really as risky as others say?

Is it possible to do palliative treatment, only deal with the current cardiac tamponade, and let go of the heart gap that has been blocked by blood clots.After the pericardial tamponade is relieved, closely observe the condition of the wounded, and if the tamponade recurs after the operation, choose dangerous heart repair.

Or you can carefully observe the situation after the heart beat when the blood clot in the pericardial cavity is clear. If fresh blood overflows, it is not too late to consider doing heart suture
In the eyes of outsiders, it took less than half a minute for Carvey to verbally clarify the use of surgery to treat cardiac tamponade, and to receive the scalpel and prepare for the operation.But in Carvey's mind, he has already rehearsed many possible situations, and even the rare pseudopericardial tamponade is also within his consideration. 【2】

These combined circumstances ended up changing Kavey's previous decision by some mysterious circumstances.

He changed the original pericardiotomy and drainage + heart repair into simple pericardiotomy and drainage, and he put the rest of the heart repair after the pericardiotomy.This is a performance of seeking stability, because Carvey is not too sure about the success rate of the heart repair.

He didn't think that failure would affect his status and identity. What he cared about was that if this operation failed, the number of doctors who would dare to perform similar operations in the future would drop significantly.

Since a simple pericardial incision and drainage was chosen, the surgical location also needed to be changed.

The fifth and sixth intercostal space incisions used for heart suture will have various complications. If only the pericardium is cut, it is safer and more reliable to choose the subxiphoid incision.

Subxiphoid pericardial fenestration is a very common method of pericardial drainage, and the indication is severe pericardial tamponade like this.

In order to save the lives of the wounded, there is not even an absolute contraindication to this operation.That is, regardless of the special circumstances of the wounded, as long as the doctor judges that the pericardial tamponade is life-threatening, he can choose to perform this operation immediately.

Demonstrating the whole process of the operation in front of so many surgeons is to hope that they can master this operation, because similar patients will appear at any time on the battlefield in the future.

Carvey put Lucius and Goram on the stage, and gently cut the lower edge of Rogerini's xiphoid process with a scalpel: "I remember that in 1810, a French surgeon named Larry risked his job. , bravely drained the pericardial effusion in a patient with a mediastinal tumor. At that time, the position where he cut was the fourth costal cartilage, which went down vertically along this anatomical position”

"I have the impression." Lucius said suddenly, "The patient lived for 23 days and finally died of severe pericarditis."

"So it is very important to disinfect before and after surgery."

Carvey's scalpel entered the 5cm longitudinal incision under the xiphoid process of Rogerini, continued downward, cut the abdominal linea alba, separated and found the xiphoid process: "I chose to avoid the xiphoid process of the chest. Incision, which preserves the integrity of the bear's ribs, and has far fewer complications. Give me the rongeur."

What he has to do is to cut off the xiphoid process that affects the surgical approach downward, exposing the surgical field of view.Regardless of whether the indications for surgery are clear or not, and whether the surgery is really suitable for Rosherini, at least Kavey's technical techniques are enough to subdue these opposing voices.

After a few clicks, the xiphoid process was removed.

"Come on, wash off the broken bones." Carvey continued to go down, separated the pleura on both sides, and then found the diaphragm below, "One hook for each person and pull it out. Give me needles and thread and four hemostats."【3】

The function of the needle and thread is not to suture, but to open the pericardium next.

Carvey retracted the stump of the sternum and quickly saw the pericardium.Unlike a normal heart, the pericardium at this time did not beat with the heart, but appeared very full, like a plastic bag filled with clean water.

"The tamponade is already serious, and if the drainage is not opened, something will happen."

Carvey used a scalpel and scissors to make a small incision in the pericardium. After separating it, he used four sutures and four hemostats to pull the four corners of the pericardium window to create space for himself to remove the blood clot. 【4】

"Have you seen these black jelly-like things?" Carvey took the suction device from Goram, "I think you should know what these things are after frequent autopsies."

"Blood clot."

"Because these blood clots are stuffed in the pericardial cavity and seriously affect the beating of the heart, a series of symptoms will be produced." The suction device in Carvey's hand started to work, "What we have to do is to remove the blood clots that are in the way."

Perhaps it was improved by the Laszlo Foundry, and the suction power of the suction device has reached a higher level. When a large semi-solid blood clot penetrated into the suction pipe, a dark red viscous liquid flowed from it like a waterfall. Seepage from the upper pericardial space.

"gauze!"

Carvey immediately realized that the blood clot on the opening in the heart had fallen off, and it was impossible to stop the bleeding with just a small window.He handed the suture thread to Lucius, the first assistant, and the suction device to Goram: "The suction device and gauze stop the bleeding, and then quickly suture the pericardium."

The two assistants didn't follow his train of thought at all, and they still didn't react when they saw the scene just now: "Shall I sew?"

"The heart is bleeding, and I'm going to do a heart repair right now." As soon as the words fell, Carvey's scalpel had already landed on the skin above Rogerini's fifth rib.
(End of this chapter)