Nineteenth Century Medical Guide

Chapter 248 244. Acute Gangrenous Cholecystitis
No one except Carvey knew why Rogaro had the surgery.

Surgery requires surgical indications and technical support to complete the operation. Cholecystectomy has experienced "cannot be cut, can be cut, if not cut, only stones are removed, stones have to be cut, symptoms are cut, and laparoscopy can be done. "Laparoscopic cut" bumpy process.

Nowadays, the indications for cholecystectomy are patients with symptomatic gallbladder stones (cut only when there are symptoms), rather than what was thought in the past (cut only when there are stones).

However, there are exceptions, such as patients living in remote areas with poor medical conditions, and gallbladder stones can be considered for preventive cholecystectomy. The medical conditions in the 19th century were definitely not good, and patients like Rogaro really had to have their gallbladder removed as soon as possible.

Luo Jialuo is a typical symptom, with severe pain in the right upper quadrant, obvious tenderness and rebound tenderness, and Murphy's sign. He just measured his body temperature at 39°C, and it is basically confirmed that he is cholecystitis.

Even if Carvey's diagnosis was wrong, the high fever and abdominal pain for three days would require an exploratory laparotomy as soon as possible, so no matter what, the operation would never be wrong.

"Gallbladder surgery is basically based on resection, because there are a lot of stones in it, and acute inflammation can easily become chronic. It is not wise to keep the gallbladder, and it may even be counterproductive."

Carvey originally wanted to make a midline upper abdominal incision, but his confidence in diagnosis allowed him to take the most commonly used right subcostal incision in gallbladder surgery: "I have already mentioned the symptoms and surgical indications of cholecystitis on the way, and now it is Incision selection for cholecystectomy."

Hermann distributed the retractors to Damirgang and Beckett, one pulled the skin and subcutaneous tissue, the other stretched the costal margin of the right upper abdomen, and he and Carvey cut down the skin and tissue.

While working as an assistant, he thought about this new operation, and soon had a question after his own independent thinking: "If it's just a stone, can you cut the gallbladder and remove the stone inside, maybe it can be done." Rinse it again, wait until it is clean, and then suture the gallbladder?"

That's a nice proposition, at least in the early days of modern general surgery.Even at the end of the 20th century, surgical technology had developed to a certain height, and some people put forward similar views.

It's a pity that the evidence-based medicine followed by modern medicine has resolved the controversy with large sample data.

"It's not necessary, just cut it off." Carvey changed his usual attitude of focusing on fine operations, and directly denied this point of view.

Hermann’s ideas were limited to abdominal anatomy in the 19th century, which was very similar to Donilson and Ignatz: “But the anatomical structure around the gallbladder is very messy, and resection is easy to cause operational errors. "

Carvey tapped the tissue forceps in his hand with his needle holder and reminded: "The proposal is good, but this is my operation, so I have the final say."

".Yes."

"If you think gallbladder removal is not good, you can handle this kind of patients yourself." Carvey didn't mean to blame him, "but I think you should give up such thoughts after entering the abdominal cavity."

Herman couldn't understand the meaning of his words, until the incision was made downwards, the abdomen was cut all the way, and the liver was seen and gently turned up, and then gradually realized the seriousness of the problem.

"Give me the organ hook." Carvey took the hook given by the nurse, helped to press the liver, lifted it up slightly, and said, "Do you see the tissue structure under the liver?"

"I saw it."

"Can you see clearly?"

"cannot."

"I said before when I was doing appendicitis resection, inflammation will stimulate the adhesion of the surrounding tissue. It is very difficult to distinguish the adhesion. There is no possibility that simply cutting the gallbladder is more convenient than removing the gallbladder. And"

Carvey looked at the chaotic gallbladder triangle and the surrounding purulent fluid, feeling bad: "The greater omentum is wrapped up, and yellow-green fluid can still be seen around it."

"Is this pus?"

"Maybe."

Carvey used tissue forceps to slowly separate these adherent tissues, and his movements became more cautious: "The first part of the adhesion that we have to deal with is not the liver and gallbladder, but the hepatic flexure of the colon below the liver and gallbladder. We need to be extra careful when separating this kind of adhesion. Careful separation must be achieved under the premise of ensuring the basic hand speed, without damaging the surrounding tissues."

The tissue above the hepatic flexure is dissected to free the hepatic flexure, usually to the second segment of the duodenum and the head of the pancreas.Then put the wet gauze pad between the gallbladder, transverse colon, and duodenum, and then pull the transverse colon downward to expose the neck of the gallbladder well. 【1】

However, only a part of the gallbladder was exposed, which was completely different from the gallbladder they usually saw during autopsy.

Carvey gently touched the gallbladder wall with tissue forceps, and said: "The adhesion is severe, the epidermal tension is high, the shape is enlarged, and the texture is still very brittle. It is a typical gangrenous cholecystitis. If you are not careful, it will break. The leak leaked, and the pus inside poured out, and the consequences were disastrous."

"What will happen?"

"Similar to acute peritonitis, with shock at the end."

The visible blackening of the gallbladder increases, and the surrounding tissues are tightly wrapped.If even the simplest tissues around the gallbladder cannot be separated cleanly, the most important gallbladder triangle is even more troublesome.The anatomical structures there are all mixed together, full of blood vessels and bile ducts, and anyone who is damaged will be fatal, which will greatly affect the prognosis of the operation.

Ordinary cholecystectomy involves simple stretching of the gallbladder itself.

For example, the ampulla of the gallbladder can be clamped, pulled to the head and sideways, and then the serosa layer of the hepatic duodenum can be opened, so that the anatomical relationship within the hepatic hilum can be clarified. 【2】

But now the texture of the gallbladder can't withstand clamping at all, thank God if it doesn't break, how to separate it?
Carvey put down the tissue forceps, postponed the scheduled cholecystectomy, and changed his mind.Since the gallbladder was severely swollen and adhered, and I was afraid that it would rupture and leak fluid, I decided to get rid of these troubles before performing surgery: "Nurse, give me a syringe."

The needle was pierced into the gallbladder fundus [3], and 4ml of pus was slowly drawn out. The surface tension of the gallbladder became smaller. Carvey also discovered two key points from the puncture.

One is that the wall of the gallbladder was found to be very thick during the puncture, which should have exceeded 4mm, which was caused by the hyperplasia of the gallbladder after inflammation stimulation.The second is that there is not much pus, and there are more gallstones in it, especially the sand-like gallstones.

Based on these two points, Carvey's separation became bolder: "If it is an ordinary gallbladder stone and the gallbladder volume does not increase significantly, we may first dissect the gallbladder triangle.

But now that the anatomy of the gallbladder triangle is chaotic, it is more reliable to separate the gallbladder first, and it also provides more vision for the subsequent dissection of the gallbladder triangle. "

Speaking of vision, he changed the position of the candle holder in Bergett's hand: "Now we continue to separate the tissues around the gallbladder and separate the gallbladder from the gallbladder bed of the liver as soon as possible. The nurse is going to prepare the stove and wire, and may need to cauterize the wound."

Kavi's preparations were very timely.

Because the swollen gallbladder of gangrenous cholecystitis will fit closely with the liver, bleeding from the separation wound will often occur when it is separated.Moreover, the amount of bleeding is often large, and ordinary needle and thread sutures do not work.

Modern surgery will choose medical hemostatic glue and hemostatic gauze, but what Carvey can use is the backward combination of pituitary extract + gauze + cauterizing wire.

Peel off, bleed, cauterize to stop bleeding.

Peel again, bleed, stop bleeding again
It took him more than 20 minutes to separate the gallbladder, which was basically the same speed as before when he took the stage. Considering the current conditions, it can be said that he performed supernormally.But this is not enough. The ideal operation time should not exceed 50 minutes, that is, the end of the first ether anesthesia.

"The separation of the gallbladder is completed. Let's put it aside for a while and start to separate the gallbladder triangle downward."

Because the gallbladder decompression was done just now, the gallbladder wall is also very thick, as long as it is well protected, be careful that the stretching will not cause the gallbladder to rupture: "Heman gently pulls the tissue forceps, yes, outward, then outward, don't use too much force , good! Just keep it like this!"

When separating, it is first necessary to open the serosal layer of the hepatoduodenal ligament to clarify the anatomical relationship within the hepatic porta. 【4】

Carvey quickly saw the cystic duct, and used silk thread to do a double ligation, and then said: "The double ligation is to prevent the small sand-like stones in the gallbladder from being squeezed into the common bile duct through the cystic duct during the operation. cause unnecessary obstruction."

"Where is the cystic artery?" Herman's eyes were dazzled, and he really couldn't figure out the positional relationship within the gallbladder triangle.

"Go on and do the dissection slowly," said Carvey, carefully turning the surrounding connective tissue. "The gallbladder artery originates from the common hepatic artery, and it may also originate from the right hepatic artery. Anatomical variations here are very common, so it should be carefully Identify the structures of the biliary tract and arteries, and avoid damaging unnecessary tissue structures."

In fact, in addition to these two types, there are many special variations, which are also important factors for the troublesome anatomy of the gallbladder triangle.

For example, it originates from the left hepatic artery, or the dual cystic arteries come from the left and right hepatic arteries respectively. 【5】

Fortunately, Luo Jialuo's cystic artery is not troublesome, and the starting position is the standard right hepatic artery.But this does not prove that the dissection is easy. Before the right hepatic artery tortuously enters the liver parenchyma, it will accompany the cystic duct and gallbladder, and it is easy to be mistaken for the cystic artery, resulting in mistakes in ligation.

"So, no matter what the situation is, the cystic artery should be clearly dissected, and it must be clear that it has indeed entered the gallbladder before it can be ligated."

Carvey's anatomy is very detailed, but his hand speed is not slow at all.The anatomical structure of the gallbladder triangle in front of everyone's eyes gradually became clear, and the cystic artery gradually emerged as his walking path.

"Generally, the cystic artery runs on the surface of the cystic duct and then enters the gallbladder vertically."

Carvey changed the pulling direction of the gallbladder, exposing more anatomical areas of the gallbladder triangle, and the course of the cystic artery became clearer: "Give me a set of suture needles and silk thread first, and then prepare two sets of the same, I want to Do a triple ligation."

Cholecystectomy is not a particularly troublesome operation, and it is one of the operations that Carvey hopes to hand over to them as soon as possible.

Difficulty and popularity should be comparable to cesarean section and appendicitis resection.

But a troublesome part of this kind of duck-feeding teaching is that many details are difficult to grasp, and they must be repeatedly emphasized to strengthen their memory.Therefore, during the interval of ligation, Carvey once again emphasized the key points of dissecting the gallbladder triangle and ligation of the cystic artery.

"I want to emphasize repeatedly that dissecting the gallbladder triangle is very, very important. The course of the cystic artery must be fully exposed, otherwise the cystic artery should not be ligated and cut off. In this case, repeated confirmation is required to make a judgment. Don't be irritable, you must patience."

After the blood vessels were cut off, Carvey cut off the cystic duct with clamps, and the huge gallbladder was removed from Rogaro's abdominal cavity.

"Normal saline, quickly flush the abdominal cavity."

"How many times?"

"Do it three times first, rinse carefully, especially the area where the operation was performed just now has a lot of pus and bleeding."

"I understand this."

Bergett poured the normal saline solution in the metal basin in his hand into the abdominal cavity. Damirgang shook the abdomen, and then sucked out the liquid through the suction device: "There is not much bleeding, some purulent remains but not much."

"Well, put two drainage tubes under the liver after cleaning."

"Ok"

After Carvey put the blackened and swollen gallbladder into the tray, he gently cut it open with scissors, and separated the gallbladder wall with forceps, revealing a large number of gallbladder stones inside: "Make a record, 'remove the huge gangrenous gallbladder, size 9*8 *3cm, there are a lot of sand-like stones in the gallbladder after the incision, and the largest stone is 3cm in diameter."

[Mother-in-law is gone, pulmonary hypertension, right heart failure for nearly 20 years, it has been long enough.I've been a bit busy recently, so I suggest you all to gain weight]

(End of this chapter)