Nineteenth Century Medical Guide

Chapter 252 248. Creativity is the upper limit of surgeons [2]

[This thing has a bit of stamina, I'm on duty and I haven't rested these days, so I haven't coded it, sorry. 】

Carvey previously used a midline incision in the lower abdomen, and the lower edge was just wide enough to extend 2 cm below the right common iliac branch.Now that the blood vessel is severely broken, the length of the incision is stretched. If you want to do a good job in the next step, you have to expand the incision downward. 【1】

"The rupture of the right common iliac artery is severe, and there is a considerable distance between the end of the external and internal iliac artery. If you are the one to deal with it, what should you do on the premise of limb salvage?" Carvey walked down the original incision It was extended by 5cm. Seeing that they didn't respond, he continued, "If you want to be the chief surgeon, you have to learn to think independently."

They also want to think independently, but the current situation is completely beyond the cognition of the three assistants.The vascular disconnection defect reached 4cm, and no matter how strong the elasticity was, it was impossible to tighten it and continue to suture. It can be said that there was no room for manipulation.

If Kavi wasn't there, the leg would have been amputated long ago, and so much time would not have been wasted.

Compared with the wounded soldier's leg, the lives of other wounded soldiers are more important.But now seeing Kawei's determined appearance, they all want to see how this operation will develop.

The ischemia of the right lower limb is severe, and half an hour has passed, so I have to speed up.

With the help of Damirgang, Kavi quickly separated the skin and muscles, and continued to ask: "Then let me change the question, which parts are the internal iliac artery and the external iliac artery responsible for the blood supply?"

This is not difficult for the three of them, and they quickly gave the answer: "The external iliac is responsible for the lower limbs, and the internal iliac is responsible for the lower abdomen and pelvis."

After cutting the skin and muscles, Carvey changed the position of the retractor and expanded the surgical area from the right side to the left side: "In order to provide blood supply to the right lower extremity, it is necessary to infuse the blood pumped by the heart into the right external iliac artery. So the question is, which vessel is the right external iliac artery closest to now? Is it the severed right common iliac artery?"

"Obviously not."

The three of them were at a loss again, and this was not a problem, because there was only one major artery around them, and there was no possibility of connecting them.

But while speaking, Carvey has already started to dissociate the left area.From the questions to the operation, they were reminded that the next operation area was on the left side, and what he was going to do was also a kind of blood vessel grafting that no one had tried before.

Should it be connected to the left iliac vessel?

This pathway is indeed boldly chosen, but the problem is that the position of the broken end of the right external iliac artery is fixed, even if it is turned to connect to the left internal iliac artery, it will not be able to reach it at all, and the middle is so far away.
emmmmm doesn't seem right!

The three of them seemed to have captured something extraordinary. After looking at each other twice, and then at the surgical incision, they came back to it.

"Could it be connected to the left internal iliac artery?" Damirgang tried to answer, "Let the blood from the abdominal aorta go through the left common iliac artery to the left internal iliac artery and then flow into the right external iliac artery, so as to save the patient's limbs."

Carvey nodded slightly, but he was fiddling with the stump of the external iliac clamped by the hemostat, and asked, "The left internal iliac is here, and the stump is here. How do you plan to connect it?"

Seeing that Kavey had begun to separate the left common iliac, external iliac, and internal iliac arteries, Damirgang tried to answer again: "There is a long distance between the stump and the left internal iliac artery, and grafting through a hole is definitely impossible." , can only cut off the left internal iliac artery, leaving enough length to actively connect the right external iliac artery."【2】

"Not a bad answer."

The answer is correct, but the three of them don't know the deep logic behind this answer.

It is said that the more you know, the more questions you will have. While you are suddenly enlightened about the surgical plan, after you calm down and think about it, you will find many illogical places: "But if this is done, both internal iliac arteries must be Do ligation, will this affect the pelvic blood supply?"

"Not bad, it's great to think of this step." Carvey finally separated the left internal iliac artery, but still didn't want to give an answer directly, "Do you still remember the cesarean section?"

The three of them said in unison, "Remember."

"How do I manage when a major hemorrhage is expected?"

"Tie the cervix."

"Ah."

"Compresses the uterus."

"Ah."

"Gauze stuffing?"

"Well, then what?"

Because Herman and Carvey had performed several cesarean sections, he was deeply impressed, and immediately connected with the current situation, and replied: "Ligate the uterine artery."

"Yes, if heavy bleeding is expected, I will definitely ligate the bilateral uterine arteries." Carvey said, "Does ligation of the bilateral uterine arteries mean that the entire blood supply of the uterus is destroyed? Is this uterus useless? Is it?"

"No! In addition to the uterine artery, there are many collateral circulations that transport blood to the uterus, but the blood transport is negligible under the premise of compressing the uterus and binding the cervix." Herman brought the topic to the current surgery, " Is it the same for the bilateral internal iliac arteries?"

"The blood supply of the pelvic cavity and buttocks is supported by the inferior mesenteric artery in addition to the bilateral internal iliac arteries. Usually, these three vessels have abundant interconnected collaterals. As long as the blood supply of the three vessels is good and the collaterals are abundant, Any two of them can be ligated without causing ischemia of the pelvic organs and buttocks.”【3】

"I see."

"Prepare two hemostats, and then prepare sutures, and we will do the anastomosis again." Carvey said, "The next step is the same as before. Hold the hemostats and expose the field of view with sodium citrate."

"Ok."

"Ok."

Carvey sutured the broken ends of the right common iliac artery and the right internal iliac artery, kept the stump of the right external iliac artery, calculated the length from the left side, and then found the position to cut off the left internal iliac artery: "A hemostatic clamp at the proximal end, One at the far end, and the middle part is sutured with a blade to close the distal end"

After repeated inspections of the three stumps without bleeding, Carvey returned them to their original positions with confidence, leaving only the left proximal internal iliac stump and the right external iliac stump.

The second anastomosis took a lot of time, and the suture tension is also very subtle because a part of the suture distance is reserved in advance: "Damirgang, it's your turn this time, please help to close the last gap together, wait for me Release the hemostat when you're done sewing."

"Ah."

It seems that Kawei's head is too tight, and he still delegates this operation to the assistant.But if you look closely, you can still see that he has learned his lesson. At least the tone of the order and the vocabulary used are different: "The movement must be very, very gentle to bring the blood vessels together, it must be very gentle, very gentle! Gentle! Understand? "

"OK."

Damirgang's hands are similar to Herman's. It is good that the strength he has cultivated through limb orthopedic surgery all year round can adapt to the environment in the abdominal cavity. Now he must be more careful when dealing with the tender blood vessels.

"Slowly, definitely slowly."

Damirgang was holding two hemostatic forceps, and the force in his hands was transmitted to the blood vessels through the handle of the forceps.Under his guidance, the stump of the blood vessel gradually moved closer to the center, and Carvey slowly tightened the suture along this force: "Good job, keep the tension like this, ready to tie the knot. Come on, nurse, give my hand Pour some warm water on it to soften the coagulated blood around the thread."

The next knotting is Damirgang's strong point, as long as he operates according to the strength of his hand just now, there will be no problem.

"The suture is complete." He carried it out carefully until the last moment, and even removed the needle holder cautiously, for fear of messing up the operation again. "Next, let's loosen the hemostat completely."

"Well, loosen the distal end first, then loosen the proximal end." Carvey simply checked the suture quality, "OK, the anastomosis was successful!"

The two loosened vascular clamps are like the gates opened by the dam, and the gushing blood is the rushing river water, which instantly flows into the blood vessels of the wounded's lower limbs from the newly anastomosed passages.The right external iliac artery, which was lifeless just now, pulsed evenly and vigorously with the heartbeat.

Carvey asked them to reach out and feel the pulsation of the right external iliac artery. He didn't want to rely on this to judge the success of the suture of the blood vessel, because the pulsation of the blood vessel can be seen just by looking at it: "Remember this feeling, and do it in the future. Large vessel hemostasis is very important."

"The dorsalis pedis artery is also pulsating!"

"Blood pressure and heart rate are good!"

Good news came from the nurse and Amor, but the operation was still not ready to be declared a success.The bullet went through the lumbar spine and entered the front blood vessel, but it has not been found so far, and it is likely that it has entered the abdominal cavity.

Whether the bullet itself can be found is secondary. The main thing is to prevent intestinal fistula in the intestine that was shot through, so the abdomen cannot be closed for the time being.

"First suture the retroperitoneum, and then we have to carefully check whether there is any leak in the intestinal tract." Carvey handed over the stitching to Damirgang, and he and Bergett began to check the intestinal tract step by step with their fingers, "wait Wash the abdominal cavity after suturing"

If there is no problem with repeated abdominal cavity flushing + finger inspection for 2-3 times, Carvey can be sure that there is no problem with the intestinal tract, and there is no way to look for bullets.After all, the danger of a metal bullet floating outside the organs is far less than that of a long-term laparotomy.

As for the lumbar spine surgery just done, since the suture has been simply done, let it go for now, and choose a further treatment plan depending on the recovery of the wounded soldier.

So for Carvey's team, checking the condition of the abdominal cavity became the last step in the whole operation.

It's just that the time required for this last step is much longer than the grafting of the right external iliac artery just now, so that the Prussian army outside Gablenz couldn't hold back and launched a new round of attacks.

Carvey said before that a large military hospital is not suitable to be built in a forward area like Gablenz. Although there are many residential buildings, buildings, churches and warehouses suitable for wards, considering the previous war situation, they were attacked. It's also just a matter of time.

The most reliable way is to only do simple first aid here, and send the remaining wounded soldiers as far as possible to the rear, far away from the turmoil of the front line, and treat them with peace of mind.An important city that meets these conditions and is a certain distance from Gablenz is Kiscin.

It's a pity that almost no 19th century army can do this after a terrible defeat.

In particular, the troops on the western front have not yet undergone long-term escort drills, and there are also large loopholes in the storage of carriages and transporting medical equipment.Sending good surgeons to the front lines seemed like a simpler alternative.

According to the division of labor of the Military Medical Office, Carvey is only responsible for the affairs of the General Hospital of Fortress Omirz on the northern line, and several emergency teams are also active on the northern line.

But the war on the western front is tight, and compared with the lukewarm northern front, medical resources really have to be tilted.The "tactful" request given by Grand Duke Brecht also made it difficult for Kavi to refuse. Considering that there are not many people at hand who can be useful, Kavi can only come to the western front to support himself.

Of course, what supported him to come to the Western Front was not only courage or the aristocratic complex called serving the empire, but also the escort given to him by Franz.

"Doctor Carvey, it's too dangerous here!" The captain of the guard who followed Carvey before was rushing into the operating room with his team members, "Please evacuate immediately!"

"What's going on outside?" Carvey was still checking his intestines, and the sound of gunfire seemed to have smashed into the Gablenz Central Hospital that had just been besieged. "Could it be that the Prussians have already invaded?"

"I don't know the exact situation, but the sound of the gunfire has reached here, it must be not far from the city center!" The captain stepped forward and wanted to pull Kawei's arm, "Leave the operating room now, we can retreat in the direction of Kischin , where you can"

However, Carvey didn't want to listen to his command. He shook his arm and looked back at the captain: "Don't affect my operation."

"Doctor Carvey, now is not the time to care about surgery!" The captain and Carvey have been living together for the past few months, knowing his temper, this time he is really anxious, "Other doctors and wounded soldiers have already started to evacuate. We can't stay any longer!"

"I'll be done right here!"

The team leader doesn't understand surgery, he only knows that he has been fiddling with his intestines and doesn't know when it's a head: "You assistants don't help to persuade!"

The four of them knew very well that the chief surgeon on the operating table was the biggest, so they looked at each other a few times, and they didn't dare to persuade them.Carvey was speeding up in his hands, but he still had to keep everyone's minds steady. After all, the operation was almost over: "What did His Majesty the King say when he asked you to be the captain of my guard?"

"Protect your life at all costs!"

Carvey nodded: "So stay outside the operating room and obey orders!"

"The Prussian shells don't have eyes, maybe the next shot will hit the operating room!" The captain of the guard gritted his teeth and exchanged glances with his subordinates, stepped forward and hugged Karvey, carried him on his shoulders, and stretched his legs. Running to the operating room, "Hurry up and pack up and leave together! Leave quickly!!"

Kavey has never been treated like this before. He looked at the ground with both hands and feet and still couldn't break free from his iron-like arms: "Hey, what are you doing?! Put me down!!!"

"I am obeying His Majesty's order! Because this is the most direct way to protect your life!"

(End of this chapter)