Nineteenth Century Medical Guide

Chapter 259 255. Innovation in Vascular Transplantation (1)

Mendelstein followed Carvey into the operating room.

This time he wasn't doing it for surveillance. There were already two company soldiers watching in the temporary operating room that was converted from the confession room. If something went wrong, he would tell him immediately.Followed to the operating room, mainly because of the safety of his subordinates, and secondly because of his own curiosity.

In war, maxillofacial injuries like Opper's are not uncommon. After all, the head is the most important part of the human body. Bayonets, bullets and gun stocks all like to greet this place, and stones are not uncommon.

But he always felt that Carvey's handling was different from the military doctors he had seen.

He certainly doesn't understand surgery, but it doesn't mean he hasn't seen it.As a soldier who has served for so many years, he has helped surgeons more or less, and he has also recuperated injuries in field hospitals.He is not blind, and he has never seen a Prussian military surgeon perform a tracheotomy on a soldier.

In fact, Mendelstein has always been skeptical of tracheotomy.

He still doesn't know why he cut a hole in his neck, and he doesn't know why he inserted that strange tube into it.He only made this decision relying on the big heart that always gives orders to his subordinates. Now that Opal said that his breathing has become much smoother, he can be considered relieved.

After Opper stabilized, his main concern now was naturally the wounded soldier who had just been sent to the operating room.

Unlike Opal's friendship, this is more of an officer's desire to protect his subordinates, but unfortunately it is not allowed in Carvey's operating room.Considering that the other party is absolutely strong, his expression was a little more tactful: "Sir, the operating room is a place that needs to be kept clean, and outsiders should not come in."

Mendelstein didn't understand: "Where did this come from? Isn't surgery all performance events? The operating rooms in Berlin hospitals are all open."

"It was an operating room in a big city, with ventilation facilities, and clean water for disinfection and cleaning." Carvey explained, "The current temporary operating room is small and poorly ventilated, and there are too many people. The incision is bound to fester."

"But."

"If you don't want him to die, please take those two soldiers out too." With the previous "record" in dealing with Opal, Kawei's attitude gradually became tougher, "Please trust my professionalism, sir. And please don't insult my profession."

Mendelstein was overwhelmed by him for a while, and he didn't know where to start when he wanted to refute.

Looking at the busy figure in the confession room, he could only do as he said, and called two soldiers to stand guard at the door: "I have done as you ordered, I believe in your professionalism, and I respect you Professional ethics. Still the same sentence, please cure him."

The threat of these words is much less than just now, but Kawei still dare not be careless, and asked: "How are the vital signs?"

"not too good."

"How much fluid do you have?"

"500ml goes into 200."

Carvey probably understood the situation, turned around and said to Mendelstein: "I will try my best to cure him, but I need the help of the officer."

"What are you busy with?"

"Need to shed a few drops of blood on all your soldiers."

The size of the confessional is really small. In the middle is a long table brought from the house next door, which is a makeshift operating table.Ignatz, Herman, and Bergett stood on both sides, and the nurses pretended to be patients to deceive others, so they had to be replaced by other doctors.

The room was stopped by them, and there was not much free space around it, including the equipment boxes, medicine boxes, and clean water basins.

The young soldier lying on the operating table was named Craig. He injured his right leg. The bullet directly severed his right femoral artery and vein.The blood vessels were not completely severed, but there was a large defect, and the entire lower limb was ischemic for more than 3 hours.

Now the right lower extremity is pale and cold, and the pulse of the dorsalis pedis artery and posterior tibial artery cannot be felt.

The bullet hit the root of the thigh, and Ignatz chose the most common surgical approach.

Starting from about 3cm above the inguinal ligament, a longitudinal incision about 15cm long was made along the outer edge of the femoral artery pulse. 【1】

"The middle of the blood vessel has been completely broken. Fortunately, a part of it is connected, and the broken end has not rebounded. I can only do a simple debridement first, and then the surgical field is too blurred." Ignatz is a novice in vascular surgery , "You still have to do the rest of the blood vessel suturing."

In Gablenz before, Carvey had done a ruptured iliac artery and then sutured it.

At that time, the bleeding was serious, and it was more critical than now, and the subsequent suturing also encountered a lot of trouble.In comparison, the leg in front of him was much cleaner, but it was a little creepy.

"Did the bleeding stop without the hemostat?"

"It seems a bit strange for you to say that." Ignatz finally realized, "I opened the wound just now, and there are blood clots inside, and the bleeding is not too much."

"This shows that quite a lot of blood clots have been blocked in the blood vessels." Carvey simply washed his hands, put on his gloves and put his fingers into the leg incision, and found the defect, "The blood flow is completely blocked at the top .”

"Can you get it out?"

"Clamp the distal end, cut off the blood vessel and rinse it." Carvey briefly introduced the process, but quickly denied it, "But it doesn't work, the defect in the middle of the femoral artery exceeds 2cm, and the defect in the vein is bigger, even if you do this It doesn't make any sense. And the sodium citrate used for anticoagulation in our hands is very limited, and there may be no way to clean it."

Ignatz sighed: "It seems that I can only amputate, give me a bone saw."

"Wait." Carvey didn't want to amputate easily, "The damage is only 3 hours, it's a pity to have amputation."

"How can the blood vessels be connected without amputation?" Ignatz asked. "This is not the iliac artery. The femoral artery is the thickest blood vessel. There are so many blood vessels around for you to graft."

"Don't worry."

If it was in the 21st century, such injuries would generally be anastomosed with artificial blood vessels, but for poor families with low income, autologous great saphenous veins can be used as a substitute.The reason why artificial blood vessels can replace the great saphenous vein is mainly due to the mismatch between the diameter of the great saphenous vein and the large blood vessels.

The case of Gablentz explained this well before, but now Carvey has no other way.

"Do an autologous transplant."

"Autologous transplant?" Ignatz was a little puzzled, "Is it the interception of a section of the great saphenous vein as you said before for transplantation?"

"Correct."

Carvey did not act in a hurry, but stood by the operating table and considered how to solve the problem of mismatched tube diameters.

The walls of blood vessels have certain elasticity, and the elasticity of veins is worse than that of arteries. If there is a problem with the blood vessels of the upper limbs, the great saphenous vein can well complete the task of autologous transplantation.But the defect is in the lower limbs. The diameter of the common iliac artery alone has reached 9mm, and the great saphenous vein with a mere 3mm cannot be transplanted.

The injured part is in the thigh, where the diameter of the femoral artery is not smaller than that of the common iliac, so a forced transplant is likely to cause serious problems.

The strength of surgeons is not only their dexterous hands, but also their imagination.

Before that, Carvey demonstrated how to do vascular grafting to solve the problem of large defects that cannot be anastomosed.Grafting is impossible now, the only thing that can be done is transplantation and anastomosis, but there are many kinds of transplantation and anastomosis. Simply transplanting the great saphenous vein is transplantation, if there is a little flexibility in the middle.
Carvey seemed to have a good idea: "Give me the hemostat, and we'll cut off a section of the femoral vein first."

"Cut off the femoral vein?" Everyone, including Ignatz, expressed doubts about his whim, "Isn't the femoral vein going to be anastomosed? Why do you need to cut it off?"

"The arterial blood flow is turbulent, and the lumen of the great saphenous vein is much thinner than that of the femoral artery. Direct transplantation may cause blood supply problems after surgery."

Carvey took over the hemostat, blocked the femoral artery and femoral vein, and then trimmed the two vessels properly: "But the femoral vein is different. Although the femoral vein is a vein, its diameter is almost the same as that of the femoral artery. It can cope with the tassel of arterial blood. So I choose to transplant each other, first cut the femoral vein and graft it to the superior femoral artery, and only graft the great saphenous vein to the femoral vein.”【2】

This is a relatively safe approach, avoiding the problem that the large difference in diameter affects arterial blood flow.

Since the femoral vein is the venous blood that returns to the heart, the blood flow speed is obviously much slower, and the narrower diameter should not be a big problem.

Carvey cut off the broken wall at the two ends of the femoral artery, peeled off the adventitia, and then cut a section of blood vessel less than 4cm in length from the femoral vein: "Clean the blood clot inside."

"it is good."

While Bergett was cleaning, Carvey and Ignatz were not idle and continued to intercept the great saphenous vein.The interception of the great saphenous vein is different from the femoral vein, and has certain requirements on the length, so the location selection is very important.

"Continue to extend the incision down to the position above the knee." Carvey said, "The defect of the femoral vein has reached 8cm now, and the great saphenous vein must be cut at least."

Before he finished speaking, he thought of a huge hidden danger, so that he wanted to overthrow all the decisions he just made.

The anastomotic blood vessel will cause the blood to form a vortex. The femoral artery may not be a big problem, but the venous blood flow is slow, and the vortex is easy to form a thrombus.After modern vascular surgery, patients are generally given anticoagulants for a certain period of time to reduce postoperative thrombosis.

But there is no such thing now, and sodium citrate can't anticoagulate in vivo. 【3】

Even if the wall of the slender great saphenous vein expands, it is only about 4-5mm, which is less than half of the femoral vein.If a thrombus occurs, not only this leg will be damaged, but the thrombus may fall off and return to the heart, and then enter the lungs through the pulmonary artery, causing a pulmonary embolism.

If there is a pulmonary embolism, even if God comes, it will not be saved.

How to do? ? ?
"What's wrong with you?" Ignatz couldn't help asking when he saw him stop suddenly.

"It's a bit troublesome." Carvey said, staring at the defective femoral vein, "Even if the defective femoral vein is replaced with the great saphenous vein, the return blood flow rate may not be enough."

The other doctors on the same stage didn't know where the knowledge about blood flow in blood vessels came from, but listening to Carvey's words always gave people a convincing feeling.

Of course, while being convinced, you still have to speak out your doubts boldly, so as to improve your medical skills.On this point, Ignatz has always done a very good job: "You said before that the vein branches are very rich. If you don't care about the femoral vein, just suture all the upper and lower ends of it, is that okay?"

"No, the return of the lower limbs depends on the femoral vein." Carvey explained, "If the femoral vein is sutured, although it will not completely block the blood flow back to the heart, it will still cause swelling of the lower limbs. Blood stasis in the lower limbs will cause swelling sooner or later. The problem, if it is serious, maybe the compartment syndrome will appear the next day."

Herman on the side also asked: "Is it okay to have the great saphenous vein for reflux?"

"No, otherwise, why would I dare to intercept the great saphenous vein? It's not because of the presence of the femoral vein, the great saphenous vein is not important."

"I see."

"If you can't find another way, I think it's better to do it first." Bergett said while cleaning the femoral vein in his hand, "After all, it has been ischemic for such a long time, and if it is exhausted, the blood vessel will be connected. His right leg may not get better either."

Ignatz sighed: "I think amputation is safer."

"The captain outside the door will not let us go." Carvey pointed to the door and said.

"Amputations are too common, and limb salvage is not normal in this situation!" Ignatz suppressed his voice and cursed softly, "If it weren't for the large number of them, I wouldn't have operated on the Prussians!"

"Shh~~~ Don't talk nonsense, he's still at the door."

"It's really suffocating."

Strictly speaking, Ignatz is also a soldier, and after getting along with soldiers for a long time, he will definitely develop feelings.Thinking of the guard soldiers who were wiped out by the opponent before, he felt uncomfortable: "Don't think about it, just do the transplant directly. If it doesn't work, just amputate it."

"There will be no anesthesia for the next amputation."

"Yeah, if the amputation is done without anesthesia, it's a serious problem."

Carvey has too many factors to consider, and the best result is to solve all the problems once and for all in this operation: "Amor, how much anesthetic is there?"

"It's only enough for two hours."

"No amputation, absolutely no amputation!" Carvey looked at the femoral vein, then suddenly turned to look at Bergett, "By the way, how many silk threads are there in my box?"

"Silk thread?" Berget got up and handed the cleaned blood vessels to Carvey, and replied, "There are probably two more bundles, you brought quite a lot."

"Two bundles, that's enough! You go and prepare the silk thread!" Kavi took the blood vessel and said to another assistant beside him, "Give me the scalpel, I have to continue to extend the incision downward."

The assistant who passed the equipment handed it to Carvey, with a look of surprise on his face: "Where is the extension?"

"To the knees." [4]

(End of this chapter)