Nineteenth Century Medical Guide

Chapter 260 256. Innovation in Vascular Transplantation (2)

The time goes back to just after Mendelstein left the operating room.

He didn't expect that he could also contribute to this operation. Although this "contribution" method was once again beyond his comprehension just like the tracheotomy just now, he was still willing to follow Kavey's request. Do.

"Captain, how is Craig?" A Prussian soldier asked anxiously when Mendelstein walked out of the operating room.

"It's not going well, they're still operating."

"Just let them operate like this?" The soldier also doubted the identities of these people, "What if it is."

Mendelstein shook his head slightly and gave him a wink. The direction of his eyeballs turned was a doctor who accompanied him: "I believe in Dr. Carvey's professional ethics and his ability. Now Craig The situation is not good and the surgery needs our help."

The soldier quickly understood what he meant: "How can I help?"

"It's very simple, just draw some blood." The doctor walked forward with two glass bottles in one hand and a rubber tube and syringe in the other, and said to them in standard German, "Everyone has to draw blood." A little bit, and then judge who can give the patient blood transfusion."

It was another term that he had never heard or seen, and Mendelstein even began to worry about whether Prussian surgery had fallen far behind other European countries.

"What do you mean by blood transfusion?"

"Craig, is that his name?" The doctor continued to explain to them, "Craig was bleeding very badly because his blood vessel was interrupted by a bullet, so he needs to be given some blood."

"Isn't it usually bloodletting? How did it become a blood transfusion?"

The doctor smiled: "The treatment method is not absolute, it depends on the situation. Because there are many types of blood, the same kind of blood can be injected into his body, so I need to collect your blood for matching."

For the soldiers of the reconnaissance company who often lick blood on the front line, blood collection itself is not painful, but what really makes them nervous is the true identities of these doctors.

"Are you also a student of Dr. Chino?"

"Yes, that's right."

"Italian too?"

"Yes, we are all doctors at the Central Hospital of Florence, Italy."

"You speak pure German, I almost thought you were from Austria."

Mendelstein raised his mouth abruptly and watched his reaction by the way.Unexpectedly, the other party was not surprised, but laughed even more happily: "My German was taught by my mother. She is a Prussian, and my father is a Florentine."

"Oh, by the way, I haven't introduced myself yet." At this point, he changed back to Italian: "My name is Bottini."

This was the only doctor in the audience who was actually from Italy, and he spoke Italian more naturally than the Latin used by the others.Of course, the other party doesn't understand Italian at all, as long as they can say a few sentences, and then bring an Italian accent to German.

The whole camouflage operation was initiated by Kavey, who no longer used the combat experience of the guards, but the identity of a doctor and the advantages of mastering multiple languages. After all, French and Latin are the languages ​​​​that doctors must learn.

The guard soldiers and nurses pretended to be locals here, and stayed here on the grounds of not having horses and being sick.

Carvey also paid attention to diseases, but cholera and the Black Death were useless.Because the former needs to go to the toilet all the time, while the latter is too contagious and pathogenic.There are more than a dozen Black Deaths, and it is impossible to kill people. Even considering the contagiousness, these Prussian soldiers may directly choose "humane destruction".

After thinking about it, Carvey chose a better disguise of tuberculosis, just lying in bed and coughing.

If it weren't for the fact that the research on tuberculosis is almost zero, no one knows the transmission route of tuberculosis, and maybe even the questioning is avoided.Fortunately, those in the guards were experienced, and the nurses who could be selected by Kawei were also smart people, and they didn't show their flaws after several rounds of questioning.

But it is not easy to completely deceive the other party, especially this kind of group deception, the preparation time is extremely limited, and it is almost impossible to achieve perfection.

Considering that Mendelstein has always been suspicious, the blood collector will definitely become the target of all the soldiers, and the easiest person to pass the test is none other than Bottini.

Things were just as Carvey thought. After hearing his Italian, Mendelstein immediately gave up asking: "Do you think the operation will be successful? Can Craig survive?"

"Surgery is difficult, but I believe Kavey." Bottini habitually said Kavey's name first, and immediately added, "...and Mr. Chino's technique, they are the strongest surgeons in our hospital. "

Mendelstein had seen too many soldiers who died tragically due to thigh injuries, and he still had no idea: "Can he survive?"

Bottini held the syringe in his hand and said, "It depends on whether you have enough blood."

Blood vessels are the network of hollow tubes that run throughout the body, and vascular surgery is like a plumber.

In the early days, due to the lack of materials and blood flow theory, vascular surgery was doing work of checking for leaks and repairing pipeline deformities, mainly dealing with trauma, hemangiomas and varicose veins of the lower extremities.

With the increasing understanding of blood, thrombus has become a new topic in vascular surgery.

From early treatment of varicose veins, vascular repair at the end of the 19th century, hemangioma bomb disposal at the beginning of the 20th century, thrombus-endarterectomy in 1946 for the treatment of peripheral arteriosclerotic obliterans, and then in 1965, the use of catheters to dilate narrowed femoral arteries to create blood vessels Endoluminal technology, followed by balloons, stents, autologous vascular grafts, and artificial blood vessels.
Vascular surgery is to modern medicine like blood is to the body. Although it cannot be seen on the department list of a hospital, let alone a ward, it has already been integrated into various surgical departments.

The continuous advancement of science has extended various branches of vascular surgery, and the innovative thinking and methods of surgeons have allowed these branches to display unexpectedly brilliant colors.

At this time, the church is actively collecting blood to match blood types, and a very new thing is being tried in the confessional.

"The femoral vein defect exceeds 8cm." Carvey measured the distance with a ruler again, "Extend the incision to 20cm, I want to take more saphenous veins, double the amount!"

"Double?"

Bergert was too inexperienced, Hermann was experienced but knew very little about blood vessels, and the others beside the operating table couldn't keep up with Carvey's thinking.The only person on the scene who saw his intention was Ignatz who was standing in the first aid position.

In fact, he couldn't be sure, because the operation that came to mind was too difficult.

"Are you going to join two blood vessels together?"

"Mr. Ignatz is still amazing." Carvey's practice is extremely rare even in modern surgery. Ignatz's guess is enough to prove that he also has talent in this area, "The diameter of the blood vessel is not enough, then Make it bigger. If one isn't enough, get two."

"Expand the pipe diameter? Two?"

Heman also seemed to have reacted, and raised his fisted hands as cross-sections of two blood vessels. His five fingers slowly separated to form two semicircles, and then his fingertips were brought together.The original two semicircles merged into one larger circle: "Are you going to cut open the blood vessels and sew their sides together?"

"Correct."

Carvey cut down the skin and muscles, made an irregular and slightly oblique incision, and used a retractor to expose the great saphenous vein running beside the knee: "Let's not talk about this, separate the great saphenous vein as soon as possible." Come out, the ischemia time is not short.”【1】

The great saphenous vein has many advantages. It is straight enough in shape and long enough in distance, so it becomes the first choice for autologous transplantation in vascular surgery【2】.But there are also many disadvantages, such as small diameter, valves unique to veins, and many branches.

In addition, the autotransplantation required a length of nearly 20 cm. In addition to breaking the branches, the surrounding tissues had to be separated, and the valves in the lumen were removed. The technical difficulty of taking blood vessels was not too difficult, but it was time-consuming.

The four-person group began to carefully separate the great saphenous vein from the distal to the proximal end of the lower limbs. Unlike coronary artery bypass grafting, because of the merging of blood vessels and lumens, the surrounding tissues must be separated cleanly without any residue【3】.

Otherwise, there will definitely be misalignment during the combined suture, and blood leakage will occur during the suture, so the gain outweighs the loss.

While separating the surrounding tissue, they cut and ligate all the small branches.The whole great saphenous vein was freed, and then the upper and lower ends were controlled with hemostats, and a spare blood vessel about 20 cm in length was cut.

Carvey has tried to speed up the speed, but the quality of the equipment is not enough, the number of branches is too large, and the assistants are not skilled in operation, so the dissociation process, which originally only took 20 minutes, was extended to 45 minutes.

Amor's second anesthesia has gone off, and time is passing quickly.

"Bergett, just like before, put the blood vessel into normal saline, add a little sodium citrate, and clean it." Carvey gave him the blood vessel, and changed it to the femoral arteriovenous anastomosis, "Teacher and I Connect the femoral artery first, even if the backflow is not smooth, it is temporary, at least now it can get enough blood to its lower limbs."

At this moment, Bottini walked into the operating room with two bottles of whole blood: "The blood is here. There are five people with matching blood types. I got 1000ml first."

"Hang it up."

"How are people?"

"Young men are physically strong and can hold on."

"What about the blood supply to the lower extremities?"

"Still making preparations." Carvey checked that there was no valve in the femoral vein, put it into the femoral artery defect, and then gave the seat to Bottini, "The length and diameter are very good, you can directly Sew it up."

It is not difficult to anastomose such a large blood vessel. As long as he masters the suturing method, a doctor like Ignatz with a solid surgical foundation can complete this operation very well.Bottini's skills are not bad, and he has proved himself in the four months before the war, otherwise Carvey would not have put him by his side.

During the time when he gave up the position of the chief surgeon, Carvey was not idle. He needed to help Bergett deal with the great saphenous vein.

Compared with the femoral vein, which was less than 5cm just now, the difficulty of handling this great saphenous vein has risen sharply, and it cannot be solved by flushing with normal saline alone.

The first thing to do is to use scissors to further clean up the tissue around the lumen, then put clean gauze on the blood vessel, fill it with saline with a syringe, and check whether there is any leakage at the disconnected ligation of the surrounding branches.

"You pinch that end with your hands." Carvey sucked the saline solution with sodium citrate, and the blood vessel was completely inflated. "Very good, there is no leakage at the sutured place."

"What are we going to do next?"

"Give me the silk thread and blood vessel suture needle, and then look in my box. There should be a magnifying glass." Carvey checked the blood vessel repeatedly. After finding no problem, he picked up the scissors and divided the blood vessel into two, and then Cut the lumen longitudinally, "Hold up the mirror later, I have to prepare the two-in-one vein first."

The diameter of the great saphenous vein is only 3mm, and the silk thread and suture needle are all specially customized, which are barely usable, but it is difficult to be accurate because of Karvey's limited naked vision.

Microscopes help in modern surgery, but in the 19th century they could only use rough magnifying glasses as a substitute.Thanks to Carvey's excellent technology, two great saphenous veins with a diameter of 3mm were merged on the side to become a substitute for a femoral vein with a diameter of 8mm.

"We're done here." Ignatz said, "The arteries have been cleared, and you can feel the pulse on the dorsum of your feet."

"it is good!"

Carvey continued to perfuse the newly made blood vessels with saline as he did just now: "Don't leak, don't leak, just force it, it should work."

The side suture of the blood vessel is not an anastomosis of the nozzle, and the quality of the suture needle and thread in Carvey's hand is not high, so there will definitely be a gap in the sealing.Now I am only doing femoral vein transplantation. Venous blood is much easier to deal with than arterial blood, as long as the leakage of normal saline is not obvious.

"Can we continue with the anastomosis?"

"Yes, cut off the end of the femoral vein first, and peel off the adventitia." Carvey carefully let go of the saline, and then put this carefully made brand new blood vessel on the operating table. It's a little smaller, but I removed the valve inside and it's not a big deal."

Ignatz, Herman, and Bottini all stared at the blood vessel: "It's so delicate."

"how did you do that?"

"Rely on the magnifying glass." Carvey said, "When I return to Vienna, vascular surgery will definitely be necessary. I have to move the microscope into the operating room."

"The sides are all sutures, is it really possible?"

"Don't worry, I tried it just now, and the leakage is not obvious." Carvey said, "The flow rate of venous blood is slow, and its viscosity is higher than that of clean water. Even if it really leaks, it will soon be blocked by blood clots. ,,,,,"

He is very clear that such an operation has very high requirements for postoperative surgery, and there is a shortage of doctors and medicines. Whether it can be really successful is still a big question mark.

But the matter has come to this point, and the time for anesthesia is approaching, and Carvey has no other way to go: "Needle and thread, let's match!"

(End of this chapter)