Nineteenth Century Medical Guide

Chapter 283 279. Cut the bladder

Edm is an old man in his sixties, with a lot of fat in his lower abdomen. It is very troublesome to perform incision and stretching. In addition, the field tubes are also piled up here. If you want to investigate carefully, you need to further expand the surgical field.

Carvey raised his foot and kicked the table leg on the left: "Put your head down a little more."

"it is good."

Damirgang, who was preparing the infusion bottle, freed his hand, held the handle on the side of the table, and continued to lower the mattress on the head side for a certain distance.The descending body pulls on the skin, but also allows the organs to move toward the head with the help of gravity, freeing the tight, intricate structures of the lower abdomen and giving more room to the bladder.

Carvey explained in detail the reason for choosing the position with the head lowered and the feet higher, and then changed the subject and said while checking the bladder: "I heard that recently some people reported that this movable operating table would cause arm function damage, and then questioned the function of the operating table. Change, and even feel that this kind of change itself is innocuous, and the harm outweighs the benefit.”

This is one of many rumors about his pharmaceutical products.

Many people on the stage began to chat in low voices, and soon a surgeon stood up: "Dr. Carvey, there is indeed such a situation. The two operations I performed followed the principle of lowering the head and lowering the foot to reduce the amount of bleeding, but the operation Afterwards, they all developed symptoms of decreased arm function.”

Carvey listened to his complaints and nodded slightly, seeming to agree with him, but what he was talking about was the bladder: "The previous cystoscopy failed to see the tumor. I first put my hand into the back and side of the bladder to explore The location of the tumor is correct, it was Teacher Musa who spoke just now, right?"

"Yes, it's me." Musa sat on the seat solemnly, with a stern expression, "I don't dare to be a teacher, I can only be regarded as your colleague at best."

He withdrew his right hand, let Herman and Damirgon return to the operating table together, and opened the skin on both sides of the abdominal incision.The bowel and omentum are then pushed upwards and protected with gauze pads to expose the pelvic organs.

"It seems that there are not many."

The latter blocked his future on hemangioma resection, from simple resection to vascular suture is a compulsory course for him now.

The former is proficient in amputation of various parts, and the success rate has risen from the original 40% to more than 65%.How to carefully debride the wound, how to choose the plane of interception, how to ligate the blood vessels, and how to embedding the myocutaneous flap are all handy for him.

Carvey doesn't care about this, but anyone who is younger than himself, at first he called the teacher: "Why can the teacher be sure that the patient's arm dysfunction must be a problem with the operating table?"

After all, both internal iliac arteries were ligated.

After all, the time for the surgery report meeting was limited, and nearly half of it was arranged by Kawei.

As a product salesman, Kavey will get a share for each operating table. Now that feedback has been collected, an explanation needs to be given in a timely manner.

In the context of the gradual refinement of surgery, both types of surgery need to improve their own hemostasis methods to reduce the risk of death by reducing bleeding.Carvey's body position change operating table can just achieve the purpose of reducing the amount of bleeding in the lower body, so they all customized one from Laszlo's instrument factory.

Excision is easy to say, but it is very cumbersome in practice. Separation and ligation are basic skills.It takes a lot of practice to cut the bladder well and wonderfully.

Now Sergei is on the march with the troops, and it is Musa and Paischer who appear in the theater of surgery.

Carvey gently incised the retroperitoneum at the bifurcation of the common iliac artery, freed one side of the internal iliac artery【2】, wrapped it with a silk thread and lifted it up to block it.At this time, a nurse who was standing by the operating table and was ready to help at any time cooperated tacitly and reached out to touch his dorsalis pedis artery: "The dorsalis pedis artery is still there."

"It's a catheter for temporary drainage of urine from Mr. Laszlo's vulcanized rubber factory, which is just right for this operation," said Carvey. Urine. The size is just right, and even the anti-slip fixation is omitted.”

Carvey repeatedly judged the tactile sensation sent back to his brain from his fingertips, and finally heaved a sigh of relief after confirming that everything was normal: "The tumor is single, there is no adhesion to the surrounding tissues, and there is no surrounding metastasis."

"Don't worry, they won't just be soft-bodied."

"Yes, it's a relatively small balloon." Mossier made a circle with his fingers, "Just fill it with water and it will expand."

"Yeah, Dr. Carvey, it's not that we want to embarrass you, it's really annoying to be complained."

"That's a good question."

This is an extremely simple question in modern times. Combined with the structure of the operating table, medical students who have studied anatomy can answer it.

Carvey threw it away casually, and regarded Mosier as a salesman: "Actually, when I was undergoing prostate expansion surgery, I chose to use an expandable rubber balloon to forcibly expand the hyperplastic prostate. During the communication with Dr. Wei, it seems that this dilated rubber balloon can also be used to fix the urinary catheter in the bladder.”【4】

Just when everyone thought that the operation was about to start removing the bladder, Carvey returned to the common iliac vessels to deal with the retroperitoneal lymph nodes.

"Beside the internal iliac artery, we can still see the ureter [3]." Carvey used vascular forceps to slowly separate it. "After we found the ureter, we slowly and bluntly dissociated it to the bladder. When we reached the bladder wall, Cut it off and do a ligation on the bladder side with a silk thread."

Carvey nodded: "Has anyone else encountered this kind of thing?"

"Sounds like a good thing."

Because once distant metastasis is found, the operation itself is not very meaningful. 【1】

The hemostatic effect was indeed good, at least adding a little calmness to their frantic operation, but the complaints of patients after the operation followed one after another.

"The finished product is just in the next few days, and there will be a brief introduction meeting at that time." Carvey said, "The cost should be 10 crowns a piece, which is not too expensive. But because it is a consumable, there is a quantity requirement when purchasing , and please pay attention to the instruction manual, and don’t make the same mistake as the operating table again.”

The operation is divided into two parts. The first part is the radical cure of bladder cancer. The first step is to remove the bladder.

The two cleaned the lymph, and simply sold an item that hadn't left the factory.

But they didn't have any hostility towards Kavi, they were just inferior to others.They can accept their own mediocrity, not as tangled as Hills, and will come to see Carvey's operation from time to time, hoping to improve their skills.

"Bergett."

"Give me the scalpel, let's cut off the blood supply to the bladder and the ureter first."

"exist."

Musa was the unlucky doctor who was squeezed out of the surgery report meeting of the School of Surgery by Carvey. There were also two other doctors who were squeezed out, one named Paischer and the other named Sergey.They received letters of resignation from Dean Waterman, and they never got a seat at the report meeting.

But in the 19th century, when neuroscience was hardly developed, it was not so easy to immediately recall the cause of the injury and find out the crux of the problem.Instead, they would think wildly about the details of their own procedures, perhaps attributing the damage to their own misplaced instruments on the patient's body.

Now with rubber tubing, bladder catheterization can be easily accessed if done properly.It has a very good effect on urinary retention caused by benign prostatic hyperplasia and bladder stones. "

Carvey is extremely proficient in freeing the surrounding tissues, which was not obvious during the autopsy. At that time, it was for practice and to help several assistants familiarize themselves with the operation.

"Other questions? Where do other questions have such a high degree of overlap?"

Now that he is in the body of a living person, there is pressure on time, and he strives to do his best every step of the way, so he has no reservations.After the ureter was cut and ligated, Carvey looked at the diameter of the ureter and said, "Take the thinnest catheter."

He continues to play the role of "carrying goods". While introducing products, he also needs to answer everyone's questions one by one.

"understood."

Lymph node dissection is a big project, and Carvey didn't dare to move on Fernan's body.Suddenly at the operating table, it entered the "boring" time from the beginning.

"Then how to fix it after entering the bladder?" Another doctor said, "The front part of the silver tube has a bulge. Although the insertion process is extremely painful, after entering the bladder, the front part of the tube can be locked in place by the bulge to prevent the tube from falling off."

"The cleaning started 10 minutes ago."

In addition to confirming the location of the tumor, he also needed to check to make sure that there was no metastasis in the surrounding organs and lymph, and that there was no adhesion of the iliac vessels behind the bladder.He even needs to touch the liver upwards to make sure there is no tumor on the surface of the liver, so he can rest assured.

Many people on stage raised their hands.

Carvey took the scalpel and made Bergett, who was unable to get on the operating table, stand beside Edem's head, and controlled the light of the candlestick: "Everyone, the loss of function of the arm means that the nerves that control the arm have been damaged. Think carefully about the arm. Function is controlled by which nerves, where are these nerves, and during the operation, is there something compressing them?"

After two saline flushes, the two performed two more carpet searches of the retroperitoneal lymph.

Carvey explained: "Right now I'm only using a single-lumen tube, but the rubber factory is already working on a double-lumen tube. One tube is used to urinate and the other tube is used to inflate the rubber balloon in the front. .”

"There has never been such a problem in the operation performed before." Musa said a reason that he thought was irrefutable, "Doesn't this prove that it is caused by the new type of operating table? Because the only difference between the operation and the operation It's the operating table."

"Now the heart will encounter some pressure, remember to monitor the vital signs at all times."

Not to mention general surgeons like them, even director-level doctors like Olgi and Massimov are in danger.Because if the evaluation is really based on the difficulty and completion of the operation, the report will become a one-man show for Kawei alone.

In the absence of imaging examinations, abdominal exploration is far from over. Carvey extended the incision up to 4cm above the umbilical cord in order to fully explore the abdominal cavity.

If you still can't find the answer after the operation, I will be responsible for answering.But for now, I still hope that you can focus on Mr. Erdem's pelvic cavity, and watch the operation while looking at the atlas. "

However, Carvey could clearly feel the audience's attention on the two urinary catheters in the stands, and explained: "This is the first medical rubber catheter in Austria. Compared with the silver tubes used before, they are very soft. There are many people in the stadium. Urologists should know that the physiological curvature of the male urethra is not suitable for the insertion of the silver tube, which often causes great pain.

"Like a balloon?"

"it is good."

Communication becomes a professor.

It ranges from the bifurcation of the common iliac vessels to the opening of the femoral canal, including various lymphatic nodules around the external iliac artery, around the external iliac vein, around the internal iliac vessel, and around the obturator nerve.

"Let's ask Dr. Mosier to introduce it here."

Similar to the original hysterectomy, ligation of the internal iliac artery does not affect the blood supply to the pelvic floor, but for the removal of the bladder itself, it can greatly reduce bleeding.

The bladder is located in the pelvic cavity and has an extremely rich blood supply. The main blood supply comes from the anterior branch of the internal iliac artery.Now the operation time is quite long and the conditions are limited, so Kavey needs to reduce bleeding as much as possible.

"I hope there is no diversion." Carvey was still rummaging in Edem's stomach with his right hand, and the topic returned to the adjustable operating table, "I didn't expect all doctors to fall on an operating table, you didn't Have you considered other issues?"

"I also have this problem. The patients will have numbness and sensory disturbance at the most severe postoperative period. Some people still feel soreness and weakness in their arms after more than a month." Pescher said, "This is undoubtedly an arm dysfunction."

"Can the rubber tube really enter the bladder smoothly? What should I do if I encounter resistance?"

But after the investigation just now, he has figured out the location of the tumor. Compared with product after-sales service, surgery must be more important: "Mr. If the right side is bent 15-20°, you may be able to see it, but it’s a pity.”

"Very well, I'm sure it's the internal iliac artery." Carvey explained, "The external iliac is responsible for the lower extremities. Cutting off the blood flow will cause the lower limbs to lose their pulse. The internal iliac is responsible for the pelvic cavity. You need to deal with the iliac artery during pelvic floor surgery." If you cannot distinguish between the two in the internal artery, you can judge according to the process I have demonstrated."

"Give the candle to the nurse, and you go and make pathological sections of these lymph nodes." Carvey said, "Koch and Savarin should be here soon."

"Give."

Everyone knew about Carvey's temper, and they all silenced, and he was the only voice left in the entire theater.

Seeing that many people on the stage were still whispering, Carvey tapped the hemostatic forceps with the handle of the scalpel and reminded: "Everyone, it's time for the operation, and I won't answer any questions unrelated to the operation.

Carvey looked at the "clean" retroperitoneal tissues, and changed his gloves with Mossier: "Others came to help, the instruments used just now need to be rinsed, and a new set has to be brought up."

"Double lumen? Balloon???"

"How's your heart rate and blood pressure?"

"Stablize."

It took more than half an hour to ligate the blood vessels, cut off the ureter, and dissect the lymph nodes. This was only the first step of the whole operation, because they didn't even see the surface of the bladder.

"Next we start working on the bladder."

(End of this chapter)