Nineteenth Century Medical Guide

Chapter 285 281. Three in One
Like most surgeries he'd had before, Erdem's bladder cancer remained a blind box.

Even if the nature of the tumor has been clarified by the prior microscopic examination, even if the exact location of the tumor can be seen with a cystoscope a week ago, it will not be possible to get a full picture of the tumor due to its wanton growth pattern.

The lack of imaging positioning is ultimately a flaw in surgery.

The bladder is a pouch organ, and tumors tend to penetrate the inner wall and spread outward, often affecting adjacent tissues.

The most common ones are the upper peritoneum, the rear rectum, the lateral sperm, the lower prostate and urethra, and of course the ureters, blood vessels and nerves connected to the bladder.Now the freeing work is still in progress, there is nothing in the rear, and the right side is also safe. For the time being, it can be confirmed that the left side is affected.

"It's a mixed blessing."

Carvey said: "The worry is that the trauma will increase after the resection area increases, and postoperative recovery will become more difficult. The good news is that the unilateral spermectomy does not affect any function. If the prostate is also removed, it will be more difficult. The benign prostatic hyperplasia that is typical of elderly men will also go away. Although Mr. Erdem urinates normally, it is a kind of precaution.”

Everyone on the stage knew Kavey's surgical skills and innovative ability, but unlike other surgeries that were more innovative, this surgery had too many revolutionary things.

Just hearing that the patient's bladder was going to be cut off made many doctors' jaws drop, and the subsequent reconstruction filled their heads with question marks.

Can the bladder be removed too?
Can it be rebuilt after being cut?

What to rebuild with?

A cow or pig bladder as a substitute, or a new rubber bag?

I don’t know how many doctors said it was impossible after they learned that Kavey wanted to use intestines to rebuild the bladder, but as they gradually deepened their thinking, they would find that this might be a good way .

However, there was another wave of ups and downs, and now Kavi had to remove the sperm and prostate around the bladder, not giving them a chance to digest.

The prostate is wrapped around the urethra, can this also be removed?
How should this thing be cut?
Will cutting it affect the function of urination?
What if it is broken?
These few questions are still at the high-end level, and most of those who can think of them have a good understanding of the prostate.

In fact, there are so many doctors on the stage, at least half of them don't even understand the anatomical structure of the prostate itself.They also gave up thinking early, or already knew that instead of thinking on their own, it would be more straightforward to listen to Kavey's dictation confidently.

Benign prostatic hyperplasia is a very common disease in modern times, and it can be treated by long-term medication or simple surgery.

But before the 19th century, this kind of disease was rare. Naturally, the reason is that the average life span of a person is only in his early 30s, and it has not yet reached the level of onset.But with the gradual development of medical treatment, the average life expectancy of Europeans has increased, and the prostate gland has begun to bloom everywhere in the elderly male group.

Mosier's 30 years of practicing medicine are 30 years of watching these old men suffer.

He has tried many ways to help these patients. Simply dilating the urethra is the most common and cheapest treatment, but the effect is very limited.

He also tried cutting the urethra directly, and even chose to use cautery to burn some obstructed areas in the urethra, using pain to replace the urinary obstruction.The effect of physical expansion is definitely there, but patients who have survived these treatments can only maintain unobstructed urination for a short period of time, and the old problem will return after a long time.

Later, Mosier also read many books and articles by other doctors, and found that the gao pills seemed to be inextricably linked with the hyperplasia of the prostate gland, so he also tried cutting off the gao pills to fight the hyperplasia of the prostate gland.

Generally speaking, castration is still very effective, but that kind of change requires a certain amount of time, and the most precious things of men must be sacrificed.

No matter how he tried, the behavioral restrictions brought about by the solidification of medical thinking and the human instinct of fear of damaging the surrounding tissue and making the patient suffer further torture after surgery made him never think of resorting to surgery to forcibly cut it off. That swelling prostate.

Even if I really thought about it, it was a flash of inspiration.

It's a pity that this flash of inspiration naturally lacks enough energy to drive him to eliminate all kinds of unknown risks brought about by the operation step by step.

As a result, his 30 years of day-to-day work have made his techniques more proficient in catheterization and urethral dilation, and he has also become a doctor loved by old men in Paris.But Mossier was not happy, the pain from the dysuria had never gone away, and he never really beat the disease.

Or looking at it from another angle, he may be the "loser" left after fighting the disease.

Listening to Carvey's new concept of rubber urinary catheter casually, Mocier felt the technological changes brought about by vulcanized rubber.The abdominal wall stoma and remodeling of the bladder made him completely change his understanding of the original surgery, and he even denied his 30-year work.

And now, it's his most proud prostate treatment.

In fact, during the five days of practice, Mosier had heard more than once from Carvey that the prostate might be removed during surgery. After all, the growth pattern of the tumor is destined to make several surgical records in advance.

But when he heard that the prostate would be removed according to the original plan, he still looked at Carvey in surprise, and couldn't help asking: "Do you really want to remove the prostate?"

"Although you can't see it with the naked eye, it's very likely that the tumor has touched the prostate." Carvey didn't have any worries at all, and just said, "Mr. Mosier and I have practiced together so many times, isn't it just to deal with this situation? Well, we should be more confident."

So many times?

Whenever three times is too much.
"Whether you don't cut sperm or not, you need to do a good job of freeing, because the autonomic nerve of the cavernous body is behind it." Carvey repeated this knowledge point again, "If you consider doing this operation in the future, please be sure To protect the patient's neurovascular bundle."

The operation entered the first difficulty. Many doctors wanted to see the anatomical structure and operation steps clearly, so they had to get up and leave their seats and lean forward as much as possible.

The ticket price is divided according to the seat, as long as one or two people do not obey the rules, others will follow suit.For a moment, the entire theater was clattering, and the audience moved forward one after another.

"What are you doing?"

The first person who disagreed was Watman who was standing by the operating table. He was the last person who wanted to break the rules as he occupied the VIP position: "Who allowed you to move around?"

"Dean, we are too far away to see clearly."

"The price determines the seats. If you mess around like this, then the theater will have a unified ticket price in the future."

Massimov, who was sitting by the side and had just digested the autonomic nerve function of the cavernous body, also chimed in: "Yes, thanks to the operation theater of the Municipal General Hospital. It is replaced by the former theater on the banks of the Vinn. If you don't follow the rules, don't even think about it." It's time for surgery."

After hearing these words, everyone dared not speak. Regardless of their position or status, they did not have the capital to resist. In the end, they could only mutter a few words to return to their original positions.

"It's not that I don't want you to come forward. After all, this is not the theater of the Academy of Surgery. I don't care if I say it."

Watman stood behind Carvey and watched his operation carefully. Just when he was about to get angry, he saw Carvey looked back at him, and quickly changed his words: "The surgery area of ​​the School of Surgery is large enough, and it is more suitable for everyone to approach. Learn. Here, let’s forget it, keeping a distance is also a kind of protection for the incision.”

"The dean is right, the number of people in the operation area should not be too many."

Carvey took the tweezers, asked the nurse to wipe the sweat from his forehead, and continued: "When I have a chance, I will go to the School of Surgery as a demonstration."

In fact, for others, the transition from ordinary tissue tracheectomy to fine dissection of neurovascular is really a big span.It is obviously not enough and unrealistic to learn by watching an operation.

What is more important is repeated anatomy exercises.

"When separating sperm, it is necessary to free the vas deferens【1】."

Carvey used tissue forceps to gently pick up the left vas deferens that had just been separated: "cut off after clamping, and then continue to separate along the distal end toward the spermatic direction until the seminal fascia of the prostate, that is, the Denonvilliers fascia."【 2】

Watman squinted at the dense layer of fibrous smooth muscle tissue, but didn't remember it for a while: "This name is so familiar."

"Charles-Pierre Dinonville." Mosier must know this term better than these Austrian doctors, "He discovered this in 1837. It is the fascia tissue between the peritoneum and the perineum. On both sides are the neurovascular bundles.”【3】

"Mr. Mosier is right." Carvey said, "This layer of structure separates the rectum from the prostate, and also covers the posterior surface of the sperm and neurovascular bundles. It plays a very important role in this operation."

The rear fascia has almost been separated, and now the two sides are further separated, and the bladder is gradually becoming loose.

"We try our best to protect the neurovascular bundle, but the nerve is invisible to the naked eye. I can only distinguish it through the accompanying blood vessels." 【4】Kawei gently separated the levator ani muscle and fascia on the side, revealing Several tiny arteries, "The blood vessels can be seen after separation to this extent, try to avoid them."

"The location is just outside the fascia, right?"

"Yes." Carvey slowly completed the separation work, and continued, "However, the neurovascular bundles are very scattered, and the only thing that can serve as a marker is probably the sperm. If you see it, you should be careful in the next anatomical separation. "

The operation took more than half an hour to separate the bladder and prostate. It seemed that neurovascular bundles hindered the operation, but in fact there would only be more troubles to come.

"We pull the bladder forward, exposing the spermatic triangle in the rear, lifting the Dieter's fascia at the base of the prostate, and then...give me the scissors and we carefully incise"

Carvey made a small incision in the fascia, and then used his fingers to perform a blunt dissection, which required a complete separation of the prostate and rectum until the apex of the prostate. 【5】

It may be a long-term chronic inflammatory reaction, or the adhesion is already serious, and the separation is not optimistic.This is also what is often encountered when separating the prostate and rectum, and Carvey has encountered it several times on cadavers.

"There are a lot of adhesions at the bottom." Carvey fiddled with his fingers a few times, and then backed out, "We'll start with the lateral ligament of the prostate, remove the vascular pedicles on both sides, and then slowly move closer to the middle."

Compared with other abdominal operations that Carvey has shown, this radical cystectomy is more complicated than many doctors imagined.

Although many doctors know the positional relationship of those anatomical structures, surgery on a living person is completely different from an autopsy. The fascia, blood vessels, nerves, and ligaments in the pelvic cavity are densely arranged in a mess, making it impossible to know where to start.

Even Kavey, who has a strong foundation in pelvic floor surgery, will inevitably make some small mistakes.

From the beginning of the operation to the present, rupture of small blood vessels has become a common occurrence.

There is no blood loss of hundreds or thousands of milliliters here, and every time a blood vessel breaks, it seems very slight, and the bleeding can be stopped immediately by Damirgang and Heman.The amount of bleeding does not seem to be much, but it is very frequent, and because it is close to the vascular and nerve bundles, suturing can easily affect the surrounding structures, and the bleeding can only be stopped by compression.

It is this seemingly simple work that has been repeated more than a dozen times since the operation began, and will continue over time.They will hit the tense nerves of the four people on the stage time and time again, and once a mistake occurs, it may cause unpredictable results.

The atmosphere in the surgery theater was tense, and the outside of the theater was not peaceful either.

The impact of Carvey's postponement of the operation time was far greater than he himself imagined. Not only was Edward framed in Vienna, but even the secret negotiations planned by Franz and Brecht had to be temporarily put on hold.

The meeting to negotiate a truce cannot be handled by a small person, and any big person leaving Vienna may make Edward suspicious.

Even if this possibility is not high, they are not willing to take risks, so they have been suppressing the news and keeping it secret.

"Mr. Edward, why are you here again?" Franz looked at him annoyed, "It's too strange that you run to the Hofburg Palace every day."

"I'm anxious." Edward had a lot of worries in his mind. Whether it was the Pu'ao front line or the operation in Vienna, he was tormenting him. "I just received a report last night. It seems that the front line has been calm for several days."

Franz looked at the document in his hand and said with a smile, "Yes, the Prussian attack has been suspended, so we can take a breather."

Edward frowned tightly, always feeling that the man in front of him had something to hide from him: "The Prussian army attacked very quickly and violently at the end of September, but now the attack has suddenly stopped. Will there be other plans?"

"Another attempt?" asked Franz, closing the file. "What is Mr. Edward's opinion?"

Where does Edward have any insight, some are just some unrealistic guesses: "I just find it strange."

Franz laughed and opened another document: "They just blocked their attack. Maybe they want to adjust their strategy. It's not a big deal. Mr. Erdem's operation should have already started. Your trip to Paris Are you ready?"

"I've been waiting for a whole week." Edward sighed. "Everything is ready. As soon as the operation is successful, Mr. Carvey and I will leave for Paris immediately."

"It seems that everything is going well." Franz looked very calm, far less nervous about the success or failure of the operation before, "I am here to wish you and Dr. Carvey a pleasant journey in advance. Oh, yes, I also wish Edem Mr.'s operation was successful."

(End of this chapter)