Nineteenth Century Medical Guide

Chapter 287 283. Clean Surgery

In the operation, to distinguish the positions of various tissues, it depends on the touch of the fingers and the difference in color and texture brought about by vision.Compared with the subjective sense of touch, the difference in color is much more intuitive and objective.Unfortunately, this objective difference is easily destroyed by other factors.

The light source is a variable.

One of the important reasons for the slow development of abdominal surgery in the mid-nineteenth century was the lack of brightness of the lights.Coupled with a lack of understanding of anatomical structures, there are very few people who dare to perform abdominal surgery and do it well.

The bladder and prostate are located on the pelvic floor, and the position is very low. In the absence of electric lights, it is a luxury to maintain a clear surgical field at all times.

In a sense, the operation has only been an hour so far, and the most tiring one is definitely not Mosier, who is following in Kavey's footsteps but still has enough energy, nor is it the nervous but experienced Kavey, but the one who has never had surgery before. Bergert of instruments.

According to the progress of the operation, Bergett needs to repeatedly switch between the candles, the huge candlestick on the top, and the kerosene lamp with higher brightness according to the constantly changing position and angle.A single slender candle can be closer to the incision to help illuminate the deep anatomical structure, the ceiling candlestick is similar to a weakened version of the shadowless lamp, and the flame of the kerosene lamp can ensure sufficient brightness.

At the same time, he had to adjust the angle of the light to prevent the wax oil from dripping, and the position of his station should not affect the four surgeons, and he had to avoid relatively sterile surgical instruments.

In order to maintain the light, he almost lay on top of Erdem.

Of course, due to limited external conditions, it is unrealistic to rely on Bergett alone to maintain the clarity of the surgical field, and Carvey, as the main surgeon, also needs to make adjustments.

Leave the suture thread unknotted, lift 12 o'clock, the second and third from outside to inside, respectively, through the 7 and 10 o'clock positions of the urethra.

Wearing masks, everyone circled clockwise around the operating table, poking their heads forward one by one, trying to carefully see the fascia layer and neurovascular bundles left by Kavey's separation.Some people also sketched the anatomy scene, and the problems continued.

"The treatment of the pelvic floor needs to be as clean as possible, that is, to lock the blood in the blood vessels." Carvey picked up the suture needle and thread left on the pubic symphysis perichondrium just now, clamped the needle holder and said, "From the broken back After the venous complex, use this thread to continue suturing the distal edge, so as to achieve the goal of complete hemostasis.”【1】

"I'm here." Hans stood up lightly, a smile appeared on his face, which was enough to make half the beauties fall in love, "What's Dr. Carvey's order?"

"When cutting the urethra, be careful not to cut it all at once, and don't damage the internal urinary tube." Carvey tilted his head, carefully distinguishing the urethra and the urinary tube inside, "This is not an amputation. Cut off 2/3, and keep the rest for now."

"The catheter is in," Amor said.

However, when processing, it is not only the grapefruit meat that needs to be protected, but also the meridians that must be peeled off.

During the operation, the open incision will lose a large amount of body fluid, and bleeding will require a bottle of rehydration throughout the operation.Under the premise of long-term rehydration, urine will naturally continue to be produced.However, under general anesthesia, the sphincter is closed and cannot pass urine smoothly. If there is no catheter, the bladder will be full soon.

He quickly sutured the wound in a continuous "V" shape. 【2】

The scissors were quickly replaced with three needle holders.

Although the color can be restored by rinsing with normal saline, once the rinsing is done, the fluid must be sucked out with a suction device, which will waste time.It’s okay if the number of times is not many, but the pelvic floor is full of various blood vessels, and it will be covered again by the blood that comes out almost immediately after washing.

However, they are almost completely attached to the outer side of the prostatic fascia and are in the blind area of ​​the top-down view, so we must pay attention to it when doing the resection.

Then comes the fourth and fifth, passing through 2 and 5 respectively. 【4】

"Don't be greedy here. Be sure to stabilize the rhythm and take it slowly." Carvey said while doing it, "until the entire prostate is freed, and the neurovascular bundle is no longer connected to the prostate. Take it!"

"Give me the gauze." Carvey spread a total of 10 thread ends in five places on the surgical drape, then covered the gauze and a pair of hemostatic forceps, and pressed the thread ends, "Amor, remove the catheter."

After the two sides were opened separately, the freeness of the prostate was further increased, and because of Kavey's excellent hemostasis work, the position where the neurovascular bundle traveled was completely exposed. 【8】

"understood."

"it is good."

In fact, preoperative catheterization is routine.

Aside from light source illumination, the most important variable affecting color is bleeding from the tissue itself.

So at first Carvey only asked for the bladder to be emptied, and no catheter was placed.

Even if they could really step forward and take a look now, it would not be of great help to them.

Mossier clamped the pelvic fascia covering the prostate with tissue forceps, Carvey made a small incision with a knife, and Mossier inserted right-angled forceps into it, spreading out to expose the shear space.

"Anaesthetized for the second time."

But before that, I need to give Mr. Edem an explanation.

However, there is no rubber tube with an air bag at present, so it is difficult to do self-fixation, and the number of urinary tubes is limited.In addition, the nature of the operation determines that the ureter will be severed at the beginning, and the situation of urinary retention will no longer exist.

Therefore, when dealing with the dorsal vein complex, Kavi tried to be as "clean" as possible

In the past, intra-abdominal surgery often did not pay much attention to small blood vessel bleeding. If it is a drastic limb surgery, this kind of bleeding is even less of a concern.But now the light is limited, the operation is not only located in a low position, but also the operable range is small. In addition, the main surgeon and the first assistant and four hands keep blocking the field of vision, so it is obviously unrealistic to rely on lighting back and forth.

"Mr. Hans!"

"Okay." Carvey said, pointing to the compressed dorsal vein complex covered with gauze, "the suture used before the separation was not enough to stop the vein complex, and now the bleeding is serious, and compression is obviously not enough. We need to do it again." Stop this wound with sutures and give me the needle holder"

The urethra was transected, the urethral suture was placed, the posterior part of the striated sphincter was cut, and then the underlying Denonvilliers' fascia was completely freed.The bottom part of the prostate was finally incised. It can be said that only the last part of the radical operation is left.

"Maybe the prostate is not within the scope." Carvey quickly smoothed things over, "Medical medicine is a process of accumulation. It doesn't matter if you don't understand it for the first time. You will gradually understand after watching and listening."

Carvey nodded and asked: "There is still a catheter in the equipment box. Go and insert it for him. The urethra must be propped up before the prostate is severed."

"I see that many people are falling asleep." Watman looked around and joked, "The operation is so wonderful, probably less than 20% can understand it."

Next, this piece of tissue will be divided into several small pieces under the scalpels of Koch and Savarin, just like the lymph node that was just cut out, and then dozens of pathological sections will be made.

With the permission of the chief surgeon, Watman couldn't say much, so he could only let other doctors step down to observe.

Lifting, freeing, exposing small branches, suturing and cutting off.【10】

"The next step is to undo the relationship between the prostate and the rectum?"

Now that the operation is about to separate the prostate and urethra, it is still necessary to insert a urinary catheter for support, so that a reference object can be added to the urethra to see the relationship between the internal and external structures of the urethra.

"It's not cheap"

The blood will adhere to the surface of the mucous membrane, uniformly dyeing the tissues that can be distinguished by vision red.

The right-angle forceps spread the surrounding tissue, exposing the space below the smooth muscle, and giving Carvey scissors enough room to operate.

"Lifting up the severed prostate tip, we can see that there are still a lot of adhesions on the left and right sides that need to be dealt with." Carvey used tissue forceps to draw a few places behind the prostate, "We need to slowly make the tendons Membrane detachment, carefully exposing and severing those tiny branches of nerves and blood vessels, taking care not to damage the part that remains in the body."

This is a very basic but practical assistant operation. After five days of practice, the two have reached a tacit understanding, and Watman and Massimov nodded repeatedly.

This will not only cause damage to the bladder, but sometimes it will cause a catastrophe due to excessive pressure.

"it is good."

This anatomical structure has appeared more than a dozen times, or even dozens of times. It seems very nagging, but Carvey still has to say that only repeated reminders can deepen their impression.

With the previous handling methods, the next step is a very procedural work.

Amor put a mask on Edem, and while listening to the vital signs reported by the nurse beside him, he watched his body's reaction: "The reaction is normal, the anesthesia is over, and the vital signs are normal."

But this is not enough for Carvey: "Don't open the mouth of the scissors too much. When cutting the last 1/3 of the urethra, you can't cut it all at once. You need to cut half of it first and then switch to the other side for separation. Because the scissors are The eyes are not long, and the front teeth of the right-angle pliers are not long, so if you only rely on the feeling, there may be a countermeasure.”

Carvey took Mosier's right-angle forceps, and gently separated the neurovascular bundle, and even saw some of the tiny branches closely connected to the prostate: "Fortunately, I kept most of the branches, and I am doing Before leaving, everyone who is interested can come down and take a look."

The next thing to do is to deal with the outer edge of the dorsal vein complex of the prostate, separate the fascia of the levator ani muscle, and slowly peel off the skin of the grapefruit.

The outer levator ani fascia is the outer skin on both sides of the grapefruit, the Denonvilliers fascia is the white membrane underneath, the prostatic fascia is wrapped around the grapefruit meat and cannot be broken, and the neurovascular bundle is something similar to the meridian that needs to be disconnected below . 【6】

In fact, when the operation is free to the prostate, many people can't understand it.Barely studied anatomy popped into their ears one by one, and the brain simply didn't have time to process them, let alone integrate them into a spatial model.

Mosier still did the same operation as before.

The superficial fascia is incised along the bladder neck all the way to the apex of the prostate. 【7】

"To be precise, it is the relationship between the Denonvilliers fascia and the rectum." Carvey lifted a layer of dense structure with right-angle forceps and cut it open with scissors. In parallel, it is necessary to separate them one by one, clamp and cut off the blood vessels, and then continue to repeat the previous way of dealing with neurovascular bundles.”【9】

To make an analogy, removing the prostate is like peeling a single piece of grapefruit. You need to take out the tender grapefruit flesh inside.

"After removing the urinary catheter, the sixth needle holder left the suture scissors." Carvey pulled out the thread again, and cut off the posterior 1/3 of the urethral tube wall with scissors. Cut downwards. When cutting, we still have to pay attention to the most important point, the neurovascular bundle.”【5】

"Press the prostate." Carvey moved the pressure plate in Damirgang's hand down a little distance, "Don't force too much, just expose the junction of the prostate and the urethra. The next thing we need to do is to separate the outside of the urethra striated sphincter, exposing the internal urethra."

Carvey asked, "Did Mr. Edham ask for a drawing of his bladder?"

Mosier took a pair of right-angle forceps and inserted it just behind the smooth muscle of the urethra near the tip of the prostate.Then expand the forceps teeth outward to make a cavity under the smooth muscle of the urethra, so as to avoid the neurovascular bundle close to the urethra and prevent accidental injury caused by the scissors in Carvey's hand. 【3】

"Emmm, it doesn't seem to be there." Hans put aside the drawing paper he had just made a draft on, and changed to a new one. "However, according to Dr. Ekawi, this should be a very important thing."

The first part of the operation was successfully completed with the bladder and prostate completely dropped into the metal curved disc.

"Do the final separation."

"They should have done their homework," Massimov said.

The first one passes through the urethra at 12 o'clock: "It is easy to distinguish the urethral mucosa on the inside by relying on the catheter, and the smooth muscle of the urethra on the outside should also be seen. Do not damage the smooth muscle when suturing, otherwise the postoperative urinary continence function will be restored. It's going to be difficult."

Nerves run on the posterolateral surface of the prostate, and branches continue to extend into the prostate. It is necessary to cut off those small branches while keeping the trunk branches, and then peel off the neurovascular bundle little by little.

Carvey did not dare to give an affirmative answer, but asked Savarin: "How is the lymph node pathological examination?"

Savarin drew a mark on the small piece of paper next to the glass slide with a pen, and replied: "Not all of them have been checked, but tumor cells have been found."

The pathology result is the best diagnosis report, and the diagnosis of bladder cancer is clear.

After hearing this, Carvey nodded and looked at Hans: "This is really important. This is the world's first radical cystectomy, and what is on the plate is the world's first resected bladder and prostate tumor. It is very important. commemorative."

(End of this chapter)