Nineteenth Century Medical Guide

Chapter 289 285. Shape Tension Volume Pressure and Angle

For the bladder replacement bladder, in principle, there are certain physiological indications for the location of the intestinal segment.But in clinical practice, surgeon preferences take a more dominant role.

The reason is still that no matter where the intestinal segment is, it will not have much impact on the patient after it is lost, and the most important urinary control mechanism has nothing to do with the position of the intestinal segment.In addition to the nerves and smooth muscle of the urethra that must be protected during the operation, attention should be paid to the treatment of the intestinal tract. After all, it is the surgeon's technique, not which segment of the intestinal tract is taken.

In the history of the development of making the intestinal tract into an urinary bladder, surgeons have used a lot of spatial imagination.

The reconstructed urinary bladder needs to uphold the three important characteristics of high capacity, low pressure, no reflux and reabsorption.

And these three points determine the choice of Carvey.

"First of all, we need to understand the characteristics of the bladder." Carvey found the ileocecal, lifted a section of ileum, and said, "Why can a 3*4*5cm pouch store 500ml of urine?"

"It's because there are many folds in the bladder wall, which increases its compliance," Watman replied.

"Yes, compliance." Carvey said, "The intestinal tube itself is not the bladder, and the compliance is not great, but the rebound and contraction performance after expansion is stronger. The same volume of urine enters the bladder and the intestinal tube. The pressure is different. So we need to increase the capacity, otherwise the patient will suffer from frequent urination after surgery.”

"It doesn't look good to have a colon that isn't very elastic," Massimov said, "and you also mentioned the cleanliness problem earlier."

Anti-reflux, as the name suggests, is to prevent urine that enters the bladder bag from returning to the ureter due to pressure, body posture, etc.

Kavi nodded and looked at Musa who asked the question: "It's a good question."

"There is also the blood supply, the most important thing is the blood supply! If the incision and suture of the intestinal tube is not handled properly, the blood supply will definitely be affected. Even if the anastomosis is sealed well, there will be problems after a long time."

"If we really change to this replacement bladder, then the usual 2-3 hours of urination will become half an hour." Musa shook his head, full of doubts in his heart, "Dr. Kawei, don't be foolish, tell us directly Well, how to do it?"

Very neat answer, not like that Kavey who can come up with wonderful ideas in everything.

What a mess! ! !

"Pay attention to protecting the incision of the transverse colon, and the end-to-end anastomosis will be done later." Carvey asked Damirgang in the distance, "Is the cleaning solution ready?"

He didn't dare to make too many changes in the shape of the bowel, he didn't dare to operate on Edem as Fernand, he didn't dare to bet.

Finding the most suitable shape requires long-term clinical practice, from cadavers to patients, and everything is indispensable.

But in the 19th century, what Carvey did was a one-shot deal.

What weighs on Carvey's heart is what they said in case.

Postoperative upper urinary tract injury actually takes a long time to settle, ranging from a few years to decades.Patients undergoing urinary diversion neobladder surgery are basically elderly people with a limited life span, so anti-reflux is necessary but not the first priority.

"I'll understand when I keep doing it."

Even after many dissection exercises, even if all the cadaver resources in the hospital were sent to him, even if Mosier and him cooperated very well, he still felt that the success rate of the operation would not be too high.

In the past, this was definitely a major operation that required the mobilization of several department directors for consultation and handling.

"Okay, after we cut the ileum, you can do the flushing."

After distinguishing the blood vessels, Mocier used two tissue forceps to clamp the colon tube horizontally, leaving a gap in the middle for Carvey's scalpel to cut.

"Indeed. There are still many cases of intestinal fistula in intestinal anastomosis."

"Correct."

Damirgang wrung out two pieces of gauze from the disinfectant and cleaning solution, loosened them, and carefully covered the intestinal tube.

"I didn't expect that there is such a way, the idea is too clear!"

While explaining the anti-reflux structure, he was freeing the ascending colon.

"Ileocecal part, you mean the ileocecal flap???"

"Yes, even if it is made into a long-shaped tunnel, the compliance is not great, it is only about 100ml, which is far less useful than a bladder."

Carvey loosened the tissue around the hepatic flexure, flipped the intestinal tube, and exposed a large amount of mesentery on the inside: "We need to distinguish the colic artery and the branch of the hepatic flexure, and then determine the location of the colon cut. Mr. Erdem's right colon is not long, We cut it all at once." [5]

"So... nothing." Carvey smiled helplessly, "If it's gone, it's gone. Let it go."

"Come here and help, the lights are not bright enough!"

"Yeah, the intestinal anastomosis doesn't look very difficult, but I'm afraid that something might happen. If something goes wrong after the operation, it will be too troublesome."

"But complete dissection requires very high anastomotic techniques."

Watman was confused, and couldn't help looking at Massimov beside him, hoping to get some useful information from him so that he would not appear so embarrassed.But Massimov was even more confused, and didn't understand what Carvey meant at all.

After what he said, those doctors who were still a little puzzled finally caught up with the train of thought, and the discussion gradually became louder: "It turns out that it is like this, but it is a good idea."

It has been more than half a year since Carvey appeared, and half of the people present have learned to perform intestinal anastomosis.

"According to Dr. Carvey, there is no need to cut the mesentery. As long as the suture is done carefully, the blood supply should not be a problem."

This is a very ambiguous sentence, and many people here did not understand it, including Massimov and Watman who were standing on the sidelines: "What do you mean by this sentence? What do you mean by changing your position?"

"it is good."

But this time the dissociation was different from the previous ones. Kavey removed most of the loose tissue, but kept a part specially, and only pulled out a part of the bowel: "Give me wet gauze, it needs to be warm."

In fact, it took more than 20 years of hard work by urologists all over the world from the development to the maturity of this operation, and the final shape depends on the proficiency of the surgeon and is not static.

"These are just intestinal tubes, and what can be used is only a small section."

"No, your statement is a bit taken for granted. Such a large-scale incision and anastomosis will definitely cause blood supply problems, which cannot be avoided by saying 'careful'. Think about why we were still doing intestinal anastomosis half a year ago. Worried? Isn’t it because of carelessness in operation? Is this kind of carelessness easy to avoid?”

But Kavey is also a human being, not a god. It is unrealistic to solve all problems with his own hands.

Although there are not many people who have actually performed the operation, it seems that it is not too outrageous to hear the weird operation that should not have occurred at this time.In their eyes, the interception of the intestinal tube is not too demanding, but the shape of the intestine as a material is fixed, and how to expand the volume is the key.

Carvey started to mobilize the ascending colon, found the hepaticocolic ligament, and prepared to cut it off: "So two days ago, I gave up the so-called complex reconstruction. Instead, I wanted to achieve the purpose of forming a bladder by changing the position of the colon and ileum."

"You just talked about the hype, but now you want to give up rebuilding?"

What he is afraid of is the burden that the excessive operation time will bring to Edham: "According to the original plan, the operation needs to complete a full 40cm bowel reconstruction, and the suture distance exceeds 1 meter. The time spent on reconstruction alone is too much. It will take an hour and a half."

"There is, but it's not necessary." Carvey wrapped his fingers in wet gauze and separated the loose mesh tissue under the peritoneum [3]. "The lack of ileocecal valve just causes some diarrhea, but if it takes more time To rebuild, may cause unnecessary damage."

"so?"

Modern urology may not be interested in reflux. After all, there are enough powerful antibiotics, a large number of advanced surgical instruments, and a mature enough postoperative medical system to support it.

Carvey separated the lateral peritoneum of the ascending colon and cut it open with scissors【2】: "Bladder stones are caused by inflammation stimulation, but the inflammation of the lower urinary tract rarely moves up into the kidneys, because the urine flows from the top to the kidney. Downwashing and anti-reflux mechanisms of the ureterovesical orifice.

Opening the bowel to make a lot of shape changes will greatly prolong the operation time, and postoperative recovery will also take a certain amount of time.Moreover, a large number of incisions and sutures are required during the operation, which requires very high technical requirements.

"In the past few days, I have tried many intestinal reconstruction methods, and I have used the intestines of almost every cadaver for reconstruction."

Who made Edem not the former Prussian soldier, let alone Fernand, old age + tumor has taken away the health of this French gentleman.

Carvey took the tissue forceps and gauze from the nurse and said, "I have tried the W-shaped bending, S-shaped twisting, V-shaped and T-shaped anastomosis mentioned earlier. As long as the tube wall is cut longitudinally, Remove their original tubular structure, and then anastomose the sides to form a pouch shape."

"Mr. Massimov, this is actually a kind of reconstruction, but it's different from changing the shape. What I'm doing is changing the position." Carvey thought for a while and explained, "If you insist on making a comparison, it's ' Remove the corpses in the dissection room and add a few more seats, and that's the 'surgery theater' feel."

"But Dr. Carvey, choosing the ileocecal valve means that the ileocecal valve in the intestinal tract has disappeared, so how can we prevent food from the small intestine from entering the large intestine too quickly? What about the backflow of feces in the colon?"

Carvey cut off the hepatocolic ligament, and after measuring the length, Carvey chose a 20cm ascending colon and a 10cm terminal ileum [1]: "First of all, I would like to explain the anti-reflux mechanism of reconstructing the bladder, which is closely related to urinary tract infection .”

In front of everyone is a very simple math problem, 1.5+1.5=3 hours
This does not include the final anastomosis of the ureter and the new bladder, the anastomosis of the urethra and the new bladder, and the hand speed difference caused by seeking stability during the operation. The four-hour operation time is definitely considered conservative.

"Yes, intestinal fistula, this is the most troublesome."

"coming."

Of course, what he had in mind was not the anastomosis of the intestinal tract. After all, intestinal anastomosis is a common skill in emergency surgery, and he has long been familiar with it.

"Yes, on the basis of what I just said, the ileum has the greatest compliance among all intestinal segments, but its contractility is much smaller. As long as enough intestinal tubes are selected, an environment with high capacity and low pressure can be created."

This is an important landmark in the anatomy of the vesicoureter.
There will definitely be infection during the operation, whether it is in the urinary tract or outside the urinary tract, given Mr. Erdem's age and physical condition, infection is certain.Under the premise that infection is basically certain, the reflux mechanism can effectively protect the upper urinary tract.No matter how severe the lower urinary tract infection is, the kidneys are safe. "

"When dealing with the ascending colon, that is, the right colon, you must pay special attention to the duodenum [4] below the colon." Carvey used dissecting scissors to carefully handle the tissue here, and said, "Explore with your fingers first, and then Exposure, followed by separation. Bergett, is the cleaning solution ready?"

"To increase the volume of the urinary bladder, all we need to do is to change the original shape of the intestine." Carvey made a few simple folds of the intestine in his hand, and said, "Remove the shape of the tube, re-sew it and change it to an S Shaped, W-shaped, or more oval or spherical in appearance."

After the operation, the treatment is over. Even if there is a problem with the operation itself, the opportunity to correct it is basically lost. Not many people can survive two consecutive operations.Without complex and efficient postoperative support, all he can do is to try to squeeze all the problems into the operation to solve them.

"Don't forget, in addition to the blood supply, there is also infection caused by the operation, which will also affect the intestinal anastomosis."

"I've never seen an operation that took that long."

It's only [-]% at most, and if you're more conservative, the probability may be only half.

"Is there no way to rebuild it?"

"almost done!"

Before Carvey appeared, it was absolutely unconscionable to cut the intestines and then suture them.

"It's ready, methylene blue saline at about 30 degrees Celsius."

"You must be very familiar with urinary tract inflammation, it will bring a series of symptoms and bladder stones." Carvey asked Bergett to put down the candle in his hand, and only use the light on the ceiling to perform ileocolon separation, "go and Damier Gang prepares the disinfectant cleaning solution."

In addition to the establishment of external volume, Carvey also needs to establish an adequate anti-reflux mechanism.

"Yes!"

Now, these pressures are all on Carvey alone.

After all, he pointed to the ileocecal part that is still connected to the abdominal cavity by the mesentery: "There are two anti-reflux mechanisms I have set up, the first is the interface between the ureter and the intestine, and the second is the interface between the ureter and the intestinal tract. It depends on the special anatomy of the human body."

"Five hours may be too long for the surgery."

The original intention of the operation is not to show off one's own technology, but to complete the purpose of the operation as much as possible with the lowest health cost.Therefore, after repeated practice, he chose a surgical method that is relatively simple and can minimize the impact on urination function.

"Yes."

The procedure for resection of the terminal ileum was the same as for the right colon, and Carvey delegated this step to Mosier and Hermann.And he carefully dragged the newly removed right half of the colon, and said: "Next, I need to loosen the colon in order to rebuild without cutting the intestine."

"Untie?"

"I'm going to remove the colon band around the bowel tube and free the colon."

(End of this chapter)