Nineteenth Century Medical Guide

Chapter 290 286. Intraoperative Surgery

Colonic bands are three cord-like structures formed by longitudinal muscle thickening of the intestinal wall, arranged in parallel along the longitudinal axis of the large intestine, and finally converge at the root of the appendix.

If the colon is a plastic bag, the colon band is the tape that is wrapped tightly around the outside of the courier delivery.Removing the colonic band is equivalent to cutting the tight tape, stretching the plastic bag, and increasing its volume and compliance in disguise.

With the theoretical support of "removing the colon belt" and "replacing the bladder with the ileum", the rest is the practical part.

The process of removing the colon belt in Carvey's hands is tedious, and what is needed is pure basic skills, which need to be completed without accidentally injuring the colon serosa.The stump suturing and ileocolonic anastomosis in the hands of Mossier and Hermann require more skills, which is another important knowledge point in the eyes of outsiders.

This kind of operation seems easy, just like being a tailor, shortening the cut sleeves and re-sewing them on the clothes, but you will encounter various difficulties when you really get started.

"The first is the suture method." Carvey pointed to the two stumps in the hands of Herman and Mosier, and said, "The colon has a large caliber and the ileum has a small caliber. It must be difficult to perform an end-to-end anastomosis directly. So we found another way, Seal the opening on the original colon, and then create a new anastomosis suitable for the ileum."

At this point the two had begun working on the stump left by the transverse colon.

Herman already had solid basic skills, and with the hard work these days, he gained a lot of experience in suturing intestinal tubes.Today he works mainly on the colon stump with interrupted sutures using absorbable gut.

The main point is not to sew into the liposome. After the suture is tightened, the previous suture needs to be embedded in it to achieve the effect of pouring the serosa on the serosa【1】.

Massimov dealt with a new incision next to the colon, connected to the stump of the ileum just after amputation, that is, the (ileum) end-(colon) side anastomosis.

The end-to-side anastomosis method is close to the natural anatomy and physiology, and is safe and easy to operate. It is a mature method of large and small intestine anastomosis in modern times.But in the 19th century, this technique was absolutely new.

"A curious anastomosis method, sealing off the slightly larger incision, and then making an opening of the same diameter on the side."

"I am more concerned about the suture technique. Such a large-scale suture is bound to encounter some uncontrollable infections and omissions. This reminds me of many unforgettable memories. I am really sorry for the patients who had intestinal fistula after surgery. them"

"The blood supply to the ileum is really a problem."

Mossier simply calculated the incision distance, and clamped the colonic band without affecting Herman's suturing [2]: "Pay attention to the color of the intestinal tube when pulling, clamping and suturing. When the blood supply is indicated to be insufficient, this section of the small intestine should be resected decisively until a viable stump remains."

Carvey nodded: "But resection is just a last resort. If possible, it should be done in one step."

Mosier used a pair of tissue forceps to clamp the anterior band of the colon laterally and bring in a small portion of the intestinal wall [3].

Then place the two tissue clamps of the terminal ileum and the anterior band of the transverse colon in parallel, and use a tougher silk thread to make a mattress suture between the serosa layers, so that the terminal ileum is fixed on the transverse colon.The silk threads at the corners of both sides after suturing are not cut temporarily, and are kept as traction lines【4】.

"Mr. Mosier, I have finished suturing here."

Mosier glanced at the stump made by Herman to close the mouth, took the scalpel from the nurse with satisfaction, and said, "Go get two tissue retractors, and then cooperate with me to do the anastomosis."

"it is good."

"We excised part of the intestinal wall that was previously clamped with the anterior colonic band, creating an opening in the colon [5]." Mosier cut open the intestinal wall with a knife, and then released the two tissue forceps, only using more The intestinal tubes on both sides are fixed with gentle intestinal forceps, "The length of the resected part is not enough, let's expand the incision."

The anastomosis just now is only the posterior wall of the ileum, and then the mucosal layer will be sutured from the middle of the posterior wall.The sutures at the corners of the two sides that were kept just now can just continue to be sutured inward to ensure that the mucosa is inverted. 【6】

After the mucosal layer is sutured and closed, a row of mattress sutures on the anterior wall is done with silk thread, and all the anastomosis is completed.

"The whole stitching sounds complicated, but as long as you know the principle, it is not difficult to master, and the rest is practice."

Mossier also expressed his feelings, because he did not perform intestinal suture five days ago: "Just remember to do the mattress suture of the posterior wall first, keep the silk thread and then do the inversion suture of the mucosa layer, and then the Mattress suture on the front wall. If it is found that the anastomosis of the corners on both sides is not strong enough, you can add a few more stitches like Heman is now."【7】

"it is done?"

While loosening the colon belt in his hand, Carvey was still concerned about the progress of the other side: "How is the anastomosis passing?"

"I tried it just now, and I can pass a finger."

Carvey checked briefly: "Okay, cover it with gauze and help me."【8】

For the stump anastomosis of the ileum, in addition to this (ileum) end-(colon) side anastomosis, there are also end-to-end anastomosis, (colon) end-(ileum) side anastomosis and side-side anastomosis [9].

There are indeed many methods, but now that the operation has come to the most important part, Carvey has no time to explain other methods.

"Since I was removing the colonic band of the right colon just now, you can see that the colonic pouch at the lowest ileocecal part has disappeared." Carvey opened the serosa and quickly found Edm's appendix. "You two go on with the appendectomy and I go on with my colon strip."

"it is good."

For many doctors on the stage, the whole operation was done in a "cloudy and foggy manner", and they couldn't grasp the key points at all.There are many steps that can only be heard clearly but not understood, and the operation picture is even more difficult to capture.

However, they came here more to learn, just to witness the completion of this operation is enough to pay back the ticket price.

Perhaps no one would have imagined that there would be a friendly appendectomy hidden in this operation that had long been beyond their ability.

In fact, looking at the entire European and American continents, there are very few doctors who can perform appendectomy well.

Before Carvey, conservative Austrian surgery was not good at this type of surgery.However, since Carvey and Ignatz jointly performed a case of appendicitis, the theory of appendicitis seems to have gradually become dominant in the medical world, and the number of appendectomy operations in Vienna has also been on the rise in the past six months.

Although the success rate is not high, there will be various problems after the operation, and some patients have to die in the hospital bed.

But rather than fighting hard for a few days and causing appendix abscess to rupture, and finally forming peritonitis and dying at home, taking the risk of surgery may bring miracles to oneself, and colleagues will also bring more positive effects to the development of medicine.

And it was these attempts and failures that gave many doctors in Vienna the experience of the first wave of abdominal surgery.

So when they heard that Mossier was going to have an appendectomy, many doctors who had tried it and even had considerable experience in the operation were interested.After all, watching the operation itself is not only learning, but also a sense of pride that one's own side is superior after comparing with each other.

They all wanted to see what the doctor, who had never really dabbled in celiac surgery, would do with the appendix.

Hermann used wet gauze to separate the ileocecal part from which the colonic band had been removed, while Mossier cut off the mesentery of the appendix with hemostatic forceps and carefully ligated the blood vessels [10]: "When doing blood vessel ligation, simple ligation is not enough bleeding, and the high tension caused by ligation can also cause bleeding in the mesangium”

Several doctors on the stage quickly nodded in agreement: "This does happen."

"How to avoid it? Do more ligatures?"

"Do not."

Mossier took out one of the needles and threads laid out by the equipment nurse, and said, "Do a mattress suture directly at the clamp position to completely block the blood flow."

The operation of appendectomy is much simpler than the previous operation steps, and the cooperation between Mosier and Herman is also tacit than before.While one is suturing, the other is already preparing for the next step, clamping the end of the appendix with right-angle forceps. 【11】

"We ligate the appendix proximally with right-angle forceps." [12]

Mossier gave up this place to Herman, and performed a purse-string suture on the cecum wall at the base of the appendix: "When doing the outer purse-string suture, the mesenteric blood vessels must be avoided to prevent damage to the blood supply." [13]

The operation of appendectomy is not too difficult, and it is much easier than the ileocolonic anastomosis just now. This may also be the operation with the most training and the most confidence of the two.

It took them only 15 minutes from taking over to completing the separation, ligation and purse string suturing.The next thing to do is the cut between the ligature and the basal right-angle clamp.

Hermann pulls on the right-angle forceps and cecum to expose the cutting space. 【14】

"Metal disc." Mosier quickly cut off the appendix, threw it in together with the right-angle forceps, and then changed the hemostat, "We use the forceps to insert the stump of the appendix after cutting into the cecum wall, and then insert the The surrounding pre-made purse-string sutures are tightened and knotted to seal the stump inside." [15]

Herman took the end-point suture from him and was in charge of tying the knot.

At this time, Watman on the side had some doubts about their treatment: "Since it is a urinary bladder, the lower end must be connected to the urethra."

"Yes, after the ureteral anastomosis, I need to do the anastomosis of the colon and the urethra."

"Does it have to be re-opened? Why not choose the appendix incision?"

"It's a good thing it's Dean Watman." Carvey's eyes lit up, and he praised with a smile, "Theoretically, it is indeed possible to connect the urethra with the tear left after the appendectomy. This can reduce the damage to the right colon, Postoperative risk is also lower."

Watman sighed: "So, you have a reason for not doing it."

"of course."

At this time, Carvey had already removed three colon bands, and the right colon, which was originally similar to a long mesh bag filled with garlic, was now completely round and empty.

He rotated the right colon + ileum that had been severed at both ends counterclockwise, and moved it toward the pelvic cavity: "I have loosened the surrounding mesentery as much as possible, but the position of the urinary bladder can only reach here, and the distance between the appendix incision and the urethral opening is still There's a long way to go."

"I see." Watman nodded Lianlian, "It's still for the blood supply of the right colon."

"Yes, each person's mesentery has a different structure, and the position of the blood supply branch is different, so the scope of loosening is also different. It is not wise to loosen the mesentery too much, and we can only make a new opening."

Carvey and Mossier changed positions again while speaking, and Mossier was free to suture the stump of the right colon, while Carvey was in charge of the most difficult part of the second half of the operation: the ileal-ureteral anastomosis.

"I kept a large amount of mesh tissue in the lower half, and now the right colon has enough volume after the 'removal of the colon belt', and the urinary bladder has taken shape." Kawei turned his head and waved to Damirgang, "You need to do a good job of cleaning before sealing."

Cleaning is carried out in three waves, using methylene blue, carbolic acid and alcohol in combination with normal saline, and each time it needs to be left in the right colon after isolation for 5-10 minutes.

Only thorough washing can ensure the cleanliness of the cyst cavity.

"While they are cleaning, I need to continue to deal with the ureter, which is the anti-reflux mechanism mentioned earlier." Carvey said, "The anastomosis of the ureter and the bowel directly determines the degree of urine reflux, and indirectly affects the degree of urine reflux. The probability of urolithiasis, urinary tract stricture and obstruction after surgery."

There are three commonly used methods of ureteroenteric anastomosis in modern times, submucosal tunnel, mucosal groove and intussusception vaginal valve.

The **** valve is the most used in modern times, because the anti-reflux function is reliable enough, and this method is also the standard method for reconstructing the ileocecal valve.The specific process is to insert the ureter into the intestinal canal, turn it outward to make an intussusception, and then suture the edge with the intestinal mucosa. 【16】

But as Carvey said before, it takes a lot of time to make a penis.

The reconstruction of a single ileocecal valve has already taken about 20 minutes. What he is facing now is a thinner and more tender ureter, or two.Obviously, the breast valve is not suitable for Edm, or it is not suitable for this era when the craftsmanship is not fine enough and the surgical support system is not perfect.

Carvey finally chose the simplest mucosal groove method.

"First cut a hole in the ileum wall with a hemostat."

Carvey pressed the front end of the forceps against the wall of the tube, cut a small opening with scissors, and then poked the forceps open, and carefully passed the ureter through the hole and entered the intestinal cavity: "We will make a T-shaped incision on the ileal mucosa around the amputation hole, pay attention to The incision should not be too deep or too long, just 3cm."

The mucosa is slightly separated with the help of the incision, and then the ureter is secured by sutures on both sides of the ureter. 【17】

"Excellent design!!!" Although Waterman has never done this kind of anastomosis, he can roughly guess the effect of such an anastomosis based on his surgical experience. It is difficult to re-squeeze the urine into the ureter, not to mention that the large-volume colon does not give much pressure, and the ileocecal valve acts as the first wave of anti-reflux."

"It's really wonderful! In addition to the design, he also used ureteral stents." Massimov pointed to two slender metal pipes and said, "I remember using them before?"

"Yes, I have used it, and the effect is not bad."

"If you don't use it, the ureter will stick together, right?"

"Yes, once the adhesion is narrow, it will directly affect urination, which will be very dangerous." Carvey gently pushed the two tubes in, "Who made the ureter so thin."

"It's true that every step can't be wrong, and the links are intertwined."

Although there were not many steps for Kavey's anastomosis, the operation was time-consuming and laborious because the ureter itself was too thin, and it took him a lot of time.

As a result, after half an hour of cleaning the right colon, he had just completed the anastomosis.

"The operation has finally come to the final step." Carvey listened to the vital signs reported by Amor, and the big stone in his heart finally fell. "Give me the needle holder, and the last closing work is left."

(End of this chapter)