Nineteenth Century Medical Guide

Chapter 293 289. Separation of Human Skills
Surgery in the 19th century was still in the middle of Pangu’s creation of the world, and urology, obstetrics, and gynecology had already been separated on the surface, but many surgeons had common techniques without clear divisions.

For example, Guyon, who is currently in the No. 2 surgery theater, is a senior student of Albaran under the tutelage of Mosier, and his research direction is urinary tract stricture and prostate.After Mosier temporarily left the main palace hospital, he was the director of the urology department here, a serious urologist.

But now, Guyon was asked to be an assistant in this operation.

And the chief surgeon standing opposite him was Chief Surgeon Cedieu, who was about the same age as Watman, and what he was doing was a blank in the history of surgery—partial gastrectomy.

"What did you do???"

Carvey thought he had heard it wrong, so he asked Albaran to repeat: "The patient suffered from gastric outlet cancer, and a mass could be seen in the upper abdomen. Professor Cedieu wanted to cut open his stomach and separate the tumor from his stomach. All tissues in the distal part of the stomach are removed together."

It sounds very reliable. Although partial gastrectomy for modern pyloric cancer is complicated, the risk has been greatly reduced. Basically, general surgery in all tertiary hospitals can do it.

But now it is November 1866, 11, and Bill Roth, known as the originator of gastrointestinal surgery, is taking care of a large number of wounded soldiers in Fortress Olmitz.It will be 10 years before the world's first gastrectomy is officially successful.

Of course, Carvey believes that the time to complete this operation with his help will be greatly reduced, but even if the person who completed this operation is not himself, he should not be a French talent.

With the current surgical technology and equipment foundation in Paris, the success rate of the operation is infinitely close to 0.

"This operation is not easy."

Carvey said it very tactfully, because if you think about it, you can find many difficulties that other surgeons cannot handle, including the details of the free stomach and duodenum, the spilled gastric acid, the appropriate anastomotic method, etc.: "The plug Has Professor Dio performed this type of operation before?"

"I did it once, and the patient died on the operating table. But the professor has practiced for several months for today, so it should be fine." Albaran's eyes were full of admiration, "Of course, surgery has huge risks, what? Anything can happen.”

The words are very pertinent, but as long as you are a sensible person, you should see from the face of the assistant who came to shake people that the operation is not going well.

"Where is the surgery?" General surgery is the key project of emergency surgery, and gastrointestinal surgery is the most important part of it. It is impossible for Carvey to understand, "Free duodenum? Is the tumor being removed? Or is it ready to do it?" Matched?"

The assistant's face turned pale, and he shook his head repeatedly: "I, I don't understand very well, I just came to find Dr. Albaran according to Teacher Guyon's request."

"All right."

In just 2 minutes, Carvey had already thought of several surgical options and possible problems in his mind, and quickly prepared various remedial measures.If you really need to go on stage by yourself, you won't be unable to do anything.

But surgery depends not only on technology, but also on other aspects of support.

Carvey could think of the original intention of the other party to try this kind of operation, but it was because of general anesthesia, which gave them more time for operation.Although the surgical mortality rate is high, as long as the number of patients willing to operate continues to increase, there will always be success.

It's a shame Cedieu didn't appreciate the variety of preparations required for surgery.

There is no disinfection, no masks, no gloves, no blood transfusions, no first-aid medicines and corresponding countermeasures, and even the monitoring of vital signs cannot be done.This kind of tertiary surgery is always dangerous, and the process is full of pitfalls
The three of them bypassed the flow of people and pushed open the door of the surgery theater. What directly hit the eyeballs was the tense operation scene in the arena, and the audience around them was similar to the Vienna surgery theater.

The Main Palace Hospital is actually more like a church hospital. All items in the hospital, including treatment, are free. Of course, the surgery theater is only open to the public, and the audience must at least be medical students who come to practice.

They were all wearing gray or black formal coats, with pens and notebooks in their hands. Although they communicated, they were all restrained. All eyes were focused on the 20cm long incision.

The only thing that could be heard in the audience was the cry of the chief surgeon Cedieu: "Quick, gauze! Quick, press here, the bleeding here is serious!"

"Where is the suction device? I can't see anything, suck it up, suck it up!"

"Keep the lights down!"

Albaran didn't dare to say anything. After entering the door, with the help of his assistant, he changed into a surgical leather skirt, and walked past Kawei: "Teacher, professor, I'm here."

"Where did you go?"

"I, I went"

"Forget it, hurry up and get another suction device and help suck it together. There is too much bleeding."

There are a large number of blood vessels around the stomach and duodenum, and extra care should be taken when freeing them.The duodenum, in particular, not only has a rich blood supply, but also is structurally the junction of many important abdominal organs.

One side is the bile duct and portal vein, and the other side is the pancreas, and its position is also backward, making it difficult to dissociate.When the operative field itself is not clear enough, no bleeding or as little bleeding as possible is the basis for completing the entire operation.

If you can't even do this, then the operation is close to murder, and there is no need to do it at all.

Karvey shook his head slightly, walked into the auditorium alone as a Chinese student in the eyes of outsiders, found a seat in the corner, and wanted to see the next follow-up.

However, not long after he stood still, the patient's condition took a turn for the worse. The experienced nurse at the side knew something was wrong just by taking his pulse: "Professor."

Cedieu was concentrating on the huge incision on his upper abdomen at this moment: "Very well, the bleeding seems to have stopped, add some gauze, and work harder! After the vision is clear, we will do another surgery on the edge of the tumor." Clamp, then."

"Professor Cedieu!"

The nurse couldn't help calling him again, and the 62-year-old surgeon finally responded: "Huh? What's wrong?"

"The patient," the nurse sighed softly, and then shook her head, a signature gesture when euphemistically expressing the news of a patient's death.

Cedieu guessed the result right away, but he still didn't give up: "What happened?"

"Mr. Boris' pulse is gone."

Albaran dropped the suction device, put his blood-stained hand on the patient's carotid artery, and moved his finger to the nose and mouth after a while.The result is self-evident, the patient's heartbeat and breathing stopped completely, and he did not endure the shock caused by massive blood loss.

As he stopped, everyone also stopped.

Sediyo couldn't accept this fact for a while, his head was buzzing, and he couldn't even stand up.But out of the self-esteem of the surgical director of the oldest hospital in Europe, he stabilized the scene with the help of other assistants:

"I am here to announce the death of Mr. Polis. He did not survive the hemorrhage during the operation. It is unfortunate. The operation was a pity. It was only the last few cuts to remove the tumor. I could not save his life. .”

At this time, the other two suction tubes that penetrated into the patient's abdominal cavity were still working, and the accumulated blood in the abdominal cavity was sucked clean.The gauze in Guyon's hand did not stop, but carefully wiped off the remaining blood, exposing the tumor: "Albaran, get the tissue forceps."

"it is good."

Sai Diyue was unwilling, and sincerely hoped that there would be another patient with a similar condition who was in urgent need of surgery.

However, abdominal tumors can only be diagnosed when they grow to the extent that they can be touched by hand. In addition, patients still have feelings of resistance to surgery. Finding such a surgical candidate is purely luck.

Ugh.
Suddenly, fragmented applause broke out from the auditorium on the stage, accompanied by the sentence "Professor Saidiyo's innovative spirit is really refreshing", everyone's rainbow farts spewed out, and the applause gradually became more and more harsh.

Unlike Kavey, Cedieu seems to like this kind of praise very much. Perhaps this is his inner driving force for insisting on surgery.

His operation was not over, and half-baked operations were not allowed in the surgical theater: "Next, we will remove the tumor for Mr. Boris. Then we will also remove the distal stomach and part of the duodenum that it invaded."

It was another typical separation of human beings. After Carvey improved the success rate of Vienna's overall surgery, I haven't seen this kind of situation for a while, and now I feel a lot of emotion.

However, unlike seeing Hills at the beginning, he no longer looks at this phenomenon with a purely critical eye, but has become more objective.

The vast majority of surgeons, including Cedieu, are not stupid. They all know that the patient's life and death are the most important goals, but they still choose to retain their original understanding of surgery.

That is to say, the patient's life and death belong to the patient, and the doctor must care about it, but he doesn't care that much.The doctor's operation belongs to the doctor. The success of the operation depends on whether the original surgical goal can be achieved, and the survival of the patient can be regarded as an accident when the established goal is completed.

This is not their cold-bloodedness, ignorance, or psychological distortion, but a special excuse created to alleviate the guilt caused by the failed operation.

After all, in this day and age, death of a patient is an accident, and survival is also an accident in a sense.

Unsurprisingly, after Mr. Boris was declared dead, the scrambling surgical team became much calmer.The weight of lifelessness made their techniques gradually mature and skillful, and the tension just now disappeared from everyone's face.

It seems they are still more used to dissecting the dead than treating the living.

Carvey hadn't seen such an exaggerated visceral tumor for a long time. Even at such a distance, he could still see the patient's pylorus swell into an apple.There are ulcers and adhesions around, and there must be metastases in the abdominal cavity. From a modern point of view, it is actually not suitable for surgery.

If you put this point aside, Carvey still prefers the Bi-I operation in terms of the operation method alone.

The source of the name "Bi" is Billroch of Billroth. The operation has been improved and fine-tuned since it was created more than 140 years ago, and it is still active on the operating table of general surgery.

The Bi-I method directly anastomoses the remnant stomach and duodenum, and the operation is simple. After the anastomosis, the gastrointestinal tract is close to the normal anatomical and physiological state, so there are relatively few complications. 【1】

There are many advantages, but the disadvantages are also obvious.

Because the tumor has adhesions, the duodenum itself is dragged down by the surrounding complex structures, so it must be difficult to dissociate.In addition, if the scope of the tumor is large, if the scope of gastrectomy increases, the tension will increase during gastroduodenal anastomosis.

If the tumor really affects the anastomosis after resection, Carvey will still switch to the more flexible Bi-II method.

Also designed by Bill Roth, the complex anatomical structure is directly discarded, and the duodenum, which cannot be flexibly anastomosed, is directly discarded, and the simple jejunum is used instead.There is no limit to the scope of gastrectomy in the Bi-II type, and it is more widely used clinically. 【2】

However, due to the complicated operation, the original normal anatomical and physiological structure has changed, and there will be more complications.

Judging from Cedieu's statement, what he wanted to do was also the Bi-I style, but he did not completely complete the necessary dissociation work before the tumor resection, which led to massive bleeding.

In Carvey's view, the key is to find the location of the bleeding and clarify the mistakes in his operation.But Cedieu didn't seem to have this plan: "My judgment on the level of gastrectomy is not wrong, and the position of the stump of the duodenum is also correct. The upper and lower parts should be cut well."

The audience around were amazed and hooked, and even called Cedieu the No. 1 abdominal surgery in the world.

It is estimated that only Carvey will feel uncomfortable in the audience.

He didn't care about those false names, and it wasn't the name he gave Cedieu that made him uncomfortable.He is very clear that the theoretical knowledge in his mind and the technology in his hands are all passed down through the efforts of these sages.

The only thing that made Kavey uncomfortable was the operation itself, and Sediyo's operation was too rough.

Speaking of this step of tumor resection, the correct way is to first close the proximal and distal ends of the stomach with large closing forceps, then perform full-thickness intermittent sutures with sutures, and finally cut with a scalpel.Sew first and then cut can effectively prevent the gastric acid secreted by the mucosa from spilling out, and it can also prevent bleeding when the stomach wall is cut.

However, Cedillo's inexperience makes it impossible to know these details.

"Doctor Guyon, you are responsible for the pathology of the tumor."

"it is good."

"Albaran, come and give me a hand. I'm going to do the next stump anastomosis."

"Yes."

In Cedieu's view, tumor cutting is the most difficult step, and the current suture is only the finishing work, so the mood is quickly relieved from Boris' death.His technique returned to the usual lightness and softness. At the same time, he also remembered Albaran's main task today:

"I remember you are going to the train station in the afternoon, right?"

"Yes." Albaran looked up and glanced at the auditorium. Seeing that he couldn't find Carvey, he said, "At the request of the Ministry of Foreign Affairs, I will go to the train station to pick up a guest on behalf of the hospital."

"I know, it's the surgeon hired by Edward who is domineering in Vienna." Cedieu chuckled twice, "If it was Watman or Ignaz, maybe I would go there, but no think"

Albaran held the duodenum in his hand and didn't know what to say: "He has already arrived at the hospital."

"Oh, just come, if possible, I really hope he can see this operation." Cedieu is very confident in his skills, "Although Mr. Boris' death was an accident, not everyone can do it." Do a gastro-intestinal anastomosis."

Albaran is just a young doctor who just graduated. He is not even considered a doctor here, he can only be an intern or an assistant.

In the face of the chief surgeon, he dared not say a word, let alone resist, because no one knew what changes his resistance would bring to the future.

While the audience was discussing a lot, a sentence in French with a slight German accent suddenly floated from the corner: "Professor Cedieu, I am watching from the auditorium."

(End of this chapter)