Nineteenth Century Medical Guide

Chapter 435 431. Charming sphincter
After determining the entry point and administering general anesthesia, Landreth and Payon took out a thin rubber catheter and tape. They inserted the catheter into Little John's bladder, but because there was no water bag fixation device, they could only use tape to fix it to his head.

Kawi explained the first key point of the operation to everyone present: "I know that many surgeons are not used to inserting urinary catheters into patients. But whether it is a urological operation or not, urinary catheters have a certain guarantee. It can ensure that patients who cannot urinate normally under ether anesthesia can urinate normally, and it can also observe the loss of body fluids during the operation and replenish them correctly.
Of course, catheters are particularly important during urological surgery.

The patient has a recto-urethral fistula. If the fistula opens in the urethra, retaining the catheter will easily help us identify the location of the urethra during surgery, prevent damage during dissection, and protect the healing of the fistula anastomosis after surgery. However, there will be difficulties during the insertion process, and it is easy to enter the rectum through the fistula. Therefore, we insert a metal guide wire into the thinnest urinary catheter for children to ensure that the front probe enters the bladder. "

Peon and Landreth were not experienced in catheterization, and since it was a newborn, it was definitely not easy for them to manipulate such a tiny thing. They practiced on a boy's body dozens of times yesterday, but they still encountered some difficulties when it came to little John.

In order to cooperate with them, Kawi deliberately slowed down his hand speed and waited until cool urine appeared at the other end of the catheter before he began to cut the subcutaneous tissue: "Congratulations to Dr. Landreth for successfully overcoming the difficulties of catheterization for infants and young children."

"It's catheterization of a newborn baby with rectal urethral fistula." Landreth took a breath and emphasized, "This should be the first case in the world."

Kavi nodded, "From what I understand, yes."

"That's fine."

Landreth and Payon took off their gloves that were stained with paraffin oil, washed their hands, put on a new pair of gloves, and stood on the operating table.

After the catheterization, the control of the operation fell into the hands of Kawi again: "The second key point of the whole operation, and also the first difficulty, appears in the initial stage of the operation, how to correctly dissect the anal sphincter complex."

Sphincter is an old but somewhat unfamiliar term.

The discovery of the anal sphincter can be traced back to the 16th century, when only the structural concept of the external anal sphincter was proposed.

More than a hundred years later, Dr. Galen, who inherited Hippocrates's teachings, pointed out the movement of the muscles around the anus and divided the muscles around the anus into two layers of sphincters and two layers of levator ani muscles. This understanding was not broken until the 19th century.

After in-depth research by anatomists in the early 19th century, the detailed anatomical structure of the anal sphincter was determined, which is divided into three layers: subcutaneous layer, superficial layer, and deep layer.

The anatomical level ended here. In the nearly 100 years of medical history, there were few opportunities to apply this anatomical knowledge to anal surgery. It was not until the difficulties of abdominal surgery were basically solved and various surgical procedures for rectal cancer appeared, with anus preservation as a prerequisite, that the anatomical knowledge of the sphincter was brought back to the operating table.

Although the audience were all surgical masters and clinical experts who had a good understanding of the anatomy and physiological functions of the sphincter, many people became confused when Cavey added the word "complex" after such a term.

"What does complex mean?"

"How can a complex appear in a muscle that is divided into three layers and is specifically used to contract the anal canal? Are there other muscles?"

Cavi did not want to attack at a lower level, and he had no choice but to bring up the concept of the relationship between the external anal sphincter and the levator ani muscle, which was explained by a Mexican doctor named Pena more than a hundred years later. After all, the surgery he was doing now was a modified version of the Pena surgery. In order to ensure that Little John had normal bowel function after the surgery, and to promote this surgery to more children with rectal anal malformations, the sphincter must be explained clearly.

"I need to thoroughly dissect the external anal sphincter complex, drag the newly made rectal incision through the center of the muscle complex and suture it. When suturing, I try to restore the normal anatomical relationship between the rectum and anus, which plays an important role in controlling defecation after surgery."

From surgery, you can learn the thinking, the sequence of surgical operations, and the suturing techniques. These are difficult but can be overcome. Only the anatomical techniques are the most difficult to learn.

Everyone knows that dissection is about separation, but it is not possible to separate them completely. A simple verb can lead to two completely different results in different people's hands. Various bleeding, injuries, and even damage to anatomical structures all increase the difficulty of surgery.

So when the doctors in the audience heard that what was important was anatomy, or muscle anatomy, they all shook their heads.

Even if you stand next to Kawi, you can't learn this operation by just doing one operation. Not to mention the students and interns, even Landreth, who is closest to Kawi in the surgical field in Paris, never thought he could learn it in one go.

Kavi didn't feel that way. He just thought that with the help of electrical stimulation, the difficulty was moderate: "We must make sure to cut from the midline, the muscles on both sides of the incision must be aligned, the muscle layers must be aligned, and the number of muscle bundles must be equal. This separation process is also reshaping the anal opening. If the incision deviates, the repaired rectum will deviate from the center of the entire sphincter, affecting the postoperative anal control function to varying degrees."

As he spoke, he separated the muscles downwards and used an electrical stimulation probe to confirm the center of the intense contraction: "We need to carefully identify the course of each muscle bundle. If fat appears on one side during the muscle separation process, it means that the incision is biased towards that side and should be corrected in time."

The operation was carried out amid the noise of the intern's small generator crank, Kavi's point-like electric shocks, and Little John's butt twitching slightly from time to time.

The incision went all the way down, separating the sagittal fibers, the syndesmotic tendons, and the levator ani muscles. Using a spreader to separate the tissues, Kawi continued to expose downward.

According to his plan, if he was lucky, he could see the rectum swollen due to poor defecation by cutting the anal levator muscle. This meant that the fistula was in the bulbar urethra and the rectum was lower, so the operation would be easier.

If you are unlucky, the rectum is not exposed clearly enough and can only be found in the incision below the coccyx. This means that the fistula is in the prostate, which will further increase the difficulty of separating the rectum.

If the luck is even worse, that is, the rectum is further elevated and the fistula is opened at the bladder neck, the operation will be more difficult. To complete the anorectal surgery, not only a posterior sagittal incision is required, but also an open abdomen is required to separate the rectum from the bladder.

However, this operation requires a sagittal incision to create a space to accommodate the descending rectum, but there is no way to free the rectum from this position. The intraoperative trauma is large, and the postoperative prognosis is not good. The probability of autonomous defecation at the age of 3 is no more than 20%. This is modern data. In the 19th century, it is hard to say whether it could be 10%. In addition, due to the low weight, long operation time, and large bilateral incisions, Kawi was unwilling to perform this operation.

If that was the case, he would have chosen to close the incision directly and only make an abdominal stoma. When John grows up and his body can tolerate such major surgery, he can help him with reconstruction. Fortunately, luck was on Kawi's side this time. The rectum was located just below the coccyx and could be seen without much exploration: "Everyone, little John is lucky. The deformity is located lower than others, which reduces the depth and difficulty of the operation. Now the posterior wall of his rectum is right in front of me, showing a clean white color, which is very easy to identify."

Before he finished speaking, many doctors could not help but lean forward to look, and some even took out binoculars, hoping to see what the neonatal rectum looked like when the posterior sagittal incision was made.

The princes and nobles in the first row were also very excited.

Many of them had seen the complete autopsy process, and the incisions were basically made in the front. Even when dissecting the back and buttocks muscles, no one would cut the buttocks in half along the central axis. Excitement and novelty were the purpose of their coming here. The excitement was maintained by the smell of blood and various instruments that invaded the human body, and the novelty depended on Kavi.

"We use dye to mark the intervening muscle layers in preparation for suturing later."

Landreth used methylene blue to distinguish between muscles, and Kawi began to separate the fascia of the posterior and lateral walls of the rectum: "There is a layer of fascia-like dense connective tissue on the surface of the rectum, connecting the posterior wall of the rectum and sacrum S3-S4, which can be called the rectosacral fascia."

Kavi gently lifted the fibrous membrane and separated the rectum as close to the posterior wall as possible, but ensured that the posterior wall of the rectum was not damaged. The anatomical separation technique was so exquisite that only Landreth, who was very knowledgeable about anatomy and could observe closely, could deeply feel it.

As the chief of surgery, he had dissected many gastrointestinal structures, but he had never discovered that there was a dense membrane between the rectum and the sacrum. Because the posterior wall of the rectum had always been a place he had ignored, who would have thought of entering the abdominal cavity to find the rectum from this position?

"Dr. Landreth, prepare the sutures."

"Forehead"

Kawi focused all his attention on the rectum. After confirming the midline of the rectum, he sewed two silk threads on both sides. Then he cut the back wall of the rectum and officially entered the intestinal cavity: "When doing similar operations, you must pay attention to the rectal structure, touch the urethra where the catheter has been placed, and be careful not to damage the bladder."

Kavi continued to slowly cut the rectum distally, while Landreth and Payon worked together to sew more silk threads around the cut edge of the rectum. By clamping the end of the silk thread with a small hemostatic forceps and simply fixing it with the weight of the forceps, the intestinal cavity could be better exposed.

Many people in the audience didn't know why so many silk threads were sewn around the posterior wall of the rectum, but they also knew that now was not the time to ask questions. The entire operation theater was like a movie scene that had been paused, and everyone was holding their breath and looking at the operation area.

Kavi slowly asked about little John's physical condition while cutting open the intestinal cavity and separating the dense tissue around the rectum, trying to free the posterior wall of the rectum completely.

Until a fistula appeared in front of my eyes.

Although a mechanism for raising and lowering the chandelier was installed at the end of last year, and a new large chandelier that can hold 30 candles was installed, and an assistant for raising and lowering the chandelier was also assigned to it, the light in Kawi is still not ideal. The precision required for pediatric surgery and cesarean section is completely different. When it comes to the key points, you still need to ask for help: "Albarran, light!"

Albaran walked to the wall, took down the oil lamp, and placed it on the long metal hook next to the operating table.

"A little lower. Up. Yes, to the left. Okay, that's it."

The pole is specially made, with several joints to control the height and angle, and can be locked with bolts after the position is determined. Except that the brightness is not enough and it is troublesome to unlock and re-lock it, there are no major disadvantages.

The posterior wall of the rectum was completely opened, and with the help of the fairly reliable lighting, Kavi successfully found the fistula on the anterior wall of the rectum. It was a very small depression, with some dirt vaguely visible around it: "I can see the fistula now, and even the catheter inside the fistula!"

This is a phased victory, and the surgery is considered quite successful in the eyes of many people.

According to their expectations, the operation was successful as long as the rectum and urethra were separated, the fistula was blocked, and the rectum was pulled out along the incision and sutured. But Kavey did not do this, or what he did was completely different from what they expected.

It’s still the suture line, but this time it’s replaced by Kavi.

"Continue to sew silk threads above and on the sides of the fistula. You don't need too many, 3-4 will be enough." Kavi's hands were extremely gentle, but his hand speed was not slow at all. "The intervals between the suture positions should be even."

Many surgeons in the audience had only seen Kavey perform cesarean sections, and were impressed by his violent techniques for opening the abdomen, removing the placenta, and suturing the uterus. But now he handled each suture as gently as possible while ensuring his vision, just like a watchmaker handling tiny parts, not daring to make the slightest mistake.

Of course, they still don't know why ten silk threads were sewn into an area with a diameter of less than 5 cm and left without ligation.

Everyone was just shocked.

They all know how fragile the rectal wall of a newborn baby who is less than 3 days old is, perhaps even weaker than the Figaro newspaper?
To be honest, few people have tried it, and even if they have, they would not deliberately touch the rectum, because they can't even do rectal surgery on an adult, let alone a newborn. Soon, this technical gap beyond their own understanding made many people sit back in their seats, with various "wonderful" expressions on their faces, and then simply recorded the process in various ways in their notebooks.

With Kawi's explanation, they did understand the surgical process, gained a deeper understanding of the anatomy around the anus, and gained some knowledge of the key points of the operation.

But does this make sense? It makes no sense!
This level of surgery is completely different from the previous cesarean section. The layers are not so clear, and the anatomical position is quite complicated. Without dozens or hundreds of autopsies, they dare not go on the operating table. Even if they really dare to do it, will the parents of the child dare?
They feel sorry, but they can't do anything about it; this is reality.
However, the treatment of sutures is not the difficulty in Kawi's understanding, nor is it even the key point. The real difficulty is just beginning:
"The next step is to free the anterior rectal wall, which is the third key point of the operation, the second most difficult part, and the most difficult part. Because it is surrounded by the prostate and seminal vesicles, and the anterior wall is closely connected to the urethra, with only a 1-cm shared muscle layer, it cannot be clamped during freeing, and the surrounding important anatomical structures must not be damaged. So I chose sutures for traction."

After that, he took all the sutures in his hand, lifted them up gently, and then performed the dissection between the rectum and urethra.