Nineteenth Century Medical Guide

Chapter 436 432. Sometimes you need to take the initiative to make mistakes
Unlike the surgeons behind him who were sometimes excited, sometimes sighing, and sometimes jumping in anxiety because they didn't have time to record but dared not jump too loudly, those in the first row showed very stable emotions about Cavi's operation.

Many people came out of curiosity and to show off their status, such as Grand Duke Vladimir and Ortans, and Venice on the other side.

Some were not interested in the operation, but came just for the people, such as Osman and the Prince of Wales. The former was concerned about the safety of Shirina's son, and the latter was concerned about Kavi. Of course, Venice's excited and frightened expression was also one of the motivations for Bertie to spend 9 francs.

Some are a little more complicated.

"Dear, what do you think of Dr. Kavi's skills?" Mathilde glanced at the center, then immediately turned to Rochester beside her and asked in a low voice, "Even Louis said that his technique is excellent. Look at those slender and flexible fingers and the silk thread. Don't worry, I just think his skills are first-class, that's all."

Rochester had been smiling since he entered the door, and he had been watching every step of the operation carefully since the beginning. When the princess called him, his tone of reply was a little different from before, and it was much gentler: "I don't know, I don't understand these, but I know you are doing this for the future of both of us."

Mathilde, once the queen of Parisian social circles, has reached her age now. She has become accustomed to the ups and downs of love between herself and others, and always feels that this thing no longer matters.

But now she had to admit that she was still moved by such "sweet words". She held the hem of her skirt tightly with both hands, not wanting others to see her inner feelings, but a happy smile appeared on her face that she could not help but smile.

She didn't speak immediately, but waited for the doctor behind her to sigh before she said, "After this operation is over, I will go to see Dr. Kavi. You should come too, and let's set the time for the operation together."

"Didn't you say in two weeks?"

Rochester seemed to be stimulated by something, but soon regained his rationality. "What I mean is, since the time has been set, don't change it. Dr. Kavi is also very busy."

Mathilde didn't notice his change in mood. She squeezed his hand up and down tightly, like she was holding a beef patty. "Don't worry. As long as you are willing, it's okay to delay the operation for a few more days."

Rochester nodded, without pulling his hand away, and returned to his previous focused state: "That's good."

Compared to the two who were careful about the volume, Grand Duke Vladimir didn't care so much about surgical etiquette. However, his words were mostly one-sided, and Ortons beside him had no interest in surgery and even felt a little disgusted.

Since she entered the scene, she has only made simple responses and has never said a complete sentence.

But this does not mean that Orthu is in a bad mood. On the contrary, she is very excited, so excited that her heart is about to jump out. For this actress and the world's second soprano singer, being able to appear in public with a prince is already enough to attract attention.

At the age of 19, she now even imagines herself as the wife of some important person, just like she played in Offenbach's "Duchess Groshstein".

Of course, none of this can be revealed.

She had just entered the social circle, and she used the most shameful means. Sitting next to her were the mistress and cousin princess of the three emperors. She was young and of humble status, and she was already giving Grand Duke Vladimir a great deal of face by not being driven away. If she dared to speak nonsense again, she would really violate the taboos of the upper class, and she would never be able to gain a foothold in Paris again.

Compared to the much younger girl, Venice on the other side was much more at ease.

29 is the age when beauty begins to decline, but charm rises greatly. She is not as immature as Hortans, who is as immature as a sour fruit, nor is she as bloated as an old princess, who is as bloated as a peasant woman in Corsica, the ancestral home of the Bonaparte family.

Venice really likes anatomy and surgery, and was very excited about a scalpel used to perform fistula surgery on Louis XIV. In her eyes, the sharper the knife, the more it reflects Louis XIV's strong willpower.

The surgery that Kavi was performing in front of her fascinated her even more: "What did Dr. Kavi just say? Rectosacral fascia?"

Bertie was a little surprised and stared at her for three seconds. He really didn't expect that this woman had such a strange hobby: "Uh, maybe."

“That’s such a cool word!”

"is it?"

Venice twisted her waist, half leaned forward, and asked enthusiastically: "Don't you think this strange professional vocabulary sounds oppressive?"

Feeling of oppression?
"There are words that respectable women cannot and will not utter until their death, ranging from obscene nicknames to strange terms of human anatomy and biology, but Venetia, who was not of noble birth, enjoys them all.

Bertie immediately found a few troublesome military and political terms in his mind. At least in the military, these terms are very troublesome. Just as he was about to say it, he held it back: "Medical terms are indeed difficult to pronounce. There is a strange feeling that 'the more difficult it is to understand, the more stylish it feels'."

"Yes, that's it!"

Venice leaned in closer, revealing the design flaws of the operating theater chairs, as if she knew what she was talking about. If there were a customer survey here, she would definitely put "love seat sofa" first.

This was not entirely done to get closer to Prince Bertie, but more to fight back against the neglect that Na San had given her during this period.

Jumping from the French emperor to the British crown prince heir must be a scandal that would shock the upper class. What she lacks now is scandal. If she can still be surrounded by scandals at this age, it is enough to show that she is still charming and can firmly sit on the throne of the Queen of Paris.

It's just that sometimes the vulgarity in her bones that lacks education would suddenly jump out, covering up her beauty, figure and all her advantages, making people shudder with fear: "Look, Your Highness, he has pulled out his intestines!!!"

Everyone turned their eyes to the Queen of Paris.

Bertie laughed, not because Venice was embarrassed, but because of Kavi's incredible expression when the operation was suddenly cut off at its climax: "Did you see that, Leighton? He was stunned. Even Dr. Kavi, who can deal with all kinds of emergencies at any time, was stunned. Hahahaha."

The words were whispered, but the body language spoke volumes.

"Cough cough."

Cavi couldn't criticize Venice too much, let alone Bertie, so he could only smile and remind her: "I'm easily distracted and easily influenced by the outside world. The operation is wonderful, but please remain restrained." This little episode soon calmed down. After all, the surgeon was not those reporters, and the attention soon returned to Cavi's hands.

But Venice felt humiliated.

She wanted gossip and the throne of the Queen of Paris, not scandal and this single chair that was watched and laughed at by hundreds of eyes. She wished she could leave this seat now and disappear from their sight in an instant.

"Don't worry, honey." Bertie stopped laughing and patted her cold hands affectionately. "Look at everyone's expressions. They were as stiff as sculptures just now, but now they look much softer. Your enthusiasm melted the cold operating theater, honey."

"is it?"

"of course."

Bertie comforted her, and at the same time thanked Carvey in his heart, thanking him for letting him see this woman clearly. At least he was not interested in spending a night with such a woman now, maybe in a few years, when he figured out the routine of upper-class ladies, he might have some ideas about her.

But by then, how much charm will Venice have left?

Let's talk about it later.
Kavi naturally didn't know about their little thoughts.

The operation reached a critical moment, and the shout just now almost scared him to the point of tearing the traction line. After checking again and finding that there was no problem, he continued to separate the rectum and urethra.

"When we do the separation, we must not only look at the muscle layer between the anterior wall of the rectum and the urethra, but also observe the side wall of the rectum to avoid any traction injury until the rectum and urethra are completely separated."

Kavi gently lifted the rectum with one hand and separated it with the other, while asking Landreth to hang the fistula with a silk thread:

"This part of the anatomical separation is the most delicate part of the whole operation, especially at the beginning, which needs to be performed close to the anterior wall of the rectum. Newborns are small, and little John is a low-birth-weight baby. The so-called anatomical gap between the rectum and the urethra does not exist at all under naked eye observation. If you lack experience, you will often make mistakes in the operation, and once the operation goes wrong, it will cause many serious complications."

What is more serious is that due to the fear of damage and the anatomical structure here, fearing that it will affect the pelvic nerve plexus hidden in the connective tissue around the anterior wall of the rectum, the patients do not separate it enough or simply give up separation and forcibly pull out the rectum, causing deformation of the urethra and the formation of a diverticulum.

"If you are lucky enough to perform this kind of surgery in the future, don't be afraid, and don't be afraid of making mistakes. It is inevitable that you will find it difficult at the beginning, and if you are afraid of making mistakes, you will never do it correctly. I suggest that instead of being afraid of making mistakes, you should take the initiative to 'make mistakes' and directly separate the rectal submucosal layer, leaving part of the rectal wall muscle layer on the side wall of the urethra. This is better than damaging the urethra and surrounding nerves."

While performing the separation, Kawi made a suggestion that was very suitable for other doctors. He asked Landreth to suture and close the upper fistula, and then suture and embed the tissue around the fistula to prevent the recurrence of urethral fistula.

He showed his own anatomical separation results: "Of course, what I am demonstrating here is the normal separation method."

Even Kawi, looking at his newly completed work, still laughed, which was rare. After heaving a sigh of relief, he also joked: "Now it's time to really lift the rectum."

The operation lasted for more than an hour, and halfway through, laughter broke out in the theater. Kavi took advantage of this break to ask about the patient's vital signs and give instructions for the second ether anesthesia, giving the patient some rest time: "Next, we'll continue with the rectum."

"And you have to deal with the rectum?"

"Isn't the rectum separated?"

The short break helped many people regain their spirits, and the depressed mood just now also dissipated a little, and questions began to appear. Kawi still adhered to the principle of surgery first and questions later, and motioned them to be quiet first: "You can take a look at the inner diameter of Little John's rectum. Is it different from the rectum of the children's corpses that we usually see?"

“Is there rectal dilatation?”

"It is indeed larger than the rectum diameter of an average child."

"But it's just a simple expansion. Do we need to deal with it?"

For this kind of situation that requires a lot of surgeries and postoperative follow-up feedback, Kawi can only inform the risks and has no way to explain more: "If there is only rectal dilatation, it does not need to be treated as long as it is not serious. But if there is anal atresia, reconstruction of the anus will cause anal stenosis. At the same time, the sphincter nerve reflex also needs time to recover. The combination of these three conditions will cause severe constipation."

"I see."

"That's very thoughtful."

Cavi lifted the rectum, made a simple narrow incision, and then used methylene blue to make a cutting line on the outer wall of the rectum: "Little John's rectum is quite dilated, so make a wedge incision and remove part of the posterior wall of the rectum in full thickness. Remember! Do not cut the anastomosis of the anastomosis wall, otherwise the suture line of the anastomosis will be close to the urethra that has just repaired the fistula, which can easily cause the recurrence of the urethral fistula."

The cutting and suturing of the rectum were given to Landreth and Payon. By suturing the intestinal wall in two layers, the inner diameter of the rectum can be reduced to 1-1.5cm, making it a normal funnel shape that is wide at the top and narrow at the bottom.

Kawi continued to use electrical stimulation to re-determine the ends of each muscle fiber, including the front and back boundaries of the anal sphincter. After comparing with the previously made marks, the center of the sphincter was determined. Then, the anastomosis point of the anal sphincter boundary was made with sutures and marked with sutures.

"After using electrical stimulation to determine the posterior edge of the levator anus muscle, place the rectum in front of the levator anus muscle, and then suture the posterior edge of the levator anus muscle with interrupted sutures." Kavi handed a bundle of sutures from the rectal fistula to Peon, and after giving him a few words of warning, he and Landreth put the rectum in the right position. "When suturing, the muscles can be brought up to the posterior wall of the rectum to fix the rectum and prevent retraction and prolapse after surgery."

"Of course, banding the posterior rectal wall is just banding, it doesn't have to be sutured." Cavett missed a few stitches and warned, "This is how surgery works. If you don't do it, it will be unstable, but if you do it too frequently, it will cause rectal stenosis."

The second half of the operation is all finishing work. There are not many processes, but each step is extremely tedious, which tests the experience and anastomosis skills of the surgeon and the assistant.

When the cut layers of muscle and tissue were carefully sutured back together, Little John's butt was restored to its original state, and a brand new anus appeared before everyone's eyes.

Use the thinnest absorbable suture to make a circular suture around the new anus. After the suturing is completed, cut off the damaged and poorly blood-supplied rectal edge, and finally leave a thin steel tube to prevent adhesion.

At this point, the world's first posterior sagittal approach sacroperineal anoplasty was completed.