Gou in the operating room to add some upgrades

Chapter 194 Operation and clinical thinking (please subscribe)

"Uncle Yun? What do you mean?" Fang Xian was puzzled, but paused.

"In the operating room of the trauma center of the Shonan University Affiliated Hospital where you were previously, there are many advanced operating instruments and supporting equipment that other hospitals do not have. Including the operating room of the trauma center of the Changshi No. 1 Civil Hospital where we are now, they do not have them either. What should I do with these devices?”

"If you only think that Professor Yang and Professor Zhou are the only two celebrities in the Shonan University Affiliated Hospital, then you are wrong!" Fang Yun continued to walk upstairs.

"Think about it carefully and don't frame the theory and basic skills to death."

"The theory must be memorized more firmly and profoundly so that it can be more flexible when applied."

Fang Xian frowned.

What should you do if you don’t have such useful things?
Make bricks without straw?

This was Fang Xian's first reaction.

The second reaction is, is Shonan University Hospital so conservative and selfish that it doesn’t spread good things to others?

No, equipment is not exclusive to hospitals. If these useful equipment were really practical, they would have been promoted across the country or even the world to make money.

The more income and tax paid by medical device companies in China, the cheaper domestic medical prices will be in comparison, and the more subsidies they can afford.If most medicines and equipment need to be imported from abroad, then prices will definitely remain high.

Obviously not.

However, now is not the time to think about this issue.

There must be some things that I haven't considered comprehensively.

Abdominal aortic pseudoaneurysm belongs to the third category of disease. The target mortality rate is equal to the partial damage. If you are not careful, the aneurysm may rupture, cause massive bleeding and cause death from shock.

However, the level of treatment development for this disease is obviously more sophisticated and mature than that of damage.

Few cases of pseudoaneurysm heal on their own, and the traditional treatment is surgery!
In the initial stage, the surgical treatment of pseudoaneurysm includes ligation of the parent artery, aneurysm resection and end-to-end anastomosis and vascular transplantation, and intra-sac vascular repair.

This is the most traditional and initial treatment method. It is a relatively simple treatment method. There are no specialist procedures, but it is based on the flexible application of basic skills such as incision and suturing.

Let’s save lives first and then talk about it——

First, ligation is performed to stop the bleeding, then the aneurysm is removed, and finally the blood vessel is transplanted, sutured, and the blood vessel repaired.They are all basic skills, which are further combined with the specialized skills of vascular surgery including vascular resection, vascular suturing, and vascular repair and reconstruction.

The patient can survive, and the postoperative recovery is barely okay, but this is obviously not precise enough, and the prognosis is not the best.

However, after further development.

Intravascular treatment uses detachable balloons, tungsten wire spiral coils to occlude the aneurysm cavity, the parent artery, or spring coils to occlude the parent artery.This is a further specialist skill, a specialist skill for pseudoaneurysm.

And if it is a huge pseudoaneurysm of the carotid artery adjacent to the subclavian artery that is difficult to treat with surgery or endovascular treatment alone, use a balloon catheter to temporarily block the parent artery through the lumen of the blood vessel, and then cooperate with open surgery. treat……

For relatively superficial external carotid artery pseudoaneurysms, after diagnosis, a puncture needle is used to directly puncture the aneurysm, and a spring coil or tungsten wire micro-spring coil is inserted through the puncture needle to occlude the aneurysm...

Of course, there is a bigger problem here.

The treatment principles for pseudoaneurysms and true aneurysms of the abdominal aorta are actually similar.

All are intracavitary repair procedures with covered stent placement.

Endovascular repair for the treatment of true and false abdominal aortic aneurysms has the advantages of less trauma, faster postoperative recovery, and lower incidence of complications. It has now become the preferred treatment method for true and false abdominal aortic aneurysms.

By placing a covered stent across the diseased site and fixing it on the normal artery wall at the distal and proximal ends, the aneurysm is separated from the normal blood flow and promotes the formation of thrombus in the aneurysm, thereby preventing the aneurysm from growing and rupturing.

Of course, there are more advanced treatment measures that are temporarily unavailable.

Fang Xian stopped talking nonsense and said, "Uncle Yun, would it be suitable to use a covered stent implanted into the cavity for repair?"

"Take this surgery apart." Fang Yun replied without hesitation.

Fang Xian was caught off guard: "Uncle Yun, wait a moment, I didn't know enough about vascular surgery expertise before, I."

The difficulty of such a surgical operation is at least level four. In the past, Fang Xian was a master of basic medical skills. How could he handle such a serious disease?

On the contrary, because the basic theory of vascular surgery was promoted to level 5 by Fang Xian, he knew that such a thing existed, so it took a certain amount of time to extract it.

"Don't be in a hurry. You can watch it first today, don't rush to operate it. Such a difficult technique cannot be accomplished overnight. You need to go deep into the more basic operations layer by layer -"

"This is your first time following me. I'll help you quickly break down this operation and this disease."

"First, it must be percutaneous access under ultrasound guidance or direct puncture into the left common femoral artery. This is the access and incision for the operation. Imagine!"

Fang Xian nodded, he could figure this out.

For any surgery, there must be an access and operating space before subsequent operations can be performed.

Of course, although Uncle Fang Yun said it simply, in addition to puncture, he will definitely need experience in operating surgical related instruments in order to be more comfortable and handy.

"And insert the left common femoral artery sheath, which can be 6-French or domestic. This is not important. This kind of arterial sheath has been available many years ago, but if you want to promote the treatment of this disease, In fact, revising the arterial sheath model is also an idea to advance the therapeutic effect."

“At the same time, we also need to expose the right common femoral artery through the inguinal incision for device placement.”

"Do you know why we need to continue to open the right common femoral artery?"

"One side is for vision, and the other side is for operations." Fang Xian replied without hesitation.

Fang Yun's dismantling of the surgery was very clear. Fang Xian's own theory was not bad and he responded immediately.

"The sheath is inserted into the right common femoral artery and an angled guidewire with a catheter is advanced into the abdominal aorta. A pigtail catheter is then advanced through the left common femoral artery sheath."

"Pigtail-shaped catheter, so named because the end is curled and the end is shaped like a pig's tail!"

"Time is running out! If you can understand it, digest it yourself. If you can't understand it, we will conduct a retrospective analysis later." As he approached the operating room, Fang Yun sped up his explanation:

"The right CFA was dilated over a stiff wire using multiple dilators and a 24-French sheath was placed."

"The stent graft implanted intrathecally in the ascending aorta was advanced through the 25-French sheath, and the stent was deployed in a conventional manner. The stent graft was deployed 15 mm proximal to the bifurcation of the left and right common iliac arteries and proximal to the origin of the innominate artery; the stent graft was deployed The stent was fully deployed. In this manner, the pseudoaneurysm was completely covered. No balloon dilation was required and the completed angiogram showed the device position…”

In order to speed up, Fang Yun replaced it with English abbreviation.

CFA is the common femoral artery, Fang Xian knows it...

After the two entered the operating room, the other surgeons had completed the preliminary preparations for the corresponding operation, including the placement of the left and right common femoral artery sheaths. After Fang Yun took over the operation, Fang Xian was still in a daze thinking about the danger of this disease. and prognosis.

Surgery is over.

Fang Yun ordered: "Now that I have filled the breach, and promoted coagulation, resection, and debridement of the peripheral hematoma, there is no need for me to do it myself, right?"

"No, Director Fang. Thank you for your hard work." The director who performed the surgery didn't know whether to laugh or cry.

He had tried this kind of operation before, but during the operation, he couldn't move smoothly and didn't dare to operate further. The result was good for Fang Yun. After he came in, he could divide three by five.

Just get rid of this operation, which is as difficult as level [-].

Fang Xian also looked at it in astonishment.

However, Fang Yun had already stepped down. Looking at Fang Xian's confused eyes, he knew that Fang Xian had not paid much attention just now.After Ke Ye took off his clothes, he patted Fang Xian on the shoulder and motioned him to go out, while saying: "The actual operation of this surgery is not difficult, because the stent graft has already packaged some important difficult operations. The most important thing is Position and put the bracket in place.”

"This is actually the positioning technique within the vascular sheath and the instrument operation technique. It is not particularly difficult."

"Now, we can continue to take a closer look at this case. As well as its current treatment status and prospects, you can see whether the development of medicine is embarrassing."

Fang Xian was helpless, but he still had a chance.

Maybe I have read all of Uncle Yun's operating procedures, but what I have learned is still limited. What I need is more points, rather than a real opportunity to teach.

Watching others with a bit of envy as they performed punctures and preparations for debridement, Fang Xian walked out.

Fang Yun continued: "Aortic pseudoaneurysm is associated with high morbidity and mortality, mainly due to a higher risk of rupture."

"During traditional surgery, pseudoaneurysm is a common postoperative risk after vascular surgery. It mainly comes from factors such as insufficient suture quality, surgical technique problems, or infection."

"Now, some patients whose treatment methods were accumulated in the past have become a new round of topics that require concern."

"If this patient undergoes traditional incision again, he may develop another pseudoaneurysm after surgery. After all, no one can absolutely guarantee the surgical technique and risks."

"But fortunately, the aortic aneurysm has an intraluminal stent in the abdominal aorta."

"Unfortunately, endoluminal stents in the ascending aorta, for example, are not readily available, so surgeons have to use thoracic and abdominal aortic stents to treat thoracic aortic pseudoaneurysms or other vascular aneurysms. "

"Did you find any problems?"

Fang Xian nodded: "Is it okay?"

"Yes!~"

Fang Yun also nodded and sighed: "The more you move forward, the more you will find that the essence of medicine seems to be to improvise everywhere, improvise all the time, improvise all the time, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise, improvise. Relatively adaptive or absolutely adaptive treatment methods appear..."

"The development of surgical techniques is like this: first use basic medical skills to deal with it, then use professional basic skills to deal with it, and then use professional skills to deal with it, until a one-to-one corresponding, standard, mature, and absolutely beneficial surgical technique appears."

"Even so, you still have to wait for the right medicine, the right equipment, the right placement, the right operating equipment, etc. to be handy. Then, the therapeutic effect of this disease can be expected."

"For now, in the entire medical field, the best prognosis is normal pregnancy. Currently, the mortality rate can be reduced to less than one in [-] or even less than one in [-]. In other areas, there is still room for improvement."

"But even if it's one in [-], hundreds of people die every year. One corpse and two lives. Maybe one is alive, but either the mother is missing or the child is missing. This is still the best..." Fang Yun said. Feeling, quite a bit pitiful.

Fang Xian did not grasp the problem and let it go directly, but asked: "Uncle Yun, if the abdominal aorta and thoracic aorta stent is used in the ascending aorta, what is the patient's prognosis? What is the difficulty during the operation? ?”

"TEVAR (thoracic aortic stent) and EVAR (abdominal aortic stent) stents require manual adjustment before each use to obtain the best results."

"But in most cases, even if you adjust the length of the stent; but you know, the ascending aorta is curved, and its curvature and various other key structures are difficult to adjust."

"In addition to the use of thoracic and abdominal aortic stents, other attempted endovascular treatments for ascending aortic pseudoaneurysms include the Amplatzer occluder device. The results of its use have been documented in case reports and some case series —Bittersweet.”

"If you make do, you can only have mixed joys and sorrows, but it cannot be perfect."

"So, you don't have to worry about your inability to make a difference in treating a disease like this. Everyone has this kind of time. In fact, the most painful one is Professor Zhou." Fang Yun suddenly said with emotion, but he was halfway through the sentence. , but he stopped abruptly.

"Professor Zhou?" Fang Xian turned his head away curiously.

Professor Zhou is so awesome and a perfect doctor, what else does he have to worry about?
Fang Yun turned his head and looked at Fang Xian: "You are Professor Gui's student, so there is no need to avoid suspicion."

"Actually, old Professor Gui Yuanping was able to fly to the west of Hexi many years ago, and he was quite peaceful. But somehow, Professor Zhou's skills were very high, and he was able to bring him back half way from the gate of hell..."

Speaking of this, Fang Yun's voice trembled slightly, as if that operation still shocked Fang Yun today.

But then, Fang Yun added: "But it's this half that has made Professor Zhou regret it for at least four or five years, maybe even longer, even for a lifetime."

"You don't have to wonder. Just think about the state that old Professor Gui Yuanping was in at the end. Did he have any quality of life?"

Fang Xianwen was silent.

"What if we could save him but didn't? Isn't that right? We can't get over this hurdle in our heart. Before it happens, no one knows whether we can recover better."

"Yeah, no one knows..."

"But Professor Zhou just can't get out." Fang Yun shook his head, feeling a little sad.

"Is it impossible that Professor Zhou knew in advance? If he knew in advance, he would definitely not perform the surgery." Fang Xian asked confused.

"Of course I won't know. Forget it, I don't want to think about it anymore."

Fang Yun looked at the time and then said, "Fang Qi'an will be out of school for a while. Let's continue to dissect the case just now. You can use it as an analogy to move forward."

"The development process of treatment of pseudoaneurysm is actually a reference for the advancement and advancement of treatment methods for all diseases. It is not the first reference, but it is also one of the classic diseases."

"The current difficulty lies in the fact that there are no breakthrough new devices or breakthrough new technologies. However, the treatment methods for single diseases have already developed quite maturely, and the postoperative recovery rate and prognosis are very worth looking forward to. If we want to Going a step further, it is a high-level medical exploration, and it is not of great significance in terms of treating diseases."

“It’s just about improving the quality of life.”

"Life and death, disease treatment, survival, and improvement of quality of life are some issues that cannot be avoided in the medical field, and they are also the purpose of every technological development."

"The devices used in the abdominal aorta and thoracic aorta are not actually the most suitable or perfect when used on the aortic arch."

“Therefore, the more professional the content, the narrower its scope of application, and the more basic the content, the wider its scope of application.”

"But if the scope of application is wide, part of the therapeutic effect will definitely be sacrificed. At present, the medical community has not yet found a suitable solution, but you should probably have such a framework in mind."

Fang Xian nodded when he heard the words. He had also been popularized before. The reason why basic medical skills are paid special attention to is because they are highly malleable and have a wide range of uses. Because basic medical skills are often used to save lives. .

Simple and crude, refined just to save lives.If each one is used well, it can save someone's life at a critical moment.

But if you want to cure a disease?
It depends on how you define treatment: "Uncle Yun, I have a question."

"Can't all diseases be treated with other technologies or other equipment?"

"I think it's inappropriate to characterize it like this, right?"

Fang Yun tilted his head and looked at Fang Xian: "The fact that you have such doubts proves that you are thinking very seriously——"

"Actually, whether you can borrow other technical concepts and operating methods to adapt to this disease depends on how you recognize the disease, the sequelae of this disease, and how you treat it!"

"Let me give you a very simple example."

"Vitiligo in dermatology is a stubborn disease, right? There is currently no absolutely effective treatment plan."

"But it itself is not very harmful to the patient's body. If you try it with drugs used to treat other dermatological diseases, it may or may not be useful. This is a question worth exploring."

"However, if it is a disease like aortic dissection, if you don't go to a specialist to develop it, how dare you borrow the equipment and operating procedures for lower extremity arterial dissection to treat aortic dissection?"

"Of course not."

"Oh!" Fang Xian suddenly realized.

Whether to find the most suitable treatment method and treatment plan, in fact, the most important thing is to see the severity of the disease on the patient's body and whether it causes damage to life and function.

(End of this chapter)