Start From Emergency Doctor

Chapter 199

Even if there is a mm gap, the incision will not fit perfectly, resulting in blood leakage.

When suturing the fascia, Zhou Yuan did not suture the incision of the deep fascia.

The blood vessels in the deep fascia are ischemic due to the operation to block the blood vessels. The muscles, nerves and other tissues that are supported by it have been ischemic for a long time. After the blood vessels are repaired and blood flow is restored, reactive swelling will occur. This leads to an increase in the contents of the interspace and increased pressure, which leads to compartment syndrome.

This is a disease with a vicious circle and progressive necrosis, which can be formed within 24 hours after the onset. After the onset, there will be obvious swelling and pain in the limbs, high tension in the deep fascial space, tenderness, and passive traction of deep fascial muscles. Pulling pain even produces clinical manifestations such as neurological dysfunction and physical signs.

The treatment method is to surgically incise the fascia to decompress. This is also the reason why Zhou Yuan retained the deep fascia incision.

After bypassing the deep fascia, Zhou Yuan sutured the superficial fascia layer by layer, and then used a drainage tube to draw the blood in the wound out of the body. Finally, with the help of He Jianyi, the upper limb was bandaged with an elastic bandage.

The next step is the highlight of the operation.

Zhou Yuan cut through the skin of his chest with a scalpel, exposing the heart.

There are two more steps before heart bypass surgery: establishment of extracorporeal circulation and myocardial protection.

Since Zhou Yuan chose the beating heart bypass surgery, only myocardial protection is required.

This step is not complicated. After the skin is dissected, the aorta is exposed, and then the aortic root is cannulated with cold cardioplegia at 4 degrees Celsius for retrograde coronary sinus perfusion.

The reason why conventional antegrade perfusion is not chosen is that the conventional anterograde perfusion of coronary arteries through the root of the aorta is not effective in protecting the ischemic myocardium at the distal end of the stenosis.

Especially in recent years, with the gradual expansion of surgical indications, a considerable number of cases have severe coronary artery stenosis, and cases of complete occlusion have also increased.

In this case, the long-used defect of anterograde perfusion of the aortic root on the ischemic myocardium becomes more obvious.

The coronary sinus retrograde perfusion, because the coronary venous system is a valveless pipeline, and can exchange materials with myocardial cells through capillaries and sinusoids, so it will not be affected by vascular stenosis.

Another point is that coronary artery disease generally does not involve the coronary venous system, so even if there is extensive coronary artery disease, the retrograde cold cardioplegia perfusion through the coronary sinus can still evenly enter the myocardium.

Most of the cardioplegia flows out of the coronary ostium through capillaries, and a part is directly drained to the right ventricular cavity through the The-besius sinusoidal vascular system. There is also a small amount of cold cardioplegia that flows into the left ventricular cavity through the sinusoid space, or The precardiac vein flows into the right atrium.

Laboratory observations have also proved that during retrograde coronary sinus perfusion, the distribution of cold cardioplegia in the left ventricle is better than that of the right ventricle, and the subendocardium is better than the epicardium. This situation is just suitable for myocardial protection. The important principle is to strengthen the protection of the left ventricle and subendocardium.

Therefore, Qian Wei, who has 80% coronary artery stenosis, obviously uses retrograde coronary sinus perfusion to be the best choice.

“Fluorocarbon cardioplegia.” Zhou Yuan shouted.(Read more @ wuxiax.com)

Zhou Yuan infused 800 ml of fluorocarbon cardioplegia along the catheter at the root of the aorta, and then handed it to the director of cardiology surgery, saying: “An infusion of 400 ml again every 20 minutes.”

“Ice chips.” Zhou Yuan said.

The instrument nurse took the medical icicles.

Zhou Yuan put some ice chips on the surface of the computer to cool down.

“The perfusion of fluorocarbon cardioplegia is complete.” The director of the cardiology surgeon’s voice rang again.

Zhou Yuan nodded, “Scalpel.”

“Exposure of the coronary arteries and start the selection of coronary anastomoses.”

Zhou Yuan glanced at the data of the radial artery vascular bridge measured by the director of the cardiology surgery, then picked up the scalpel and began to search for the coronary artery.

The coronary artery is below the epicardium, and He Jianyi has exposed it.

Zhou Yuan began to search for the lesions of the coronary arteries based on the lesions shown by the previous coronary angiography.

The selection and incision of coronary artery anastomosis is an important part of heart bypass surgery, and it is also the key to the success of the operation.

It is necessary to choose close to the stenosis or obstruction of the normal wall of the distal tube for anastomosis, because the closer to the proximal lumen, the larger the diameter of the blood vessel, and the more convenient it is to perform the anastomosis.

·········Ask for flowers···········

Soon, Zhou Yuan found the lesion near the end of the epicardium and marked the incision with indigo.

“Vascular clamp.”

He Jianyi was helping to expose the surgical field, so the director of cardiac surgery ran up to help Zhou Yuan stop the blood circulation.

When making a coronary artery incision, the lumen must be kept full, otherwise the blood vessels will become deflated and the anterior and posterior walls will stick together. When the anterior wall is cut, the posterior wall may be accidentally injured.

Zhou Yuan cut open the epicardium covering the blood vessel to expose the coronary artery inside, Zhou Yuan put down the scalpel.

“Little blade.”

The scalpel is too large for the coronary vessels, and the dissection of the coronary vessels requires the use of fine small blades.

Zhou Yuan pinched the small blade and used the tip of the blade to cut longitudinally at the central bank of the forearm of the blood vessel. After cutting the lumen, Zhou Yuan still looked at the blood vessel under the microscope, freed up one hand, and said, “Small angled scissors. ”

……… .. …

After receiving the small angulation scissors, Zhou Yuan made several cuts along the incision toward the distal and proximal ends of the coronary arteries to enlarge the incision.

In this step, the incision needs to be completely controlled in the center of the coronary artery. Once the incision is deflected to one side, the vascular anastomosis cannot be accurate, and adverse consequences such as bleeding will occur.

“Coronary artery probe.” Zhou Yuan said.

This is an instrument used to measure the diameters of the distal and proximal ports of the coronary arteries. It is also a unique surgical instrument in the Department of Cardiology and Cardiovascular Medicine. It is not used in general surgery.

After the measurement, Zhou Yuan made an 8mm incision, and the coronary vessel incision step ended.

In other words, the roadbed on both sides of the bridge is built in the vascular bypass surgery, and now there is one step short of connecting the bridge.

That is, the anastomosis of the vascular bridge is performed.

The diameter of the coronary arteries is small and the anastomosis operation is very difficult, so special microvascular devices are required.

The choice of sutures is also very particular. 6-0 sutures are generally used for anastomosing blood vessels with a diameter of 2mm or more, 7-0 sutures are used for anastomosing blood vessels below 2mm, and 7-0 sutures are used here.

Because the diameter of the coronary artery is very small, a slight pulsation of the blood vessel may cause the suture needle to deviate and penetrate the entire blood vessel, which requires extremely high requirements for the main knife. A.