Chapter 178: Extremely difficult clamping, Xin Su strikes again
Generally speaking, choosing an intercostal incision, or an incision in the neck, below the sternum, and in the abdomen is gentler than this method.
However, when formulating a surgical plan, the doctor will take all aspects into consideration.
The chest must be opened from the front, and it must be opened.
The risks and possible sequelae will be explained clearly to the family members and patients before the operation.
The diameter of this patient's aneurysm was more than 5.5cm, which was extremely dangerous. It had severely compressed the surrounding organs, causing great physical pain to the patient.
The most direct and quickest way is to open the chest in the middle.
Director Xue methodically directed her three assistants to perform thoracotomy on the patient. She performed the critical high-risk parts herself or instructed one of her assistants to do so. The surgical team she led was quite strong.
Even Dr. Long could only barely get the position of third assistant.
Ichisuke seemed to be older than Director Xue, with a lot of white hair on his temples, and gray hair that had spread to the top of his head. He had relatively few wrinkles.
Being a doctor is a very stressful and high-risk profession, and premature aging has almost become a common phenomenon.
Many people have gray hair after completing their medical clinical studies.
In addition, the evaluation of doctors' professional titles never takes age into consideration. As long as the length of work meets the evaluation standards, and academic, surgical volume, written examination, scientific research achievements and other aspects meet the evaluation requirements, they can apply for review.
Some talented and hardworking doctors can be promoted to chief physicians at the age of 42.
Some people, however, may be stuck in one aspect, or fail to meet the requirements in many aspects, and are still working as attending physicians when they are nearly sixty years old.
This first assistant is at least five or six years older than Director Xueyan.
It was quite scary to see him swaying a bit as he was sawing open the sternum.
"Remember this, because this aneurysm is close to the sternum, you need to skillfully swing the sternum saw when sawing through the sternum to avoid tearing the aneurysm wall and causing heavy bleeding."
While directing an assistant to saw open the sternum, Director Xue explained the key points of the operation to other junior doctors.
After hearing this, Zhou Can suddenly realized.
I thought Ichisuke was old and his hands were unsteady.
It turned out that the sternum saw was swung deliberately and consciously.
Being able to become an assistant and gaining Director Xue’s high trust, he is indeed very capable.
These valuable experiences were summarized by our predecessors through lessons learned through blood.
After opening the chest cavity, the huge aneurysm could be seen.
It must be pointed out that aortic aneurysm is a vascular wall lesion that occurs due to various reasons and causes damage to the normal structure of the aortic wall, resulting in local bulging outward to form a tumor-like expansion.
It's not a real tumor.
The nature of the two is also completely different.
The greatest danger of an aneurysm is rupture, causing massive bleeding.
In addition, when it continues to grow and compresses the surrounding organs and tissues, it will cause great pain to the patient. If it is an intracranial aneurysm, it is even more dangerous. If it compresses any important nerve, blood vessel, or brain tissue, it may cause serious problems.
Whether benign or malignant, tumors replicate themselves crazily, destroy the body's immune system, and invade normal cells and organs throughout the body.
Tumors also present the problem of compressing surrounding organs.
The largest liver tumors can even occupy most of the chest and abdominal cavities.
"Director Xue, this aneurysm is located on the brachiocephalic trunk, very close to the ascending aorta. Do we need to prepare for establishing extracorporeal blood circulation first?"
The anesthesiologist for this operation was Dr. Guan.
He has the integrity of an anesthesiologist and usually keeps silent and does not interfere with the surgeon's operation.
This reminder will only be given when it is believed that there is a great risk during the operation.
Ascending artery aneurysms are not suitable for interventional surgery.
The common treatment method is excision and replacement with an artificial blood vessel.
Director Xue chose to clip the aneurysm instead of removing it, probably because of the huge risks involved in the vascular replacement process.
Even today, when the technology for ascending artery replacement is very mature, the mortality rate is still as high as over 10%.
If the surgeon has a poor technical skill or some accident occurs during the operation, the mortality rate will be even higher.
After listening to Doctor Guan's reminder, Director Xue hesitated for a moment before saying, "Establishing extracorporeal blood circulation requires systemic heparinization and femoral artery and femoral vein cannulation, which will cause certain physical harm to the patient. Because it is just a clipping operation, the risk is relatively small, so let's not make this preparation for now!"
She has her considerations.
This is not to save trouble, but to consider the patient's perspective.
It can save patients surgical costs and avoid harm to their bodies.
Doctor Guan said nothing more and the operation continued.
Zhou Can discovered that the aneurysm was located in a very bad position, at the junction of the brachiocephalic trunk and the ascending aorta.
How to say it, the ascending artery and the aortic arch are like a round arch, and then three important branch arteries are separated from this arch: the brachiocephalic trunk, the left common carotid artery, and the left subclavian artery.
These three branching arteries are very interesting.
The left common carotid artery and the left subclavian artery both branch off directly from this arch.
However, the right common carotid artery and right subclavian artery branch off from the brachiocephalic trunk.
The right common carotid artery is slightly higher.
From here, we can see that the brachiocephalic trunk is equivalent to the integrated trunk of the two branch arteries on the right. Its blood supply is very large.
It can be thought of as half of the total amount of blood pumped by the heart.
Not to mention the ascending artery.
Equivalent to the arterial assembly.
The location of this aneurysm is very special, and clipping surgery is extremely difficult.
Some highly skilled doctors particularly like to challenge this type of surgery.
Zhou Can currently does not know Dr. Xue’s specific treatment plan.
Since it is a clipping operation, even using three clips may not be able to completely clip this particular aneurysm.
Also, when such a large aneurysm occurs, it is usually accompanied by hardening of the blood vessel wall and spots.
The best treatment is resection and replacement with an artificial blood vessel.
"Although this aneurysm is somewhat special, I have successfully completed aneurysm clipping surgery at the intersection of blood vessels before. Now the surgical field of view is sufficient, and the difficulty of the operation will be relatively reduced. If the operation is done well, two artery clips are enough to complete this clipping operation. Director Lu, you will use the temporary blocking clip to temporarily block this section of the blood vessel."
While making arrangements, she repeatedly selected the appropriate aneurysm clip.
This type of clip comes in a wide variety of styles and sizes, sufficient to meet all aneurysm clipping needs.
It can be seen that Director Xueyan is very steady in doing things.
Not only did we select two of the most suitable aneurysm clips, but we also prepared three more to be used for remedial measures in case of accidents.
“Let’s get started!”
She motioned to Ichisuke.
"Doctor Guan, is it okay to block it for about a minute?"
She asked the anesthesiologist for advice.
"Of course. But it's quite difficult to complete the clipping operation within one minute. And there's no extracorporeal blood circulation pathway established, so I feel a little uneasy."
Dr. Guan is still full of worries.
Experienced anesthesiologists often experience many surgical accidents.
There are many unpredictable risks and accidents often happen in an instant.
He has seen too many surgeons who were full of confidence before surgery, but ended up with accidents during the operation, putting the patients in extreme danger.
"It's okay, a minute will pass quickly. Don't worry!"
Director Xue comforted him.
The surgeon had already said this, so Dr. Guan didn't say anything more.
There was only worry between his brows.
"Block it!"
She signaled to Ichisuke again.
He is several years older than her and was under her command during the operation, which means that Director Lu should be an associate chief physician.
Deputy Director Lu operated the temporary blocking clamp to precisely block the junction of the ascending artery and the brachiocephalic trunk.
This operation is quite difficult and tests the doctor's skills.
He successfully completed the proximal block.
Next, the upper end of the brachiocephalic trunk is also temporarily blocked.
This is equivalent to framing the aneurysm, preventing effective blood flow from entering.
This is equivalent to completely cutting off the blood supply to this section of blood vessel, ensuring that Director Xue's aneurysm clipping process is safer.
The two sides cooperated very well.
Director Xue’s operation was also very precise.
It took less than ten seconds to complete the first clipping task. But when placing the second aneurysm clip, it didn't seem to go as smoothly as she expected.
The location itself is quite special, and if the blood supply to the entire aneurysm cannot be blocked, the treatment effect cannot be achieved.
Therefore, placing the second clamp is the most difficult.
One minute is a very short time.
She kept adjusting but could never achieve satisfactory results.
At this moment, it is equivalent to letting the patient's whole body blood
There was no other way. Seeing that the time was up, she could only place the second aneurysm clip first.
"Try to clear the blood first! If it doesn't work, adjust it again!"
Cutting off the blood supply for too long is very dangerous.
Any part of the body that is ischemic will have cells die rapidly, and if it lasts a little longer, a large area of tissue will become irreversibly necrotic.
After the blood flow was cleared, everyone stared at the clipped hemangioma nervously.
The blood pressure on the main road is very strong.
As soon as the blood is circulated, it starts to circulate again at a very fast rate.
Most of the aneurysm was clipped, but some were still missed.
Blood was forced into it, and the aneurysm seemed to be growing larger.
After seeing this situation, Director Xue did not panic, but observed the gap in the clamping position very calmly and thought about a solution.
“Maybe you need to use three clamps!”
She seemed to be talking to herself, or discussing with other doctors.
"Using three clamps is indeed safer and easier to operate. Director Xue is sometimes too kind and considerate of the patients."
Ichisuke agreed with her opinion.
I admire her character very much.
From what she did during the operation, it can be seen that she was thinking about the patient at every turn. She took all the risks herself.
It is said that appearance is determined by the heart.
She has such a good temperament and is still very beautiful in her forties, which is enough to show how kind she is.
Using one less hemangioma clip can save patients a lot of money.
"This patient's family burden is quite heavy. He makes a living by delivering takeout food and his wife is blind. They belong to a vulnerable group, so we will help them if we can," she said.
The poorer the family, the more likely it is to suffer from serious illnesses.
Some diseases are caused by saving money, and some diseases are caused by overwork.
Poverty makes them put off treatment for illnesses, and they are reluctant to go to the hospital for checkups. They are reluctant to throw away food that has already gone bad. In addition, they have a terrible working environment and work hard without regard for their health, which makes it easy for them to get some serious diseases.
The world is not all about beauty, there is also suffering.
After a short rest, the blood vessel is blocked again and then clipped.
It should be mentioned here that it is not necessary to block the blood vessels before clipping can be performed, but surgeons generally strictly follow the relevant procedures for safety reasons.
“Beep, beep…”
Not long after the signal was blocked, the life monitor sounded the alarm.
The patient's heart rate plummeted, accompanied by ventricular fibrillation.
Dr. Guan was panicked.
"It must be the continuous blockage of blood supply that induced the cardiac arrest during the operation. This is a big problem."
This is the first time I see Dr. Guan so panicked.
This shows that the problem is extremely serious.
Director Xue's face turned pale, and there was obvious palpitation and panic in the depths of her eyes.
This happened so suddenly.
Women are not suitable to be surgeons. Besides being physically weaker than men, their mental qualities are also generally much worse.
When faced with emergencies, fear can easily make them lose their minds and the ability to think and judge.
Deputy Director Lu frowned and looked serious.
The other medical staff all looked nervous.
The most feared thing during surgery is some unexpected accidents, because the consequences are often death.
"Doctor Zhou, please help me insert the extracorporeal blood circulation tube."
Dr. Guan had no choice but to ask Zhou Can for help again.
Cardiothoracic surgery is often accompanied by high risks, and various dangerous situations may occur almost every day.
What can be prevented can be prevented, and what cannot be prevented can only be resolved by the concerted efforts of medical staff.
Therefore, a strong surgical team is very important.
They can cooperate well in handling all the difficult surgical parts of the operation and help patients survive the danger together.
"Who is Dr. Zhou?"
Director Xue was a little confused because there was no doctor named Zhou in her surgical team.
Then, she saw the intern who was punished by Dr. Zhao to clean the operating room walked quickly onto the operating table and quickly established an extracorporeal blood circulation channel for the patient with very professional and skillful movements.
If Director Xue could personally perform the femoral artery and vein cannulation and complete it in ten minutes, it would be a very good performance.
But Zhou Can only took less than thirty seconds.
It's really shocking.
She seemed to see the legendary Sweeping Monk reappear.
"Doctor Guan, please perform pericardial compression immediately! Otherwise, the patient's brain will soon suffer from ischemia and necrosis." Zhou Can urged Doctor Guan.
He learned various rescue knowledge and techniques from several chief physicians in the Department of Critical Care Medicine.
When faced with an emergency like this, it immediately comes in handy.
"OK!"
Dr. Guan had actually asked the nurse to put on gloves and prepare to perform pericardial compression.
If cardiac arrest or ventricular fibrillation occurs during open-chest surgery, it is extremely dangerous.
If effective and precise rescue measures are not implemented immediately, the patient will die soon.
Zhou Can then calmly began to perform the work of inserting the superior and inferior vena cava catheters, regardless of the extremely shocked expressions of the others as if they had seen a ghost in broad daylight.
Only Dr. Long, who had seen Zhou Can's skills, remained calm.
Because he already knew that Zhou Can had extraordinary abilities.
The most shocked person was Dr. Zhao.
He really never dreamed that this resident intern whom he looked down upon would be so amazing. The various intubation operations completely refreshed his cognition.
"Who is this?"
Deputy Director Lu was shocked and asked the doctors around him.
His eyes first turned to Dr. Zhao.
Because when he came in, Dr. Zhao said that he was the one punishing Zhou Can to clean here.
Doctor Zhao was just a resident at the bottom of the cardiothoracic surgery department, and he didn't know much. How could he know Zhou Can's background? He was also confused.
He stammered, "He, he is a resident who just rotated to our cardiothoracic surgery department today."
"Can a trainee be so amazing?"
Deputy Director Lu didn't believe it at all.
"What's his name?"
"It seems to be... Zhou Can, yes, it's Zhou Can!"
Doctor Zhao only remembered that Zhou Can's surname was Zhou, and it took him a long time to remember Zhou Can's first name.
"Ah...it turns out to be him, no wonder he's so awesome!"
Deputy Director Lu is much more informed than Doctor Zhao.
He had heard of the name of the trainee student Zhou Can a long time ago.
It is said that this intern creates a huge wave every time he enters a new department for training. His strength and talent are so great that even Vice President Ye is alarmed.
It is said that Director Xie of the General Surgery Department tried to recruit Zhou Can several times, promising him various extremely high salaries, but Zhou Can refused every time.
The chief doctors in the departments where Zhou Can worked were full of praise for him.
Such a strong intern was punished to clean the operating room on the first day of his rotation to the cardiothoracic surgery department. Dr. Zhao is so ignorant.
When Director Xueyan heard Zhou Can's name, she subconsciously shifted her gaze away from the patient's pericardium and looked at Zhou Can.
"Doctor Guan, shall we establish extracorporeal blood circulation now?"
"certainly!"
Doctor Guan answered while pressing the pericardium.
He didn't dare to look up or away.
Chest compressions during CPR are protected by the entire rib cage of the chest. During thoracotomy, only the pericardium can be compressed urgently.
It's like pressing directly on the heart.
The danger is self-evident.
"I think the patient should be given vasoactive drugs immediately!"
While operating and establishing extracorporeal circulation for the patient, Zhou Can also made suggestions.
"Yes, yes, yes, I almost forgot about this. Director Xue, please arrange this matter immediately. I can't get away from here."
Dr. Guan was quick to accept Zhou Can's suggestions.
Even if Director Xue was stupid, she could see that Zhou Can held a special position in Doctor Guan's mind. Moreover, he was extremely powerful. In a very short time, he had already prepared for the establishment of extracorporeal circulation.
And every suggestion is very accurate and to the point.
What is reflected is Zhou Can's comprehensive rescue capabilities.
"It's a good thing we have Dr. Zhou to help today, otherwise it would be difficult to save the patient." Director Xue's evaluation of Zhou Can in her heart rose to an extremely high level.
It was also a glimpse into Zhou Can's true abilities.
Seeing is believing, hearing is not.
After witnessing Zhou Can's series of extracorporeal circulation establishment operations with her own eyes, she felt that Zhou Can was even more capable than the rumors said.
