162. The troops are divided into two groups

From the 18th century with a more reliable surgical operation to 1866 where Kavi is now in, breast cancer treatment underwent total mastectomy, total mastectomy + dissection of lymph nodes, and joint resection of whole breast + axillary tissue. The doctor's problems have always been about how to cut and how much to cut.

Because of the high recurrence rate of breast cancer, doctors can only expand the scope of resection as much as possible. This method of nicotine does not miss it is indeed effective. The recurrence rate for surgical treatment of early and mid-stage tumors was once lower than 10%, which also established the status of radical surgery in breast cancer resection surgery. [1]

I have to say that Austria's understanding of breast cancer surgery was always at the second and third level.

As early as 1852, the United States had the concept of lymphatic dissection. Now German doctors have given the theoretical basis for lymphatic metastasis, but so many Austrian doctors, including the president of the Academy of Surgery, are still skeptical about axillary lymph node dissection.

In order to help these colleagues get enlightened, Kawei chose a staining method based on sentinel lymph node biopsy technology commonly used in modern breast cancer. [2]

He believed that Austrians who were extremely obsessed with art would naturally believe in the relationship between lymph and breast tumors after seeing such a picture similar to a blue star chart.

"My injection point was chosen subcutaneously, next to the tumor and under the **, and now it presents a picture of the lymphatic duct." Kawei and Damiergaon pulled the skin externally, revealing a blue duct. "We need to introduce the concept of sentinel lymph nodes here."

After saying that, according to the preoperative drill, the nurse opened a black curtain beside the wall, revealing a large blackboard behind it, which was the subordination diagram of the lymph nodes drawn by Kawei before. [3]

"We can clearly see that lymph node metastasis is just like railway transportation. The tumor will first enter the first stop from the cancer tissue through the lymphatic vessels, which is the sentinel lymph nodes mentioned by Teacher Watman. After entering the sentinel lymph nodes, they will then transport and transfer step by step."

Kavey buried his head in helping Watman separate subcutaneous fat and said, "It can be seen from this simple grid diagram that any distal lymphatic metastasis must pass through the sentinel lymph nodes, and it is impossible to 'jump'."

This seems to be very easy to understand in the eyes of ordinary people.

But in the eyes of 200 surgeons, before Kawei said this, many people believed that tumor metastasis was jumping. Many people even did not have the concept of lymphatic metastasis, so they believed that tumor metastasis was a recurrence of a new tumor.

“Our principle is”

"Doctor Kavey! Wait!!!"

The sentence just now is a bit convoluted, but it is so important that many people don’t have time to write down the entire content: “You just said that any 'metastasis' of lymph nodes is what we have always said before, and you must pass through the sentinel lymph nodes first?”

This is a good question.

The main focus is “swelling of lymph nodes that can be palpated”.

"So, does the swelling that is difficult to touch mean that the lymph has not metastasized?"

Kawei raised his head and looked at the sound of the question just now: "When there is sentinel lymph node metastasis, we will do a cleanup, and if we don't, we won't do it. This will prevent many tumor recurrences caused by misjudgment, or excessive resection of surrounding tissues."

The concept of sentinel lymph nodes was previously, but now it is the significance of sentinel lymph node biopsy.

Kawei completed a new knowledge point teaching in just ten minutes:

"Because everyone here can be a surgeon, I should try to make the statement of sentinel lymph nodes as concisely as possible. In principle, it is strictly for the rapid pathological examination of sentinel lymph nodes to perform resection. This requires my teacher: Professor Ignaz and Dean Watmann's two pathological assistants: Dr. Bergert Foncelestin and Dr. Robert Koch."

Pathology was originally a discipline that assisted surgery in judging tissue types. The examination was often postoperatively and was only responsible for the final diagnosis and had no guiding significance for the surgical process. No matter how you look at it, it was a discipline that was more theoretical and had a relatively marginalized research content.

Who would have thought that a surgery chaired by a surgeon actually required pathological examinations to determine the scope of the surgery.

Fortunately, the lineup of doctors for pathological examinations is luxurious. Ignaz is the strongest surgeon in Austria. He has achieved first place in urology, intestinal surgery, orthopedic surgery, regardless of the speed of surgery or postoperative survival rate.

It was outrageous but reasonable to ask him to do a pathological section next to him. Who made his father and students on the operating table?

Behind him was the son of Viscount Krish, the House of Lords. He had just graduated from medical school and was still very young now. He was nominally a student of Ignaz and had a bright future.

But who is Robert Koch who is the one who walks in the end?

Why have I never heard of it?

"Koch. What a familiar name." Edinson thought of the conversation he had with Professor Lange of the Anatomy Department when he went to the Medical School of the University of Vienna. "I remember it seemed like a German who had just come to Vienna."

"A fresh German?"

“When did it come?”

"It looks amazing."

"I can actually do a pathological examination with Dr. Ignaz."

These words almost popped out of the mouths of the four people beside him. Edinson explained: "It's a German doctor of medicine, who has not graduated yet. I heard that I came here to study, and I have to go back when the time is over."

Edward thought that the two places of Pu'O's had already been at odds: "Are there still Germans willing to come to Vienna at this time?"

Franz said helplessly: "After all, I haven't broken up yet, and some activities have to continue."

"It seems that it's just a small person, otherwise why would Prussia let him go?" Edward seemed to have found the "weapon" that hurts the Ao Emperor again: "The German little person actually became the pathology consultant to the director of the surgery in Vienna, which is too."

As a diplomatic ambassador, he shouldn't have competed with Franz everywhere.

But France won the French-Austrian War too thoroughly before, but now Austria is about to start a war and has a demand for it, which gives Edward quite a lot of courage. However, after all, he is in Vienna and has not said enough, and the subsequent sentences are nothing more than sarcastic sentences about the decline of Austrian medical talents.

Franz's face looked a little ugly, but the Foreign Minister Carl, who was standing by, took the sentence with a smile and mixed it up: "Yes, being the pathology consultant to President Watman must have an extraordinary side, and Prussia is too unsighted to look at people."

The same thing was said by both of them, but in the end there was no conclusion.

In fact, Koch was an ordinary doctor of medicine at this time, and many hospitals in Berlin did not have a job. If there were no one in the Institute of Chemistry who could help him speak, he might have to put on a bed to work in the countryside as a young doctor.

Now he has been sent to the highest level of surgical theater in Austria. Although he is not able to go to the operating table, following Ignaz for a pathological examination is enough to make everyone remember his name.

The original pathological examination was usually done by the surgeon himself, which was time-consuming and labor-intensive.

Now Kawei has moved out of the assembly line operation, and the dyeing has been completed. It only takes four steps to make xylene transparent, put into the mold to seal wax, slice, and microscopic examination. Although it has not been dehydrated, it is a quick slice inspection after all, and there is no way to take care of so many things.

"Come on, sentinel lymph nodes!"

With the help of Kavi, Watman cut a piece of fat tissue with blue embellishment from the breast [4], threw it into the nurse's metal plate, and then sent it into Ignaz's hand: "Wait, it seems there is still."

Sometimes the sentinel lymph nodes are single in number, but sometimes they are several groups of lymph nodes that gather together. The Countess's situation belongs to the latter.

"Second piece"

"There is a third piece"

"It should be gone."

Kawei looked around and shook his head: "It should be just these three."

Watman breathed a sigh of relief: "According to the original surgical plan, Dr. Kavey and I will first remove the Countess' breast tissue. After the pathological section of this sentinel lymph node is found, we will decide whether we need to remove her armpit."

At this point, the surgical team was divided into two groups, one group of Ignaz did the section, and the other group was Watman and Kavi for mastectomy.

The name of the surgery seems to be just the word "resection", but behind it is "radical cure".

Furthermore, the breast gland is different from ordinary amputations. This is a three-dimensional multi-layered structure that includes skin, fat, glands, fascia, muscles and various vascular lymphs.

To be honest, Watman is not good at breast cancer resection, and there are very few patients. He has repaired the breast structure, blood supply and lymphatic reflux in these three days, and has a systematic and comprehensive understanding of them. [5]

In addition to being familiar with various knowledge points, Watman also made further improvements to the operating table that could be bent back and forth.

The operating table in front of them is now tilting to the left, exposing Justina's entire right breast and armpit structure, while also reducing the surgical distance of the assistant on the other side.

Considering Giustina's high requirements for postoperative quality of life, the surgical incision was chosen to have an oblique fusiform incision. It started from the front of the axillary and the inner side of the rib arch below. This type of incision can reduce the impact of scars on upper limb movement. [6]

The skin was already incised when the sentinel lymph nodes were removed, and now Watman needs to further peel off the inner flap of the incision.

Damilgaon and Amor each took four tissue forceps, clamped the edge of the skin and lifted them up, making a reverse confrontation, exposing the innermost cutting surface. Watman used a scalpel to cut, while Kawei took a suture needle and thread to sew and stitch the uncontrollable blood vessel bleeding at any time. [7]

Watman learned a lot of key points of mastectomy from Kavi. After several simulations on the corpse, he at least achieved the effect of sharpening the gun in the last battle.

But Kawei's reminder is still very necessary: ​​"Now the director is using a surgical blade to stick to the skin, and sharply peel it along the shallow layer of fat tissue, so that no fat tissue remains on the skin on both sides. In order to prevent the tumor from spreading and metastasis, this high-precision peel needs to continue to the distal end of the flap, and you can choose to retain fat until the end."

"Give me a warm salt water gauze." Kawei took the wet gauze handed over by the nurse, tried the temperature, and then gently pressed it on the peeling surface of some small bleeding points. "Generally, it is necessary to peel the end, up to the clavicle, down to the upper part of the anterior layer of the rectus abdomen sheath, the medial to the midline of the sternum, and the lateral to the anterior edge of the latitude dorsi muscle."

As soon as he started speaking, he looked up and saw that the heads of the operation were buried, and there was another dense sound of writing and recording.

"When you encounter small bleeding, you can use warm salt water gauze to stop the bleeding, and the larger ones will be directly sewn. As long as you grasp the separation level like Dean Watman, you will generally not have too much bleeding."

The peeling of the flap ended smoothly, and the next step was the muscle removal.

Kawei did not want to undergo an early radical breast cancer surgery, because cutting off the chest and small muscles would affect the function of the upper limbs, and the Countess' daily life after surgery would inevitably be affected. However, in the 19th century without chemoradiotherapy, he did not dare to assert that improved radical cure could completely resolve the recurrence of breast cancer. All he could do after thinking about was the radical surgery. [8]

"Next we cut off the countess' pectoralis major muscle."

According to prior exercise, Watman first separates the cephalic vein in the triangular pectoralis major sulcus to reveal the entire process of the cephalic vein. Then separates the fat tissue on the surface of the pectoralis major muscle downward to reveal the lateral edge of the pectoralis major muscle, and separates the other side upward to reveal the dead point.

The two of them bluntly separated the deep surface of the pectoralis major muscle with their index fingers, preparing to separate the pectoralis major muscle and the cephalic vein along the direction of the fibers, and then they can cut it near the tendon. [9]

However, just as Watman's scalpel blade was pressed against the surface of the muscles and was about to exert force down, the blood vessel clamp in Kawei's hand suddenly inserted forward to block the hilt.

Watman knew very well that Kawei must have a purpose in doing this, and was shocked. The muscles of his arm contracted and took back all the strength that was about to be cut: "What's wrong?"

"Wait, there seems to be blood vessels here." Kawei removed the blade and the blood vessel forceps in his hand, and gently stirred his fingers inward, and seemed to have a soft tissue fisting next to the vein of the head. "This is so cunning. He actually walked on the inside of the vein of the head, close to the attachment of the tendon clavicle."

The previous second, Watmann hadn't felt anything, and everything had already been trained on the corpse. But the next second, his forehead was covered with sweat, and only one knife was left. If this knife was cut, the breast cancer removal would probably turn into death and rescue.

"This is."

"It's the mutated thoracic acromion arteriovenous arteriovenous." Kawei smiled and breathed a sigh of relief, then took the forceps from the nurse beside him, "It doesn't matter, it's not a particularly large blood vessel. You just need to separate, ligate, and cut it off. Then, as planned, you can cut it along the inner side of the pectoralis major muscle." [10]
Chapter completed!