Chapter 187 184. Blindly wearing "three degrees"

The question caught Kawei off guard, but he had always claimed that his adoptive father was dead and had never disclosed his name, so it was not too much trouble. He just passed by a few fools.

"Die? How did you die?"

"When dissecting the body, I accidentally scratched my fingers and then got infected." Kawei missed the most common cause of death for surgeons. "This is why I have been calling for gloves to be worn during surgery. No matter how I look at it, this method not only protects patients but also protects the doctor."

Masimov seemed to be even more sad than Kavi: "The surgical master with such superb skills actually fell like this?"

Kavey suddenly remembered that he didn't seem to explain this to Ignaz last time, and immediately added: "Actually, he had already used his own debridement technique to solve the wound. If nothing unexpected happens, he should be cured. But at the last moment, he had a serious car accident on the way to the clinic, and several carriages hit each other. The horse's hooves were trampled, the wheels and the debris boards splashed, alas."

“This is really unfortunate.”

"He is just a surgeon in a small place, and he stays in his clinic all his life. Even if he has a little eye-catching idea from time to time, he is not famous." Kawei drilled into Madame Santini's skull and shook his head helplessly. "I wanted me to inherit the clinic, but later unfortunately died, so I sold the clinic and came to Vienna."

"A good choice, it's a pity to stay in the countryside without publishing books and writing biography." Masimov sighed after hearing these: "Oh, if possible, I really hope I can have a good chat with him."

"Teacher, let's focus on the surgery first." Kavey pulled out the bone drill in his hand and wiped off the surrounding bone meal. "Mrs. Santini's skull has been drilled open by me."

This should be the first neurosurgery operation of Masimov and the two surrounding surgeons. The operating table was still the same operating table, but the position had changed a lot. Because the brain was not like the abdominal cavity and could not withstand a little infection, there was only one Ersupplement who delivered the device around the head, except Kawei and Masimov. [1]

The skull drill was taken away, and Kavet left a layer of dura mater and did not continue down. [2]

Just like marching and fighting, the operation must be done before the troops move. The operating room is in a simple condition, the assistant is not strong, and the ability to resist infection is poor. In order to minimize the exposure time of brain tissue, he temporarily puts the puncture aside and does the subsequent diversion path first, that is, the duct burial work that connects the abdominal cavity. [3]

"Give me a scalpel."

Kawei made a shallow incision under the puncture point with a knife, reaching the fat layer only. After stopping the bleeding, hemostasis clamped the front end of the hose with tissue forceps and stretched forward forcefully. Then he opened the pliers to expand a certain area, clamped the hose and stretched forward, and then expanded.

A clear tunnel appeared under the skin of this blunt separation, but the length of the tunnel was related to the length of the forceps. It reached its limit as soon as it crossed the back of the head, and the exit was set at the edge of the neck.

After all, it is a conclusion drawn from decades of clinical practice, and it is difficult for Masimov to see the significance of this operation as soon as possible.

Kavey explained: "This is for Mrs. Santini's daily life considerations, and it is necessary to bury the hose in sections under the skin as much as possible."

The disinfected hose is poked out of the neck outlet, exposed a small piece, and then enters the subcutaneous skin again above the clavicle. With the same routine and distance, the second exit is set in front of the chest by Kawei. Then the third section is poked out from the chest to the upper abdomen, and the work of burying the tube in the middle has come to an end.

Finally, as long as the puncture of the upper ventricle is completed and the hose is connected to the tube, a new incision can be made in the abdomen and officially enter the abdominal cavity.

This kind of tunnel-like work seems to be not difficult, but in fact there are many details to consider.

"You must grasp the depth of the skin. If you want to do the same surgery in the future, be sure to practice more on the body." Kawei put down the tissue forceps and switched to a scalpel. "If the separation is too deep, it will cause bleeding and infection. If it is shallow, it will destroy the nutritional supply. The skin will easily necrotize. The best depth is the fat layer under the skin, and the movements should also be gentle."

Watching the tunnels and hoses along the way, let alone the second helper who handed out the surgical instruments, even Masimov was amazed at Kavi's basic skills.

VP shunt surgery means to penetrate two holes in the body and then connect them with a tube. It sounds very simple, but it is full of details when it comes to practical operations. Now that it is just a general preparation, Masimov has no confidence anymore.

But Kawei's operation further aroused his desire to learn new technologies: "Does it take a ventricular puncture next?"

"right."

If it was in modern times, the nurse handed over a ventricular puncture needle with a metal guide core at this time [4]. However, the conditions are limited now, this slender hollow metal pipe is difficult to make, and it is impossible to have a ready-made one. The temporary opening of the surgical instrument box of St. Mary's Hospital is filled with thicker attractions.

The suction head placed in the abdominal cavity is too thick and long, and the ordinary needle is too thin and too short.

The Municipal General Hospital has silver tubes of similar thickness, which Kavey made for Raslow to catheterize patients. However, this tube only has two openings in front and back, which is too single for cerebrospinal fluid diversion and drainage with high protein content, which will lead to poor drainage and even obstruction.

Faced with this difficulty, Kawei could only find another way before the operation: "Where are the quill pens you collect?"

"It's all soaked in carbolic acid."

"The length is about 10cm and the diameter is 3mm." This is the puncture replacement that Kavey asked to prepare before. "It doesn't matter if there is some floating up and down, the key is that the surrounding feathers must be cleaned up."

"There are 55 pens in the hospital. We picked out three of them. In order to remove the feathers, we cut off the wall of the pipe a layer."

“Has it been smoothed?”

“Very smooth.”

The second assistant of the transmission device sent three "piercing tubes", which meet the requirements of Kavi. Although the material is not as strong as metal, Madame Santini has not used it for a long time compared to other patients who need to be diverted. [5]

"The front end of this is too thin to use; there are too many cracks in the middle to use; this one is not bad, but it needs to be processed again."

Kawei carefully poked several small holes in the wall of the tube with a fine needle, and soon made a simple 19th century ventricle puncture needle. On the premise of ensuring that the outer wall is basically smooth, Kawei held a pen tube in his hand and prepared to insert it directly into the ventricle from the drill hole. [6]

This is the key to determining whether the operation can be successful. It is necessary to consider the depth, angle and strength of the puncture. Any problem may be at a very serious coma and die directly on the operating table: "The puncture position has been determined, and the angle is aimed at the front eyebrow arch, and the depth of the needle is inserted?" [7]

While explaining, Kawei began to forcefully pierce the puncture needle.

In the entire surgical theater, no one spoke, and the two assistants did not have any other operations. All their attention was focused on Mrs. Santini's head.

1cm3cm5cm【8】

The distance from the scalp to the ventricle is not long. In this short distance of 5cm, the surgeon must withstand huge psychological pressure. Especially when the cerebrospinal fluid still does not appear after the puncture needle is 5cm, the surgeon who put aside distracting thoughts needs to consider many factors, fighting against the patient's brain structure, himself, and even the air.

For neonatologists, the whole process from the needle entering the brain and not seeing cerebrospinal fluid until they penetrate 5cm deep into the scalp is very harsh. The degree of nausea continues to increase as they go deeper, and they are forced to make a choice.

There are generally two possibilities at this time.

One possibility is that the puncture depth is not enough, so you need to continue moving forward, and maybe you can enter the ventricle 1-2mm further. But if the direction is really incorrect, no matter how far you enter, it will damage other brain tissues.

The deeper you go, the more damage you get, the heavier it will be.

It may be that the ventricle veins are coming from, causing intracerebral hemorrhage [9].

It may be the dibrain, causing sensory disorders and emotional abnormalities; it may also be the brainstem, affecting spontaneous breathing and heart rate regulation. [10]

If the doctor is a little more "scrupulous", he may determine that there is no cerebrospinal fluid as having a problem with his puncture angle. At this time, he must not change the puncture direction halfway, and he can only exit the puncture needle according to the original path and re-select the appropriate angle to puncture.

But re-puncture does not mean that the situation faced is getting better, and the problem of puncture angle still exists. If cerebrospinal fluid appears at the mouth of the tube after entering 5cm, everyone will be happy in the operating room, but what if it still does not appear?

Should we continue to go deeper at this time, or do we start over again after quitting?

If you choose to continue to go deeper, it means that there is something wrong with the judgment just now. Is the angle correct this time, or is the angle you chose to exit just now?

If you choose to withdraw again, even if the re-piercing is successful, a total of three punctures will have caused serious brain damage and the patient may have lost a lot of neurological functions. For the doctor, this is a complete failure.

Such immediate failures of surgery can easily cause psychological impact on the surgeon and will further affect other subsequent surgeries.

And this is based on the successful operation. What if even the third time failed?

Of course, these are all problems that newbies who are just starting to undergo puncture surgery need to be troubled. Even if veterans like Kavey are unfamiliar with their hands, they will not have any problems in their judgment of the puncture angle.

After entering about 5cm, Kawei did not hesitate and confidently continued to look forward 3-4mm. Suddenly, he felt an extremely slight vibration on his fingers, and then a clear liquid with a lot of bloodshot was sprayed out from the outside tube mouth.

"The front end of the needle enters the ventricle, and you need to go deeper inward for a while."

Masimov and his students looked at the cerebrospinal fluid that was spraying out and breathed a sigh of relief: "Do you still need to go deeper?"

"Of course," Kavey explained, "or why would I open so many small holes around the drainage tube? It would be easy to block just a little further ahead."

As soon as he finished speaking, he inserted the entire pen tube into Mrs. Santini's mind, and only a small part was exposed, "Give me the infusion valve."

This valve can control the flow rate of cerebrospinal fluid drainage in vitro. Although it is much worse than the multifunctional shunt valve used in modern medicine, it is always better than connecting nothing. [11]

The valve connects the puncture needle and the lower hose together. What Kawei can use in his hand is the common surgical tape to seal it. The connection is directly sealed under the skin, and the cut skin is also sewn with needle thread again. The side of the brain finally came to an end. [12]

"That's all right, right?"

"Turn on the valve, connect the drainage tube below, we will open a hole in the stomach and put the other end into the abdominal cavity." Kawei released some bloody cerebrospinal fluid, lowered the pressure on Mrs. Santini's head, and then closed the valve according to experience and began to process the abdominal incision, "Come on, give me a scalpel."

There is no minimally invasive technology or a qualified puncture needle. He can only make a slightly larger incision in his abdomen, and follow the steps of abdominal surgery to separate the muscles and peritoneum layer by layer, and put the other end of the tube into the large omentum.

The reason why cerebrospinal fluid can be drained into the abdominal cavity is that the strong absorption capacity of the omentum can be reabsorbed cerebrospinal fluid into the circulation, and a new closed loop is formed while isolating external invasion.

This is the core of the theory that such surgery can be successful. In addition to abdominal drainage, ventricular puncture can also perform atrial drainage through the neck vein. [13]

"So, everything must be completely closed. Not only should the skull opening be completely closed, but the lower abdominal cavity opening must also be closed, and the middle subcutaneous tube buried." Kawei still regrets the operation. "It would be great if all the hoses in the middle could be buried under the skin. Now we can only hope not to have an infection."

"Doctor Kavey, you've done a really good job!"

Masimov is a big eye-opener. This is more exciting than the modified breast cancer removal. Every step seems so fresh and exciting: "If this surgery can really reduce brain pressure and relieve headaches for a long time, will it also be applicable to children suffering from cerebrospinal fluid (hydrocystosis)?"

"After all, children need to grow up." Kavey hit the point, "Height growth is a very troublesome problem."

"If it really works, it's acceptable to change the hose frequently. After all, this type of child will die soon, and there is no other way."

"That's the problem with infection. This kind of surgery is very easy to get infected. You must be careful when operating it." Ka maintained a pessimistic attitude, but still praised him with a smile, "Teacher Masimov has a good idea, you can try it."

The operation was completed under Kavey's operation. The next step was to see some routine postoperative observations. At the same time, it was necessary to wait for Mrs. Santini to wake up and repeatedly adjust the flow rate of cerebrospinal fluid.

As for how to deal with incision and medication after surgery, and how to take methylene blue orally to fight infection, Kawei doesn't need to do it personally. What he and Masimov have to do is notify Ednelson, who has been waiting outside the handbook theater for a long time, to postpone tomorrow's electrotherapy schedule.

But at this time, there were not only Ed Nelson and Jenny outside the theater, but also Mr. Santini and another man in black coat.

The man was pacing back and forth with a cigarette in his mouth, and his expression was even more nervous than everyone: "Why haven't he come out yet?"

"It should be soon," Ed Nelson was still savoring the rain he had with Jenny just now, and he was increasingly dissatisfied with the results of Kavey's surgery. "If the sheriff doesn't mind, I can do it for you. After all, Dr. Kavey's surgery is very difficult, and it is the least surprising that an accident is the least surprising."

"I know you have excellent medical skills, but" Witt was in trouble: "But that guy only recognizes him, and it's useless if other doctors go there."
Chapter completed!