Chapter 252 248. Creativity is the upper limit for surgeons [2]

[This thing has a bit of a strong momentum, and it has even been on duty. I haven't had a rest these days, so I don't have a code to write it. I'm sorry.]

Kawei used a median incision in the lower abdomen, with the lower edge just enough to be opened 2cm below the right common iliac branch. Now the blood vessel is severely broken and the length of the incision is very tight. If you want to do the next step, you have to expand the incision downward.

【1】

"The right common iliac artery has a serious fracture, and there is a considerable distance between it and the fracture end of the external and internal iliac artery. If you are here to deal with it, what should you do if you take the limb preservation as the premise?" Kawei went down along the original incision

The expansion was extended by 5cm, and seeing that they did not respond, he continued, "If you want to become the main surgeon, you have to learn to think independently."

They also want to think independently, but the current situation is completely beyond the cognitive range of the three assistants. The blood vessel breakage and defect has reached 4cm, and no matter how strong the elasticity is, it is impossible to tighten and continue to do suture. It can be said that there is no room for operation at all.

If Kavi was not there, this leg would have been intercepted long ago and would not have been wasted so much time.

Compared to one leg of this wounded soldier, the lives of other wounded soldiers are more important. But now seeing Kawei's sure appearance, they all want to see how this surgery will develop.

The right lower limb ischemia is severe, and half an hour has passed, so I have to speed up.

With the help of Damiergaon, Kavey quickly separated the skin muscles and continued to ask: "Then let me change the question, which parts of the internal iliac artery and the external iliac artery are responsible for? "

This was not difficult for the three of them, and the answer was quickly given: "The external iliac is responsible for the lower limbs, while the internal iliac is responsible for the lower abdomen and pelvic cavity."

After Kawei cuts the skin muscles, he changed the position of the hook and expanded the surgical area from the right side to the left: "In order to provide blood supply to the right lower limb, it is necessary to perfusate the blood pumped out of the heart into the right external iliac artery.

So the question is, which blood vessel is the right external iliac artery closest to? Is this broken right common iliac artery?"

"Obviously not."

The three of them were confused again, and this was not a problem, because there was only one major artery around them, and there was no possibility of being connected.

But while speaking, Kawei had already started to dissect the left area. From the question to the surgical operation, he reminded them that the next surgery area was on the left, and what he wanted to do was also a kind of thing that no one had tried before

Vascular grafting.

Should I connect it to the left iliac blood vessel?

This pathway is indeed very bold, but the problem is that the breaking position of the right external iliac artery is fixed, and even if you turn to connect to the left internal iliac artery, it is completely unattainable, and the middle is so far away.

Emmmmm seems to be wrong!

The three of them seemed to have caught something amazing. After looking at each other twice, they looked at the surgical incision before they came back to the smell.

"Do you want to get the left internal iliac artery?" Damirgaon tried to answer, "Let the blood from the abdominal aorta flow through the left common iliac artery to the left internal iliac artery and then into the right external iliac artery, thereby protecting the patient's limbs."

Kawei nodded slightly, but gently fiddled with the external iliac cut-off of the hemostasis clamp on his hand, and asked, "The left iliac is in this place and the stump is here. How do you plan to connect it?"

Seeing that Kavi had begun to separate the left common iliac, external iliac, and internal iliac artery, Damiergaon tried to answer again: "There is a long distance between the stump and the left internal iliac artery, so it is definitely impossible to open a hole and graft.

, the left internal iliac artery can only be cut off, leaving enough length to actively connect the upper right external iliac artery." [2]

“The answer was pretty good.”

The answer is right, but the three of them don’t know the deep logic that supports this answer.

The more you know, the more questions you will have. While you are suddenly enlightened about the surgical plan, you will find many logical differences after calming down and thinking: "But if you do this, both internal iliac arteries on both sides must be

Will this affect the blood supply in the pelvic cavity?"

"It's not bad, it's very good to think of this step." Kawei finally isolated the left internal iliac artery and still didn't want to give the answer directly, "Do you still remember the cesarean section?"

The three of them spoke in unison: "Remember."

"How do I deal with it when there is a heavy bleeding?"

"Tie the cervix."

"Um."

“Press the uterus.”

"Um."

“Gauze stuffing?”

"Hmm, then what?"

Herman was impressed by several cesarean sections with Kavey and immediately contacted the current situation and replied: "Lin the uterine artery."

"Yes, if there is a major bleeding, I will definitely ligate the bilateral uterine artery." Kawei said, "Is ligated with the bilateral uterine artery equivalent to destroying all blood supply to the uterus? Is this uterus useless

Is it?"

"No! In addition to the uterine artery, there are many collateral circulations that transport blood to the uterus, but only deliver blood in tiny under the premise of compressing the uterine body and binding the cervix." Herman brought the topic to the current surgery,"

Is this the same thing with both internal iliac arteries?”

"In addition to the internal iliac artery on both sides, there are also submesenteric artery to support the blood supply in the pelvic cavity and buttocks. Usually, these three blood vessels have rich interlocking collaterals. As long as the blood supply of the three blood vessels is good and the collaterals are rich,

You can ligate any two of them, so that they will not cause ischemia in the pelvic organs and buttocks." [3]

"I see."

"Prepare two hemostatic forceps, then prepare sutures, and we will make the analges again." Kawei said, "You will continue to hold the hemostatic forceps as before, and sodium citrate will expose your vision."

"OK."

"OK."

Kawei sutured the fracture end of the right common iliac and right internal iliac artery, retained the stump of the right external iliac artery, calculated the length from the left side, and then found the position where the left internal iliac artery was cut: "A hemostasis forceps at the proximal end,

A handful of the distal end, and use a blade to sew the distal end separately to close the distal end"

After repeated examination of the three stumps, Kawei sent them back to their original positions with confidence, leaving only the left internal proximal and right external iliac stump.

The second time fit took a lot of time, and the suture tension also seemed subtle because of retaining part of the suture distance in advance: "Damirgaon, this time it's time for you, help close the last gap to each other, and wait for me

After sewing, loosen the hemostatic forceps.”

"Um."

Kawei looked so hard that he still gave this operation to his assistant. But if he looked closely, he could still see the traces of his lesson. At least the tone of the command was different from the vocabulary used: "The movement must be very, very very

Gently connect the blood vessels, you must be very gentle and very gentle! gentle! Do you understand?"

"OK."

Damilgaon's hands are similar to Herman. It would be nice to have the strength created by limb orthopedic surgery for many years to adapt to the environment in the abdominal cavity. Now, you must be more careful when dealing with tender blood vessels.

"Slowly, be sure to slowly."

Damiergaon pinched two hemostatic forceps, and the power in his hand was transmitted to the blood vessel through the clamp handle. Under his guidance, the stump of the blood vessel gradually moved closer to the center, while Kawei followed this force and slowly tightened the suture line: "I did it

Yes, I just kept the tension like this and was ready to tie the knot. Come on, nurse, pour some warm water on my hands and rinse the blood coagulation around the line."

The next knotting is Damirgaon's strength, and there will be no problem as long as you follow the hand strength just now.

"The suture is completed." He carefully performed until the last moment, and even withdrew the needle holder, he seemed cautious, for fear of making the operation go yellow again. "You must completely release the hemostatic forceps."

"Well, loosen the distal end first. Then loosen the proximal end." Kawei simply checked the quality of the suture, "Okay, the matching was successful!"

The two loosened blood vessel clamps are like gates opened by a dam. The gushing blood is the rushing river water, which instantly flows into the blood vessels of the injured from the newly anastomotic pathway. The lifeless right external iliac artery beating with the heart.

, pulsing evenly and vigorously.

Kawei asked them to reach out and touch the pulsation of the right external iliac artery. They didn't want to judge the successful suture of the blood vessels by relying on this point, because you can see the pulsation of the blood vessels by just looking at them: "Remember this feeling, do it for the future.

It is very important to stop bleeding from large blood vessels.”

"The dorsal foot artery is also pulsating!"

“Blood pressure and heart rate are good!”

The nurse and Amore both heard good news, but the operation was still not time to be announced to be successful. The bullet was shot into the front blood vessel through the posterior lumbar spine, but it has not been found so far, and it is likely that it has entered the abdominal cavity.

Whether the bullet itself can be found is secondly. The main thing is to prevent intestinal fistula from occurring intestinal tracts that are shot through, so you cannot temporarily shut the abdomen.

"First suture and then peritoneum, then we have to carefully check whether there is any leakage in the intestine." Kavi handed the suture to Damilgaon, and he and Bergate began to check the intestine step by step with their fingers,"

Wash the abdominal cavity after suture”

If you flush the abdominal cavity 2-3 times and check the intestines with fingers, there is no problem with Kawei, then you can confirm that there is no problem with the intestinal duct, and there is no way to find a bullet. After all, a metal bullet free from the organ is dangerous.

It's far less than a long-term laparotomy.

As for the lumbar surgery I just did, since the suture has been done simply, let’s put it first, and then choose further treatment options depending on the physical recovery of the injured soldier.

So for Kavi's group, checking the abdominal cavity condition became the last step in the entire operation.

However, the time required for this last step was much more than grafting the right external iliac artery just now, so that the Prussian army outside Gabrents could not resist and launched a new round of attacks.

Kavey had previously said that large military hospitals were not suitable for building forward areas like Gabrentz. Although there are many houses, buildings, churches and warehouses suitable for wards, they were attacked considering the previous war situation.

It's just a matter of time.

The most reliable way is to only do simple first aid here, and try to transport the remaining wounded soldiers backwards and treat them safely in the rear far away from the front line. An important city that meets these conditions and is a certain distance from Gabrents is the basic one.

Schen.

Unfortunately, almost no 19th-century unit could do this after a crushing defeat.

Especially the Western Front troops have not yet received long-term escort drills, and there are also big loopholes in the reserve of horse-drawn carriages and drug-transporting equipment. In comparison, sending excellent surgeons to the front line seems to be a simpler alternative.

According to the division of labor of the Military Medical Office, Kawei was only responsible for the affairs of the Omilz Fortress General Hospital on the Northern Line, and several emergency teams were also active on the Northern Line.
To be continued...