308. Wire saw craniotomy

Because Shebasto had been in a coma, Kawei never gave Shebasto ether from the beginning.

First of all, it is unnecessary. The coma state is very insensitive to pain, and the surgical area of ​​cranial surgery is not large. You can choose local anesthesia.

Secondly, for the safety of general anesthesia, entering the ether anesthesia zone from a normal state will go through a series of performance processes, but coma erases all these processes, making it impossible to judge the depth of ether anesthesia.

It is useless if it is shallow, and it inhibits breathing if it is deep. In this case, it is better not to use it at all.

Even if the local anesthesia effect of ether is not good [1], it can still block part of the pain sensation. Coupled with the remaining alcohol in the body and the newly poured ya tablet tincture, Shebasto can remain basically painless.

Surgery is performed under conditions.

Kawi tightened the jigsaw with his left and right hands and gave a demonstration to Payon and Sediyo: "The cutting angle should be large, and at the same time rotate the wrist back and forth so that each strand of the saw wire can play a cutting role."

Under his control, the wire saw shuttled back and forth between the two holes, and slowly cut open the skull along the established route.

It had been a long time since Cediyo had seen a craniotomy. Compared to the last time when his teacher was in a hurry, Kawi was quite calm in both the steps and techniques of the operation. Even if such a machine was temporarily built, various variables would occur at all times.

Even the difficult surgeries seemed to be under his control.

However, now is not the time to envy Kavi. He still has half of the drill hole in his hand, so he has to speed up.

Because in Cediyo's perception, his position has fallen behind Peang. The number of cuts with the wire saw is limited. Now that he has done one with Kawei, he may be able to get ahead of him in the end.

Get the opportunity to practice cutting with a wire saw.

As long as the hole is drilled before it is completely cut, he can take the initiative and ask Kavi

wrong!

Thinking of this, Cediyo suddenly frowned, and a different voice appeared in his mind: Why should I compete with Peang for the opportunity to practice mobile phones? He is just a young doctor who has just officially worked for two years, and I am the doctor.

Director, why?

That's certainly true. Even if Kawei is regarded as a top-notch doctor who goes to rural areas to help the poor, the first person to teach is the boss of the local department, and Sediyo is definitely the first choice.

But the reality is that in Payon's eyes he no longer seems to be the director, but only the shadow of Kawei. In this kid's mind, he and he are both ordinary doctors who started from scratch, and should be of the same class.

etc!!!

Why do I need to ask Kawei for a chance to practice mobile???

It's just a craniotomy, and it doesn't look very complicated. Once I master the surgical steps, I'll find a few cadavers to learn and consolidate, and I can do one when I have the opportunity in the future.

In fact, Cediyo still thinks too much, and Kawi doesn't trust them that much.

The reason why the last drilling opportunity was given to him was to appease him as an assistant. In fact, Kawei's eyes had been wandering around the position of the drill bit, for fear of something going wrong.

He couldn't care about Sedieu's little thoughts that were randomly colliding in his mind. He only knew that this operation, which was not complicated in the eyes of others, was full of traps and dangers. This is why Kawei wanted Sebasto to stay awake.

One of the reasons: "Mr. Director, if you feel uncomfortable in any way, please tell me as soon as possible."

Sebasto's hands had been freed, and he didn't forget to make a gesture of nothing: "No problem, I'm fine now!"

Drilling and jigsaw cutting were progressing in an orderly manner, and Kawei did not delegate the power at all when it came to guiding the metal plates, as Sedillo thought.

"When using the guide plate, be sure to keep it close to the inner plate of the skull, and move it slightly from side to side while pushing it forward. The tactile sensation transmitted back can let you know what the front end of the guide plate encounters, and can also avoid damaging the dura mater."

He talked and demonstrated, but the guide plate punching was not handed over to them several times.

The main problem is that even when he is guiding, the metal guide plate may puncture the dura mater. If not handled properly at this time, it is easy to damage the cerebral cortex under the meninges [2]. The only thing that can be left to them is the last step of wire sawing.

Cutting, almost no technical difficulty.

"What if this guide plate with a hard front end accidentally pierces the meninges during perforation?" Suddenly Kawei asked, "How will you solve this trouble?"

"Pull it back and put it on again."

Peang's unthinking behavior was indeed without much thought, and he soon received a blank look from Cediyo: "What are you thinking about? The diagonal penetration angle of the guide plate will also cause brain damage if it is retracted."

"Then put another guide plate in the original position."

"No, the meningeal tear has already appeared, and the second guide plate that goes in may get into the tear."

"The professor is right." Kawei affirmed his two responses, but was not satisfied. "But repeated denials will not solve the problem."

Cediyo has never even done drilling, so he definitely doesn’t know how to solve the problem during wire saw threading: “If this kind of problem occurs when I am doing threading, as long as the patient is still alive, I will choose to put it aside temporarily.

. Solve the cutting in other locations first, and then deal with it last. Maybe you will be able to think of a solution when dealing with other locations."

The idea is correct. It's a blessing that we didn't force it.

"Actually, it's very simple to deal with, because there are two holes on the cutting line." Kawei pointed to the hole punched on the other side and said, "If the thread is wrong here, then use another guide plate to pass it through from the other side."

That’s it.”【3】

The five holes are connected into a circle by cutting with a wire saw, and the bone flap is formed.

"Here, each person peels off the bone and sticks it in." Kawei demonstrated again. "Don't pry upward violently, but simply rotate it. Rotate it to a certain angle to break the bone flap at the root."[4]

】

The three of them worked together to open the bone flap, and Kawei used a dissector to separate several adhesions between the meninges and the inner plate of the bone flap: "Give me ointment and gauze."

Removing the skull will damage the internal barrier blood vessels, and the bleeding will definitely be serious. In modern surgical treatment of bleeding after fractures, bone wax seals are used to stop bleeding. In the 19th century, only trauma ointment could be used.

As the first country to use ointment to stop bleeding, the hemostatic ointment used in the Department of Surgery at the Palace Hospital is much better than that in Austria, and it even smells like flowers.

"Apply it around and protect it with gauze." Kawei covered the edge of the incision with gauze, which acted as a scalp clamp and sucked away some of the bleeding. "Give me the rongeur."

The purpose of the forceps is to bite off the surrounding irregular bone, and then start incising the meninges.

"Tweezers and suture needle."

Kawi changed the set of tools, used tweezers to hold a small piece of meninges, and used a suture needle to penetrate the epidural layer and lift the dura mater. He gave them to Payon and Sediyo, and he cut off a small piece

gauze cotton sliver, then use a scalpel to cut it, and insert the cotton sliver into the brain tissue for protection.【5】

Cutting will naturally cause bleeding, and the dura mater is no exception. The middle meningeal artery runs through it. Kawei did not have bipolar electrocoagulation, so suturing was not suitable. The only thing he could use was a soldering iron stick to deal with bleeding at the liver resection edge.

But this time the wire was thinner and the fire was stronger.

"It's quite warm." Sebasto lay on his side on the cold operating table, wearing a single coat. He felt warm on his back and felt better. "Although the surgery was a bit barbaric, it was really considerate.

"

"The operation will now enter a critical step. Director, please do not move." Kawei had already picked up the red-hot wire and explained with a smile, "If you really want to move, you must tell me in advance."

"Understood." Sebasto felt his nose itchy just after he finished speaking, "Can I touch my nose?"

"please hurry."

".alright."

"Stop moving!"

"OK."

Red-hot iron wire is very effective when dealing with bleeding from small blood vessels at the edge of the liver, but when dealing with brain tissue and meninges, such firepower is too strong. If it is placed directly at the bleeding site, both areas will be charred.

, even if the temperature does not meet the standard, the tissue will shrink on a large scale.

"An old method can be used in a new way." Cediyo was dissatisfied, but he couldn't help but admire him, "It can still be used like this."

"What we have to do is to make it produce local dehydration. The power must be controlled well, not too big or too much. Sometimes we can't even get close directly, just rely on the temperature emanating from the surroundings. Because once it comes into contact, it will

High temperatures will cause tissue to adhere to the wire, exacerbating damage."

Kawei gave a demonstration: "It's like putting the meat directly on the baking pan without adding oil when grilling meat."

Suddenly, Xiebasto said with a smile: "Barbecue? Oh, I only thought about drinking at the dance and didn't eat anything. I'm getting hungry after hearing what you said."

"Let's wait until the operation is over before eating."

"I don't know if I broke my head, but I always smell the smell of meat." Shebasto was obedient and didn't move. He simply shrugged his nose, "It smells pretty good. Could it be the hospital?"

A restaurant outside?”

Kawei smiled and patted his shoulder, bringing the topic back: "But this method is only suitable for small bleeding points. As for the arteries, they still need to be ligated."

If skull drilling is the basis of craniotomy, then meningeal treatment is the first advanced operation. It is of little help to the craniotomy itself, but it will affect the recovery after the operation. Once it is not handled well, the entire operation will become

It's useless, or even counterproductive.

After all, Cediyo has worked in surgery for many years and has profound basic skills. Although his operation is not skillful, at least he is not impatient. One word stands out: stable.

In comparison, Payon was not so relaxed, and his techniques were much worse.

"Dr. Payon, you should be responsible for the bone flap and the surrounding skull." Kawei took the suture needle in his hand, "The cut bone flap needs to be drilled, and the surrounding skull also needs to be drilled. There are awls and screws on the preparation table.

and connecting iron plates. Make 6 small holes around the bone flap and on the corresponding skull, and fix it at the end of the operation."

Peang knew that he was trying to drive him away, but he had no other choice.

Craniotomy surgery does not require many assistants, but more assistants are required to do some other auxiliary work. The operation officially enters the cranial cavity. If he cannot keep up with the rhythm, it is better to leave before making mistakes. Moreover, the opening itself is also training his hand skills.

Prepare for the formal drilling in the future: "I understand."

Payon was responsible for drilling holes in the skull, firstly to fix the bone flap after surgery, and secondly to suspend the dura mater.

The incised dural flap is turned over and fixed on the inner side of the previously opened skin flap. The remaining dural cut edge is suspended along the edge of the bone window to make it fit closely with the inner plate of the skull to prevent postoperative hardening.

Extramembranous hematoma formation.【6】
To be continued...