Chapter 79 76. “Empty” Blind Box

Right lower quadrant tenderness, rebound tenderness and high fever are indeed important diagnostic criteria for appendicitis, but they are not absolute. [1]

According to the modern diagnostic standards for tertiary-level emergencies, a CT scan must be performed to confirm that the appendix is ​​inflamed before a diagnosis can be made. If hospitals at the next level are more courageous, perhaps only B-ultrasound can be used to perform a laparoscopy. Further down, those who do not have surgery

A small hospital with room for treatment will choose to transfer the patient to another hospital.

However, in the 19th century, doctors had very limited understanding of intra-abdominal diseases, and any typical symptoms would be immediately diagnosed as appendicitis.

As the saying goes, those who don’t know are fearless. Their judgment is not only quick, but also very difficult to change. In Kawei’s impression, Ignatz made a clear diagnosis: appendicitis with just a simple press, and performed an appendectomy immediately.

decision.

Without imaging technology, it would have been impossible for Kawei to see a doctor with more than 50 modern differential diagnoses, nor to supervise the diagnosis given by Ignatz. Because doctors are also human beings, and even if they did not give him X-ray eyes during time travel,

Kawei is also unable to make a 100% accurate judgment.

The only thing that can be done now is to cut open the priest's belly and take a good look at what's going on inside.

As Ignatz said personally, the troublesome part of appendicectomy is finding it. Other methods, such as the location of the incision and the suturing of the intestines, are fixed. As long as you are skilled, you can do it well. Only looking for the appendix will be like opening a blind hole.

Boxes generally give people surprises, scares, or.

Nothing.

"We have entered the priest's abdominal cavity. In addition to the thick and greasy fat layers on both sides, everyone should be able to see the bright red intestines. The priest's physical condition is very good, but"

Ignatz's right hand searched back and forth in the about 10cm incision, but found nothing: "It's just that his appendix is ​​a bit difficult to find."

Ignatz is also almost 40 years old. Years of anatomy and surgery have made it difficult for his waist to maintain the same posture for a long time. Kawei very wisely waited for him to withdraw his hand before choosing to take over: "Teacher, take a rest."

, I’ll come and look for it.”

"Um."

Ignatz took two steps back to clear the surgical field of view, then used his toes to hook up a chair and sat down. He raised his hands stained with donated blood and continued quickly:

"Although the anatomical location of the appendix is ​​generally in the ileocecal area of ​​the right lower abdomen, there are still many people whose appendix position is not fixed [2]. There are many cases of appendicitis. The surgical incision is made into the abdominal cavity. The appendix is ​​right in front of you, and it can be cut.

Guanfu. But some are more difficult to find, and priests fall into the latter category.

Ignatz really tried his best.

With the current poor knowledge and experience in abdominal surgery, a surgeon who can recognize the variation in the position of the appendix is ​​already considered a T1 surgeon. If it had been anyone else, once the appendix was opened and the appendix could not be seen, they would have searched twice to no avail.

Will choose to keep it quiet.

After all, misdiagnosis and misoperation are common. It is normal to close the abdomen and do nothing. It is better than dying on the operating table. As for how to handle the surgical process after surgery, you have to look at the surgeons.

literary skills.

Carvey knows the troubles of acute appendicitis.

The "cheapness" of being able to see the appendix through laparotomy is not something you can always find. Many appendix surgeries often take more than an hour, and most of the time is spent looking for it.

There is no trick to finding the appendix. It all depends on personal experience. The most basic and easy-to-learn method is to search along the colonic band of the cecum [3].

Because the root of the appendix is ​​at the junction of the ileocecal part, no matter how it changes, the root is there. As long as you find the ileocecal part along the cecum, you can find the root of the appendix, and then further find the inflamed appendix.

So here comes a new question, how to find the cecum?

Ignatz made the mistake of many young general surgeons. He opened the abdomen and went in to see the winding small intestine. His scalp was numb when he saw it, but he couldn't find the cecum at all. If he couldn't find the cecum, he couldn't find the ileocecal part.

Without the ileocecal part, searching for the appendix is ​​like finding a needle in a haystack.

The same mistake is made by modern young residents because of their inexperience, while Ignatz is limited by the backward anatomy of the abdominal cavity.

Kawei didn't like to put his whole hand into the abdominal cavity, which was not something worth showing off in general surgery. He first shook the priest's belly back and forth, and after the small intestine returned to its position with the mesentery, he used his fingers to lift out a section of the small intestine.

The abdomen follows the mesentery of the small intestine toward the lower right and reaches its root, where the cecum should be.

However, surgery is always accompanied by various uncertainties, and the length and walking angle of the small intestine exceeded Kawei's expectations.

emmm it's a bit troublesome

Looking at the small intestine slowly walking towards the right upper abdomen, even Kawei, who was used to seeing big scenes, was stunned. His fingers followed the mesentery to the upper edge of the incision, but the cecum was not where it should be.

superior.

Judging from the anatomical position, you have to look higher.

Therefore, in addition to the mutation of the appendix, the human cecum will also mutate, double mutation, double happiness.

"You can't find it either?" Ignatz sighed, realizing that today's surgery would be a tough one. "Let Herman try it."

Kawei gave up his position, but did not let go of the intestines in his hand. He stretched out his index finger and pointed at Schmidt's liver area: "I think the priest's cecum is not in the right lower abdomen, but higher up."

"More above?"

Ignatz recalled that he had indeed not seen the appendix in the right lower abdomen just now, and joked to the audience: "Father Schmidt is indeed a loyal believer in God. Even the appendix in his body is trying his best to get closer to God."

A holy place, respectable and admirable.”

Perhaps influenced by Hills' departure, he did not leave the chair, but insisted on letting Herman try it. Herman had no experience in abdominal surgery, and he was sweating while rummaging around in the silent atmosphere of the theater.

, gave up within a few minutes: "Teacher, I really can't find it."

Ignatz knew that it was inevitable that today's operation would fail, and he was going to search for it twice more. If he still didn't find it, he would have to find a medical vocabulary as an excuse, and then close the abdomen as soon as possible.

"I think we need to extend the incision upward."

Kawei would never let them close the abdomen. After opening the abdomen and seeing a small amount of yellow-green pus mixed in the intestines, he decided that this must be an infection. Regardless of whether the inflammation comes from the appendix or not, if there is an infection, it must be removed.

Otherwise, the priest will definitely die regardless of whether he is pregnant or not.

At this time, the significance of extensive preoperative disinfection is reflected. The 15cm area around the incision can be extended at any time.

"Once the search for the appendix fails, the abdomen should be closed as soon as possible. This is the consensus of surgical colleagues. If you persist, it is likely to cause an surgical accident." Ignatz advised, "Little Schmidt and the monks and nuns of St. Mary's Church are all there.

We are waiting for news of the operation outside the theater. It would be too ugly for the priest to die on the operating table."

"But closing the abdomen can't remove the lesions, and sooner or later you will die." Kawei glanced at the dried saliva at the corner of Schmidt's mouth and said, "Give me some more time, I still want to try."

Ignatz was calm: "We can also think about it from another angle. Maybe we misdiagnosed it. The priest does not have appendicitis."

Kavi:???

Isn't this just showing off?

Kawei shook his head, picked up the scalpel, and handed the handle to Ignatz: "Whether it is appendicitis or not, we have to catch it first before we can make a conclusion, but I firmly believe that the teacher's diagnosis is correct."

Ignatz felt relieved for a moment after saying this.

"I'll listen to you just once." Ignatz stood up and picked up the scalpel again, "Everyone, since the priest's appendix cannot be found in the entire lower right abdomen, the appendix looks like a prisoner who has escaped without a trace.

.We now need to extend the incision upward by about 5cm, cut more muscles, fascia and peritoneum, and then expose more of the small intestine."

Kawei stared at the small intestine in his hand and continued to search upward along the mesentery. At the same time, he did not hang himself on a tree, but used another method to find the cecum, lifting the lateral peritoneum and moving inward along the lateral peritoneum.

Find.【4】

The two directions went hand in hand, and the result soon came: "Teacher, the priest's appendix should be in front of you."

Less than 2 minutes after the incision was expanded, Ignatz was surprised and delighted by Kavi's discovery: "What an unexpected surprise. It seems that my diagnosis is not wrong. The priest has a very typical appendicitis. Here is the cecum, and below is

In the ileocecal area, yellow-green pus can also be seen there.”

For a small amount of pus encountered in the abdominal cavity, modern surgery will use a suction device for temporary treatment. If an abscess cavity or perforation is found, a large amount of normal saline needs to be used to clean the abdomen during the operation.

In the 19th century, it was much simpler. Because there were no high-power aspirators, many surgeons just ignored them and did not know how to deal with them. They just left them there naturally and let them flow to various tissue spaces with the peristalsis of the intestines.

The pus accumulated in the body may continue to cause inflammation, or may infect the surgical wound, making the entire operation useless.

Kawei didn't speak, and it wasn't wise to interrupt the operation now, so he took two pieces of clean gauze and quickly wiped away the pus while Ignaz was looking for the ileocecum. Although the simple wiping did not clean it with water.

It's clean, but it's also a way to prevent the spread of infection.

Ignatz didn't notice these small movements, his focus was entirely on the ileocecal part he had just found.

Part of the cecum is fixed on the peritoneum, and the connected ileum can be seen in the free part. The three colonic bands converge here, which is where the root of the appendix is: the ileocecal part. However, in everyone's eyes, this is a mess.

The appendix, which should be connected to the end of the ileocecal part, is missing.

Ignatz was surprised and was speechless as he performed blunt dissection of the cecum: "This is really surprising, the priest's appendix is ​​gone!"

After hearing this, there were doubts everywhere, and the food in his hands suddenly became tasteless. A patient who needed an appendectomy urgently could not find his appendix in his body. And it was not a mutation of the appendix.

It's not that there's a problem with the surgeon's technique, it's that he really can't find it.

Even Varela, who had seen many surgeries abroad, was shocked. He couldn't help but said to himself: "This should be the ileocecal part. There is no reason why we can't find the appendix."

"Did I look in the wrong place?"

Ignatz smiled and doubted himself for a moment, then compared the intestinal tube in his hand. After confirming that it was the ileocecal part, he expressed his opinion unceremoniously: "The appendix has indeed disappeared. This may be a brand new

His internal organs mutated, and he was born with a missing appendix!"

In front of them is Austria's chief surgeon, Ignaz. His explanations and operations are textbooks, and the audience can easily accept them.

Since the appendix is ​​missing, there is no choice but to end the operation. Ether anesthesia is unstable, and no one knows when it will fail.

Half a month ago, Morasso almost ruined the operation due to insufficient anesthesia. He woke up halfway and almost ruined the operation. The chaotic scene was still replaying in Ignatz's mind. He did not dare to take risks: "It seems that the priest did not have appendicitis."

Herman was already preparing his sewing: "Do you want to close your abdomen now?"
To be continued...