The road to the rise of great doctors

Chapter 115 Knowledge
Liu Dong was holding the hook next to him, craning his neck to watch with a solemn and serious expression.

After exposing the parathyroid glands, Chief Physician Wang Jian showed it to everyone who participated in the operation.It is obvious that there is a nodular mass under the left lobe of the thyroid gland. The mass is brown and has no obvious adhesion to the surrounding tissue.

The surgeon removed the nodular mass completely along the outside of the tumor capsule.After carefully stopping the bleeding, Liu Dong took the sample and touched it. The texture was medium, neither hard nor soft.After the circulating nurse had written the specimen bag, Liu Dong sent the tumor from the stage to the opened specimen bag off the stage, preparing to send it to rapid pathology.

Seeing that the specimen had been put in the specimen bag, Chief Physician Wang Jian said to the circulating nurse, "Let's go and take a look at the patient's family first, and then send it for a quick pathology examination."

"I have filled out the pathology form and put it on the first page of the medical record folder. The space for 'Intraoperative findings' on the form is empty. Nurse teacher, please help me fill it in," Liu Dong continued.

The itinerant nurse picked up a pen, and quickly filled in according to what Chief Physician Wang Jian saw during the operation.

After filling it out, she took the pathology bag and pathology sheet and helped Chief Doctor Wang Jian to open the door. The two of them walked towards the conversation room at the door of the operating room one after another.

Others on the stage continued to wait by the operating table.Liu Dong covered the surgical tissue with a piece of gauze moistened with normal saline, moistened it slightly every few minutes, and checked for any abnormality such as bleeding and dealt with it in time.The anesthetist glances at the monitored blood pressure, oxygen saturation and other indicators from time to time to confirm that the patient is in a normal and stable state.

Soon after the conversation, Chief Physician Wang Jian returned to the operating room.He took off the surgical gown that he went out just now, and he didn't go on stage for the time being. He wanted to wait for the pathology results to come back and then go on stage depending on the situation.

After a while, the traveling nurse came back.

About 10 minutes after the nodule was removed, Chief Physician Wang Jian glanced at the itinerant nurse and said, "Draw this patient's blood and check for parathyroid hormone."

After hearing this, the circulating nurse immediately walked to the patient, took a test tube, drew blood, and walked out to the door of the operating room so that waiting field colleagues could deliver it as soon as possible.This is an urgent hormone test, and an appointment has been made one day before the operation.As for the rapid pathology just sent, I had made an appointment with the pathology department the day before the operation.With an appointment, the results are guaranteed!

About half an hour later, the itinerant nurse who was waiting for the results at the door of the operating room came back with the results that had just come out.

She read aloud, "Parathyroid hormone result report: PTH 134 ng/L, preoperative PTH test was 1200 ng/L."Then, walked out, came back a few minutes later and read, "Frozen section: Parathyroid adenoma."

Hyperparathyroidism may be caused by parathyroid adenoma, parathyroid hyperplasia, or parathyroid cancer.

If only the hyperplastic parathyroid glands are removed according to the preoperative imaging examination, and the treatment of other glands is ignored, the lesion may be missed, and the recurrence of hypercalcemia after operation may occur.The disadvantage of frozen section is that it is difficult to identify adenoma, hyperplasia and early cancer.In order to prevent the above situation, the clinician adopts the plan that the excised tissue specimens can be sent to frozen section examination during the operation, and the parathyroid hormone can be measured 5-10 minutes after the specimens are excised.If the intraoperative serum immunoreactive parathyroid hormone value drops by 50% after the abnormal tissue is removed, it indicates that the resection is successful; otherwise, the lesion is not an adenoma but a hyperplasia.

This patient's parathyroid hormone dropped significantly after the tumor was removed. Combined with the intraoperative frozen section results suggesting parathyroid adenoma, these comprehensive evaluations show that the surgery successfully solved the problem!
After Chief Physician Wang Jian heard the results, he asked Zhao Gang and Liu Dong on the stage to do it first, while he stood beside the stage to guide.After all, the key steps of the operation have been completed, and only the finishing work is left. For the two doctors in the team, he is relatively relieved, and with him on the side of the stage, he can come to the stage to save the scene in time if necessary.

Zhao Gang took over and Liu Dong continued the operation as the first assistant.First, they checked the bleeding situation of the wound again. After all the bleeding was completely stopped, a drainage tube was placed at the surgical site.

Then, after the circulating nurse and the doctor on the stage counted the number of instruments and dressings correctly, Zhao Gang and Liu Dong began to suture and close the incision layer by layer. The surface skin was also sutured with intradermal suturing, using absorbable sutures.Cosmetic suturing is a newly promoted direction for exposed incisions such as neck surgery. After all, everyone does not like to have obvious surgical scars on exposed parts.

Liu Dong cooperated skillfully.Then there were some thoughts in my mind, thinking about the surgery method and the precautions after the surgery.

The surgical methods for primary hyperparathyroidism vary depending on the disease.The pathological result of this patient was an adenoma, so the surgical method for parathyroid adenoma was to remove the adenoma.If it is parathyroid hyperplasia, subtotal parathyroidectomy or total parathyroidectomy + autologous transplantation will be performed.If it is parathyroid cancer, it will be differentiated according to whether there is cervical lymph node metastasis. When there is no cervical lymph node metastasis after radical surgery, surgery including the ipsilateral thyroid and isthmus, peritracheal lymphoid fat tissue and part of the thymus tissue will be performed. Mass resection; when there is regional cervical lymph node metastasis, combined radical resection should be performed.

However, after undergoing an adenoma resection and understanding the anatomy, Liu Dong believes that he will be relatively easy to handle if he encounters similar diseases in the future, even if they are hyperplasia or cancer.

During yesterday's pre-operative conversation, Liu Dong had already told the patient and family members that vital signs and blood biochemistry should be closely monitored after the operation.Successful surgery does not mean that all problems are solved immediately, and there will be recovery time.

This recovery process is the result of senior doctors summarizing the experience of countless similar surgeries and publishing articles. Based on those summarized experiences, Liu Dong learned and told the patients and their families that the serum calcium within 24 hours after the operation The level drops to normal or hypocalcemia occurs, which is most obvious within 1 week after surgery. In addition, hypocalcemia in most patients is temporary. It usually decreases to the lowest level 4-5 days after surgery, and then gradually rises.In this way, if hypocalcemia occurs after surgery, it can be treated symptomatically, and the patient will not be too dissatisfied or suspicious.Of course, attention should also be paid to whether there is abnormal magnesium metabolism. If calcium supplementation cannot control tetany, hypomagnesemia should be considered.

At that time, Wang Rong's husband also asked a question, "What is the cause of temporary hypocalcemia after surgery?"

There are actually answers to such questions, which are summaries of previous clinical studies and the results of basic research.Therefore, Liu Dong directly answered this question at that time: "There are three main reasons for temporary postoperative hypocalcemia: 3) bone hunger and bone repair; 1) due to the long-term high secretion state of parathyroid adenoma, which causes Other normal parathyroid function is suppressed, and temporary hypoparathyroidism occurs after surgery; 2) Some bones or kidneys resist the parathyroid glands."

This also provides ideas for Liu Dong's future scientific research direction. Scientific research is closely related to clinical practice. The most important thing in clinical scientific research is to solve unmet clinical needs!
If you work on the front line and are good at thinking, summarizing, and cooperating, you will provide yourself and fellow scientists in basic research with great ideas.

There is a saying that describes it better, Liu Dong thought, "The road is long and long, I will search up and down."

(End of this chapter)