The Godfather of Surgery

This patient is an acquaintance of Director Zhou, and it is time for the Municipal People's Hospital to re-establish its brand. If even a fish bone cannot be solved, it will seriously affect the establishment of the brand.

Although this fish bone is indeed very troublesome, as a patient, I don’t think so. If I haven’t found a fish bone after thoracotomy, what kind of level is this?

These are still secondary. If the fishbone is not removed from the blood vessel, it will be a hidden danger wherever it stays. It is very dangerous and can cause unpredictable and controllable bleeding, infection, embolism, etc. If it enters the brain, That would require a craniotomy, which might cause intracranial infection.

"Would you like to take another photo with the C-arm camera?"

Director Zhou reminded in a low voice that he had just used a C-arm camera to take pictures, but couldn't find it. Maybe Professor Yang would make new discoveries.

"Take out all the photos you just took and show them to me."

After all, the X-ray C-arm machine uses X-rays, which contain ionizing radiation. Taking too many X-rays is not a good thing. Yang Ping decided to take a look at the X-rays they had taken before. If any omissions needed to be filled, it would not be too late to take more pictures.

The doctor observing in the audience immediately turned the screen of the C-arm machine over so that Yang Ping could see it, and then pulled out the film that had just been taken.

There was no need to take additional shots. All the front and side X-rays from head to toe were available. Yang Ping looked closely and carefully, but found no fish bones.

Fish bones are made of bone and have a density similar to human bone tissue. Therefore, they appear as tiny needles on X-rays, which are quite conspicuous. Except for the parts blocked by bones, other parts are easy to find.

There are not many parts blocked by bones, such as the inside of the skull, the spinal canal, the ribs of the chest, etc.

Therefore, the role of the C-arm machine is limited, and it has a blind spot for inspection. At this time, color ultrasound must be used to make up for the shortcomings of the C-arm machine. The combination of the color ultrasound and the C-arm machine can basically make the fish bones have nowhere to hide, because they Just enough to cover the opponent's blind spot.

"Let's repair the damage to the esophagus and aorta first, and then use color ultrasound to explore." Yang Ping decided to give color ultrasound a try.

There are only a few methods that can be used at present: the only ones currently used are X-ray C-arm machines and color ultrasound. As for CT, the operation needs to be completed and transported to the CT room for inspection. After the examination, the second stage operation is performed to remove the fish bones. During this transportation process and During the waiting time, the fishbone is likely to become displaced again.

Try to solve the problem with this surgery, but if it doesn't work, leave it to the next surgery.

Director Zhou and his assistant repaired the aorta and esophagus, and the fishbone punctured the wound very small. The current manifestation on the aorta is hematoma under the adventitia of the blood vessel. Only by opening the adventitia and removing the hematoma can you see the punctate The pinhole and esophagus are similar, but the hematoma is not so obvious.

The hole in the aorta is just at the aortic arch, and the pressure on the blood supply is very high. The blood supply may be squeezed out of the small hole at any time, and then tear the blood vessel, causing massive bleeding and death. Even if there is no major bleeding and there is no bleeding temporarily, it is easy to cause Aortic dissection is also very dangerous and the patient may die at any time.

Bleeding can also enter the esophagus through esophageal aortic leakage, causing the patient to vomit blood. Accidental inhalation of vomited blood into the trachea can cause death by suffocation.

In short, this breach must be repaired, otherwise it will be a fatal time bomb.

Director Zhou was repairing the breach in the aorta and esophagus, while the circulating nurse prepared a color Doppler ultrasound machine and a sterile ultrasound probe.

After Director Zhou had repaired the breach in the aorta and esophagus, Yang Ping decided to use a sterile color ultrasound probe to first explore the surgical area and the sterile area around the surgical area. The main target was the aorta and esophagus in this area.

There may be very few fish bones hidden in other parts of the surrounding area. If they are only in nearby places, the C-arm X-ray machine can easily find them because the surgical area is now open and there is no obvious sternum obstruction. The director used many oblique films when taking pictures of this area, trying to avoid the ribs being blocked.

According to the physiological laws of the human body, fish bones must travel further and further along the direction of blood flow, and they will definitely get stuck somewhere and cannot come back. Therefore, in theory, a carpet-like search along the direction of blood flow can be carried out. It can definitely be found, it just depends on whether the doctor's color ultrasound recognition level is good enough.

If there is no sterile area in the surgical area or nearby, then the chest should be closed. The chest should not be left open all the time. After closing the chest, go to explore other places. Yang Ping told Director Zhou: "Close the chest. After closing the chest, we will try again." Explore other places.”

The surgical area was not explored, which made Director Zhou feel a little more uneasy. The patient had reluctantly agreed to the operation, but now the fishbone could not be found during thoracotomy, which was difficult to explain.

It’s okay if we can find it later, but if we can’t find the fish bone, we will have to explain a lot to the patient’s family after the operation. In the end, this matter is not over yet, and we will definitely have to look for fish bones. After the patient rests for a few days, the second operation is Absolutely unavoidable.

Director Zhou led his assistant to close his chest in anxiety, and his whole person became a bit mechanical. After all, he had never seen anything big in the world.

In recent years, the thoracic surgery department of the Municipal People's Hospital has not had any decent surgeries, and he has not had the opportunity to go out for further study, so there is no way he can make progress.

At this time, Director Zhou became more and more upset as he thought about it. In this mood, he led his assistant to complete the chest closure and waited for Yang Ping's next instruction.

Soon, the color ultrasound was ready. Yang Ping followed the shape of the aorta and its branches, detecting it part by part, looking for ultrasound images of fish bones in the blood flow.

Yang Ping first looked at the main trunk of the aorta, because the intraoperative color ultrasound just followed the principle of asepsis and only explored the surgical area that was not covered by sterile drape. Other areas such as the abdomen were not examined.

After inspection, no fish bones were found in the main trunks of the thoracic aorta and abdominal aorta. After the aorta emerges from the heart, it gives off many branches, and these branches give off branches. After Yang Ping saw the main trunk, he could only explore the parts controlled by these branches one by one. .

Look up at the neck, armpits, and upper limbs on both sides; down at the liver, gallbladder, pancreas, spleen and other organs in the abdominal cavity; then look at the pelvis and lower limbs on both sides. In short, every part cannot be missed. It can go to any possible place. place.

It is common for fish bones to pierce the esophagus and aorta, but it is very rare to follow the blood flow everywhere. Yang Ping clearly remembers that the Vascular Surgery Department of West China Hospital once published an SCI paper, reporting a case of fish bones entering the aorta. , and then ran away in the direction of the blood flow.

At that time, the doctor did not find the fish bone after the thoracotomy, so he had to give up the operation and asked the patient to return to the ward and do a CT scan again. The result was that the fish bone was in the hepatic artery. When the patient could withstand the second operation after resting, the doctor gave him another The patient underwent an operation. He entered the abdominal cavity from the right subcostal margin, directly found the hepatic artery, found the location of the fish bone by touching it with his hands, and cut the blood vessel to find the fish bone.

But now this patient's fishbone is obviously not in the hepatic artery, and there is no shadow of fishbone in the entire abdominal cavity. Is it really necessary to give up the operation, do a new CT scan, and then plan a second operation?

Yang Ping is still very confident in his color Doppler ultrasound skills, and there is no chance of a diagnosis being missed due to his own inability to see.

After all the thoracic and abdominal cavities were done, no fish bones were found. Director Zhou was even more worried: "Should we send him for a full-body CT scan to take a look?"

Of course it is good to do CT, but if it can be discovered with color ultrasound, it does not need to be so troublesome. It is much better to solve it directly in the operating room than to add another operation, which at least reduces the impact of the operation on the patient.

"Don't bother!"

Yang Ping spoke firmly, and the color ultrasound probe in his hand began to explore the neck and both upper limbs. Fish bones stuck in blood vessels will definitely have an impact on the local state of blood flow, and this impact will be reflected in the ultrasound image.

Both upper limbs were missing, and Director Zhou could no longer hold his breath, but he couldn't say anything else for fear of affecting Yang Ping's operation.

Since there are no upper limbs, let's take a look inside the skull. The probability of entering the skull is slim, but not impossible. Yang Ping began to carefully explore the intracranial arteries along the vertebral arteries and common carotid arteries on both sides.

Yang Ping's eyes were fixed on the screen, ready to capture the small changes in the rippled color ultrasound image. Unfortunately, the intracranial color ultrasound did not show fish bones.

Yang Ping had no choice but to complete a color Doppler ultrasound of the lower limbs, but no trace of fish bones was found. Although the combined color Doppler ultrasound and X-ray C-arm machine were not 100% able to detect it, it was close to 100%. At Yang Ping's level, it was no better than a full-body CT scan. Difference.

So where did this fish bone go? Is it not found yet, or is it really missing?

A two-centimeter fishbone cannot just disappear. It must be somewhere, but it has not been found yet.

Director Zhou was obviously losing his composure at this time and seemed upset, but Yang Ping was very calm. After so long training, Yang Ping has become very calm, rational and objective, and there will not be any big emotional fluctuations during the operation. .

"How about pushing it down for a full-body CT scan?"

Director Zhou suggested again that this was no choice but to do this, otherwise, it would be impossible to keep the patient lying on the operating table.

Yang Ping thought this was strange. The C-arm machine and color Doppler ultrasound could not trace the traces of this fish bone. This fish bone was powerful enough. He said that it was okay to hide it in front of others, but the possibility of hiding it in front of himself was too small. Where did the problem lie? Yang Ping thought about the entire operation and then considered all the possibilities.

It is either in situ. If it is not in situ, it is either in nearby tissues, or in the aorta or esophagus. If it is in the esophagus, it will move to the gastrointestinal tract. However, I have just checked it with a color ultrasound or X-ray machine and found nothing. .

If it didn't work, he could only do a whole-body CT scan, but Yang Ping still followed the steps carefully.

Yang Ping thought about it in his mind and glanced at the basin where gauze was collected on the ground: "Go around and search for all the gauze, piece by piece, to see if the fish bones are stained on the gauze."

Is it possible that when looking for fish bones, the fish bones came out inadvertently, and were then taken out by gauze and so on. Now they are not in the patient's body. Yang Ping decided to look for them first. If it was not possible, he ended the operation and did a new CT scan, elective. Second surgery.

The practicing nurse on duty began to check the gauze. The intern nurse used a flashlight. The traveling nurse spread out the gauze piece by piece and carefully checked both sides of the gauze. The two nurses checked together to confirm that there was no contamination on the gauze, and then checked and collected the gauze. There is no gauze basin inside either.

"Has the liquid in the suction bottle been changed?" Yang Ping focused on the suction bottle.

The nurse said, "It hasn't been changed yet."

"Filter all the liquid in the suction bottle with gauze to see if it's inside." Yang Ping didn't even let go of the suction bottle.

Because the fish bones are taken out of the body, this is a loophole. If this loophole is not considered, it will be very passive. Everyone will limit their thinking to the fact that the fish bones still stay in the patient's body.

Although this fish bone is two centimeters long, it is very thin, has no forks, and is not very curved. It can be sucked away by the suction device. If it is vertical when entering the suction device, it can just enter the suction bottle along the straw.

Check that if the suction bottle is not there, it must still be in the patient's body. We can only call it a day and do subsequent processing, do a new CT scan, and schedule a second surgery to remove the fish bone.

In order to be meticulous, Yang Ping checked the suction nozzle and asked the nurse to replace the suction tube for inspection. He asked Director Zhou to check his gloves, the sheet he had just removed, and even the floor.

Now that the fish bone is gone, it is either in the body or has come out. This is a big deal, and the nurse does not dare to neglect it at all.

So the two nurses began to work together again. One took a large piece of gauze as a filter cloth and opened the gauze with both hands. The other nurse slowly poured the liquid in the suction bottle onto the gauze and filtered it through the gauze. The filtrate slowly flowed out. into a collection bottle.

Director Zhou and other doctors were already restless and could not accept Yang Ping's excessive behavior, but they did not dare to say anything and could only follow what he was told.

Just checking the gauze was a bit excessive. Now I am not even letting go of the filtrate in the suction bottle. I am conducting a filtration check. Could the fish bones be sucked away accidentally?

Yang Ping remained calm. He acted according to his plan. Regardless of whether the fish bone could be found or not, this step must be done, otherwise it would be difficult to finish the work now and follow up.

If the fish bone is still in the body, a CT scan can be performed to find the fish bone, and a second surgery can be performed to remove it.

But what if no fish bones are found on the whole-body CT scan? Don't care about it later? The absence of CT findings does not mean that the fishbone is not in the body. Could it be that the patient is living with a time bomb.

There was a lot of liquid in the suction bottle, almost 3,000 ml. It took a while to filter it with gauze. The nurse squatted on the ground and was very serious.

"Fish bone!"

a nurse shouted excitedly.

The instrument nurse immediately threw the vascular forceps to the nurse. The nurse used the vascular forceps to pick up the fish bone and showed it to Yang Ping and Director Zhou. Sure enough, it was a thin fish bone about 2 centimeters long. This fish bone had no branches or cross sections. , is a complete root.

No wonder I couldn't find it. The fish bone had been sucked out by the suction device.

"You can issue a SIC in this case." Yang Ping smiled.

The West China Hospital's fish bone case published a serious SCI article. It took a lot of effort to find this fish bone, which is enough to publish an article.

Director Zhou couldn't help but be afraid. If Yang Ping hadn't found the fish bone just now, the patient would have ended up hastily. Was the fish bone taken out or not?

What if it really stays in the body and CT doesn’t detect it?