"0.5% lidocaine and half a syringe of milk," Zheng Ren said.
Milk was the nickname for propofol—an intravenous anesthetic commonly used in the induction of general and continuous epidural anesthesia. It was not as useful as a local anesthetic agent.
Shocked, the anesthesiologist considered protesting, but the determined look on Zheng Ren's face made him think twice.
This surgeon was going to operate on a case of appendicitis in pregnancy without general anesthesia. Nothing else in the world could faze him.
"Five-milliliter syringe, but use a one-milliliter syringe needle tip." Zheng Ren's profile loomed under the shadowless surgical light. His every order was firm and left no room for doubt.
A smaller needle tip meant less pain for the patient but made it more difficult to deliver the anesthetic.
Local infiltration anesthesia began and the anesthesiologist watched with rapt attention as the needle rhythmically and expertly pierced the patient's skin.
After each injection, there was a pause to allow the mixture of lidocaine and propofol to take effect before moving on to the next site. Zheng Ren's technique was attentive but accurate. Judging from the patient's vitals, there was no sign of any pain response from each injection.
Amazing! No wonder he chose local anesthesia for this appendectomy.
The anesthesiologist recognized talent when he saw it. His eyes remained fixated on the scene.
In the surgical demonstration classroom, Old Chief Physician Pan and Chief Surgeon Liu exchanged a look.
Old Chief Physician Pan put down his copy of Limited Views when he realized the ongoing appendectomy was on a pregnant woman.
At the sight of Zheng Ren prepping for local anesthesia, anxiety rose in Old Pan.
"Old Chief Physician Pan, you have sharp eyes." Chief Surgeon Liu felt victory in his hands already. This time, Zheng Ren's suicidal attempt had nothing to do with him. Chief Surgeon Liu felt more relaxed as he began to denigrate his competitor, who had bitten off more than he could chew.
"Appendectomy on local anesthesia; it's been many years since my last one. Old Chief Physician Pan, you must be familiar with the procedure, especially after your time at county-level hospitals. Today, I shall watch and learn."
Satisfied, Chief Surgeon Liu shifted into a more comfortable position and continued watching the projection with a small smile on his lips. Zheng Ren had started local anesthesia.
Old Chief Physician Pan wanted to fire back, but now was not the time.
It was already midnight when over a hundred Xinglin Garden accounts came online and rushed to watch the livestream.
[My my, what am I seeing, a case of appendicitis in pregnancy? And operating on local anesthesia! Is the god livestreaming a shortcut to death?]
[What do you know? Just sit down, you're blocking my view.]
[I've never done locally anesthetized appendectomy before. This is a good opportunity to learn. Hopefully our god operates slowly, I'm gonna tell others to come and watch.]
[Have any of you done a local anesthesia appendectomy before? Not me. Sit down and learn from the god.]
[Nope +1]
[Never +2]
[...]
[Never +10086]
Behind each Xinglin Garden account was a physician. It was a website for professionals and came with strict requirements—one's real identification and legitimate, verified physician's certificate—for user registration.
A routine appendectomy called for continuous epidural anesthesia.
Those staying up for this livestream were young physicians around thirty years of age. None of them had ever performed an appendectomy on local anesthesia before, despite being professionals.
[Why is the syringe so turbid?]
[I think I heard something about propofol just now. Is there an anesthesiologist in this room? Can you shed some light on this outrageous practice?]
[I'm the deputy chief anesthesiologist from one of the Class Three Grade A Hospitals. I am dumbfounded, no idea what's going on.]
As the surgery commenced, the professionals entered a collective state of confusion.
Local anesthesia appendectomy was an uncommon surgery to begin with, but the surgeon was pushing his luck if even an anesthesiologist could not make sense of the anesthetic being used.
The comment section started to overflow.
[Why does he pause after each injection? What's the reasoning behind this?]
[My guess is that it allows the local anesthetic to take effect and avoid agitating the patient. Infiltrative 0.5% lidocaine will take effect around 12 seconds post-administration, though, so why is he spacing out the injections at three-second intervals?]
[Don't tell me that's the use of propofol?]
[I'm kneeling. Please accept my reverence.]
[Oh please, stop commenting. Watch the surgery! Watch!]
The last call for silence was futile and was quickly lost in a sea of incoming comments.
[I remember the textbook incision for an appendectomy in pregnancy starts at the McBurney's point1 on the right side of the rectus abdominis. Isn't the god's incision point a bit high? Or am I remembering it wrong?]
[It's possible that the position has been confirmed through palpation.]
[A five-centimeter incision on a pregnant woman for an appendectomy. How gutsy he must be!]
Although it was just an appendectomy, everyone watched hungrily. The live comments dwindled as the first layer of skin was peeled open.
…
…
Zheng Ren drew the scalpel across the skin and proceeded to perform a blunt dissection on the tissue and muscles underneath. The peritoneum was the last layer.
Every move required the administration of local anesthesia. The surgery was not a quick one but his movements were steady.
The anesthesiologist looked at the surgery, then at the patient's vital signs, and then back at the surgery. They were at the peritoneum now, and the patient's blood pressure, heart rate and breathing remained stable.
This indicated that Zheng Ren's local anesthesia technique was effective and the patient did not feel any pain.
'This man is a daredevil,' the anesthesiologist thought.
Zheng Ren's performance was of the highest caliber. Even a professional anesthesiologist would not have done as well. Was this the effect of the propofol? Could it perhaps be tested in the next surgery?
The anesthesiologist shook his head to clear the outrageous thoughts from his mind. He should keep to standard protocols for anesthesia. If something were to go wrong, he would not be able to shoulder the responsibility.
After cutting through the peritoneum, Zheng Ren looked inside and promptly located the appendix with the curved surgical forceps.
The swollen appendix was gently clamped between the forceps. There was not an ounce of unnecessary force in Zheng Ren's grip.
With one hand on the scissors, Zheng Ren motioned for Xie Yiren.
A smaller pair of curved forceps was placed in his hands.
"Not this." Zheng Ren rejected the instrument. "The syringe."
With a start, Xie Yiren realized her mistake. This was not the standard appendectomy she was used to, but a local anesthesia appendectomy. The clamping of the ligaments and arteries surrounding the appendix had to be prefaced with administration of anesthetic.
Xie Yiren's eyes twinkled as if a new toy was before her—Zheng Ren's procedure had her full attention. All the routine appendectomies she assisted in had bored her to tears.
A quick round of local anesthesia later, Zheng Ren continued separating the ligaments.
Zheng Ren considered himself unlucky to be saddled with a case of appendicitis in pregnancy at such a precarious moment, and to operate with only local anesthesia.
Although he had practiced local anesthesia appendectomy in the System, he still prefered to avoid such outrageous practices as the risk of accidents was high.
However, there was some luck on his side as this case w
as not as complicated.
Due to the pregnancy, the patient's uterus was enlarged and the greater omentum which usually covered the appendix had been pushed away. If the appendix ruptured without the greater omentum's protection, the patient would suffer severe complications and the surgery would have been even more troublesome.
It was unclear to him how the swollen appendix was still intact. He chalked it up to a quick and timely diagnosis. The patient's youth and general good health also likely contributed to the cause.
The inflammation around the appendix was also mild.
Zheng Ren thanked his lucky stars.
He removed the appendix and tied up the appendicular artery, then closed up the residual stump with a purse string suture, adding an extra stitch at the end.
The whole process was clean and beautiful.
It was a success that stunned everyone into silence—from the surgical demonstration classroom to Xinglin Garden. : McBurney's point is the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus (navel).
Chapter 22 - Complicated Surgery, Round Two
[Kneel before your god.]
The silence lasted a moment before comments once again poured into the Xinglin Garden livestream.
Most standard appendectomies took longer than what they had just witnessed, what more in an expecting mother. Although no one in the chatroom had performed such surgery before, they understood its sheer difficulty.
Despite its complexity, the surgery had been completed within ten minutes.
Viewers entering the livestream at this point were only greeted with the finale.
[Was I late again? Some consolation please.]
[You missed a once-in-a-lifetime opportunity. This live surgery was one-in-a-billion.]
[Isn't it an appendectomy during pregnancy? How did it end so soon? I just made a cup of coffee in expectation of a three-hour operation.]
Some users grumbled while others teased them. Meanwhile, those who caught the livestream from start to end were still up to their eyes in disbelief.
A minute passed and incoming messages all sang praises, posting '6661' in the chatroom.
[Accurate incision point, effective local anesthesia, a clean and successful surgery. Amazing!]
[I think I'm gonna stay up. I'm suddenly inspired to write an article on elective incisions. Any recommended papers?]
[In my opinion, the administration of the anesthesthetic was the key step. I personally have never seen a patient not feel any sort of pain under local anesthesia, but maybe that's just me.]
The operation had ended earlier than anticipated, but the livestream chatroom was still buzzing with users analyzing and discussing what they had just witnessed.
Some doctors wanted to use the video as an educational material while some planned to use this appendectomy during pregnancy for a case study discussion.
In the surgical demonstration classroom of Sea City General Hospital, Old Chief Physician Pan sat on his couch calmly. He looked down at the empty operating theater and smiled.
In the same room, Chief Surgeon Liu still had a look of bewilderment on his face. He was at a loss.
Since Zheng Ren's transfer to Sea City General Hospital, he had been in the general surgery department, where Chief Surgeon Liu could not figure out the man's surgical caliber.
There was nothing impressive about performing a routine appendectomy without another surgeon's assistance.
However, this surgery was an appendectomy during pregnancy. It was a blow to Chief Surgeon Liu's pride.
If he were the one at the operating table, would the surgery have been as clean?
No.
Most definitely not.
Even if the patient was on continuous epidural anesthesia, he would have followed the textbook-recommended incision at McBurney's point, right next to the rectus abdominis.
Following that, some time would have been spent on searching for the swollen appendix. Moving the intestines around might have caused the patient discomfort and increased the risk of miscarriage, but it would have been necessary.
How did Zheng Ren manage to pinpoint the exact spot? Who taught him such skill?
This would have been a jackpot for Chief Surgeon Liu were it not Zheng Ren who was performing the surgery. He would have brought the video recording home for research.
Any discovery related to surgical entry technique was worth a lot.
Curses!
Chief Surgeon Liu clenched his fists tightly as anger leaked out from within his heart.
"What do you think, Chief Surgeon Liu?" Old Chief Physician Pan was now on the offensive. "Zheng Ren is still young. If you have any opinions on his methods in this case, I'll guide him to improve."
'Opinions? F*cking opinions!' Chief Surgeon Liu fumed internally.
'What f*cking opinions can I have? Even I want to bring that videotape back, and you dare ask me if I have f*cking opinions!' Chief Surgeon Liu thought.
He gritted his teeth. There was nothing he could say to Old Chief Physician Pan in the face of such utter defeat.
Patience. He had to wait for Zheng Ren to make a mistake.
All he needed was one mistake. Just one!
…
…
There were people still chatting in the Xinglin Garden livestream.
Around ten minutes had passed when there was sudden movement in the livestream. Preparations were being made for another patient.
[I'm game for a second round!]
[Luckily I haven't left. I'll get to watch from start to end.]
[My, my, there's still another live surgery? My coffee-making was clearly not a wasted effort, haha. Thank you, my lucky Nestle instant coffee. Love you.]
The livestream chatroom started to become lively again.
An opportunity to observe a live surgery was few and far between.
While preoperative preparations carried on in the background, doctors shared the livestream through WeChat to lure in colleagues, friends and classmates who were still awake at this hour.
[What am I seeing? Why are my eyes straining?]
[Is that a stent? Such an overweight patient will have a high risk of myocardial infarction.]
[The case is out. This is a quality livestream that even provides live case studies. Man, it's another appendectomy. Is he doing an appendectomy challenge with different difficulty levels?]
When a mountain of flesh was lifted onto the operating table, the live chatroom went crazy.
Appendectomy on a bariatric patient was not as uncommon as an appendectomy during pregnancy. Even if the doctor was not a general surgeon, they would have encountered such a case during their internship rotations.
This type of surgery was not as difficult as the previous one. However, every doctor knew the pain of dealing with the postoperative care of an overweight patient. The fat liquefaction and multiple dressing changes required daily was enough to make one crave death.
At least it was not their case, though, and they were just enjoying the show. Comments came in in torrents—everyone was rooting for Zheng Ren.
Xinglin Garden did not have a 'like' feature, so there were no rocket or racecar emojis floating onscreen.
More and more people entered the stream, breaking Xinglin Garden's viewer record.
Everyone's attention was on the case details: 168 centimeters and 112.5 kilograms. The mountain-like abdomen, no doubt covered with layers of adipose tissue, was like a pretty lady tugging at the heartstrings of the doctors staying up for the surgery livestream.
Old Chief Physician Pan read through the patient's file on the computer and said, "Chief Surgeon Liu, aren't you crafty."
The patient had arrived not long ago. After his preliminary medical history assessment, he was immediately pushed into the operating room. Old Chief Physician Pan noted that this patient, like the pregnant one before him, was from a district bordering Sea City.
Ol
d Chief Physician Pan was a 'do no harm' kind of man, but after years in medical practice, he had witnessed countless underhanded tactics.
From this small detail, he could tell that something was afoot.
They were both from bordering districts and the surgeries they required were complex and taxing.
No way this was a coincidence.
"This is Zheng Ren's lucky day. It's none of my business." Having crawled out of his pit of despair and regained his composure, Chief Surgeon Liu shut down Old Chief Physician Pan's accusation.
Such things had to be denied unless one was caught red-handed.
"Huh." Old Chief Physician Pan dropped the subject and focused on the live screen, his right hand tapping on the old and tattered copy of Limited Views. A chatroom slang term used to describe someone who has incredible skills.
Chapter 23 - Operation: Blind Appendectomy
Standing behind Chief Surgeon Liu, Cen Meng's face was pale.
As the chief resident in the general surgery department, he had not considered Zheng Ren a rival. He figured some quiet guy who did not curry favor would not be likable to anyone.
Hence, Zheng Ren had never gotten the chance to operate solo and was not a threat to him.
However, after three non-standard appendectomies in a row, Cen Meng had to face the fact that Zheng Ren was definitely miles ahead of him. Zheng Ren's skills might even surpass that of the Sea City Supreme Scalpel, Chief Surgeon Liu.
"Has the laparoscope been fixed?" Chief Surgeon Liu asked knowingly. He did not bother to lower his voice, wanting Old Chief Physician Pan to know.
"Chief, did you forget? The laparoscope broke down three days ago and was sent out for repair. The vendor said they need a week before it can be sent back," Cen Meng replied.
The best practice for an appendectomy on a bariatric patient was to use a laparoscope. After the previous success, Chief Surgeon Liu was glad he checked the laparoscope's availability. What was Zheng Ren going to do now?
Old Chief Physician Pan frowned. The tapping on the old copy of Limited Views picked up.
When the full details of the case were revealed, the chatroom of Xinglin Garden turned to chaos.
The Surgeon's Studio c1-799 Page 15
