Since the patient had an old surgical wound, the incision was a little unusual in order to avoid scar tissue.
What followed was blunt dissection. It would only be worth watching after the opening of peritoneum, and commenters used this window to flood the bullet screen.
The neurosurgeon's words had resonated with many and they began chatting together.
In a live surgery broadcast, doctors benefitted much more from the perspective of the operating field instead of the normal observation deck. It offered a better view than even the first assistant's
Modern medicine was an empirical science. All the doctors watching the live surgery broadcast in Xinglin Garden were aware of how rare the opportunity was to watch a skillful surgeon demonstrate surgery of so many rare diseases.
Until today, the demonstration had only involved general and interventional surgeries. Some of them were disappointed, but at the same time had greater expectations.
After a few minutes of non-stop comments, the viewers concurrently ceased talking to pay attention to the surgery as the peritoneum was exposed.
The anatomical structure of the peritoneal cavity had been altered by the previous surgery.
Furthermore, the disease had resulted in inflammatory edema and several unidentifiable adhesions.
[If I were him, I would have given up already. I'd just close it up in case the patient does not come out of the surgery alive.]
[The adhesions are so extensive; would it hurt the proliferated blood vessels?]
[Yeah, it is impossible to identify the tissues… This condition would make anyone feel like throwing in the towel after one look.]
Zheng Ren was not perturbed by the condition of the peritoneal cavity. He extended his hand and Xie Yiren placed a pair of blunt scissors on his palm.
The blunt end of the surgical scissors was used to separate the proliferated connective tissues, either by peeling them apart or cutting them off. He did it at a steady pace, neither too fast or too slow.
Su Yun frowned.
How was Zheng Ren differentiating the locations of abnormal blood vessel growth under such extensive tissue adhesion?
Such knowledge was definitely not in any textbook.
This was too peculiar.
At the same time, although he had requested to learn Zheng Ren's skills and techniques, Yang Lei realized he could not understand Zheng Ren's surgical methods now that he was at the table with the man.
After Zheng Ren separated the tissues, clamped them down and stitched up a rather thick vessel with a #4 suture, Su Yun piped up: "How did you manage to locate the vessel?"
"I felt it," Zheng Ren answered coldly.
His entire focus was on the surgery. He had no time to explain to Su Yun that the proliferated blood vessel also had pulsation. If one's tactile senses were sharp enough, they could feel it beating.
Zheng Ren had mastered this technique after countless practice runs in the System's operating room.
Most importantly, he did not know how to describe this minute yet extremely important technique.
[I suddenly have a feeling that this surgeon has laser-guided eyes and can see proliferated blood vessels hidden within the connective tissues.]
[Yeah, I thought that too. There is no other explanation for how they could perform blunt separation of the connective tissues without harming any blood vessels.]
[Until now, blood loss is below 5 mL. This is a display of skill at its finest.]
The doctors in the Xinglin Garden were intrigued. However… they could not figure out how Zheng Ren operated.
As he dissected the tissues layer by layer, the complicated anatomic abnormalities became clearer.
Even though Su Yun could not comprehend how Zheng Ren had managed to locate the vessels, he still understood the intention behind each step.
The appendix retractor and small surgical hook in his hands appeared without fail at the appropriate location every time to help Zheng Ren open up the next surgical field.
Finally, after five minutes, Zheng Ren separated the last connective layer and the room was instantly filled with the rotten, foul odor of pus. The author mentioned Chu Yanzhi was about to administer anesthetics in the previous chapter, but he named Chu Yanran in the raw text, possibly a typo.
Chapter 312 - Problematic Operation (Part 4 of 4)
Zheng Ren reached out and an uncovered aspirator was placed in his hand.
In the surgical field, blueish-green pus was visibly leaking out from the ileocecal fossa.
He hesitated before putting the aspirator on the patient's t.h.i.g.h. "Pass me a scr.a.p.er."
"Yes." Xie Yiren blinked and passed him the tool before picking up some sterile gauze.
Zheng Ren did not drain the pus by suction. Instead, he scr.a.p.ed at it and wiped it off on the gauze in Xie Yiren's hand.
It was a sample for subsequent microbiological culture. Xie Yiren had understood his intentions without a word.
Even though the greenish pus in the ileocecal fossa seemed to be caused by infection by Pseudomonas aeruginosa, they could not confirm it until they performed a test.
After collecting the sample, Zheng Ren began draining the rest of the pus with the aspirator.
Xie Yiren carefully put the contaminated tools aside and organized the sterile tools for closure later.
Everything was in order.
[Wow, it's green!]
[It's blueish-green. From the color of the pus, we already know the infection is extremely bad. Even after surgery, there's no guarantee that a combination of Tienam and vancomycin can actually control the infection.]
[The surgeon took a sample. This surgery seriously has no flaws.]
After Zheng Ren cleaned up the pus, he continued to examine the surrounding connective tissues and edematous adhesions.
The patient's gallbladder had been removed 24 years ago. Zheng Ren carefully searched for the biliary duct and separated it from the pancreas.
This was the most difficult step. He could feel Su Yun paying full attention to keep up with his thought process for each step, but Yang Lei seemed bewildered.
Zheng Ren felt slightly sorry since no one had control over their natural talent.
The pancreas was slightly swollen, but it was nothing serious. The patient would be put on somatostatin for some time to prevent uncontrolled acute pancreatitis.
"Yang Lei, remember to tell Chief Xia to administer somatostatin post-op, normal dose for three to five days," he said, getting the man to note down the key reminder.
Yang Lei acknowledged the order.
Zheng Ren continued to separate the hepatoduodenal ligament and explore the duodenum, soon finding the ileocecal fossa he had drained the pus from earlier.
Its wall was covered in abscesses.
Xie Yiren's view was obstructed from her angle, so Zheng Ren extended his hand and, in a rare display, said out loud, "Small scr.a.p.er."
Before he could finish his sentence, a handy scr.a.p.er was placed in his hand.
Surprised, he turned to look at Xie Yiren, who was smiling at him.
[The sight of abscesses is giving me a headache. When I previously encountered something similar, the patient suffered a fever for twelve days post-surgery.]
[Yeah, this surgeon isn't planning to scr.a.p.e off those abscesses, right?]
[He better not… the abscesses are heavily attached to the intestinal tract so it's not advisable to puncture the intestine. Edema in the intestine makes the patient even more vulnerable.]
[Mortals, don't try to predict the surgeon's next step with your simple minds.]
[I can sense that the surgeon is going to scr.a.p.e off the abscesses… He's moving, he's really moving! He's scraping them!]
Zheng Ren used the scr.a.p.er to remove the surface layer of the abscesses, then asked for a mosquito clamp, searched for an area with more deeply-rooted abscesses and began separating them from the intestinal wall.
Su Yun held the surgical hook tightly and
carefully, his breathing becoming shallower.
He was afraid to move for fear that the slightest movement would make Zheng Ren falter, leading to the rupturing of the swollen intestinal walls.
If that happened, in addition to leakage of intestinal contents, the edema would not subside even after they stitched the intestines back together. It could worsen to a point where the patient would require a second laparotomy.
What Zheng Ren was doing was incredibly bold given his skill. After all, he had done many surgeries involving similar separation techniques in the System's operating room.
Nevertheless, he was still very cautious. He patiently sought out small gaps and inserted the mosquito clamp to separate them.
This surgery was progressing at a painfully slow pace, at complete odds with the lightning speed with which he had performed the laparotomy.
In both the operating and live broadcasting rooms, viewers held their breath anxiously.
Five minutes…
Ten minutes…
Fifteen minutes…
At the 22nd minute, Zheng Ren retrieved the mosquito clamp and small scr.a.p.er from the patient's peritoneal cavity. There was an irregularly shaped, 20 cm² wide abscess on the clamp.
[My goodness, this is the best operation I've ever seen.]
[This looks like a microsurgery. It's hard to believe this surgeon did it with their n.a.k.e.d eyes.]
[Bullsh*t; the difficulty of this operation doesn't depend on one's surgical view, it all lies with both hands. Its execution was so meticulous that the intestines remained uninjured while the abscesses were completely removed.]
Across Zheng Ren, his first assistant, Su Yun let out a long sigh.
"There's a problem in your operation," he said.
"Yes, I know," Zheng Ren replied, "but this patient has sepsis. This would reduce the risk of infection and increase the chances of survival post surgery."
"You're that confident?" Su Yun's words did not come with context, but Zheng Ren understood that he was referring to the great risk taken in scraping off the abscesses.
Perhaps, from another's viewpoint, it had been extremely risky. However, he did not feel the same way; all it had taken was a little extra effort.
It was worth it if the patient healed faster after surgery.
After removing the abscesses in the ileocecal fossa, Zheng Ren completely separated the duodenum. Then, he reached out again and the surgical blade was put into his hand.
At the same time, Su Yun also opened his palm.
An uncovered sterile aspirator was passed to him.
When the common bile duct was incised, Su Yun inserted the aspirator.
Rotten food debris, pus-like fluid and digestive juices were s.u.c.k.e.d into its tube.
Su Yun shook his hand slightly and tried his best not to leave anything behind.
The common bile duct was so full that the uncovered aspirator was obstructed after only 20 seconds.
Its hissing began to fade.
Zheng Ren covered the area with wet gauze once Su Yun removed the aspirator.
Xie Yiren had already prepared warm saline. Su Yun put the aspirator into a bucket of it and repeatedly rinsed the tubing; after clearing the obstruction, he continued to remove the contents of the bile duct.
This whole process was repeated five times before the bile duct was finally cleared.
[Does this mean the surgery is halfway done?]
[Probably. The next step should be sphincteroplasty of the sphincter of Oddi. The rest should be easier after removing the abscesses and obstruction of the bile duct.]
[This surgery is so intricate. However, how will the patient avoid postoperative infection?]
[That'll be dealt with by the ICU. Had they had not done this surgery, they would not have been able to control infection anyway with so much rubbish inside the body.]
[I read the diagnosis before surgery and saw that the patient has sepsis. The patient received this surgery quite late; hopefully the surgeon's skill can pull her back from the gates of hell.]
After suction was complete, Zheng Ren was relieved. He had been more worried about the bile duct having serious edema or containing a huge foreign body. Those would require him to expand his surgical methods and cut open the bile duct for extraction.
Luckily, that had not been the case.
Chapter 313 - Let Me Treat You To Dinner (Part 1 of 4)
After the separation of the hepatoduodenal ligament, Zheng Ren moved on to the lesser omentum and separated the adhesion between the hepatic flexure and the right lobe of the liver (lobus hepatis dexter).
He then pushed down the transverse mesocolon and cut open the retroperitoneum behind the duodenum to perform a blunt dissection.
His skill at blunt dissection had been initially developed when he was training at appendectomy. It was his best trait.
By his own estimations, that one skill alone could probably reach a Master level.
However, it was so common that most people did not appreciate its art. Zheng Ren glanced at Yang Lei and was a little disappointed when he saw that the latter had not noticed it.
It seemed like he had to point out the gist of the surgery from time to time for the man to understand it.
After finishing blunt dissection on the retroperitoneum, he moved the second and third portion of the duodenum towards him until the head of the pancreas (caput pancreatis) and the duodenum were closer to the surface of the surgical field. Then, he temporarily put gauze soaked in warm saline behind them.
Under normal circ.u.mstances, he would use the duodenum as an anchor point while performing the sphincteroplasty of the sphincter of Oddi.
However, the patient had undergone a side-to-side choledochoduodenostomy. He did not need to do this anymore.
Zheng Ren prepared to cut open the duodenum.
He used mosquito forceps to clamp it on both sides and cut open the middle region. Clamping was done between one to two mm, followed by an atraumatic needle and suture to patch up the duodenal mucosa and common bile-duct mucosa at 2.0 to 2.5 cm.
This step was performed with extra care to prevent the occurrence of duodenal fistula.
After making an incision on the sphincter muscle, he cut off the traction suture on both ends to check for any bleeding.
Then, he examined the opening of the pancreatic duct.
The opening of the duct was below the incision Zheng Ren had made on the duodenum. Directly on its right, there was leakage of pancreatic fluid.
He inserted a thin catheter into the duct to check for any signs of narrowing or obstruction.
It was important to make sure both layers were in line during a double-layer suture of the duodenum incision to prevent duodenal flexure and stenosis.
Zheng Ren did not suture directly on the incision as usual, choosing a vertical suture instead to avoid the risk of said complications.
[Hmm? This is a unique suture.]
It did not miss the keen eyes of a Xinglin Garden viewer.
After several broadcasts, loyal viewers firmly believed the host surgeon was above any mistake and began considering the benefits of the suture.
There were few comments on the bullet screen.
The viewers pondered and learned.
After suturing of the incision on the duodenum, Zheng Ren carefully retrieved the greater omentum to enforce coverage before positioning the abdominal drainage tube between the subhepatic region and the lesser omentum.
The peritoneal cavity was washed clean with warm saline and he checked for any active bleeding before administering three local antibiotics. He did not close up right away, though.
"B-scan ultrasound, sterile covers, 50 mL injector," he said.
Su Yun hesitated. "Do you really plan to do it right now?"
"Don't worry."
Su Yun did not persist. Soon after, the circulating nurse pushed over a B-scan ultrasound, wrapping the probe and connecting wire in sterile covers. Zheng Ren then began performing a sca
n directly on the liver.
Without obstruction from the skin and tissues, the image was crystal clear!
The 50 mL injector was inserted into the liver abscess cavity and s.u.c.k.e.d out yellowish-green pus under the guidance of the B-scan.
After almost 125 mL of pus was aspirated, resistance against the injector began to increase.
"Two vials of Cefoperazone, dissolve and rinse," Zheng Ren ordered.
After rinsing off with warm saline, the circulating nurse opened two doses of Cefoperazone and Tazobactam. Zheng Ren solubilized them and inserted them into the abscess cavity.
Finally, the surgery was complete. Zheng Ren carefully checked all the regions he had worked on for any bleeding or unattended foci of infection.
"Closing."
Xie Yiren changed into a pair of new gloves and passed him the clean tools she had prepared earlier.
The pace of the entire surgery was alternating wildly. Zheng Ren had been very slow and cautious when scraping off the abscesses and performing the sphincterotomy.
When closing the abdominal cavity, he had such speed that his movements seemed to leave afterimages.
He was sure that Su Yun would be able to follow his pace.
[My goodness, the only step I understood so far is this closure. How is it so fast?]
[You're just too weak, kid.]
[This is almost light speed. The surgeon was extremely slow when scraping off abscesses. Is this their way of adjusting their speed to the procedure?]
Not all the doctors had been able to understand the surgery.
However, every one of them knew the abdominal closure procedure.
The surgeon was operating at full speed, with his first assistant following closely. Together, they took less than three minutes to close the abdomen.
This speed… They were just too skillful, like rockets blasting off and leaving everyone else behind.
After the last suture, the patient began showing signs of agitation and the livestream stopped broadcasting.
The viewers were not willing to leave just yet, however; they treated it like a forum with everyone chatting against the empty video background.
The Surgeon's Studio c1-799 Page 149
