Or adhesion.Li Min noticed Director Liang's thick short thick eyebrows and began to twist them together."
There's adhesion here in the cardia too.Xiao Li, guess what could be the cause?
”"From the perspective of bloody ascites, malignant tumors are more likely.As for what part it is," Li Min shook his head: "It's all adhesions, and there is no evidence to support that it is a tumor at the cardia area, and there is no evidence to say that it is not." ”Director Zhou said, "You didn't do an abdominal CT before this operation?"
”After asking this, Director Zhou suddenly realized that this was a patient managed by Dr.
Wang, so he pretended to persuade Li Min: "Dr.
Li should not save money for patients in the future."
This CT should be done or done.There is also a commission for prescribing CT scans to patients. ”"Yes."
Li Min responded very simply, and did not argue with Director Zhou that this was not his patient.She didn't believe that Director Zhou didn't know who the patient's doctor was.Director Liang slowly peeled off the adhesions more carefully and carefully, and did not forget to remind Dr.
Wang: "Be careful of the liver." ”"I'll be careful."
Dr.
Wang's answer was also solemn.He had to fully expose the best technique to Director Liang, but he couldn't strain other organizations.The liver under his S hook, once he pulls it out, this operation may not be able to get off the stage today.The electronic clock on the wall turns the second hand silently and rapidly.I don't know how long time has passed before Director Liang distinguishes the adhesions."
Amitabha.It's okay here.There are no abnormalities in the esophageal and diaphragmatic hiatus.Now let's see if there are any abdominal contents going up into the chest.Xiao Li, tell me why you want to explore here?
”Li Min hurriedly replied: "If there is a hiatal hernia, there will also be pain in the upper abdomen.When questioned about the ward, the patient said that there was pain under the xiphoid process. ”"Dr.
Li thinks his upper pain is caused by a hiatal hernia?"
Dr.
Wang asked."
Nope.I don't think he had a hiatal hernia.His ascites effusion is biased toward malignancy.However, the order of laparotomy for acute abdomen is the liver first, then the esophagus, and then the left lobe of the liver. ”Director Liang smiled, "Our Xiao Li's endorsement is definitely first-class." ”These words reminded Li Min of the gastric perforation caused by drugs.She said awkwardly, "It's still a lot worse." ”"It's all about reading and reviewing while doing it.I don't need it for three years, and what I learned in school is almost the same as not learning. ”Director Liang did not delay the matter at hand when he spoke.After carefully examining the esophagus and the left lobe of the liver, his brow tightened even more."
Xiao Li, where should I investigate next?""
Spleen area.""
Good.Xiao Li said that he would investigate wherever he searched. ”"It's the step required for exploratory laparotomy."
Li Min smiled: "Do what the textbook requires, you won't make a mistake." ”"Makes sense."
Surgery" is written by our top experts in the country.Which version did Xiao Li learn?
”"Second Edition.""
A new version will come out in a few years."
Dr.
Wang added."
The difference isn't too big.""
Did you read the first and second editions side by side?"
Director Liang asked him."
Only some of the chapters were crossed.""
There is still a big difference between the following and the following.""
Yes."
Dr.
Wang was a little disagreeable in his heart, and his mouth should be harmonious: "Director Liang said to read it against him, then read it against him."
Dr.
Li does not read the first version?
”"Nope.I don't have a single edition of the textbook, so I'd better wait for the third edition to come out. ”Li Min intuitively thought that the second edition had been updated, so what was the point of finding a version to compare?
That's how I answered him."
Doctor Li, that's a good idea."
Why is Dr.
Wang's approval a little awkward, why does it seem to be a bit of a praising himself to block Director Liang?
Li Min felt awkward and replied, "I'm not like you."
I still have so much to learn about the basics of surgery.I hope that when the third edition comes out, I will have time to compare the different textbooks. ”Li Min directly admitted that he was not as good as Dr.
Wang, which made Dr.
Wang's heart feel a little more comfortable.Director Liang glanced up at Dr.
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Wang.Director Zhou said, "Lao Liang, you Doctor Li can speak." ”"That's it.Otherwise, I wouldn't have taken her to surgery.Find a block for yourself.Oops, how can this spleen bend be so sticky?
I hate a second laparotomy the most.It's a sticky mess in my stomach.Just peeling off those adhesions takes up half of the effort. ”Director Liang muttered to himself that it was difficult to explore the spleen area, and it was easy to separate the tissues that were adhered to the clumps, but no space-occupying lesions were found in the spleen and transverse colon."
Isn't it good that I didn't find a space-occupying lesion?"
The instrument nurse was very young and had her first exploratory laparotomy.She saw that Director Liang wanted Director Zhou to wipe her sweat, so she seized this moment and whispered to Li Min."
If it is a tumor here in the transverse colon and spleen area, the surgery is small and easy to remove."
What was not said in the back is self-evident.This is followed by exploration of the anterior wall of the stomach.…… Li Min noticed that Director Liang's right hand slowly slid from the cardia to the entire anterior wall of the stomach to the pylorus, carefully touched the greater curvature and the lesser curvature of the stomach, and also took four groups of lymph nodes above and below the small curvature of the stomach, and took four groups of lymph nodes on the right and upper sides of the greater curvature, and asked the patrol nurse to mark them and immediately send them for frozen sections.The anterior wall of the stomach showed no abnormalities with the naked eye."
Where is it?
Is it not there?
”Director Liang's heart kept sinking.He pulled out his hand, "Wash your hands, change the gauze." ”"Will it be the duodenum?"
Dr.
Wang asked Director Liang in a low voice.Director Liang shook his head, "It's hard to say."
Nothing out of the ordinary has been found.If the duodenum is there, we have to admit that we are unlucky.Dutchman. ”As he spoke, Director Liang asked for another sharp knife and made a small incision in the omentum.Director Zhou stretched his neck from the patient's head and looked at it, and asked with concern: "Lao Liang, won't it be ......"
What he didn't say, the three people on the operating table understood what it was."
I hope not."
Director Liang's tone was filled with reluctant certainty."
If so, you won't live long."
Director Zhou sighed."
Yes, just the general state of this patient, the degree of abdominal adhesions and the nature of the effusion, it is luck to live for a year.Xiao Li, did you say?
”"Yes.""
Dr.
Li, what do you think it will be?"
Dr.
Wang asked Li Min.He held the big hook, hugged the transverse colon with a large gauze of saline, and squinted at Li Min, who followed Director Liang's progress to clamp the hemostatic point.He felt that he was quite breathless with this help, how did he become a hook role to replace Li Min?
But he didn't dare to raise objections under Director Liang's nose, because the big hook was stuffed into his hands by Director Liang."
Probably pancreatic cancer."
As the lowest level of the surgical food chain, Li Min usually has to answer any serious questions in this room, especially this kind of question, which is a bit of an examination nature.After throwing the clear, most probable answer to Dr.
Wang, Li Min glanced at him from the top of his glasses.At this time, there is still time to ask such stupid things?
Dr.
Wang wanted to say something more, but saw that at this time, Director Liang had already separated the appetizer and colon ligaments from the greater curvature of the stomach and began to explore the posterior wall of the stomach and the stomach bed.The muddled organization, if you want to separate them, you have to be careful and cautious every time, and be cautious and cautious."
Tissue cut to Dr.
Li."
Director Liang changed to small mosquito forceps and used sharp tips to separate the sticky tissues.He stretched it out a little, and Li Min carefully followed it with tissue scissors to cut it a little.Both of them still held a small bend in their other hand, ready to clamp the found capillary in advance.The two of them worked forward in tacit understanding, and after making sure that the back wall of the stomach was fine, they were ready to explore the duodenum and the head of the pancreas.Except for silence and silence.This silent operating room brought more invisible pressure to everyone than usual.After Director Liang wiped his sweat again, he asked Director Zhou to help him with his glasses."
Old Zhou, I was thinking just now that I might not be able to get down this operation."
Director Liang said very seriously."
Then I'll write you an epitaph."".You see, I'm going to expose my duodenum. ”"Then why are you worried about not coming off the stage?
Idle. ”"Why do you think it's not about the duodenum and the head of the pancreas?
Something doesn't always feel right under your hands. ”Intuition is a mysterious thing.Acting intuitively can sometimes be outrageously wrong.However, Li Min feels that Director Liang's intuition is based on his 30 years of clinical experience, which should be a very reliable feeling.So she followed Director Liang's train of thought and guessed: "The liver is fine, the gallbladder has been removed early, and the adhesions are mainly concentrated in the upper abdomen, if the duodenum and pancreatic head are fine here, will it be in the body and tail of the pancreas?"
Splenic flexion adhesions can be quite severe. ”At this time, the patrol nurse came up and said: "I have been in the operating room for more than ten or twenty years, and I have never seen a tumor in the tail of the pancreatic body."
I've only heard of pancreatic head cancer once. ”Doctor Wang didn't think it was a matter of time to take a sentence: "This time, I will open your eyes and show you the tumor in the tail of the pancreas." ”Director Liang snorted, "Have you ever seen a tumor in the tail of the pancreatic body?"
”He had never done or seen this operation, Director Liang.Dr.
Wang replied honestly: "I haven't seen it." ”Through the mask that covered most of the face, you can find that Director Liang's face is bad, and even Director Zhou is not looking for something to say at this time.The nurse who patrolled the station knew that her words had stepped on the thunder, and immediately slipped to a place where Director Liang could not see."
Does Xiao Li know the surgical procedure for the tail of the pancreatic body?"
Director Liang wiped his sweat and continued to peel off the adhesions of the duodenum.Li Min cautiously replied, "I'll try."
If you don't remember everything, don't scold me, and I'll memorize it if I don't sleep when I go back. ”Just as Dr.
Wang wanted to speak, Dr.
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Liang raised his eyes, stared at him from above his glasses and asked, "Do you remember?"
”Doctor Wang hurriedly shook his head, and secretly pouted in his heart: This kind of technique, which has not been encountered in ten or twenty years, has not been eaten and supported, who is idle to carry this?
Only medical students like Li Min who have just left school will remember it.Besides, how can this abdominal cavity be adhesed so badly that it is possible to perform surgery according to the standards of textbooks?"
If it is a tumor in the tail of the pancreatic body, the conventional resection method is to free the spleen and expose the tumor in the tail of the pancreatic body.It is necessary to check whether there are lymph nodes around the abdominal aorta and whether the surrounding organs have been violated.Turn the tail of the pancreas to the right, cut off the arteries and veins of the pancreas and spleen, and then ......"
Li Min recited these words dryly, and looked at the adhesion in front of him and suddenly couldn't carry it.Director Liang sighed and said, "In our current situation, we want to turn the pancreas over......
Alas!
However, in general, caudal pancreatectomy is much better than pancreaticoduodenectomy. ”Suddenly, he raised his voice and said confidently, "You said that if I ligate the blood vessels in the tail of the pancreas and the ligaments around the spleen, I will transect the lesion area in the tail of the pancreas.Hey, what do you two say?
”Dr.
Wang immediately praised: "That feeling is good."
But look at the posterior peritoneum.What if the kidneys metastasize to cancer?
”Dr.
Wang's words were like pouring a basin of snow water on Director Liang's head."
The kidney was identified as the primary lesion, and it was just removed."
Director Liang was aroused, "If the kidneys are okay and it is determined to be the tail of the pancreatic body, I will take down the tail of the body, the spleen and the posterior peritoneum."
Surrounding infiltration?
Hmph, sweep wherever you go. ”I've been standing for more than two hours, and it's a lie to say that I'm not tired.In this way, the improved operation with less trouble and effort and less damage is safe, convenient, and has less bleeding, and the premise is to determine that it is really a malignant transformation of the tail of the pancreatic body."
In situ removal of the tail of the pancreatic body and spleen?"
Li Min became excited.I've never heard of this."
yes.Let's come up with a new and improved technique. ”Director Liang is high-spirited and high-spirited."
Doctor Li, take a good look at it, and you can write the operation record."
Dr.
Wang lightly assigned Li Min a thing, and said that this postoperative record was just an inconspicuous minor operation."
Okay."
Li Min casually agreed."
You don't want to hand over this patient to Dr.
Li, do you?"
Director Liang asked Dr.
Wang leisurely."
If Dr.
Li wants it, I naturally have to let it go."
Li Min resisted the urge to roll his eyes and said "um" noncommittally.Doctor Wang immediately hit the snake with the stick, "If you want, then this patient will be handed over to you." ”Director Liang snorted again from his nose and continued to peel off the adhesions of the duodenum.After the head of the pancreas was completely exposed, Li Min raised his head and looked at Director Liang, and his eyes were full of joy.No pancreaticoduodenectomy required!
If it weren't for being in the operating room, Director Liang would have wanted to shout, this year's luck is really good!
※※※※※※※※※※※※※※※※※※※※ pancreaticoduodenectomy is one of the most extensive abdominal surgeries, with the largest physiological structure changes, the most postoperative complications, the most difficult and complex operations.Specific resection should include the gallbladder and the entire common bile duct; the pylorus and most of the distal stomach; The head of the pancreas and the whole of the duodenum.After resection is complete, continuity of the biliary tract and gastrointestinal tract, pancreas and gastrointestinal tract, and the gastrointestinal tract itself needs to be established.Make at least three anastomies.Although pancreaticoduodenectomy and distal pancreatic (body caudal resection) are the same level of surgery, the former is naturally more difficult than the latter because it involves six organs and has more lymph nodes in the area to be cleaned.() The distance is a bit far