Chapter 199 196. Splenicectomy + Splenic Vein Cavity shunt

[To be honest, there is no anatomical basis mentioned in this chapter, and there is no picture of this chapter. It’s a bit suffocating to see it directly. If you feel bored, it’s not too late to wait for this chapter to be said. Adding the pictures will make it easy to understand.

Anyway, just remember to subscribe]

The short gastric artery, as the most dangerous anatomical structure when the hook is exposed to the visual field, has always been an anatomical term that intern medical students must learn when they go to the general surgery table. [1]

It is not difficult to see the characteristics of this artery from the literal meaning, it is short.

Because it is short, it is not conspicuous. When performing gastric surgery to deal with the side and back, interns who do not know it can easily break it due to excessive pulling. If it is a vein, it will be fine, but it is an artery.

, maintains the blood supply to the entire stomach wall. Once broken, it will cause a lot of blood loss, and it is not easy to repair.

When doing autopsy exercises, Kawei didn't say that in detail, because his previous emergency surgery often performed emergency surgery for severe upper gastrointestinal bleeding, and the exercises were just to go through the process and find the feeling.

But it’s different if you really get on the operating table, and you can’t make mistakes in every step.

"Did you see the artery?"

"See it"

"Remember, if the gastric artery is broken, it is not a problem that the surgery becomes unsuccessful, but it directly causes the patient's life." Kawei slowly let go of his hand, "Now the small omental sac has been opened,

We slowly looked downward, revealing the anatomy next to the spleen, the posterior wall of the stomach and the pancreas stomach."

This is the spleen terrain area, inside it is the spleen pedicle, which is wrapped with splenic arteries, veins, lymphatic vessels, nerves and cloaked peritoneum.

At this point, what you need to do is not only remove the spleen, but also prepare for the measurement of the next splenic vein shunt. Since it is shunt, it is to divert the remaining veins from other blood vessels, and this change is original.

Anatomical modification requires some prerequisites.

Kawei made a brief measurement and said to the horn beside him: "From the anatomical position, the patient's splenic vein has a certain length, so there is no need to trouble the renal vein. We can consider changing to the lower cavity later.

Although the distance is relatively long, the blood pressure reduction effect is much better. Before that, we will cut off the spleen's blood supply."

There is no chance for the two of them to move their phones here, and Kawei will be the one who will lead the next step.

"We first rely on arterial pulsation to find the splenic artery located at the upper edge of the pancreas, incite the posterior peritoneum on the spleen pedicle, incite the arterial hexagram, and then slowly bluntly free the artery." Kawei slowly and carefully dissipated.

Work, the arteries and veins are tightly attached, because the splenic vein needs to be shunted, so it must not be damaged, "Give me the right-angle forceps."

Right-angle forceps gently lift the splenic artery from the sheath, and then pass through a thick silk thread from Herman inward to ligate it. [2]

The blockade of the splenic artery itself can relieve a considerable part of the portal pressure, but in order to prevent excessive damage to the omental vein, Kawei decided to wait until the operation is completed before testing: "After the artery is sealed, we will not have arteriovenous artery and vein first.

Free downstream from the spleen.”

Below the spleen is the splenic colon ligament and spleen renal ligament connected to the colon. After blunt separation and adhesion, use simple hemostasis forceps to clamp and then cut off the ligation. [3]

Because novices can easily damage the blood vessels in the colon and mescolon, Kawei operates the whole process: "After the solution below, we began to deal with the loose tissue between the spleen, the diaphragm and the peritoneum. Although it sounds simple, you can use your fingers to get the

Separate, but everyone must pay attention!!!”

Kawei's hand reached between the spleen's diaphragm and then raised his throat: "The spleen, especially the giant spleen that has been stimulated by a lot of inflammation, has already grown a lot of collateral blood vessels around it because of adhesion and congestion. You must never use your fingers to blindly

Explore, and you cannot force blunt separation." [4]

Although Herman did not know about the short gastric artery, he was already very skilled in handling the spleen. Using hooks and fully exposing his vision is the assistant's top priority.

In this way, Kawei cut off the splenic diaphragmatic ligament, lateral peritoneum and adhesion tissue under direct vision.

The adhesion tissue must be bleeding again when it separates. Without an electric knife, it is impossible to do all the minor bleeding sewage. You can only press the heated salt water gauze on the side to stop the bleeding one by one. [5]

Just after the separation was done, the two hooks in Begt and Damiergaon's hands were used forcefully. After removing the last trace of resistance, the spleen was able to be lifted out of the incision, and Herman immediately stuffed it with the prepared warm salt water gauze.

The spleen was located just now, the spleen fossa.

"This gauze can effectively prevent the lifted spleen from sliding back into the abdominal cavity, and it can also act as a bleeding point in the peritoneum and diaphragm after compression." Kawei briefly explained the reason for doing this, and then took it from Herman

Hemostatic forceps, "We continue to separate the remaining upper part of the spleen and stomach ligament, which contains the short gastric artery just now."

The same operation method is still the same, clamping on both sides, cutting the center, and ligating on one side. [6]

There is no need to ligate the spleen end, and the only thing that really needs ligation is the side of the stomach. The ligation of the side of the stomach is more difficult than before, because the short gastric artery is very short, and the distance between the stumps that can be used for ligation is very short, and it needs to be done at a limited distance.

The inner ligation is firm and cannot slip at all.

Kawei has made many optimizations for the originally rough spleen resection, and has basically achieved bleeding-free surgery.

But doing this also reflects that the procedure is very serious, and every step is followed by the procedure. Fernan's heart rate is stable, his blood pressure is stable, and the surgical scene where there should have been a lot of bleeding becomes very "boosty".

"It's really the chrome intestinal thread made by Mr. Laslow is extremely tough. The sewing does not slip or break at once." Kavey gave a brief introduction, "One piece costs only 50 helles, which is very cheap.

”

"Is it the equipment factory in Laslow in the South City?" I don't know which vendor started selling speakers, but a man sitting in the doctor's area suddenly asked loudly, "Is there any discount for wholesale?"

"Yes, you will know if you go to the equipment factory to ask. In addition to the suture thread, there is also the complete set of surgical instruments I used this time."

Kawei ended the sewing, gently turned the spleen to the right with his left hand, and pointed his right hand at the posterior edge of the spleen: "Now let's go back to the operation. After freeing the ligaments and loose tissue around the spleen, we flipped the spleen to reveal the remaining ones.

The spleen pedicle. This is the location where the spleen pedicle and the pancreas connect. We can gently push open this loose tissue with our fingers." [7]

Damirgaon, as if he heard the preset alarm, dragged the flipped spleen like a conditioned reflex, let Kavi's left fingers bypass the back of the spleen pedicle and gently hook it. Then he used his right hand three times.

The elongated hemostatic forceps clamp the spleen pedicle, and finally cut the spleen pedicle near the spleen side between the middle and the spleen side of the hemostatic forceps, and remove the spleen. [8]

“It needs to be noted here.”

Kawei's suture is very selective. First of all, there are blood vessels in the pancreas. He only had a splenic artery stump ligation, but no vein.

"If it's just a simple spleen removal, we need to ligate the two blood vessels together. It's not just a simple silk ligation, but also a penetration ligation. However, in order to prevent accidents, I personally still feel that it's far away from the two blood vessels.

One ligation is made of each end, so that it is safe enough. However." [9]

Kawei left the vein: "But we will have venous shunt later, so this vein will not move, so we will deal with the spleen first."

He did not sew the broken end of the spleen pedicle on the other side. This is actually normal. After all, it is an organ that is to be abandoned, and ligation is meaningless. But Kawei's intention is not just to abandon it, but to reuse it.

Just as the spleen left Fernan's body, Misuke Beggot left the operating table again, and then a metal basin with a scale soon appeared in front of everyone. 50ml of 2.5% sodium citrate +

20ml of 50% glucose preservation solution is to bleed to the spleen.

At this time, Damirgaon also left the operating table, took four large pieces of disinfected gauze from the instrument table next to it, folded it and wrapped it around the spleen. [10]

"There is a lot of fresh blood in the giant spleen, which is not a pity for surgery." Kawei and Herman were doing hemostasis at the remaining bleeding points of the spleen fossa, saying, "By the anticoagulation effect of sodium citrate, this

The spleen should be able to supply nearly 500ml of blood to the patient again.”

On the side is the sound of bleeding after releasing the hemostatic forceps. Bergate bleeds, while Damilgang is shaking the container evenly to make the spleen blood and the preservation liquid evenly mix so that blood clots will not occur.

On the side were the two people's final work on the bleeding position. This strange scene lasted for two minutes in total, and finally the blood scale in the metal basin stayed at 540ml.

Bergert roughly calculated the dosage, then took sodium citrate and 50% glucose from the instrument box, and poured 40ml and 12ml into it. [11]

Then he chose a filter funnel and made a long re-filtration work by bowl. After the filtration is over, the blood still needs to pass through the reel bottle and enter the secondary filter dropper before finally entering Fernan's body.

12】

At this time, Damiergaon had returned to the surgery. Kawei used forceps to loosely insert the omentum into the wound in the spleen area.

"Because the patient has portal hypertension, unlike ordinary patients with trauma and splenectomy, it is necessary to try to make collateral circulation to help divert. Therefore, we stuff the large omentum rich in blood supply into the vacant spleen fossa without fixation sutures.

, just leave it."

The splenectomy ended here. After the finishing work was completely completed, the three-person team began to move towards the diversion technique.

Before the shunt, the splenic vein left just now became the protagonist of the operation. Kawei needed to free it, not only cut off part of the tail of the pancreas, but also needed to create a 2-3cm free area for the distal vein.

Convenient to match.

"We first cut the capsule on the upper and lower edge of the pancreas, free from the tail of the pancreas, the upper edge reaches the root of the spleen artery, and the lower edge reaches the termination of the lower mesenteric vein, so that the spleen vein can move to the lower right along with the tail of the pancreas.

Here I have cut off the tail of the pancreas and separated the upper and lower edges of the pancreatic body tail. Then I have cut the avascular area of ​​the left transverse mesocoral mesocoral in the duodenal suspension ligament, and through this mesangial incision, the spleen vein and pancreatic body are inserted.

The tail is raised to the left of the inferior vena cava." [13]

The three simple sentences contain a large number of anatomical nouns. Although the technique is not too difficult and the sentence is not long, it is much faster than the splenic resection that has been progressing carefully and slowly just now. These anatomical nouns are like submachine gun bullets, constantly impacting.

Everyone's brain.

Ordinary audiences have long given up, while the surgeons who have been struggling to persevere until now have been filtered out in this section.

The only ones who can still keep up with Kavi's ideas are the two assistants next to the operating table, only Ignaz, Watman, Olgi, Masimov and the other one in the audience have never been there.

Five doctors talking.

"How is it, Bill Root, you've seen it now, why don't you even say anything?"

Watman greeted his old friend with a hint of gratitude. His face looked very relaxed, but his eyes and ears didn't dare to rest for a moment, for fear that he would miss some key process if he accidentally did.

He knew very well that if this kind of compact operation was critical moment, it would be difficult to follow up once a certain link was missed.

"This person is really only 17 years old?" This is the answer Bill Rotter wants to know the most, "There is no difference between surgery skills and you and me."

He wanted to say that his skills had already surpassed them, but for the sake of the two of them, he chose a conservative statement.

"If you change the fake package, the identity proof can be clearly written." Watman's smile became even brighter. "When I was in Switzerland, I kept saying that abdominal surgery was difficult. There were not many things in the world that could do well except you.

Yes, but now it doesn't seem difficult."

"Pooh!!!"

Bill Rotter squirted softly, feeling unsatisfied, and couldn't help but make up for it a few more times: "Bah! Bah! Bah!! You touched your chest and swear to God, and try to say the words just now.
To be continued...