Chapter 235 231.Pericardiotomy and drainage

Cardiac decompression was first seen in the 17th century. A surgeon named Riolanas chose to cut the pericardium from the front. To do this, he not only needed to cut the patient's skin with a knife, but also drilled a hole in the sternum. The steps were extremely cumbersome.

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But since there was no anesthesia, the operation was completed quickly.

The outcome is unknown. The only thing that is clear is that the operation to decompress the heart has been passed down. Even with the advent of percutaneous puncture, which is less invasive, incision and decompression can still be used as the last resort for cardiac tamponade.

Appears in surgical treatment items.

Even in the early 20th century, pericardiotomy and drainage were safer than blind percutaneous pericardiocentesis due to problems such as comprehensive visual field exposure. This situation was not improved until the rise of imaging and became an important support for surgery.

However, such an effective pericardiotomy and drainage surgery is not a routine surgery, and very few surgeons are actually willing to perform this surgery.

The main reasons are two points.

The first point lies in the blood coagulation mechanism during trauma that few people understand.

When blood overflows into the pericardial cavity through a breach in the heart, the coagulation process is immediately initiated, and it does not take long to form a coagulated blood clot. The discovery and determination of this process is a rather long process.

.

Since the discovery of platelets in 1842, physiologists have spent hundreds of years successively discovering fibrin, fibrinogen, thrombin, and prothrombin [1]

Medicine is a subject composed of a variety of knowledge accumulations. There seems to be a big difference between internal medicine and surgery, but the development of any branch is limited by the development level of the overall knowledge.

Naturally, no one in Austria in 1866 understood why blood coagulated, and no one knew when blood would coagulate. Although there were doctors who could understand the symptoms and diagnose pericardial effusion, their number was extremely limited, and those who dared to perform puncture surgery after diagnosis

There are even fewer people.

If after the puncture it is found that the blood cannot be withdrawn, everyone will choose to give up.

Like those surgeons just now, they will question their judgment, thinking that the casualty did not suffer from cardiac tamponade. Even if the diagnosis is clear, they will question their puncture skills, thinking that the failure to puncture blood is due to the wrong location of the puncture.

The second point is the contraindication of cardiac surgery.

Even the most authoritative surgeon has to admit that the possibility of survival after cardiac trauma is very small. Even if the heart is reluctantly operated on, it will cause a series of problems, such as intraoperative bleeding and serious postoperative complications that are difficult to prevent.

The postoperative bleeding itself may also form new pericardial effusion, making the operation useless.

Therefore, for a long time, pericardiotomy was considered a stupid choice, and this mainstream view influenced the surgeon's decision. Kawei does not need to go back to Vienna now, he can listen in the operating room

to similar objections.

"You want to drain the pericardium? Is this really appropriate?"

"The heart is not the abdominal cavity, and cutting the pericardium will bring unpredictable risks."

These are just small fights, the one who really troubles Kawei is Bill Rotter.

This devout Austrian Catholic, like the royal family of the Holy Roman Empire, has a very special belief in the heart: "The heart is the residence of the human soul. Operating on the heart is a blasphemy to the art of surgery!"

Kavi:???

"I am not the first surgeon to incise the pericardial cavity. Doctors have been doing this since the 16th and 17th centuries." Kawei stood beside the operating table, confirming vital signs and looking for the location of the surgical incision.

"Just blaspheme, as long as the wounded can survive."

"No! You don't understand!" Bill Rotter advised. "Those surgeons who tried to operate on the heart ended up in ruins. You can go through the history of medicine. Many of them failed to survive.

Give me your name."

"I'm not interested in being able to leave my name," Kawei said. "The surgery is well-established and beneficial to the wounded, so naturally I want to give it a try!"

Billroth sighed, feeling helpless. Four months ago, he might have used his status as the vice president of the College of Surgery and his confidence in surgery to argue with Kawei, but now he has

I lost the confidence to do this and could only stand aside and shake my head.

His retreat did not change the attitude of the surrounding doctors. Under the leadership of Bill Rotter, other opposing voices gradually emerged. However, they did not consider the issue from a metaphysical perspective, but considered the issue from a more rational perspective:

"Even if there are traces, it's still very dangerous!"

"The injured person's vital signs are not critical now, and he was quite conscious before anesthesia. This shouldn't be an indication for heart surgery, right?"

"But the diagnosis of cardiac tamponade is okay." Kawei was still explaining, "Anyway, I need to open his pericardium and remove the blood clot accumulated in the pericardial cavity."

"Is it possible, and I'm just saying possible, that cardiac tamponade can be relieved on its own? The blood clot may be absorbed by itself. Physiologists have explained it before. Thinking about it from another perspective, those patients or injured people who have undergone surgery are all

If there is no good result, it is better to choose conservative treatment from the direction of internal medicine.”

"The result of their operation was not good because the patient's condition was too serious. Moreover, the operation was not sterilized. The cause of death was not the operation itself, but the severe suppurative pericarditis caused after the operation."

"But once the operation fails."

Kawei looked back at the doctors who were still trying to persuade him to stop: "I have decided."

He has never been a person who likes to explain, especially after making a decision, explaining is nothing more than helping the other party to further accept the facts. But if the other party insists on not accepting it, then Kawi will choose to give up the explanation.

He has become more stubborn since he became the emergency director. Unless a family member comes forward to stop it, no one can stop the planned operation.

Now that his power is at an all-time high, he has long lost patience with these suggestions. Moreover, Rogelini's situation is inherently special. It is extremely rare to survive firearm injuries to the heart, and luck accounts for a large proportion of them. If he gives up,

I don’t know when I’ll have to wait until I encounter such a wounded person next time.

The diagnosis was clear. The wound should be located in the left ventricle. Judging from the speed of the injury's development, the wound was not large. The symptoms of the injured were becoming more and more obvious, but the vital signs were relatively stable. Moreover, they were in the Olmitz Fortress General Hospital, which had the best logistics preparation.

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According to the practice of modern military medicine, such wounded patients should undergo thoracotomy and pericardiotomy + heart repair as soon as possible.

Kawei also considered this.

but.

Kawei is also a human being, and no matter how powerful he is, he cannot exceed the limits of a normal surgeon. As a human being, it is impossible to make every decision correct.

Therefore, in order to pursue perfection, he would consider all conditions again and again before formally confirming the surgical plan. Although Kawei himself felt that he re-examined the correctness and success rate of the surgical plan out of safety considerations, in fact, the voices around him had already

Subtly changed his mind.

Before using more than a hundred years of advanced surgical technology to lead the operation, Kawei needs to consider many other factors. For example, the current poor operating room environment, his not very skilled cardiothoracic technology, and those around him who have no cardiothoracic experience.

's assistants.

In addition, unstable anesthesia during the operation, the last location of the bullet trajectory, whether the heart rupture is serious, etc. are also important considerations.

Suturing a breach in the heart is very difficult, but it is not impossible. For safety reasons, whether it is really necessary to forcibly open the chest for suturing needs to be carefully considered. What troubles him the most is the breach in the heart.

A matter of size.

Judging from various current factors, the heart break should not be large, it may just be a tangential injury of less than 1cm, and the location is in the thicker ventricle of the myocardium. The amount of bleeding may not be large, and it may even coagulate to stop the bleeding on its own.

Although such a small wound does not require conservative treatment, Kawei needs to put a question mark on whether dangerous sutures need to be performed directly in the case of cardiac tamponade.

The opposition voices around him were suppressed, but the opposition voices in Kawei's own heart slowly rose up.

Is it really too risky to do direct heart stitches as others say?

Is it possible to perform palliative treatment? Only treat the current cardiac tamponade and put away the gap in the heart that has been blocked by the blood clot. After the cardiac tamponade is relieved, closely observe the condition of the injured. If tamponade occurs again after the operation,

If recurrence occurs, dangerous heart repair surgery is chosen.

Or you can carefully observe the situation after the heart beats when the blood clot in the pericardial cavity is clear. If there is an overflow of fresh blood, it is not too late to consider suturing the heart.

In the eyes of outsiders, less than half a minute passed between the time Kawei verbally made it clear that surgery would be used to treat cardiac tamponade, and the moment he took the scalpel and prepared to perform the operation. But in Kawei's mind, it was already

He rehearsed many possible situations, and even the rare pseudocardiac tamponade was considered.【2】

These combined circumstances finally changed Kawei's previous decision.

He changed the original pericardiotomy and drainage + cardiac repair to simple pericardiotomy and drainage, and he placed the remaining cardiac repair after the pericardiotomy. This is a sign of stability, because the card

Wei is also not very sure about the success rate of heart repair.

It’s not that he thinks failure will affect his status and identity. What he cares about is that if this operation fails, the number of doctors who dare to perform similar operations in the future will drop significantly.

Since simple pericardiotomy and drainage are chosen, the surgical location also needs to be changed.

The fifth and sixth intercostal space incisions used for cardiac suturing may cause various complications. If only the pericardium is to be incised, it is safer and more reliable to choose the subxiphoid incision.

Subxiphoid pericardial window is a very common pericardial drainage method, and its indication is severe cardiac tamponade like this.

In order to save the life of the wounded, this operation does not even have absolute contraindications. That is, no matter what special circumstances the casualty has, as long as the doctor determines that cardiac tamponade threatens his life, he can choose to perform this operation immediately.

Demonstrating the entire operation process in front of so many surgeons is to hope that they can master this kind of surgery, because similar patients will appear on the battlefield at any time in the future.

Carvey asked Lucius and Golam to come on stage, and used a scalpel to gently cut open the lower edge of Rogerini's xiphoid process: "I remember that in 1810, a French surgeon named Larry risked losing his job.

, bravely drained pericardial effusion in a patient with mediastinal tumors. The location he incised at that time was the fourth costal cartilage, vertically downward along this anatomical position."

"I have the impression." Lucius suddenly said, "The patient lived for 23 days and finally died of severe pericarditis."

"So disinfection before and after surgery is very important."

Carvey's scalpel entered the 5cm longitudinal incision under Rogerini's xiphoid process, continued downward, incised the abdominal white line, and separated the xiphoid process: "I chose to avoid the xiphoid process of the chest.

The incision ensures the integrity of the bear's ribs and has far fewer complications. Give me the rongeur."

What he wanted to do was to cut off the xiphoid process that affects the surgical approach downward and expose the surgical field. Regardless of whether the indications for surgery are clear or whether the surgery is really suitable for Rogelini, at least Carvey's technical skills are enough to convince them.

Opposing voices.

After a few clicks, the xiphoid process was removed.
To be continued...