For allanto storage of the bladder, in principle, there are certain physiological indications for the selection of intestinal segment locations. However, in clinical practice, surgeons' preferences occupy a more dominant position.

The reason is that no matter where the intestinal segment is, it will not have much impact on the patient after it is lost, and the most important mechanism of urine control has nothing to do with the location of the intestinal segment. In addition to the nerve and urethral smooth muscles that must be protected during surgery,

What you need to pay attention to is the treatment of intestinal ducts, which is ultimately the surgeon's method, rather than which section of intestinal duct is taken.

In the history of the development of making the intestine into allanto storage, surgeons have used a lot of spatial imagination.

Reconstructed allanto storage needs to adhere to three important characteristics: high capacity, low pressure, no reflux and reabsorption.

These three points determine Kawei's choice.

"First of all, we need to understand the characteristics of the bladder." Kawei found the ileocecal part, raised a piece of the ileum, and said, "Why can a 3*4*5cm capsule store 500ml of urine?"

"It's because there are many folds in the bladder wall, which increases its compliance," Watman replied.

"Yes, compliance." Kawei said, "the intestinal duct itself is not a bladder, and its compliance is not great, but the rebound and contraction performance after expansion is stronger. The same volume of urine enters the bladder and intestinal duct to store allanto, so

The pressure is different. So we need to increase the capacity, otherwise the patient will suffer from frequent urination after the operation."

"It seems that the colon is not very elastic," Masimov said, "and you have also mentioned the cleaning problem before."

"Yes, based on what I just said, the ileum has the greatest compliance in all intestinal segments, but has much less contraction. As long as there are enough intestinal tubes selected, it can create a high capacity and low pressure environment."

Before Kawei appeared, it would be absolutely fantastic to intercept the intestinal duct and then suture it.

It has been more than half a year since Kawei appeared, and half of the people present have learned intestinal anastomosis.

Although not many people have actually performed the operation during the operation, they don’t seem to find it too outrageous to hear the strange operation that shouldn’t have appeared at this time point. In their eyes, the requirements for intercepting the intestinal duct are not too high.

However, as a material, the intestine shape is fixed, how to expand the volume is the key.

"These are just intestinal ducts, and they can only be used in a small piece."

"Yes, even if it is made into a long-shaped tunnel, the compliance is not great, it is only about 100ml, which is far less useful than the bladder."

"If you really change it to this kind of alternative bladder, then urination that usually takes 2-3 hours will turn into half an hour." Moussa shook her head, and her heart was full of doubts, "Doctor Kavi, don't keep it aside, tell us directly

Well, how to do it?"

"If we want to increase the volume of allanto storage, all we need to do is to change the original shape of the intestinal segment." Kawei made several simple folds of the intestinal tube in his hand, and said, "Remove the tube shape, and then re-sew it and change it to S

shape, W-shaped, or more similar to an oval or spherical appearance.”

It takes a long time to find the most suitable shape, and from the corpse to the patient, it is indispensable.

In fact, this surgery has consumed more than 20 years of hard work by urologists around the world from development to maturity. The final shape of the surgery depends on the surgeon's proficiency, and it is not static.

In addition to establishing external volume, Kawei also needs to establish sufficient anti-reflux mechanism.

Modern urology may not be keen on reflux. After all, it is supported by strong enough antibiotics, a large number of advanced surgical instruments and a mature postoperative medical system.

The upper urinary tract injury after surgery actually takes a long time to precipitate, ranging from a few years to a few decades. Patients who undergo urinary reflux and diversion are basically the elderly, and their lifespan is limited, so they are anti-reverse.

The stream is necessary but not the first ranking.

But in the 19th century, what Kawei did was a one-time deal.

The treatment is over after the operation. Even if there is a problem with the operation itself, it basically loses the opportunity to correct it. Not many people can withstand two consecutive surgeries. Without complex and efficient postoperative support, all he can do is to try his best to do all the problems.

Stopping into the surgery to resolve.

But Kavi is also a human being, not a god, and it is unrealistic to solve all problems with both hands.

Even after many anatomical exercises and even if the corpse resources of the entire hospital were delivered to him, even if Mosie and him had already cooperated very well, he still felt that the success rate of the surgery would not be too high.

At most, it is only 70%. If you are conservative, the probability may be only half.

Who made Edham not the Prussian soldier of the past, nor Fernan, the age + tumor has taken away the health of this French gentleman.

Cutting open the intestinal canal and doing a lot of shape changes will greatly prolong the operation time, and it will take a certain amount of time to recover after the operation. In addition, a large amount of incision and suture are required during the operation, which also has very high technical requirements.

This was the case before, and it would definitely require several department directors to consult and handle major surgery.

Now, all this pressure is on Kavi alone.

He dared not make too many changes in shape to the intestinal duct, he dared not take Edham for surgery like Fernan, he dared not gamble.

The original purpose of the operation is not to show off one's own skills, but to achieve the operation as much as possible with the lowest health cost. Therefore, after repeated practice, he chose a relatively simple process, which can minimize the impact of urination function.

The surgical method.

"I tried many gut modification methods the other day, and the intestinal tubes of almost every body were used to reconstruct."

Kawei took the tissue tongs and gauze sent by the nurse and said, "I have tried all the W-shaped bends, S-shaped twists, V-shaped and T-shaped fits that I mentioned before. Just cut the pipe walls into a longitudinal direction,

Remove their original tubular structure and then connect the sides together to form the shape of a bag."

After he said this, the doctors who were a little puzzled finally followed the idea and the discussion gradually began to sound: "So that's the case, it's a good idea."

"But the complete dissection requires very high requirements for the anastomosis technology."

"There is also blood supply, and the most important thing is blood supply! If the intestinal duct is incision and suture, the blood supply will definitely be affected. Even if the anastomosis is closed well, problems will occur over time."

"Yes, intestinal fistula, this is the most troublesome."

"According to Dr. Kavey's statement, the mesenteria does not need to be cut off. As long as you are careful enough when suturing, blood supply should not be a problem."

"No, you're a little bit of a matter of course. Such a large-scale incision and anastomosis will definitely cause blood supply problems. This cannot be avoided by just a word "be careful". Think about why we were still anastomosis for intestinal tract half a year ago.

Worry? Isn’t it because of accidental operation? Is this kind of accidentality easy to avoid?”

"Indeed, there are still many intestinal fistulas when intestinal anastomosis."

"Don't forget, in addition to blood supply, there are also infections caused by surgery, which will also affect intestinal anastomosis."

"Yes, intestinal anastomosis doesn't seem difficult, but I'm afraid that if there is a problem after the operation, it will be too troublesome."

What weighs on Kawei's mind is what they said.

Of course, what he thought was not an anastomosis to the intestinal tract. After all, anastomosis is a common skill in surgical emergency and has long been familiar with the chest.

What he was afraid of was the burden on Edham due to excessive surgery duration: "According to the original plan, the operation requires a full 40cm intestinal reconstruction, with a suture distance of more than 1 meter, and the time spent on reconstruction alone is

It takes an hour and a half.”

There was a very simple math problem in front of everyone, 1.5+1.5=3 hours

This does not include the final ureter anastomosis with the neo-bladder, the urethral orifice anastomosis with the neo-bladder, and the hand speed gap caused by stability during surgery, the four-hour operation time is definitely considered conservative.

"If this happens, the surgery may take five hours too long."

“I’ve never seen such a long surgery.”

Kawei began to free the colon, find the liver colon ligament, and prepare to cut it off: "So two days ago, I gave up the so-called complex reconstruction. Instead, I wanted to achieve the purpose of forming a bladder by changing the location of the colon ileum."

This is a very ambiguous sentence that many people here cannot understand, including Masimov and Watman who were standing by and watching: "What does your sentence mean? What does changing position?"

"I just said it was a big deal, but now I have to give up on reconstruction?"

"Teacher Masimov, this is actually a kind of reconstruction, but it is different from the shape change. What I did is change in position." Kavey thought for a while and explained, "If you have to make a comparison, it is'

Remove the body in the anatomy room and add a few seats, that is the feeling of the surgical theater."

What a mess!!!

Watman was confused and couldn't help looking at Masimov beside him, trying to get some useful information from him so that he would not be so embarrassed. But Masimov was even more confused and didn't understand at all.

Kavi means.

"I'll understand when I continue to do it."

Kawei cut off the ligament of the liver colon. After Kawei measured the length, he chose a 20cm ascending colon and a 10cm terminal ileum [1]: "First of all, I want to explain the anti-reflux mechanism of reconstructing the bladder, which is closely related to urinary tract infection.

.”

As the name suggests, anti-reflux is to prevent urine entering the bladder sac, and return to the ureter due to pressure, body posture, etc.

"You must know urinary tract inflammation very well, it will bring a series of symptoms and bladder stones." Kavey asked Begter to put down the candle in his hand and use the light on the ceiling to make the colon break. "Go and Damir

Gang prepares disinfectant cleaning solution.”

"good."

Kawei separates the lateral peritoneum of the ascending colon and uses scissors to incite [2]: "Bladder stones are caused by inflammation stimulation, but inflammation in the lower urinary tract rarely moves upward into the kidneys, because urine rises from the top

erosion and anti-reflux mechanism of the ureteral bladder mouth.

This is originally an important mark of vestoureter anatomy.

There will definitely be infection in the surgery, whether it is inside or outside the urinary tract. With Mr. Edham's age and physical condition, the infection is certain. Under the premise that there will be infection, the reflux mechanism can effectively protect the urine.

Road. Even if the lower urinary tract infection is serious, the kidneys are safe."

After saying that, he pointed to the ileocecal part that was connected to the abdominal cavity by the mesia: "There are two anti-reflux mechanisms I have set up. The first is the interface between the ureter and the intestine, and the second is

We have to rely on the special anatomical structure of the human body."

"What are you talking about in the ileocecal flap???"

"right."

"I didn't expect that there was such a solution and the idea was so clear!"

"But Dr. Kavey, choosing an ileocecal valve means that the ileocecal valve in the intestine has disappeared. How can we prevent the small intestine food from entering the large intestine too quickly? What should we do if the feces in the colon are refluxed?"
To be continued...