Chapter 185

Wang Liang'an's mood was actually a bit irritable right now.

Even more so than Wu Guo Nan and Xue Tao.

Wang Liang'an was the Deputy Director under Joint Surgery Director Li Junfeng. But Director Li, although he was the Joint Surgery Director, had always liked lying flat and didn't like fighting for any position.

But Wang Liang'an felt that Director Li, if you have the capability, the Bone Surgery Chief position isn't Trauma Surgery's private preserve either — you should snatch it if you should, why must you let Wu Guo Nan have it, not even having that kind of thought.

Li Junfeng exposed the brachial artery much faster than Wu Guo Nan, so after ligating the brachial artery, Wang Liang'an, as the assistant, sped up his movements while thinking: With your level, Wu Guo Nan, you still have the nerve to fight for the Bone Surgery Chief position?

Do you think you're Director Zhang Mingcan, that the Bone Surgery Chief position was specially created for you Trauma Surgery people?

Even a simple amputation, you drag it out so slowly —

The movements pushing the upper limb amputation were quite deft!

He had already cleanly severed two and a half muscles! Just a bit more and it would have been three. A whole one more than Wu Guo Nan.

But now he was stuck right here, hurriedly covering the incision with saline gauze, then raising his head, looking around expressionlessly, tiptoeing to look toward Fang Ziye's leg...

Amputation simply understood is severing the limb.

But it has its own absolute definition.

A therapeutic measure to remove necrotic, destroyed, severely diseased, painful and life-threatening limbs, or completely useless limbs that hinder function.

The purpose is treatment.

Amputation inevitably causes disability, therefore it must not be applied lightly.

As orthopedic doctors, for such a terminal surgery as amputation, its surgical indications must be engraved in one's bones — it is the first lesson of formally entering orthopedics.

Use sparingly and cautiously.

The purpose of amputation is treatment, with strict indications:

Such as major vascular damage of the limb, missing the repair window, the limb already ischemic and necrotic, if not removed the necrotic toxins will be absorbed and endanger life — such as vascular vasculitis and other factors.

When amputating, one should try to choose a suitable length:

For example foot amputation should be at the metatarsals, not shorter than the talocalcaneonavicular joint, otherwise due to insufficient dorsiflexor attachment, difficult to counteract plantarflexor contraction causing foot drop, hindering weight-bearing...

Lower 1/3 of the lower leg has poor blood supply, the stump cannot bear weight, generally not chosen as amputation site...

Very obviously, this patient possesses the amputation indication of — thrombus formation!

It is a continuous, long-distance arterial thrombus.

Amputation indications are very clear.

And thrombus formation and harm, actually resemble a stone stuck in a water pipe, causing no blood supply distal to the blockage.

This is equivalent to cutting off the blood source of distal cells and tissues.

Limb salvage and amputation, though only one word different, is an extremely complex surgery involving many disciplines.

Strictly speaking, it is not a surgery similar to fracture internal fixation.

And to salvage the limb, there are also indications; leaving others aside, the first thing that must be ensured is blood supply...

Just like a plumber checking pipes, finding where it's blocked, then taking it out.

But in the human body, because the patient couldn't have preoperative examination in time, you fundamentally don't know where the blockage is.

Can't even find the location, then wanting to find the thrombus position is undoubtedly just gambling on luck.

So even General Surgery Director Peng Yuanming and others wearing the Vascular Surgery hat dare not guarantee they can perform limb salvage, remove the thrombus — might as well amputate to save life first...

Fang Ziye doesn't know limb salvage either.

Fang Ziye's initial thought was just to push the amputation level downward — originally planning mid-thigh amputation, if it could be pushed down to the lower thigh at the knee joint, that would be good too.

Fang Ziye thought: Can't add the big skill of limb salvage, let's add some small skills first.

Just extend the vascular plane downward as much as possible.

Preserve one more segment of limb, and the patient's function can be preserved that much more.

No preoperative examination, he could only add points to Medical Basic Physical Examination, then through enhanced tactile sense of his hands, based on physical examination results and anatomical knowledge.

Through vascular incision, take out whatever thrombi can be taken.

But after Fang Ziye performed arteriotomy and thrombectomy four times front and back, he reached the mid-lower thigh, then got a bit more greedy — what if this patient could maintain the amputation plane at the lower leg segment, then postoperative prosthesis fitting would become exceptionally comfortable.

So Fang Ziye then also removed the thrombus from the lower leg's anterior tibial artery.

At this moment, Fang Ziye unexpectedly discovered!

The dorsalis pedis artery was still patent!

Because Fang Ziye's original purpose was aimed at amputation, just wanting to leave it longer.

Men all like thick and long — it's just that Fang Ziye's length here is a bit too long...

Seeing this scene, even Wu Guo Nan standing on the opposite side had a momentary urge to strangle Fang Ziye to death.

Because now Fang Ziye has brought the surgery to a stage with uncertain prospects.

At least, on Fang Ziye's side, amputation is temporarily impossible — may have to switch from amputation to the more complex limb salvage.

"I'll look at the situation first." Wu Guo Nan lightly tossed the things in his hand into the kidney dish.

Xue Tao hurriedly reached to palpate the dorsalis pedis artery.

The most direct, most gold-standard examination for vascular patency is arterial angiography!

But the simplest, most direct method is palpation.

The patient couldn't do the gold-standard examination preoperatively, now we can only use the simplest palpation to verify.

Human arteries are continuous, therefore they strictly follow a rule!

That is: palpating arterial pulse distally absolutely proves the proximal vessels distally are at least locally patent.

Otherwise blood pumped by the heart couldn't reach the distal end.

Xue Tao's finger pulp, even through the glove layer, still felt the artery's weak throbbing.

The amplitude and force of the pulsation were both not great, and couldn't be much greater.

The patient was nearly in shock; how much amplitude could one count on from the dorsalis pedis artery pulsation?

But having it was enough.

Xue Tao immediately thought of another examination, useful on the operating table, to prove patency of blood supply.

Also the examination men like most.

Needle prick bleeding test.

"Circulating Teacher, open a syringe needle and send it up." Xue Tao immediately asked the circulating nurse for the instrument.

"It's already up on the table!" The two circulating nurses were ready at any time, not concerned with the surgical progress, merely giving a response at the first moment, very professional.

"Here, syringe needle."

At Xue Tao's call, everyone in Orthopedics stopped the work in their hands; Wang Liang'an was still the more professional one, using moist gauze to cover the avulsed muscle layer, to avoid the surface becoming too dry.

It was precisely this professionalism that was a bit ball-aching.

Yet he still looked toward Fang Ziye's side, unable to conceal a helpless look in his expression.

If you had said earlier that you could do limb salvage, Director Li Junfeng and I would have ligated the artery, stepped down, and been done with it; why go through the trouble of an amputation?

But Wang Liang'an also knew that Fang Ziye's appearance was an accident; from Xue Tao's eyes, from Fang Ziye's expression, one could discover this was an accident.

Even Fang Ziye himself was not certain whether he could perform such a surgery.

Right now Wang Liang'an felt his gluteal muscles had gone numb, so he twisted his buttocks left and right to relieve the embarrassment and struggle in his heart.

It was like taking a shit halfway, then having to force it back in with your own hand — that uncomfortable...

But fortunately, Fang Ziye was fast.

Wang Liang'an's heart immediately followed with a thought of relief.

If Fang Ziye's surgical progress was very slow, much slower than theirs.

And then the two of us, Li Junfeng and I, amputated both upper limbs, Wu Guo Nan amputated the lower limb too, and in the end Fang Ziye's leg was still there! And limb salvage succeeded.

Bingo!

Perfect four save one!

Wouldn't that be Bengbu Liao?

How would one handle it then?

Wang Liang'an didn't know what to do then, but fortunately such a thing had not yet occurred; before that, a good 'accident' had occurred.

The gazes of Li Junfeng, Wang Liang'an, and Wu Guo Nan kept glancing between Xue Tao and Fang Ziye; Wu Guo Nan was a bit unconvinced that Fang Ziye had really opened the blood vessel, so he personally reached out to touch and feel.

Sizzle.

Sizzle.

Vascular pulsation at the distal limb is certainly not as violent as cardiac pulsation or large artery pulsation; one can only feel a slight pulsation.

But the existence of pulsation is real.

Xue Tao now removed the needle from the syringe, took off the needle cap, and directly on Fang Ziye's operated left foot — the hallux and three other toes — stuck one needle in each, then waited quietly to observe the changes—

Pricking the distal body with a syringe to release blood is one of the most powerful pieces of circumstantial evidence verifying the existence of blood supply...

And it is the simplest, most economical, and effective method; merely this method is not very applicable in the clinical outpatient setting. Easy to get beaten.

So it is only applicable on the operating table.

The whole group of Orthopedics people stared at the toe tips.

As if these toe tips were very tempting.

Blood did not seep out as fast as a normal person's; a full ten seconds passed before a very small drop emerged, like a new bride, shyly half-covering her face, about to emerge yet not.

But even so!

Everyone still heavily eased a breath.

As long as it comes out it's good; bleeding is good.

Currently the patient's blood pressure itself is very low; the body's self-protection will prioritize supplying the brain, heart, and other important organs; being able to spare a little bit of waste for the distal toes is already the body mechanism's generosity!

As long as it's still patent!

Able to transport that tiny bit of nutrition to the distal limb, not starving the lower limb to death, then postoperatively it can all be made up for.

No need to look at the veins.

They're definitely thrombosed; merely the lower limb's venous network is complex, so it probably won't be completely blocked.

And there are two sets of large-caliber venous return systems; therefore, thrombi inside the veins can completely rely on postoperative systemic heparinization to slowly dissolve the thrombi!

Management of thrombi inside the arteries is the top priority in limb salvage surgery!

Wu Guo Nan took a deep breath, concealing and suppressing his inner embarrassment, then said to Fang Ziye: "Ziye, let's switch positions; you go do the right foot?"

"For the left foot side, the subsequent debridement and suturing, Xue Tao and I will do."

"You and Wang Zhongxing look at the thrombi inside the right foot, see if they can be removed."

"Good!" Fang Ziye did not play cute; he nodded and prepared to switch positions.

The reason he asked Xue Tao like that before was fearing his own inexperience, that he might have gotten it wrong. Then directly proposing it — wouldn't that bring trouble to the superior?

Moreover, after all, Fang Ziye also didn't know what Wu Guo Nan discussed with the patient's family; he only went over to get a standardized amputation consent form signed, and didn't discuss limb salvage.

Now temporarily converting to limb salvage, the surgical method is different; would it bring any trouble? That's for Wu Guo Nan to decide and bear the responsibility.

The responsibility is Wu Guo Nan's; it's not yet Fang Ziye's turn to swagger; he can only have advisory rights.

However, thinking about it, it should be that not amputating and being able to leave the operating table — such an accident, patient families are all willing to accept.

And it also happens to conform to the non-maleficence principle in medical rules.

Amputation is actually known too.

Merely being able to not amputate under limb salvage conditions is more in line with the non-maleficence principle.

But right then, from some direction in the operating room, someone poured a basin of cold water: "The dorsalis pedis artery is the continuation of the anterior tibial artery. The anterior tibial artery is merely one of the continuations of the popliteal artery downward."

"If the posterior tibial artery isn't examined meticulously, there will be a return to the OR."

"And it could be all for nothing."

The voice came from the direction of the anesthesia monitor.

It was precisely Nie Mingxian from Anesthesiology; after he finished speaking, he was handing over something with Huang Jiaoshan, the Anesthesiology Director.

Huang Jiaoshan said in a low voice: "Little Nie, don't be a busybody. Director Wu and the others will assess the surgical outcome themselves."

But by this time, Nie Mingxian had already decided to stand up: "It's fine, Director Huang. I'm an anesthesiologist now; I can't get on stage, but kibitzing from the side isn't a violation. Doctor Fang's basic operations are excellent; it would be a waste not to guide and utilize him properly."

"The fibular artery of the posterior tibial artery, and the middle and lower third of the posterior tibial artery, are the most prone locations for embolism." Nie Mingxian finally couldn't stay seated, and so walked over to the operating table.

After Nie Mingxian spoke, for a moment the faces of Peng Yuanming, Wu Guo Nan, and the others all turned relatively ugly.

Nie Mingxian's silence before meant he couldn't be bothered to kibitz because their skills were inadequate?

Not guiding Doctor Fang's current operation level would be a waste, but if they kibitzed to guide, it would just waste their breath?

Nie Mingxian's words had zero hurtfulness, not a bit, just a touch of insult.

But Nie Mingxian seemingly didn't care about these Directors' expressions.

Xue Tao was right opposite Fang Ziye, watching him seriously, and suddenly felt Fang Ziye become unfamiliar once again.

As if he wasn't the Little Fang he had known these past half month.

Wang Liang'an saw the Directors' expressions were off, so he immediately turned to the circulating nurse: "Get me a few No. 3 sutures."

Taking advantage while Li Junfeng and the others were still dueling with Nie Mingxian, he would quietly show off a little specialty — his self-created post-traumatic biceps brachii and brachialis suturing technique.

Li Junfeng didn't speak.

Wu Guo Nan hurriedly had Fang Ziye return to this leg instead, because Wu Guo Nan wasn't skilled at vascular thrombectomy incision; even if Nie Mingxian said it, he had no way to follow Nie Mingxian's words and continue.

Wu Guo Nan had self-awareness on this point; even though he considered himself capable of handling some hand surgery operations normally, hand surgery vascular anastomosis and vascular surgery thrombectomy are two completely different things with different directions, okay?

……

"Can you do limb salvage surgery?" Only after Fang Ziye had repositioned himself, and Xue Tao had digested some emotions, did he ask Fang Ziye.

This question made Wu Guo Nan instantly prick up his ears.

And this question made Peng Yuanming, standing not far away, slightly embarrassed.

Thrombus, wherever mentioned, is a vascular surgery problem; now their department flying the vascular surgery sign couldn't handle it, yet it was handled by an orthopedics person, and although no one made sarcastic remarks at him.

He felt his very existence was embarrassing!

Peng Yuanming even saw his subordinate, Deputy Chief Physician Chen Liwei, casting a strange look at him, giving Peng Yuanming an indescribable sense of shame.

Glared back.

What of it?

Not knowing how to do this kind of thrombectomy means one isn't fit to live?

I'm a hepatobiliary and pancreatic surgery doctor.

You tm want to mock me too?

Chen Liwei immediately lowered his head, hurriedly cooperating to start liver repair surgery.

Enshi Central Hospital has no dedicated vascular surgery department; if there were such vascular surgery specialty strength, it would have split off long ago……

Fang Ziye subconsciously shook his head first, then shook his head again.

The threshold for limb salvage surgery is slightly high, not inferior to osteotomy correction at all; it belongs in textbooks, hasn't become routine, and currently still belongs to theoretical surgical techniques.

He hadn't encountered it, so he couldn't speak recklessly.

"No." Fang Ziye's understanding of limb salvage surgery was that it required systematic study and research to count.

"I just wanted to amputate less, leave as much as possible."

Fang Ziye's eyes were full of sincerity, speaking truthfully.

Wu Guo Nan could only wryly smile helplessly; so Fang Ziye was a blind cat hitting a dead rat, actually still a certain distance from Wu Xuanqi.

Spoke: "Look again, see if the thrombus behind can be removed."

What Fang Ziye said, what he did, was completely flawless.

Vascular ligation — is that limb salvage surgery? No.

Arterial thrombectomy — is that limb salvage surgery? Not entirely either.

They're just the small surgeries Fang Ziye knows!

But these two surgeries are actually important component minor techniques of limb salvage surgery; Fang Ziye turned amputation into limb salvage through them.

This IS limb salvage surgery, okay?

Limb salvage surgery isn't just a rigorous surgery; it's a body of knowledge; anything achieving the limb salvage purpose can be called limb salvage surgery.

However, this can't be said now; must wait until after stepping down to say it.

……

Fang Ziye then held nothing back; with both ears listening to Nie Mingxian approach and give relatively meticulous guidance on which major vessels to check, Fang Ziye hurriedly used basic physical examination technique to probe the arterial pulses at corresponding positions.

Moreover, now with Director Wu Guo Nan and Deputy Chief Physician Xue Tao helping, they only had to release the proximally ligated femoral artery, and Fang Ziye could roughly feel where arterial pulse was poor.

"The posterior tibial artery's surface pulse is hard to palpate; requires absolute somatic talent or rich palpation experience; only an extremely tiny number of people can feel it from the surface."

"I've never seen such a person; just do open exploration directly." Nie Mingxian at the side, seeing Fang Ziye wanting to examine like he did the anterior tibial artery, directly called a halt.

Tone carried a few parts unknown whether mockery, or feeling Fang Ziye was a bit overconfident in a strange way.

Anyway, just not as amiable as his own master and true senior brothers, speaking pleasantly.

But Fang Ziye knew, no master-disciple relationship, no fellow disciple relationship; teaching is a favor, not teaching is duty; in reality, no one can be a Long Aotian, tiger body shakes, four directions come to submit.

"Good!" Fang Ziye didn't suspect anything, didn't even turn his head, directly made an incision from the lateral position, then rapidly performed exposure.

The posterior tibial artery is the core anatomical structure of the orthopedic lower leg; therefore he had long known it by heart.

After exposing the skin.

Fang Ziye immediately repeated the previous Mud Loach Catching Method.

The round knife incised the skin, the vascular clamp bluntly pierced through the muscle gap, reaching straight to the vessel's course; upon seeing the protrusion formed by the thrombus, he immediately wielded the knife to incise!

After removing the thrombus, he sutured it back up, then continued to release the proximally ligated vessel.

Repeating back and forth like this.

The process was naturally quite complex, the steps even more extraordinarily tedious.

Nie Mingxian's experience was correct; Fang Ziye opened four incisions in a row before finally clearing the four long thrombi within the posterior tibial artery and the peroneal artery.

Xue Tao continued to check the blood supply using palpation and the syringe needle.

Suitable!

In this way, Fang Ziye and the others finally counted as having completed the left lower limb salvage surgery!

Fang Ziye looked toward Nie Mingxian again.

"Unobstructed blood supply is the primary guarantee; the rest depends on fate. Even if there is no function later, it's still better than direct amputation. With blood supply, other functions can be temporarily ignored."

"Go to the contralateral side. Some small problems can also be assigned to postoperative systemic heparinization handling." Nie Mingxian guided.

Then he said to Anesthesiology Department Director Huang Jiaoshan: "Director Huang, draw another electrolyte panel. After the lower limb blood supply becomes unobstructed, it may bring back many residual substances from the body; pay attention to electrolyte disorder."

"This is a variant of reperfusion injury."

Nie Mingxian's cognition of theory was quite profound.

Huang Jiaoshan complied, instructing another deputy director physician to personally draw blood and send it for testing. After adjusting the ventilation rate and anesthesia concentration, he reported to everyone: "Vital signs are currently approaching stable; blood pressure has recovered a little."

Wu Guo Nan and Xue Tao, the two of them, began suturing one by one.

Seeing this, Li Junfeng felt a sudden pang of discomfort in his heart.

At this moment, he had just finished suturing the muscle. Opposite him, Wang Liang'an, who similarly had wanted to shirk off onto Wu Guo Nan's stubborn back view, was staring blankly after suturing the muscle, not knowing how to conduct himself.

After all, he had actually come to help Wu Guo Nan, but this help wasn't rendered, and he nearly caused a flirty/seductive smell.

Only now?

The two of them, himself and Wang Liang'an, seemed to have handled things a bit awkwardly, caught between a rock and a hard place.

However, the two had already completed the brachial artery exploration and hemostasis...

Li Junfeng cleared his throat, laughing as he said: "Director Wu, my side is all handled, hemostasis effective. I won't know the rest, so how about I leave first?"

Li Junfeng directly played the yo-yo.

(Chapter End)