Chapter 980: 959 Two Surgeries (Alliance Leader ROMATOTTI Bonus Chapter 3)

A hernia is when an organ or tissue inside the body leaves its normal anatomical position and moves through a congenital or acquired weak spot, defect, or opening into another site, forming an abnormal anatomy.

A diaphragmatic hernia is a type of internal hernia, referring to the condition where abdominal organs etc. shift abnormally through the diaphragm into the thoracic cavity; it can be divided into traumatic and non-traumatic diaphragmatic hernia.

Among non-traumatic diaphragmatic hernias, the most common are esophageal hiatus hernia, retrosternal hernia, parasternal hernia, and diaphragmatic defect, etc. Esophageal hiatus hernia accounts for over 90% of diaphragmatic hernias, making it the most common type of hernia.

Normally, in an esophageal hiatus hernia, the stomach and intestines protrude through a weak part of the diaphragm into the thoracic cavity.

The most serious complication is incarceration of the hernia sac, where the abdominal organs that have herniated into the thoracic cavity undergo strangulation necrosis.

In this situation, emergency surgery is generally required. If the incarceration is not prolonged and the gastrointestinal tract can still restore blood flow, that is the best outcome.

Otherwise, a series of resections must be performed to avoid more severe necrosis and complications such as infection-induced toxic shock.

This can be fatal.

But diaphragmatic hernias usually involve hollow organs such as the stomach and intestines entering the thoracic cavity. Organs like the liver, a large solid organ, rarely herniate.

This surgery can be performed by either the general surgery department or the thoracic surgery department.

So upon hearing about a hepatic hernia, both Zheng Ren and Su Yun became interested, as it is extremely rare, and they went to take a look.

What a ridiculous $100,000 consultation fee—it was instantly tossed out of their minds by the two.

He hurried to the emergency department; in the resuscitation room, the place was packed with patients' families, and two medical staff from a private 120 ambulance service from elsewhere were collecting fees.

Seeing Zhou Litao busy with a physical exam, Zheng Renye did not call him but instead began observing the patient.

The background on the patient's system panel was bright red, indicating a serious condition.

Asymptomatic congenital retrosternal diaphragmatic hernia, post-diaphragmatic hernia repair, hepatic hernia, atelectatic pneumonia, pleural effusion, and several other diagnoses—seven or eight in total—appeared before Zheng Ren's eyes.

A retrosternal diaphragmatic hernia—Zheng Ren seemed to have guessed something.

Abdominal organs protrude through the costotrigonal triangle into the cardiophrenic angle of the thoracic cavity; this is called a congenital retrosternal diaphragmatic hernia, also known as retrosternal hernia, parasternal hernia, anterior lateral hernia, or Morgagni hernia.

This type of hernia is relatively rare, accounting for 3%–5% of diaphragmatic hernias, predominantly occurring in the right thoracic cavity, with respiratory and digestive symptoms being the main manifestations.

However, the organs that herniate into the thoracic cavity are mainly gastrointestinal tract organs, with the liver being less common.

Hepatic hernia… hepatic hernia… Zheng Ren pondered intently.

Su Yun had already moved close to the patient to watch Zhou Litao perform the physical exam.

The little nurse in the emergency department was busy; feeling someone push forward, she raised her eyebrows, turned back impatiently, and was about to shoo the person away.

But the instant she saw Su Yun, her face flushed red, and she didn't know where to put her hands. She dared not look, yet wanted to look, feeling utterly flustered.

"What patient?" Su Yun asked gently.

"A postoperative patient sent from a nearby city hospital, who underwent two surgeries and now presents with a right thoracic cavity occupancy." The little nurse didn't know much, but she said whatever she knew, holding nothing back sincerely.

After saying that, she felt a bit embarrassed.

I know so little; this is really wrong, wuu~

"Su Yun, you've come." Zhou Litao heard someone speaking nearby, finished the physical exam, turned around and saw it was Su Yun.

"Call me Yun Ge'er." Su Yun squatted on the ground, looking at the chest bottle, and said softly.

"Yun Ge'er, the closed chest drainage is draining a small amount of gas; the lung likely still has a damaged spot." The little nurse added.

How can it be this hot already in April? She felt the heat making her mask impossible to wear. Warm air escaped with her breath through the gaps in the mask, raising the temperature of her whole face considerably.

It's all because of this damned weather, the little nurse thought.

"Cui Lao is in the office." Zhou Litao held a clipboard with a stack of A4 paper, recording many patients' conditions in his own way.

When Su Yun asked him to call her Yun Ge'er, Zhou Litao acted as if he hadn't heard, every freckle on his dark face showing refusal.

He said a few words to the family, arranged for an emergency department doctor to handle things, then went with Zheng Ren and Su Yun to Cui Lao's office.

He knocked, entered, and Zhou Litao began reporting the medical history.

Cui Lao didn't say anything to Zheng Ren, just glanced at him, then started listening attentively to Zhou Litao's report.

"The patient is a 55-year-old female, diagnosed at the local hospital with congenital retrosternal diaphragmatic hernia."

"Eight months ago, the patient began experiencing progressive dyspnea and palpitations on exertion, which worsened over two months. She was hospitalized at the local hospital and underwent surgical treatment."

"Preoperative CT reported: intestinal contents within the thoracic cavity compressed the right lung's middle and lower lobes, causing atelectasis and mediastinal shift."

"This is the image taken before the patient's first surgery."

Saying this, Zhou Litao skillfully took out a packet from the film bag and handed it to Cui Lao.

Looking at the details, Zhou Litao is indeed a capable emergency department inpatient chief. Although he only briefly understood the condition and performed a physical exam, he grasped most situations basically. His report to Cui Lao was also orderly.

Zheng Ren silently praised him.

"Continue." Cui Lao said lightly, without looking at the images.

"During the first surgery, it was found intraoperatively that the mediastinal retrosternal defect had a mid-diameter of 7 cm, with most of the herniated contents being the small and large intestines, plus the greater omentum. After hernia sac resection and right lung re-expansion, a pulmonary emphysematous bulla and spontaneous pneumothorax were discovered. On the emergency ward, thoracic surgery consulted and ordered closed chest drainage."

Zhou Litao held the photocopied case file from the patient's family, quickly flipped to the surgery record page, and highlighted the key points.

"Six hours post-op, the closed chest drainage discharged a large amount of gas. The volume was significant; after thoracic surgery consultation, they decided to return to the OR for open-chest repair of the pulmonary bulla."

"One week post-op, the patient suddenly developed ventilatory dysfunction; an urgent liver function test showed elevated transaminases. CT revealed renewed compression of the right lung, with a solid organ entering the thoracic cavity, suspected to be the liver."

"The local doctors communicated with the patient's family and recommended that the patient come to our hospital for treatment."

Having said that, Zhou Litao put down the case file and placed the most recent chest CT film onto the viewer.

Zheng Ren unconsciously placed his left hand under his right armpit, rested his right hand on his chin, narrowed his eyes slightly, and began reading the film.

Zhou Litao had explained the patient's condition in great detail. Two surgeries: one thoracic surgery, one general surgery.

Postoperatively, the patient's condition not only did not improve, but actually worsened, presenting a more severe hepatic hernia.

Emergency surgery is definitely required, but whether it should be performed by thoracic surgery or general surgery involves a very delicate balance.

Generally, doctors are unwilling to take on postoperative patients sent from lower-level hospitals.

That means a lot of trouble.