Surgery Godfather

Chapter 205: Chapter 0193: Unboxing Surgery

All day Sunday, Yang Ping was in a bit of a haze.

Xiao Su! The daughter of Professor Su, the sister of Su Nanchen, this question lingered in Yang Ping’s mind. Her stunning image of descending the steps in a long dress remained imprinted in his mind. Linking all of her identities together was overwhelming for a moment.

No matter whose daughter she was, no matter whose sister she was, Xiao Su was right. She was just Xiao Su, and with that, Yang Ping didn’t think too much about it anymore.

On Monday, the 3D reconstruction of Sisi’s condition was completed. The infrared scan reconstruction, which would be directly used for the surgery, stood out. The CT and MRI reconstructions were merely supplementary.

Based on the images, the primary tumor had spread excessively in all directions, already pervading the entire hip joint. The treatment protocol would have to be adjusted.

The spread of malignant tumors follows several patterns, with tumor cells, like seeds, dispersing through several pathways: hematogenous spread, where the seeds are transported to another location by bloodstream, take root and colonize; lymphatic spread, similar to hematogenous spread, but via lymphatic rather than bloodstream; implantation spread, where the seeds drop to another location and grow, taking territory; and direct spread, where the tumor constantly enlarges, directly expanding and invading other parts.

A local resection might involve a too wide area and cause too much damage. Thus, surgery and the ultrasound knife could be combined: first removing the bony tissue tumor, extracting the prosthesis, performing femoral lengthening, and then using the ultrasound knife to treat other peripheral tumors and distant metastases.

By seven in the morning, Yang Ping had looked through Sisi’s films and roughly planned the surgical approach. Upon entering the system space, he saw that he only had one task left in sports medicine. Upon completion of this task, he could advance to bone disease training. However, he was not sure what this task would be and when it would be released.

After handing over his shift and leading the team for ward rounds, he performed surgeries all morning. Most of the patients in the ward now were undergoing arthroscopic surgery, and the turnover was quick, usually being discharged the day after the surgery.

Word-of-mouth spread fast. Many patients were referred by those who had undergone surgery. Gradually, the ward filled to almost capacity.

At two in the afternoon, Yang Ping gave a short lecture in the teaching room. Several orthopedic surgeons attended, including a number of medical directors such as Director Han, Director Tan, Director Tian, Director Bai, Director Ouyang, and Director Ding. They also had to discuss the academic conference after the lecture.

The lecture’s content mostly centered on the case of rescuing the tree-impaling injury at Shipo and performing laparotomy under the intervention of major vascular occlusion.

This surgery is extremely difficult to perform as it often involves major blood vessels and viscera. Anyone who has watched “Grey’s Anatomy” would remember a scene where two people were impaled by a steel bar, facing each other. The doctors found themselves in a predicament: if they pulled out the steel bar, one person could survive while the other would die. How cruel!

The woman in the show had damaged her aorta and was beyond rescue, so the doctors had to sacrifice her to save the other man, whose injuries were less severe.

The damage to the aorta truly signified impending death. Once injured, a significant amount of blood would be lost in a short time, resulting in an instant death in the worst-case scenario.

On the screen, the difficult scene from “Grey’s Anatomy” played repeatedly until it froze on a frame of the two characters face-to-face, sitting in the ambulance, impaled by a steel bar.

Pointing to the screen, Yang Ping said, “Please don’t be misled by television dramas. In the show, the two patients are both lucid, chatting and laughing, indicating a stable vital sign, at least temporary stable blood pressure. Why do they insist on sacrificing one person under these stable conditions? Why can’t they save both?”

“No way, it was the director’s arrangement!” Someone quipped, triggering laughter in the room.

Yang Ping also laughed and then continued, “In our nation’s Anzhen and Fuwai hospitals, we have a high success rate for emergency treatment in cases of aortic dissection rupture, which is far more critical than this situation. Can they really afford to chat and laugh after suffering an aortic injury? We should not belittle others, but think scientifically! The surgical method shown in the TV series is extremely primitive. They even considered removing the steel bar — it is as though they are gambling with a life. You absolutely cannot remove the steel bar under these circumstances. Once removed, everything will be out of control. The method of removing the steel bar is as reckless as pulling random wires during bomb disposal. Can this be done? Of course not! So how should we proceed?”

Everyone attentively listened, knowing well that Yang Ping’s lectures were always full of insightful points, especially when he talked about surgeries. His words were not rote, but reflections of his own experiences. As for his surgical skills, there was no need to say more; he had created several miracles already.

Among the young doctors, some were taking notes, some were recording on their tablets, and some were even recording straight from their phones, a hassle-free method for later review.

“Imagine yourselves in a scenario where you have to save these two patients, how would you go about the surgery? Would you pull out the rebar too? We’re not here today to critique the show, but to use this case to provoke our thinking!” Yang Ping asked, revealing his goal of utilizing the TV show as an educational tool.

Some of the audience were eager to share their thoughts. One young doctor from the trauma orthopedics department stood up, “I have always felt that this is not the best approach. Why not saw the rebar in half from the middle, separating the two people, and then perform the surgery separately in two groups? When cutting the rebar, continuous cooling and some vibration reduction measures can be used!”

Yang Ping gestured for him to sit down, saying, “Very good! This doctor is absolutely right. The way to handle this case is not by pulling out the rebar, but by cutting it, separating the two patients, and having two teams of doctors perform the surgeries. This is entirely doable. To be precise, this is already step three. Before that, we have two initial steps. What could they be?”

The audience fell silent, momentarily unable to come up with any suggestions. A doctor from the trauma ICU somewhat uncertainly suggested, “Blood transfusion and fluid replacement?”

“Correct! It’s as simple as transfusing blood and replacing fluids, this is the first step. It’s the most common, the most effective, and an indispensable step. Trauma, if only threatening to life due to blood loss without causing fatal damage to vital organs, like severe brain injury for example, is theoretically salvageable. The key is speed, whether you can stop bleeding quickly enough and keep up with blood transfusion and fluid replacement. The first step is blood transfusion to maintain blood pressure; the second step is to assess the condition and make an initial judgment about the injury. If possible, do a quick CT scan, if not, explore via surgery immediately. The third step is to separate the rebar. What would the fourth step be?” Yang Ping then steered the group’s thought.

“The fourth step would be our preoperative occlusion of major blood vessels. We would directly occlude the large blood vessels, like in this patient’s case, clear aortic damage. According to the location, we can occlude the upper part of the aorta, thereby shutting it off completely — controlling all bleeding from the wound. However, this kind of occlusion has a time limit, for abdominal aorta occlusion, 30 minutes is safe. If we can finish within 30 minutes, the patient can be saved. On one hand, we occlude the blood vessels and stop the bleeding completely; on the other, we transfuse blood and replace fluids to restore the lost blood, thus temporarily achieving a balance in volume and buy some time for a safe surgery.” Song Zimo, who participated in this operation, replied.

“But isn’t this a high-risk procedure?” someone raised their concerns.

Yang Ping told the crowd, “All our procedures are high risk. Surgery is like flying a fighter jet, there is no absolute safety. Completing all procedures under risk is a fundamental characteristic of surgical operations, so you all need to have extensive knowledge, skilled operation techniques, and a cool head. Once major blood vessels are occluded, we move to the fifth step: the open-box surgery.”

The audience gasped. Theyd had never heard about the term ‘open-box surgery’.

Standing in the center of the demonstration room, Yang Ping waited for everyone to quiet down, explaining, “This is the highlight of today’s discourse. ‘Open-box surgery’ is a term I have chosen after much thought. It simply means opening the box to identify and resolve the problem. How we ‘open the box’ depends on the location of the damage – as established by a CT Scan or a simple estimation – whether it’s in the abdominal cavity or the chest cavity. Follow the path of the rebar, fully expose its trajectory, then consistently stop the bleeding and conduct repairs along this route before finally extracting, not pulling out, the rebar!”

“The process is like dismantling a bomb. It’s about opening the bomb casing, exposing all the components and wires inside, and then carefully disassembling it step by step.”

“For the patient shown, even the most critical one could have the aorta repaired within half an hour. If not as quickly as that, we can use a technique called large-vessel bridging, bypassing the damaged area from the proximal to distal end, temporarily diverting the blood around the injured site. This method can both ensure blood supply to the lower half of the body and allow you to slowly repair the damaged aorta. Another approach we often use in thoracic surgery for dealing with aortic dissection is the implantation of artificial blood vessels. This can even be done minimally invasively. There are numerous options. Why should we give up? Watch a few sessions of interventional surgery for aortic dissection and you’ll understand. This is not difficult. Once you get familiar with anything, it’s no longer difficult. That’s why we need to thoroughly understand. The surgery for treating aortic dissection can be applied to trauma surgery. Why can’t we carry out the same routines for abdominal or chest exploration we do on a daily basis on steel-rebar penetrating injuries? Why do we pull the rebar out, adopting such a foolish approach?”

“It’s fine in theory, but difficult in practice!” someone murmured, as not everyone had come across such a case.

The screen swiftly switched to rescue photos from Shipo Hospital, “Look, this is a real-world success story — the application of theory. Theory guides practice, and practice refines theory. Don’t separate theory from practice!”

This case was far more severe than the ones shown on TV, and yet it was successful. Yang Ping said, “It’s not just me who has successfully treated such patients. Mo Sixth, Jishuitan, and many other hospitals across the country have successfully rescued cases of severe trauma. Even thoracoabdominal penetrating injuries, I can say responsibly that if the two patients shown on TV were treated at Mo Sixth or Jishuitan, neither would have to be sacrificed; both could be saved. The same is true if they were admitted to Sanbo.”

Director Han stood up and addressed everyone, “Soon, we are going to have an academic conference. During the conference, we will livestream a major trauma emergency surgery. Tokyo University Hospital will live broadcast simultaneously. Director Tan has received some full-clip videos of their major trauma rescue surgeries. You will see how the world’s top rescue processes work, how surgeries are performed, how teams cooperate. Executing each procedure well and to the utmost is a completely different domain. Those engaged in general surgery know this, the cure rate for stomach cancer in Japan is over 80%. Do you know what that means? Our rate is 30%, and the United States’ is 60%!”

Next, Yang Ping went into the surgery details of the case where Shipo had a tree penetrating injury: how to occlude the blood vessels, how to ‘open the box’, how to explore, and how to repair.