At 8:40 PM, the surgery officially began.

The first half was exceptionally smooth. The entire laparotomy was executed flawlessly.

Yang Xu stated:

"Liver surface is smooth, no metastatic nodules seen. No nodules in the pelvic cavity, no significantly enlarged lymph nodes at the celiac trunk."

"Looks good."

The smooth start allowed everyone in the operating room to relax a bit.

Chen Jing leaned against the console, checking the gauze count while casually chatting with Lin Peidong. "Dr. Lin, the market dropped again today. How are those stocks you bought at the dip doing?"

Lin Peidong sighed. "Don’t even ask. They’re all underwater. In this market, anyone who buys the dip is doomed. I’m just going to play dead and not look at them."

"Haha, our Director Yang is the steady one. He never touches this stuff," Chen Jing teased with a laugh.

Yang Xu didn’t look up, continuing his work as he said, "Hemostat."

Jiang He immediately placed the hemostat in Yang Xu’s hand.

The two of them were working diligently while the others chatted idly. It might have looked a bit unprofessional.

But in reality, for a mega-operation like a pancreaticoduodenectomy that can easily last five or six hours, the initial laparotomy was just routine physical work for the team.

A moderate amount of chatter, or some background music, could actually help ease the lead surgeon’s nerves and conserve the team’s stamina.

However, this relaxed atmosphere usually only lasted until they hit a minefield.

The surgery progressed in an orderly fashion.

The first hour and a half were exceptionally smooth.

Ligating the right gastroepiploic artery and vein, mobilizing the gastric antrum, transecting the duodenum, clearing the lymph nodes on the hepatoduodenal ligament, transecting the common bile duct...

Yang Xu demonstrated the profound skill of a top-tier hepato-pancreato-biliary surgeon.

He identified the anatomical planes with extreme precision, and there was minimal blood loss.

Jiang He barely needed to use the suction, only needing to provide good exposure and retraction.

Everything was going smoothly.

Everyone’s mood was relaxed.

At this rate, the grueling five-to-six-hour battle might even conclude in under four hours.

However, as the operation advanced to the most critical region of the pancreaticoduodenectomy...

Yang Xu’s movements suddenly slowed.

He inserted his right index and middle fingers behind the head of the pancreas and began to carefully palpate the tumor’s border.

One second, two seconds...

Half a minute passed.

The idle chatter in the operating room ceased.

Lin Peidong keenly sensed the change in the lead surgeon’s demeanor. Chen Jing also stopped what she was doing and quickly moved to the side of the operating table.

Yang Xu: "Large laparotomy pad."

Jiang He took the warm saline-soaked pad from the nurse and packed it around the surgical field.

This isolated the surrounding intestines and gave Yang Xu the maximum possible exposure.

Yang Xu took a right-angle clamp and attempted to dissect a plane between the head of the pancreas and the superior mesenteric vein—the so-called "pancreatic neck tunnel."

However, the tip of the clamp had barely advanced a centimeter before it hit a wall...

Yang Xu’s brow furrowed as he inserted his fingers again to probe the area.

This time, he palpated for a good thirty seconds.

When he withdrew his hand, his expression had turned grim.

"This is trouble," he said gravely.

Jiang He followed the angle of Yang Xu’s retraction with his eyes and immediately understood the cause of his worry.

’This is... extensive tumor invasion.’

Yang Xu said, "This tumor has encased the superior mesenteric artery and the portal vein."

He glanced at Jiang He and began a practical lesson on the spot:

"Go ahead, feel it. It’s rock-hard, completely fused with the vessel walls. There’s no dissectible anatomical plane."

Jiang He did as instructed, placing his fingers on the junction between the tumor and the blood vessels.

It was indeed very hard.

According to standard surgical knowledge in 2008, this texture meant that the cancer cells had completely penetrated the vessel’s adventitia, forming dense, cancerous adhesions.

But that wasn’t even the deadliest part.

Yang Xu used a dissector to gently push aside a thin membrane above, saying, "A Michels type III variation."

Jiang He’s gaze sharpened.

In a normal anatomical structure, the right hepatic artery should branch from the celiac trunk.

But in this patient, an aberrant right hepatic artery arose directly from the tumor-encased superior mesenteric artery, running straight through the rock-hard tumor tissue!

Simply put, it was a dead end.

If they tried to forcefully dissect it with a scalpel, they would most likely tear the superior mesenteric artery or the portal vein, causing a catastrophic hemorrhage.

Even taking a huge step back, even if Yang Xu managed to somehow peel the tumor off, that aberrant right hepatic artery running through it would be impossible to save.

Once it was severed, the patient’s right liver would lose its entire blood supply, inevitably leading to massive postoperative hepatic necrosis. It was another dead end.

The operating room fell into a heavy silence.

Everyone knew that the patient on the table was a person of special status.

But medicine is objective. Anatomical variations and tumor invasion do not bend to human will.

Yang Xu took a deep breath, stepped back half a pace, and said:

"It’s unresectable. Locally advanced, inoperable. The tumor is encasing major vessels and there’s a rare variation. We can’t force it with the knife."

Yang Xu gave his final verdict: "Prepare for a palliative procedure. We’re abandoning a curative resection. We’ll mobilize a loop of jejunum, perform a choledochojejunostomy to resolve the jaundice and improve his quality of life for his last few months, then close him up."

Lin Peidong nodded.

In surgical oncology, it wasn’t uncommon to open a patient up only to find the tumor is unresectable and then have to close them right back up. It’s commonly known as an "open-and-close" procedure.

Though regrettable, it was the most rational decision.

"Chen Jing, go inform the family of the situation. Have them prepare themselves..."

Yang Xu had just started speaking when he was interrupted.

Jiang He said, "Professor, wait a moment."

Yang Xu turned his head and looked at him, puzzled. "What is it?"

Jiang He didn’t answer immediately. He inserted his right hand back into the abdominal cavity, closed his eyes, and meticulously focused on the tactile feedback from his fingertips.

’I felt it the moment I touched it earlier.’

’Something seems... a little off.’

Jiang He knew one thing for certain.

’The 2008 guidelines have a cognitive blind spot.’

’Perhaps...’

’It’s precisely this blind spot that led Director Yang to the wrong conclusion.’

A few dozen seconds later, Jiang He opened his eyes and withdrew his hand.

He said, "Professor, this might not be all cancer."

"What do you mean?" Yang Xu frowned.

"I’ve read about cutting-edge discussions on pseudo-encasement in the *Annals of Surgery*."

Jiang He explained, "Pancreatic cancer has a specific characteristic: it induces a very strong desmoplastic reaction. This rock-hard tissue you felt, which seems like extensive cancerous invasion, is actually, for the most part, a thick outer layer of dense fibrotic tissue caused by inflammation—in other words, connective tissue."

After speaking, Jiang He paused for a moment, then continued:

"Perhaps it hasn’t actually penetrated the vessel’s adventitia. If so, it should be possible to peel it away from the sheath of the superior mesenteric artery, like peeling an onion."