Surgery Godfather-Chapter 276 - 0260: Found it

Chapter 276 -0260: Found it

The heavy radiation door was firmly shut, with Director Ji strenuously at work inside, the expected duration being around six hours.

Despite such intense struggle, there was still the possibility of futile effort without any findings at all.

The human body is complex and mysterious. Modern medicine, be it basic or clinical medicine, is still far from advanced. You can even say that it’s just getting started.

Many diseases are listed in textbooks as ‘mechanism unknown’, ‘symptomatic treatment’ or ‘no specific drugs available’, etc.

Yang Ping decided to check the system space for any available interventional surgery training while he had downtime. There was none at the moment, only orthopedic training focused primarily on bone tumors, with correctional training up next.

Only by completing the advanced training of trauma, orthopedics, and corrective surgeries would other types of surgical training be available, such as interventional or robotic surgeries, and so on.

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Yang Ping picked some thoracoscope, laparoscope, and foraminal endoscope training inside the system. Many orthopedic surgeries involve the spine, for which these endoscopic techniques are required. Technique is similar to the hoops of a barrel; it requires a steady hand, built up piece by piece.

“What if we find nothing after putting up such a struggle?” Zhang Lin asked worriedly.

Little Five was also worried: “I think Fang Xiaoyun’s mother is likely to cause trouble. Being a doctor isn’t easy, not only dealing with these complex diseases but also coping with the wicked hearts of people.”

“That’s because our senior brother is so daring and skillful. If it were anyone else, who would dare to take risks in such a situation?”

“Zhang Lin, are you planning to have a child? I could cover for you during the surgery later, and you can simply take pictures.”

“No worries, I don’t dare to have a child in the next two or three years. At least not until I’m promoted to Attending Physician.”

Yang Ping was resting his eyes, while Song Zimo pondered over the disease – dural arteriovenous fistula, such a rare condition. Just being able to diagnose it in a patient is impressive, and now, it was discovered by Yang Ping despite being camouflaged by spinal tuberculosis. Such diagnostic capabilities are incredible.

Time drags on so painfully, especially not knowing the outcome and how long the wait could be. The wait is agonizing.

“Brother Five, shall we go out for a smoke?” Zhang Lin suggested.

Zhang Lin didn’t actually smoke when he first started working. But working late-night shifts, sometimes performing emergency surgeries all night long, the pull to smoke was too strong – just as a way to stay alert and relieve fatigue.

“Just one smoke, just one.”

Little Five intended to quit smoking as he was about to become a father. He was afraid the little one would be repulsed by the smell of smoke.

There was no smoking area in the Interventional Surgery Room, and it wasn’t appropriate for them to go searching for one in their scrub suits either. So they sneaked into the washroom and turned on the exhaust fan.

The digital clock on the wall displayed that it was past 22:00. There was still no good news from inside.

Even if they found the fistula within six hours, they would still need to perform surgery afterward, under a microscope.

Staying up all night was rather tough on one’s health. Yet, this was something they simply had to endure. It was said that the training for Resident Physicians in the United States is extremely brutal, going on nonstop, day and night.

Many residents were weeded out simply because of physical exhaustion, which some speculated was on purpose. To weed out those with weak constitutions. A good doctor must possess a strong physique and be able to endure sleep deprivation, resist the urge to urinate, and tolerate hunger.

Little Five and Zhang Lin felt much better after a cigarette. They occasionally went to check on the surgical room’s door, but it remained closed.

“Why don’t you go in and see if they’ve found anything?” Song Zimo suggested to Zhang Lin.

“Hold on, everyone should rest for a while. We still need to perform surgery later. With Director Ji’s skills, he should be able to locate the fistula. Professor Zhang with his vast experience is there too.”

Yang Ping squinted his eyes. Coming out from the system space, he felt a lot more energized. He suspected that the air inside the system space had some special effect that enhanced one’s energy level.

It was past midnight, yet there was still no development.

Zhang Lin and Little Five, like two restless monkeys, couldn’t stay still. They weren’t able to sit and rest. They were always pacing around.

“I can’t stand it anymore; I need to see what’s happening inside there.” Zhang Lin was getting restless.

Little Five pulled him back: “I’ll go in instead. You wait here.”

Little Five picked up a lead apron from the rack and put it on. He went in and returned roughly ten minutes later: “They still haven’t found it!”

They still haven’t found it even after six hours?

Was their effort akin to carrying water in a bamboo basket, yielding nothing in the end?

If they truly couldn’t find it, it would be alright if the patient understood the situation. But if they didn’t, it could lead to impatience, anxiety over a night spent in vain, and additional expenses with no results at the end.

Thus, for some cases, whether the patient understands and cooperates could lead to very different outcomes.

If they understand and cooperate, the doctors would dare to take risks and strive for the best. If they don’t, the doctors essentially wouldn’t have the nerve to put in their best effort.

How could there be the best outcome without striving and fighting for it?

“This is nerve-wracking!”

Zhang Lin slapped his forehead in exasperation.

Little Five consoled him: “Stay calm. How about we go for another smoke?”

Around one o’clock near dawn, the heavy lead door finally opened.

“They’ve found it!”

The nurse who opened the door excitedly shouted.

It was like a midwife in a maternity ward opening the door and shouting to the anxious father-to-be waiting outside, “It’s a boy (or girl)!”

Everyone stood up like springs – they found it!

“Interconnecting venous fistulas have been found in the 8-9 left intercostal area. Here, it’s clear that there’s an abnormal coiling and thickening of the perimedullary veins. Can we go for surgery?” Director Ji asked with a voice choking with excitement.

Indeed, it was a Dural Arteriovenous Fistulas – the probability of finding it was like being struck by lightning, and it happened to Fang Xiaoyun.

Fang Xiaoyun’s case consisted of two overlapping conditions, the chance of this happening was equal to being struck by lightning twice!

“She will be placed in a prone position; don’t remove the catheter. Just in case we can’t locate the fistula during surgery, we may need Director Ji to help with injecting Merlan into the catheter.” Yang Ping suggested Director Ji take a breather.

Looking at the time, they had been at this for over six hours, exploring twenty-four blood vessels. Director Ji was drenched in sweat under his lead vestment but dared not remove it. Yang Ping was still to perform surgery, during which he would likely need help injecting Merlan into the catheter to locate the fistula.

Yang Ping, Song Zimo, Zhang Lin, and Su Yixuan scrubbed up and took their positions on the stage.

“Director Ji, why don’t you take a little rest?” Yang Ping politely suggested.

“No need, I’ll just sit right here.” A nurse brought a stool, and Director Ji sat down to rest.

Yang Ping was famously quick and skilled in his surgeries at the hospital. If Director Ji removed his surgical gown now, he’d only need to put it on again very soon – not worth the hassle.

“Xiao Zeng, please make a call to my wife. The mobile is on the table over there.”

Director Ji felt a slight pang of guilt for blowing his dinner date with his wife and leaving her alone while he was in the operating room.

He wanted to call and share the good news – he had encountered a rare case, with only three hundred similar ones worldwide. He successfully located the fistula. This was the thrill of being a doctor. This would make for a great story to boast about in his old age. What else would he brag about?

Of course, he would boast about these cases, about how rare and unique they were, with only three hundred found worldwide. And he had a hand in one of these cases – this was one three-hundredth of the world’s cases – what a concept!

Given that it was one in the morning, Nurse Xiao Zeng hesitated, “Should I call your wife at this hour?”

“Yes! She’s still awake. Tell her to go to bed early and not wait up for me. I won’t be back anytime soon. Come here, I’ll tell you the passcode for my phone.”

The nurse reluctantly helped to make the call: “Hello, sister-in-law, Director Ji can’t make it home just yet. Yes, he’s with me tonight. No, what I mean is, he’s in my company tonight. No, sister-in-law, what I mean is…”

Staying up all night had muddled everyone’s brain, making it difficult to articulate clearly. She had to correct herself several times before she could get her point across.

Telling her sister-in-law at this hour that ‘he’s with me,’ almost spilled the beans. Luckily, Director Ji’s wife was accustomed to his schedule, otherwise the situation could have spiraled out of control.

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After ending the call, the surprised nurse told Director Ji, “Your wife is outside the operating room?”

“Director Ji, is this a surprise inspection?”

“What inspection? I haven’t had dinner yet. She’s here to deliver my meal. Ask her to wait a while. We’ll talk after the surgery.”

Who bothers to show off their affection now?

Indeed, everyone had forgotten about their meals. Xiao Su had ordered a pile of takeaway food and everyone was hungry.

“I was fine until you mentioned food. Now my stomach won’t stop rumbling!” Zhang Lin swallowed hard.

“Hang in there, brother, you’re not the only one starving!” Little Five heard the loud rumbling.

Using a dorsal entry, Yang Ping performed a similar procedure to a cervical “open door” technique to avoid damaging the vertebral stability. He cut three edges of the lamina to form a rectangle, leaving one edge intact to protect the periosteum. Then, just like opening a door, he lifted it up. After the surgery, the lamina could be closed to prevent instability due to destruction of the posterior pillar.

This technique required very delicate execution and could easily fail if not done correctly. When he opened the lamina, the vein did seem thick and coiled; however, patients with spinal tuberculosis would not usually undergo DSA angiography, so detecting this kind of vascular malformation on MRI was almost improbable.

This was not an issue of competence, but a limitation of the imaging technique itself, much like how a black-and-white photo can’t show colors.

The entrance to the fistula was located within this cluster of veins; it was like trying to find a point in a plane within a length of vessels. You could go vein-by-vein and possibly find it, but this would consume time and still wouldn’t confirm if there was actually a fistula.

Yang Ping paused, “Director Ji, could you help us by injecting Merlan into that arteriovenous fistula?”

The catheter inserted from the femoral artery had not been removed. Director Ji stepped onto the platform to help with the injection, “I will start the injection now!”

Merlan proceeded down the catheter and soon a spot in the venous plexus turned blue. The spot slowly enlarged, and Yang Ping located the point. There was only one fistula and its diameter was about three millimeters. A microscope was required to separate the artery and vein, followed by suturing the puncture.

“Good, that’s it, Director Ji. We’ve found it. The catheter will remain in place for post-operative confirmation with an angiogram.”

“The microscope!”

Zhou Can pushed the microscope, already covered in a sterile cover, to the operating area. Yang Ping adjusted the focus and interpupillary distance himself and began to separate the blood vessels under the microscope and repair the fistula.

“A tiny fistula can have such a great impact on the human body? To cause paralysis, it seems that human evolution has some way to go yet. The margin of error in our ‘parts’ is too high.” Zhang Lin was amazed at the small fistula, a mere 3mm hole in a blood vessel.

Normally, the artery is distinct from the vein like bridges and roads being separate entities, each with their own circulation system. The proximal ends connect at the heart, and the distal ends merge at the capillaries; otherwise, the two systems are isolated from each other. Now a path – a fistula – has formed between them.

It’s like a highway, where the lanes for incoming and outgoing traffic are separated by a divider. If there’s a gap in the divider, incoming and outgoing traffic merge, causing chaos.

The same holds for humans. The appearance of a fistula allows arterial blood to flow into the veins and vice versa. Consequently, the oxygenated arterial blood is mixed with the deoxygenated venous blood, reducing the oxygen content, and the veins’ return pressure increases due to connection to the arteries, leading to congestion.

Fang Xiaoyun’s spinal edema could not be relieved and even worsened due to venous congestion. Unlike the usual postoperative trajectory for spinal edema, which follows a parabolic trajectory, this one kept climbing and plateaued.

An abscess from spinal tuberculosis that pressurizes the spinal cord can lead to spinal edema and paralysis. A dural arteriovenous fistula that causes venous congestion can also lead to spinal edema and paralysis.

With both diseases intertwining and one hiding the other, the diagnosis naturally became more complicated.

After the surgery was completed, the surgical site was thoroughly irrigated and a drainage tube was put in place.