Chapter 178: High Stakes on the Operating Table

Generally speaking, choosing an incision between the ribs, below the neck and sternum, or from the abdomen is much gentler than this method.

However, when formulating a surgical plan, doctors consider every possible factor.

If a sternotomy is absolutely necessary, then it must be done.

All potential risks and possible complications are explained to the patient and family beforehand.

This patient’s aortic aneurysm has exceeded 5.5cm in diameter, qualifying as extremely dangerous, and it is causing significant compression of surrounding organs and immense physical pain.

Approaching through a midline sternotomy is the most direct and quickest way to handle it.

Director Xue methodically directed her three assistants as they performed the sternotomy, personally handling or supervising the critical, high-risk parts. Her surgical team was exceptionally capable.

Even Dr. Long could only barely manage a Third Assistant’s role.

The First Assistant seemed even older than Director Xue, his temples lined with abundant white hair, with the gray strands creeping over his crown, although his wrinkles were few.

The medical profession is incredibly stressful, and premature aging is all too common.

Many finish their clinical studies already with hair turned white.

Furthermore, professional titles for doctors never consider age; as long as the years of service meet the standards and academic, surgical, written, and research achievements satisfy the criteria, one can apply.

Some exceptionally talented and hardworking doctors can be promoted to Chief Physician at 42.

Others, hindered in one or more aspects, remain as attending physicians even nearing sixty.

This First Assistant is at least five or six years older than Director Xue.

When he saw the saw cutting through the sternum, his hand wavered uncertainly—it was quite alarming.

“Remember this: because the aneurysm lies so close to the back of the sternum, you must expertly maneuver the saw to avoid tearing its wall and causing massive bleeding.”

Director Xue explained the key points to the junior doctors while guiding the First Assistant in sawing through the sternum.

Dr. Zhou suddenly understood everything.

He had assumed that the First Assistant’s age made his hands unsteady.

It turns out that the deliberate, cautious swinging of the saw was intentional.

To be the First Assistant and earn Director Xue’s trust, one must undoubtedly possess formidable skill.

These invaluable lessons had been earned at great cost by their predecessors.

Once the chest was opened, the enormous aneurysm became clearly visible.

It must be explained that an aortic aneurysm is a vascular wall lesion in which the normal structure is compromised by various causes, resulting in a localized outward bulge.

It is not a true tumor.

Their natures are completely different.

The greatest danger of an aneurysm is rupture, leading to massive hemorrhage.

Additionally, as it enlarges, it compresses the surrounding organs and tissues, inflicting tremendous pain on the patient. An intracranial aneurysm is even more perilous since any pressure on important nerves, vessels or brain tissue can trigger major issues.

Tumors, whether benign or malignant, replicate uncontrollably, undermining the immune system and invading normal cells and organs.

Tumors also pose a risk of compressing surrounding organs.

The largest liver tumors can even occupy most of the chest and abdominal cavities.

“Director Xue, this aneurysm is situated on the brachiocephalic trunk, extremely close to the ascending aorta. Should we prepare for establishing extracorporeal circulation first?”

The anesthesiologist for this operation was none other than Dr. Guan.

True to the anesthesiologist’s code, he usually remained silent and did not interfere with the chief surgeon’s operation.

Only when he believed the surgical risks were significant did he speak up with a reminder.

An aneurysm of the ascending aorta is not suitable for interventional surgery.

The common approach is to resect and replace the vessel with an artificial graft.

Director Xue opted for aneurysm clipping instead of resection, likely considering the considerable risks associated with vessel replacement.

Even today, although the technique for ascending aorta replacement is very mature, the mortality rate remains above 10%.

If the chief surgeon is technically subpar or if any mishap occurs during the operation, the mortality rate would only soar higher.

After Dr. Guan’s reminder, Director Xue hesitated for a moment before saying, “Establishing extracorporeal circulation requires systemic heparinization and cannulation of the femoral artery and vein, which will inflict a certain degree of harm on the patient. Since we’re only performing a clipping procedure with relatively lower risk, we’ll forego that preparation for now.”

She had her reasons.

It wasn’t about convenience—it was about considering the patient’s best interests.

This approach could save on surgical costs and avoid unnecessary bodily harm.

Dr. Guan remained silent, and the operation continued.

Dr. Zhou noticed that the aneurysm was located in a particularly challenging spot, right at the junction of the brachiocephalic trunk and the ascending aorta.

To put it simply, the ascending aorta and the aortic arch form a rounded arch, from which three major arterial branches arise: the brachiocephalic trunk, the left common carotid, and the left subclavian artery.

These three branches are very interesting.

Both the left common carotid and the left subclavian arteries branch directly from this arch.

However, the right common carotid and the right subclavian arteries originate from the brachiocephalic trunk.

The right common carotid lies slightly higher.

From this, it is clear that the brachiocephalic trunk essentially functions as the integrated main stem for the right-sided branches, supplying a tremendous amount of blood.

It can be thought of as accounting for nearly half of the heart’s total pumped blood.

Needless to say, the ascending aorta is even more critical.

It is, in essence, the arterial powerhouse.

The unique location of this aneurysm made the clipping procedure extremely challenging.

Some highly skilled doctors relish the challenge of such complex operations.

Dr. Zhou still wasn’t aware of Director Xue’s specific treatment plan.

Since it was a clipping procedure, even three clips might not be enough to completely occlude this unusual aneurysm.

Moreover, in the case of such a large aneurysm, vascular wall hardening and plaques are inevitable.

The most definitive treatment would still be resection and replacement with an artificial vessel.

“Although this aneurysm is somewhat atypical, I have successfully performed an aneurysm clipping at a vascular junction before. With the current adequate surgical view, the operation should be somewhat easier. If executed well, two clips would suffice. Deputy Director Lu, later you will use a temporary occlusion clip to block this section of the vessel.”

She spoke while arranging and repeatedly selecting the appropriate aneurysm clips.

These clips come in a wide variety of sizes and designs, capable of meeting all aneurysm clipping needs.

It was evident that Director Xue handled everything with remarkable composure.

Not only did she choose the two most suitable clips, but she also prepared three extras for backup in case of unforeseen complications.

“Let’s begin!”

She signaled to the First Assistant.

“Dr. Guan, is a brief occlusion of about a minute acceptable?”

She asked the anesthesiologist for his opinion.

“Absolutely. Just that completing the clipping in one minute is quite challenging. Without extracorporeal circulation, I’m a bit uneasy,” Dr. Guan replied, clearly worried.

Dr. Guan’s concern was palpable.

Experienced anesthesiologists had witnessed many surgical mishaps.

There are numerous unpredictable risks; accidents can happen in a split second.

He had seen too many cases where confident surgeons encountered emergencies during surgery, placing patients in extreme danger.

“It’ll be fine. One minute will pass before you know it. Trust me!”

Director Xue reassured him.

With the chief surgeon’s endorsement, Dr. Guan said no more.

Yet the worry remained evident in his expression.

“Proceed with the occlusion!”

She once again signaled to the First Assistant.

Several years her senior, the fact that Deputy Director Lu was under her command indicated he held the rank of Associate Chief Physician.

Deputy Director Lu skillfully handled the temporary occlusion clip, precisely blocking the junction between the ascending aorta and the brachiocephalic trunk.

This maneuver was exceptionally challenging and a true test of a doctor’s skill.

He successfully completed the proximal occlusion.

Next, he proceeded with temporary occlusion of the superior aspect of the brachiocephalic trunk.

This effectively isolated the aneurysm, preventing any significant blood flow from entering.

In effect, the blood supply to that part of the vessel was completely cut off, ensuring a safer clipping procedure for Director Xue.

The teamwork was impressively synchronized.

Director Xue’s maneuvers were equally precise.

She completed the application of the first clip in under ten seconds. However, placing the second aneurysm clip did not go as smoothly as expected.

The location itself was tricky; unless the entire blood supply to the aneurysm was cut off, the treatment would be ineffective.

Thus, placing the second clip proved to be the most challenging step.

A minute is an incredibly short time.

She continuously made adjustments but failed to achieve a satisfactory result.

At that moment, with the patient’s entire blood supply at risk,

time was nearly up, and she had no choice but to secure the second aneurysm clip as is.

“Let’s restore blood flow for testing. If it’s inadequate, we’ll adjust again!”

Cutting off the blood supply for too long is extremely dangerous.

Any tissue deprived of blood for even a short period can suffer rapid cell death; a slight extension can cause irreversible, widespread necrosis.

After blood flow was resumed, everyone anxiously watched the clipped aneurysm.

The blood pressure in the main vessel was very strong.

As soon as blood flow returned, it surged rapidly.

Most of the aneurysm was clipped, yet there were still small leaks.

With the forceful influx of blood, the aneurysm appeared to enlarge.

Observing the gap at the clipping site, Director Xue remained calm and began strategizing a solution.

“We might need to use three clips!”

She muttered, as if talking to herself yet also consulting with the other doctors.

“Using three clips certainly offers more security and would simplify the procedure,” the First Assistant agreed.

He expressed deep respect for her character.

From her actions in the operation, it was clear she always prioritized the patient’s well-being, shouldering all the risks herself.

They say appearance reflects the heart.

Her graceful demeanor—being in her forties yet still remarkably beautiful—spoke volumes about her kindhearted nature.

Using one less aneurysm clip could save the patient a significant amount of money.

“This patient comes from a financially struggling family; he works as a delivery man and his wife is blind. They are among society’s vulnerable. If we can help, we should.” she explained.

The poorer the family, the more likely they are to encounter serious illnesses.

Some diseases are a result of neglect, others from overwork.

Poverty forces them to delay hospital visits, to use spoiled food they can’t even bear to throw away, and to endure hazardous working conditions and relentless labor that make them prone to malignant diseases.

Life isn’t all beauty; suffering is also a part of it.

After a brief pause, she once again occluded the vessel and proceeded with the clipping procedure.

It should be noted that while vessel occlusion is not mandatory for clipping, surgeons generally adhere strictly to the protocol for safety.

“Beep beep beep…”

Shortly after occlusion, the patient monitor began to alarm.

The patient’s heartbeat plummeted, accompanied by ventricular fibrillation.

Dr. Guan panicked.

“It must be the consecutive occlusion of blood flow that triggered intraoperative sudden cardiac arrest. This is serious.”

It was the first time Dr. Guan had seen him so rattled.

This indicated that the situation was extremely grave.

Director Xue’s face went pale, with evident signs of palpitations and distress deep in her eyes.

This development had occurred too suddenly.

Women are generally less suited for surgical fields—not only due to lower physical strength but also a comparatively fragile mental fortitude.

In emergencies, fear can easily render them incapable of clear thought and judgment.

Deputy Director Lu’s brows furrowed and his face turned serious.

Other medical staff wore looks of extreme tension.

The most dreaded events in surgery are sudden emergencies, as their consequences often lead directly to death.

“Dr. Zhou, hurry and help with the extracorporeal circulation cannulation!”

Dr. Guan had no choice but to call on Dr. Zhou for assistance again.

Cardiothoracic surgeries are inherently high-risk, with emergencies occurring almost daily.

Prevention is best, but when it isn’t possible, only coordinated teamwork among the staff can avert disaster.

A strong surgical team is absolutely essential.

When handling high-difficulty segments of an operation, effective coordination is crucial to helping the patient survive.

“Who is Dr. Zhou?”

Director Xue was momentarily puzzled; there wasn’t any doctor with the surname Zhou on her team.

Then she noticed the trainee, previously punished by Dr. Zhao and assigned to cleaning in the operating room, hurrying to the table and establishing an extracorporeal circulation channel with impressive expertise.

For cannulation of the femoral vessels, even if Director Xue herself performed it, finishing in ten minutes would be considered excellent.

But Dr. Zhou accomplished it in under thirty seconds.

It was truly astounding.

It was as if the legendary janitor monk had reappeared before their eyes.

“Dr. Guan, hurry and perform a pericardial compression! Otherwise, the patient’s brain will quickly suffer from ischemic damage,” Dr. Zhou urged Dr. Guan.

He had learned various rescue techniques and skills under numerous chief physicians in the Critical Care Department.

In such an emergency, his training was finally put to use.

“Got it!”

Dr. Guan had already instructed the nurse to don gloves in preparation for the pericardial compression.

Sudden cardiac arrest and ventricular fibrillation during an open chest procedure are extremely perilous.

If precise and effective rescue measures are not implemented immediately, the patient will soon die.

Undeterred by the shocked expressions around him, Dr. Zhou calmly began the procedure for cannulating the superior and inferior vena cava.

Only Dr. Long, familiar with Dr. Zhou’s extraordinary skills, appeared relatively calm.

He already knew that Dr. Zhou’s talent was truly remarkable.

But nothing was as astonishing as Dr. Zhao’s reaction.

He could hardly believe that the trainee he had looked down on was explosively competent. Every cannulation maneuver completely shattered his preconceptions.

“Who…who is this?”

Deputy Director Lu incredulously asked the surrounding doctors.

His gaze first fell on Dr. Zhao.

When they arrived, Dr. Zhao had mentioned that the trainee, Dr. Zhou, had been punished to perform cleaning duties in the operating room.

Dr. Zhao, an inferior resident in Cardiothoracic Surgery who knew very little, had no inkling of Dr. Zhou’s background; he was utterly dumbfounded.

He stammered, “He…he’s a trainee who just rotated into our Cardiothoracic Surgery today.”

“Can a trainee really be that skilled?”

Deputy Director Lu was skeptical.

“What’s his name?”

“I think it’s… Dr. Zhou. Yes, Dr. Zhou!”

Dr. Zhao only recalled the surname Zhou, and it took him a while to remember his full name.

“Ah… so it’s him. No wonder he’s so impressive!”

Deputy Director Lu clearly had more reliable information.

He had long heard of the accomplished trainee Dr. Zhou, whose arrival in each new department stirred up tremendous waves. His talent and prowess had even caught the attention of Deputy Director Ye.

Director Xie of the Surgical Department had, on more than one occasion, tried to recruit Dr. Zhou with extravagant offers, all of which he had refused.

Chief surgeons of the departments where he had rotated had nothing but praise for him.

Such an exceptional trainee, on his very first day in Cardiothoracic Surgery, was relegated to cleaning in the operating room. Dr. Zhao’s ignorance was truly staggering.

Upon hearing Dr. Zhou’s name, Director Xue instinctively shifted her gaze from the patient’s pericardium to appraise him.

“Dr. Guan, should we now establish extracorporeal circulation?”

“Of course!”

Dr. Guan answered while performing pericardial compression.

He did not dare to look up or away from his work.

During cardiopulmonary resuscitation, external chest compressions benefit from the full ribcage’s protection. In an open chest operation, one must compress the pericardium directly—which is essentially pressing on the heart.

The danger is self-evident.

“I think we should immediately administer vasoactive drugs to the patient!”

While establishing extracorporeal circulation, Dr. Zhou suggested this to help the patient.

“Right, right! I nearly forgot about that. Director Xue, please arrange for it immediately; I can’t step away here,”

Dr. Guan readily accepted Dr. Zhou’s suggestion.

Director Xue, no fool, clearly recognized the high regard in which Dr. Zhou was held by Dr. Guan, and that his abilities were extraordinary. In just a brief period, he had prepared for extracorporeal circulation seamlessly.

Moreover, every suggestion he made was precise and spot-on, reflecting his comprehensive rescue skills.

“Today, we’re lucky to have Dr. Zhou’s help; otherwise, our patient might not have been saved,” Director Xue thought, her respect for him reaching new heights.

Seeing his operations firsthand, she realized that Dr. Zhou was even more impressive than the legends had claimed.