Chapter 505: Navigating a Complicated Surgery

Anesthesiologist Ziqu and anesthetic nurse Qin Yue stepped into the operating room together.

Although the reforms in the Anesthesiology Department were still just on trial, the two of them were already basically teamed up with Zhou Can.

Or put it this way—as long as the Emergency Department had an anesthesia case, the two would always give it top priority.

In the Emergency Department’s operating room, Dr. Xu had the final say.

Dr. Xu viewed Zhou Can as his successor, with almost everything centering around Zhou Can.

Zhou Can and Ziqu had reached an understanding and formed a duo, something Dr. Xu silently approved and supported. For any anesthesia-related surgeries, he’d now go straight to Ziqu for help.

“What’s the patient’s condition?”

Zhou Can turned to ask Ziqu.

The anesthesiologist would already have thoroughly grasped the patient’s illness, physical status, drug allergies and more. Before the surgery, they’d also talk with the family and get the anesthesia consent form signed.

Usually, the anesthesiologist and chief surgeon would discuss the patient’s condition and confirm the surgical plan.

Today Zhou Can was especially busy.

Most likely, Dr. Xu had taken his place in drafting the surgical plan with Ziqu.

“The patient has a stubborn duodenal ulcer and extremely high stomach acid. It’s probably burning her up. On top of that, she’s broadly allergic to proton pump inhibitors—a rare constitution. Surgery is the only option.”

Too much stomach acid burns the mucosa and stomach lining, and the duodenum as well. Most common symptoms are heartburn, stomach pain, discomfort, nausea and loss of appetite.

Unless there’s a specific underlying cause, duodenal ulcers are usually pretty easy to cure.

But for a few unlucky patients, the ulcers keep coming back no matter what.

At that point, it’s necessary to dig deeper and find out what’s triggering the ulcer.

Western medicine shines here—wherever there’s a problem, it gets fixed.

High blood pressure? Get it down with antihypertensives. Respiratory failure? Put the patient on a ventilator. Ruptured blood vessel? Immediate surgery for bleeding control and vascular repair.

Basically, as long as you find the cause, Western medicine can always come up with a solution.

Even something as dire as cancer—there are already many kinds being overcome, with continued progress.

With today’s techniques, as long as cancer is caught in its early stages, most cases can be treated very successfully.

“High stomach acid is usually caused by excessive secretion. Are we planning surgery to reduce the amount she produces?”

“Exactly!”

Dr. Xu entered the room.

“Which surgical strategy do you think is best?”

Dr. Xu wasn’t just testing him—he genuinely wanted Zhou Can’s thoughts.

These days, Zhou Can often contributed fresh perspectives and even innovative surgical options.

“Uh… If it’s a stubborn duodenal ulcer caused by high stomach acid, I’d say cutting the vagus nerve is a good choice.”

After a moment of reflection and considering the actual case, he offered his surgical opinion.

“Not bad—you’re getting sharper, both in surgical skills and decision-making.”

Dr. Xu was openly impressed.

His own surgical plan probably matched Zhou Can’s.

It’s also the most common approach for this condition.

Of course, you can’t apply the same treatment blindly—everything depends on the patient’s actual situation.

The point in cutting the vagus nerve trunk is to block the nerve-induced gastric acid secretion, lowering the acid volume and hopefully curing the ulcer.

To be clear, cutting the vagus nerve trunk is a last-resort procedure, as it causes a series of side effects.

For one, the vagus nerve affects the stomach wall muscles’ function.

Once it’s cut, these muscles can no longer contract, expand, or move food properly—those abilities are all lost.

The stomach is a key digestive organ and also takes care of food storage.

Its importance to the body can’t be overstated—you could call it the ‘granary’.

So, when it loses those core functions, a slew of problems follow.

For example, the patient may experience serious gastric emptying disorder and food retention.

With such heavy side effects, this surgery is rarely used unless absolutely necessary.

For excessive stomach acid nowadays, doctors mainly use medications that suppress acid—proton pump inhibitors and H2 receptor blockers are the go-tos.

Drugs like omeprazole, rabeprazole, and lansoprazole are common in practice.

They work brilliantly to lower gastric acid secretion.

But if someone is allergic to these or doesn’t absorb them due to unique physiology, you have to look elsewhere.

For this particular patient, cutting the vagus nerve trunk is a great fit.

After the patient was under general anesthesia and catheterized, the surgery officially began.

Given the complexity of the procedure, Dr. Xu wanted to observe and assist Zhou Can directly.

These days, he rarely walked Zhou Can through surgical steps. Instead, he just provided backup, letting Zhou Can take charge.

Once the abdominal cavity was opened, a self-retaining retractor was used to hold back the abdominal wall.

The team then carefully explored the ulcer site.

Only after pinpointing the location could they prep for the nerve-cutting step.

This patient’s duodenal ulcer was really severe.

No wonder she kept moaning on her way to the operating table.

Pain and discomfort in the body aren’t limited to childbirth.

For instance, trigeminal neuralgia is recognized in medicine as among the most excruciating pains. Or when an airway is blocked more than a third of the way—the resulting suffocation can be torture.

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With a duodenal ulcer this bad, it’s a miracle she didn’t groan louder—it was almost perforated.

The corrosive power of gastric acid is more severe than most people imagine.

It can easily destroy the stomach, duodenum and even the pylorus.

Its potency is no less than many strong acids.

“Yang Zhi, Dingdong—when you perform this kind of surgery, make sure to cut the vagus nerve above the point where the esophagus meets the stomach. Otherwise, you won’t get the effect you want.”

Zhou Can explained the surgical essentials to the two of them.

He’d picked up many of these techniques from Deputy Director Liu in General Surgery and the handwritten notes he shared.

After confirming the spot, Zhou Can swiftly mobilized the left lobe of the liver.

He snipped through the triangular ligament, then had Yang Zhi pull the left liver lobe up and right, fully exposing the lower esophagus and cardia to their view.

He quickly cut through the serosa at the lower esophagus and cardia, separated the upper hepatogastric ligament, and then severed it.

Every movement was precise and rapid. Anyone watching Zhou Can in surgery would be mesmerized.

Next, he loosened the lower esophagus.

He reached for the front wall of the esophagus, feeling for the vagus nerve.

In medical textbooks, blood vessels are usually marked in red, nerves in yellow.

But in a real operation, nerves often look the same color as the surrounding tissues. That’s where hands-on experience is needed—you have to feel for them.

Zhou Can soon felt a nerve on the front left of the esophagus.

That was the left vagus nerve.

He checked the back right of the esophagus too, making sure where the right vagus nerve was.

By now, he was confident about the anatomy.

“The vagus nerves at this spot come in two—left and right. Be sure to confirm that during surgery.”

After telling the two to disinfect, glove up, and reach into the surgical field, Zhou Can had them personally feel the esophagus and surrounding tissues for the nerves.

Real hands-on experience is priceless.

Some chief surgeons, when training students, avoid extra trouble and hate to waste time—so they just point out the anatomy during surgery but never let assistants get involved.

With that approach, how could students ever become truly skilled?

Plenty of surgical residents, even after years, still fumble through operative anatomy like rookies. It’s not always their fault—they just weren’t taught well.

There simply weren’t enough chances for hands-on experience.

“I think I’ve found it. Feels quite unique, almost like a fibrous band.”

Yang Zhi was the first to reach in and feel the vagus nerve.

Once he found a suspicious spot, he immediately asked Zhou Can to confirm.

“Dingdong, you try too.”

Zhou Can turned to Pu Dingdong.

As for natural talent, Pu Dingdong was just as strong—plus he handled everything more steadily and thoroughly than Yang Zhi.

Zhou Can was pretty happy with his two assistants.

They’d both been performing well.

After a bit, Pu Dingdong located both the left and right vagus nerves, using both his hands and his eyes to verify.

“Alright, now watch how I cut the vagus nerve.”

Zhou Can carefully separated the nerve from the esophagus.

Then he directed Yang Zhi to use a nerve hook to lift it up.

He continued to separate the nerve with scissors.

This step needed scissors, not a scalpel.

Once he’d separated five or six centimeters, it was ready for resection.

You couldn’t cut it too short—usually at least two to three centimeters per trunk. The other trunk was handled with the same method.

With that, the vagus nerve trunks were both cut.

“Zhou, cutting the vagus nerve will make food sit in the stomach. Have you got a good solution for that?”

Dr. Xu had been silently observing all along, only speaking up now that they were nearly done—to address post-op complications.

“A pyloroplasty should solve the food retention issue.”

Zhou Can had already mastered the alternative.

“Looks like you’ve been doing your homework in General Surgery. Get to it!”

Dr. Xu was pleased with his answer.

Zhou Can wasted no time and performed the pyloroplasty.

In addition, after cutting the nerves, he reinforced the patient’s diaphragm on both sides, repairing the esophageal hiatus to prevent a future hernia.

Suturing the diaphragm was tough since both sides had to be pulled tight and then sewn together.

The demands for suturing and tying off were high.

He earned a nice chunk of practice and experience with each stitch and ligature.

Every ligature added noticeably to his growing experience. To maximize gains, he worked hard at each one.

By the end of the surgery, his ligature experience had gone up a lot—he was getting close to a hundred thousand.

Usually, he’d need to tie down about six thousand more ligatures to level up.

But if he could get tasks involving suturing things like peritoneum or dura, or where precision was key, he could advance much faster.

In the end, it’s these big, challenging surgeries that bring in the most experience.

“Dingdong, you go ahead and close up the abdominal cavity.”

Yang Zhi’s skills at closing up were already top-notch.

He’d always been good, and after all the experience working with Zhou Can, his skills had soared.

Pu Dingdong’s surgery skills were a bit behind.

But Zhou Can treated all his team equally when it came to training.

No such thing as playing favorites.

Seeing the surgery wrapping up, Dr. Xu left the room reassured.

“Dr. Zhou, should we wait for Dr. Pu to finish closing or move on to the next operation?”

“You and Qiao Yu can go set up in the next operating room. I’ll stay and watch a bit longer here.”

“Alright!”

Ma Xiaolan and Qiao Yu went to prep the other operating room.

By afternoons, Zhou Can was the busiest person in the emergency operating rooms.

Dr. Xu always took things at a steady pace. Only the strongest surgeons were allowed in this Class 100 operating room—less qualified ones worked in the older room.

So, in the Class 100 room, there was usually at least one free table by afternoon.

Watching Pu Dingdong suture the abdomen, Zhou Can was perfectly at ease.

Pu Dingdong’s suturing was top-notch and he worked with serious care.

Zhou Can himself had handled the initial anatomy, making the incision neat and the closure much simpler.

Both the inner and outer layers were easy to stitch.

As he watched, Zhou Can’s mind drifted to the patient who had come all the way from Magic City for treatment.

That person had a long tear in their aortic dissection.

Short of replacing the whole aorta, there weren’t many options.

But performing this vagotomy surgery gave Zhou Can some inspiration.

Vagotomy required cutting from the trunk for best results.

To solve the food retention, a pyloroplasty at the base of the stomach did the trick.

In principle, that was addressing the root problem and resolving the downstream effect.

So, for that patient with the aortic dissection, could something similar be done from the other end of the aorta?

There’s a big difference between blood vessels and nerves.

Nerves transmit bioelectric signals—very complicated ones.

If you connect circuits wrong, you get a short or unpredictable issues.

Each nerve handles its own specific kind of signal, creating a whole network of instructions.

Blood vessels aren’t like that. All the blood inside them is pretty much the same.

Blood from your scalp and from your feet can mix freely.

Blood is always circulating inside the body.

As long as you don’t mix up arterial and venous blood, you’re fine.

Zhou Can felt like he’d caught onto a new lead.

If you could work from the end of the aorta, and since all arterial blood is interchangeable,

maybe a bypass would be an excellent—even if wild—approach.

Bypasses are used in heart disease sometimes too.

So the idea itself isn’t new.

But building a bypass from the distal end of the aorta to send blood back up—now that’s innovative.

With a long diseased segment of aorta, and at least four branch arteries going to major organs and parts of the body,

you can’t just block them. But if you reconnect branches from the end of the aorta to the trunk, restoring blood flow, that might be an entirely new way to operate.