Surgery Godfather-Chapter 411 - 0383 Entering the Forbidden Zone
Chapter 411: Chapter 0383: Entering the Forbidden Zone
Chapter 411: Chapter 0383: Entering the Forbidden Zone
Professor Feng was lying supine on the operating table, and the circulating nurse connected the indwelling needle to the left radial artery, maintaining the venous channel.
Professor Ma, Mo Sixth’s anesthesiologist, performed a right subclavian venous puncture under local anesthesia, connecting various monitors to dynamically monitor the electrocardiogram, heart rate, arterial blood pressure, central venous pressure, pulse, and blood oxygen saturation.
Professor Ma administered 0.2mg of fentanyl, 100mg of propofol, and 50mg of rocuronium bromide intravenously. After successful anesthesia induction, he inserted a spring stent tracheal tube and connected it to the anesthesia machine for mechanical ventilation.
After auscultating the bilateral lung breathing sounds, which were clear and symmetrical, Professor Ma adjusted the respiratory parameters, maintaining the end-tidal carbon dioxide pressure between 35-45mmHg, inhaled isoflurane, and maintained a 1% end-tidal concentration, planning to add 2mg of vecuronium bromide every 40 minutes.
After satisfactory anesthesia, everyone worked together to change Professor Feng’s position to be prone. Each position pad and restraint band were properly in place, and Professor Feng’s eyes were also fixed with protective tape in the closed position.
The head was fixed on the Mayfield frame. Yang Ping personally installed the fixed frame, checking each screw several times, especially the three skull screws, ensuring they were installed at the largest diameter of the head, completely penetrating the outer plate of the skull, securely attaching the head with the outer plate of the skull.
If it was not installed properly and the tapered part does not penetrate enough bone, the head could slip during the surgery, which would be lethal for Old Feng.
Not only the head and neck fixation needs to be secure, but the angle of fixation also needs to be optimal. After adjusting these, Yang Ping checked the defibrillator.
Yang Ping also personally checked the sundries bag used for prone position cardiopulmonary resuscitation. This kind of sandbag is stuffed in the part below the sternum. Thus, when pressing the heart, pressing the back, the sternum below is depressed by the sandbag, forming pressure on the heart, achieving the same effect as supine press. The sandbag should not squeeze the abdomen, it should only be at the lower part of the sternum. According to the positioning principle, this position should not have a sandbag, which could easily lead to pressure sores, but to save rescue time, these considerations had to be disregarded.
The sensory-evoked potential and motor-evoked potential monitoring equipment for the brainstem and spinal cord are working normally.
Only after these detailed checks were completed and some precautions repeatedly emphasized, did Yang Ping felt satisfied and led everyone to wash their hands.
Performed disinfection and sheet preparation, pre-operation check, the anesthesiologist reported the vital signs: heart rate 75 times/minute, breathing (mechanical ventilation) 20 times/minute, blood pressure 120/65mmHg, blood oxygen saturation (low flow oxygen) 100%.
Yang Ping, wearing protective glasses, began the surgery with a laser scalpel, holding the sapphire scalpel end with a pen grip.
He played with the laser scalpel in his hand for a while, looking for the feeling, and then started the skin incision.
According to the principle of two-point positioning, Yang Ping chose to connect the posterior cervical entry with the midline occipital foramen magnum, creating a combined approach.
There are fourteen safe zones in brainstem surgery, and the medulla oblongata has six. The midline occipital foramen magnum is one of them.
This tumor affects the upper cervical spinal cord and the medulla oblongata. It would ideally be managed by orthopedic and neurosurgeons jointly, but now Yang Ping is tasked with completing the operation alone.
Yang Ping’s research on anatomy has already far surpassed these basic notions of safe zones. In the brainstem area, he has a mature and complex safe map in his mind. Even in the most dangerous areas, he knows how to execute smoothly.
After the skin was cut, the scalp clips were neatly clamped to the edge, and the laser scalpel gradually penetrated.
Two holes were drilled below the ridge line of the external occipital protuberance.
The occipital skull was lifted like a well cover, the ring vertebral canal of the upper cervical vertebrae was completely opened from the posterior, and the entire rhomboid fossa was exposed.
This exquisite craniotomy can be reclosed like a cap after surgery, and along with the closed cervical vertebrae, can be securely fixed with an internal fixation steel plate screw.
When the vertebral canal and cranial cavity were opened, the pulsating dura mater appeared in the field of vision, which enveloped the upper cervical spinal cord and medulla oblongata.
The entire brainstem is only thumb-sized, the medulla oblongata is just a part of it, about one third of a thumb, and the upper cervical spinal cord is almost the same size as the fingers.
It was also connected to a complex network of blood vessels and nerves, such as the vertebral artery, cranial nerves, and spinal nerves.
The surgery had to be carried out in this finger-sized space with complex and precise incisions, separation, and hemostasis. There could not be any mistakes. Even a minor error could cause patient death.
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Because the tumor only affected the medulla oblongata and the upper cervical spinal cord, the entire approach did not need to be used.
Yang Ping held the laser scalpel in his right hand, and the gun-shaped bipolar electrocoagulation forceps with light source in his left hand.
Under the extremely proficient anatomical skills, all the obstructions to the surgical goal were removed.
The posterior part of the entire upper cervical spinal cord and the brain stem was safely exposed in the field of vision, with hardly any bleeding.
The accuracy of the gun-shaped bipolar electrocoagulation forceps was astonishing. Every bleeding point before the appearance of red color was resolved by the bipolar coagulation in advance, completing hemostasis in one movement, without any repeated movements.
“Microscope!”
The Carl Zeiss neurosurgical microscope was pushed to the operating area.
Yang Ping changed his gloves, adjusted the focal length and interpupillary distance himself until he was satisfied, and then changed to a new pair of sterile gloves.
The subtle light of the laser knife made a Y-shaped incision in the dura mater and flipped it open.
The central hole of the fourth ventricle was opened, with the choroid plexus tissue, cerebellar tonsils and posterior inferior cerebellar artery on the side.
Gentle nerve hooks were used to pull the cerebellar tonsils and posterior inferior cerebellar artery to the sides.
The choroid plexus tissue and inferior medullary velum were separated, exposing the entire rhomboid fossa.
By now, the dorsal area of the brain stem exposed via the telovelar approach appeared in the field of vision, placing the safe surgical operation area near the facial colliculus in the surgical field of view.
The entire exposure surprisingly completed within minutes, the movement was smooth, stable, precise and swift.
The chief surgeon did not want to waste time on the step-by-step exposure process.
The job of Wen Rentao and Zeng Ran was merely to attract and expose with hooks.
The whole process was bloodless; Wen Rentao’s suction device did not play a big role, making it seem quite relaxed.
“So fast, true bloodless operation, beautiful!” John Ansen exclaimed. This was indeed at the level of a success rate of 80 percent.
The surgery had just completed the exposure phase. The excellent surgical technique, the clear surgical field of view, and the extreme mastery of dissection, all had already won over John Ansen.
As the saying goes, the layman watches the excitement, the insider watches the entrance. As a world-leading neurosurgery expert, his understanding was more profound than others.
Only, he found it hard to believe that it was an orthopedic surgeon performing the operation.
“He seemed to know in advance every possible point of bleeding. This kind of bloodless operation, this is the first time I’ve seen it.” Griffin, as a tumor surgeon, was particularly sensitive to hemostasis.
Woodhead had not taken his eyes off. As a spine surgeon, his surgery range often extended to the medulla oblongata. In the United States, spine surgery was not considered a branch of orthopedics, but a branch of neurosurgery.
At this time, he greatly appreciated this bold and open exposure, and for this careful handling of bone, he found the technique difficult to replicate.
“This kind of precision, it might be difficult to replicate?” Woodhead was both envious and helpless.
He was thinking, what kind of surgical training had Yang Ping received, to possess such a finely honed knowledge of anatomy and surgical ability.
Under the microscope’s field of view, the laser knife, the gun-shaped bipolar electrocoagulation forceps and the light-equipped suction device were in the operating field.
The earlier exposure was just a lead-in, the actual steps of the operation were still to come.
This surgical knife would have to flawlessly navigate through the central nervous system.
“Guys, stay focused.” John Ansen reminded.
The three of them sat up straight, concentrated, and started watching the video of the microscopic surgical field.
The conference room was as quiet as could be, one could practically hear the breathing of the person next to them.
“Anesthesiologist, I’m about to make an incision into the upper cervical spine and the medulla oblongata, and to start separating the tumor. Keep a close eye on vital signs.”
“Prepare the defibrillator. Remember, if ventricular fibrillation occurs, the anesthesiologist must immediately report, and the defibrillator must complete the defibrillation within five seconds.”
Yang Ping reminded everyone, but there was no immediate danger, so it was necessary to get them into the zone in advance.
The laser knife began to make an incision along the posterior median sulcus of the medulla oblongata, one of the safe zones of the medulla oblongata.
