"He needs surgery?" asked the middle-aged gentleman, somewhat puzzled.
"The patient has chronic cholecystitis and this is an acute manifestation, which means his gallbladder should be edematous and has severe adhesions. If he is treated conservatively, it'll take a long time for antibiotic infusion to take effect, and dysbiosis will most likely happen. That's why I suggest surgical removal of the gallbladder."
Chapter 79 - Let The Senior Consultant Do It
The middle-aged man remained silent. An emergency doctor in charge of ultrasonography dashed over with a portable ultrasound machine cart and examined the elderly man. The diagnosis of cholecystitis was confirmed.
When Chang Yue keyed in the patient's personal information into the inpatient admission form, only then did Zheng Ren realize that the middle-aged man was Lin Yuanshan, who worked in the province.
The admission process was soon complete, but before Chang Yue could explain the patient's condition and everything about the surgical treatment to Lin Yuanshan, the directors of Sea City General Hospital, Chief Surgeon Sun of the second general surgery department and a few clerks rushed into the emergency department.
"Mr. Lin, why didn't you inform me about your arrival in Sea City General Hospital?" Xiao Keming greeted enthusiastically from afar, even extending his right hand from more than ten steps away from Lin Yuanshan.
"The girls from the Chu family said that Doctor Zheng of the emergency department is very professional, so here we are," answered Lin Yuanshan indifferently, appearing unapproachable and arrogant.
However, Director Xiao and the rest acted as if this was perfectly normal.
"This is Old Chief Physician Pan of the emergency department, and he is Chief Surgeon Sun of the second general surgery department. They're here to ensure everything is up to par," Director Xiao introduced them one by one.
Lin Yuanshan nodded, annoyance clearly visible in his slightly furrowed brows.
After chatting casually for a while, Chief Surgeon Sun hurried to the resuscitation room and performed a detailed examination on the patient.
Zheng Ren was also experienced in examining patients, but since he had the System, the clinical examinations were merely for show and mostly performed out of habit. In all honesty, skipping the examination was completely acceptable as the System always provided him with comprehensive information and definitive diagnoses of the patients.
Chief Surgeon Sun's professionalism and thorough examination eased the irritation in Lin Yuanshan's eyebrows to a certain degree.
"He has acute cholecystitis. According to the B-scan ultrasonography report, there is a lot of gas near the gallbladder, presumably due to the inflammatory stimulation on the bowel. Surgery is the better option in this case." Chief Surgeon Sun gave his judgment.
"The patient is old, so we've to check if there are any comorbidities," Director Xiao instructed.
"Sinus bradycardia noted on the patient's electrocardiogram. Bilateral lung fields are clear without any signs of hypostatic pneumonia. Preoperative blood investigations have been ordered and the laboratory will send the results within thirty minutes," Chang Yue reported all relevant information.
The nurses had already started preoperative preparations such as urinary catheterization, nasogastric tube insertion, and surgical skin prep.
"How big is the surgical wound?" asked Lin Yuanshan out of worry.
After all, the elderly man was in his seventies and had a previous history of cerebral infarction. His physical condition had deteriorated and slow recovery was inevitable.
Lin Yuanshan's concerns were not without basis.
"Quick recovery can be expected if we perform laparoscopic cholecystectomy on the patient." Chief Surgeon Sun comforted him.
"Laparoscopy? Doctor Zheng strongly suggested an open surgery." Lin Yuanshan expressed his disagreement.
A senior surgeon in his fifties and a young brat in his thirties, who would the family member believe? The answer was pretty obvious.
When Director Xiao heard that Zheng Ren had diagnosed the patient, he asked nervously, "Zheng Ren, you're highly skilled in laparoscopic surgery, so why did you suggest an open cholecystectomy?"
"This is a case of acute on chronic cholecystitis. I'm worried about the severe adhesions in the peritoneal cavity," answered Zheng Ren frankly while ignoring the pressure Lin Yuanshan exerted on him.
A medical nerd like him could not possibly perceive that sort of aura.
Lin Yuanshan frowned.
Sorcerers who predicted upcoming misfortunes would be tied to a stake and immolated. Everyone—from westerners in the Medieval period or the modern world, or even easterners—had the same thought on their minds.
It was unconvincing, especially when it was a young man stating that the patient's condition could be complicated.
Thus, Lin Yuanshan elected to ignore Zheng Ren and asked Chief Surgeon Sun of the second general surgery department directly, "Chief Surgeon Sun, do you think he can undergo minimally invasive laparoscopic surgery?"
The Chu sisters had already left to prepare for general anesthesia, but their presence would likely not have changed his mind anyway.
"It'll be difficult," replied Chief Surgeon Sun truthfully. After answering the question, he quickly turned around and blinked innocently as a form of apology to Old Chief Physician Pan.
"If surgery is necessary, I would like Chief Surgeon Sun to perform the laparoscopic surgery. Open surgery can be attempted when laparoscopy fails," said Lin Yuanshan decisively.
"Is the emergency operating theater fully equipped?" asked Director Xiao.
If he were honest, Director Xiao would have preferred to let Chief Surgeon Sun handle the operation as well. After all, he was a senior consultant with impeccable skill at surgery, so the chances of success would be much higher.
As for Zheng Ren… It was better for him to stay out of a case that involved a very important patient.
"Yes, I've done some laparoscopic cholecystectomies recently," Zheng Ren remained unconcerned and added, "Chief Surgeon Sun, please check the equipment later and make sure everything is well prepared. You can get a replacement from the general surgery department if there are any missing or incompatible instruments."
"It should be fine." Chief Surgeon Sun had a feeling that he had fallen into a trap. He preferred not to provoke these two troublesome emergency doctors, which was why he always backed out of any conflict with them.
However, his involvement in this special case was something he could not have foreseen.
"Once the blood test results come back and there aren't any contraindications for surgery, let's proceed to save the patient." Director Xiao tried to create a relaxing atmosphere and said with a smile, "Sea City General Hospital usually performs around a thousand laparoscopic cholecystectomies each year. We even surgically treated a 108-year-old man last year and he could already ambulate on post-op day one. Don't worry, Mr. Lin."
"Hum!" Lin Yuanshan mumbled through his nose and coupled with his worried expression, the atmosphere remained slightly gloomy.
During the wait for preoperative examinations, Chang Yue began doc.u.menting pre-admission and preoperative counseling and broke the dead silence in the office with the continuous tapping of her keyboard.
On the other hand, Zheng Ren went to the resuscitation room as he disliked the current office environment.
"You're an insidious man," said Su Yun, who followed Zheng Ren everywhere like a shadow.
"What do you mean?" asked the puzzled Zheng Ren.
"You suspected that the patient has severe abdominal adhesions. If whatever you said is true, there is no way he can be treated with laparoscopy," Su Yun said, "Why didn't you stop him?"
"Will they listen to my opinion?" Zheng Ren was an honest man, but he was no fool.
He had learned to judge situations more effectively after working in the medical field for so many years. Most importantly, if he insisted on his point after the family members made the
ir own decisions, an argument would be unavoidable.
"Good, you don't have the heart of Saint Mary. I feel more at ease after knowing this." Su Yun's smile stunned a junior nurse, who was preparing the patient for surgery in the resuscitation room.
Zheng Ren felt that this brat was simply causing too much interference in the resuscitation room.
"Let Old Sun perform the surgery first. By the way, I'm curious. How can you tell that the patient has severe abdominal adhesions?"
"In the B-scan ultrasonography image, a band of free air can be seen in the gallbladder area. You can consider that sign as a simple gas disruption in normal patients, but if you look carefully, there isn't any obvious motility noted in the gas band. That's why I suspect that some inflammatory organic matter has enveloped the transverse colon and displaced it superiorly to the liver edge."
Zheng Ren immediately turned on his invincible mode when explaining medical issues.
It was one thing to make conjectures, but it was a different and much easier thing altogether to explain the condition through deduction after acknowledging the final diagnosis of the System.
Su Yun had a pair of delicate eyebrows. The delicacy remained even when he frowned without any trace of solemnity, which made him look calm and steady. His glamor intensified and blinded everyone who peeked in on him.
He desperately tried to recall the B-scan ultrasonography image during the bedside examination.
Was it possible that whatever Zheng Ren mentioned was true? How did he even acquire such an in-depth knowledge of ultrasonography?
Chapter 80 - Let Him Take Over The Surgery
The investigation results came back promptly, and the patient had no contraindications for surgery.
Just as Chang Yue was about to perform preoperative counseling, Su Yun appeared at the doorstep and signaled her to come out with a wave.
"Yes?" asked Chang Yue impatiently. Strangely enough, Su Yun's charm was impotent here as she was greatly annoyed at him for interrupting her work.
Su Yun was briefly stunned before a sincere smile formed on his face.
Flowers bloomed as if spring had fallen at that moment.
"Since the general surgery department is handling the operation, best if you don't explain the procedures yourself," said Su Yun.
"Huh? Why?"
"What is the main point of your counseling?"
"Laparoscopy, of course," replied Chang Yue whose patience was wearing thin.
"What if laparoscopic surgery fails? They'll then proceed with laparotomy, which means there is a problem in preoperative counseling. Be careful, you might end up becoming a scapegoat again," explained Su Yun, who knew that she had taken the blame in the obstetrics department before.
Chang Yue froze for a moment and immediately realized the point Su Yun was trying to make.
"Then…" She shifted her gaze into the room.
"Chief Zheng, let the general surgery department counsel the patient and family members themselves," Su Yun's words always sounded cynical when he spoke to Zheng Ren.
Zheng Ren was also aware of the trouble, which he failed to consider in the beginning, lurking in the shadows and understood Su Yun's motives instantly.
Instead of being meddlesome, he actually found it necessary to take precautions in this case. Thus, he informed Chief Surgeon Sun about this issue.
Chief Surgeon Sun smiled bitterly and thought, 'Why are these emergency doctors a pain in the *ss?'
"Chief Zheng, I didn't hide anything from you when I brought you to the operating theater in the past," he whispered.
Zheng Ren stared at him with a bewildered expression.
Why did Chief Surgeon Sun even bring up the past? It was true that he had assisted Chief Surgeon Sun in past surgeries despite not being in the same department, but those were rare occasions and definitely involved less than five cases in total.
"If I can't complete the surgery, you must help me." Chief Surgeon Sun had a bad feeling about this case for some inexplicable reason, and his gaze radiated helplessness as if he was trying to say, "Please give a brother a hand."
From Chief Surgeon Sun's skills alone, there was no way he would have said this to Zheng Ren.
However, the fact that Zheng Ren had performed many difficult surgeries, including the parasitic biliary obstruction case, constantly refreshed Chief Surgeon Sun's evaluation of him.
The rise of the younger generation was unstoppable.
Chief Surgeon Sun was mild-tempered and gentle compared to Chief Surgeon Liu of the first general surgery department, which was why he could throw aside his dignity and ask a youngster for help at a critical juncture.
"Oh, that's too polite of you," Zheng Ren quickly wore a polite smile and bowed slightly, a typical gesture noted in a junior, and said, "If you can't do it, neither can I. However, if the need arises, please do let me know."
Chief Surgeon Sun finally smiled in relief.
It was much easier to deal with Zheng Ren than Old Chief Physician Pan, likely due to the fact that Zheng Ren had only been promoted recently and still had the mentality of a junior doctor.
They could not continue the conversation any further as the patient's family and the directors of the hospital were still on the scene.
Soon, Chief Surgeon Sun's subordinate acquired signatures on the preoperative informed consent doc.u.ments. After that, the group went to the operating theater.
Zheng Ren had no intention of observing the surgery and chose to read his book in the office. Su Yun decided to stay as well, seemingly uninterested in anything, young and beautiful nurses included, apart from his phone.
…
…
After the anesthesia was administered, Chief Surgeon Sun stood before the operating table and began creating a pneumoperitoneum.
The Veress needle pierced into the peritoneal cavity and 15mmHg of carbon dioxide was insufflated afterward.
Instead of performing a conventional three-incision laparoscopic surgery, Chief Surgeon Sun chose to insert two trocars lateral to the left and right rectus abdominis muscles.
There was a high probability that laparoscopy would fail, which was why he chose these unusual entry points.
Using a dissector, he separated a small part of the tissue and was welcomed by severe intr.a.p.eritoneal adhesions without any gaps at all, especially in the upper peritoneal cavity.
Profound clinical experience saved him from making a grave mistake.
Chief Surgeon Sun immediately gave up on laparoscopic surgery and decided to perform a laparotomy instead.
He waited for his emotions to stabilize before snapping a picture of the laparoscopic image and left the operating theater to explain the situation to Lin Yuanshan.
Holding the cell phone in his hand, he showed the picture to Lin Yuanshan and pointed out the reason why he could not proceed with laparoscopic surgery.
After being explained to professionally and regrettably as if possessed by a drama queen, Lin Yuanshan finally gave his consent, which made Chief Surgeon Sun sigh in relief. Then, he returned to the operating theater, scrubbed up, changed into a new surgical gown, prepared the necessary instruments and reinitiated the surgery.
Chief Surgeon Sun was average at laparoscopy, at best.
After all, he only started learning laparoscopic surgery at forty-five years old when he was already highly competent at open surgery.
Since he had good knowledge of anatomy, It was actually easier to treat uncomplicated cases with laparoscopy.
However, if an extremely difficult surgical case was encountered, he preferred to proceed with laparotomy due to his proficiency in this domain.
A twenty-centimeter incision was made below the right costal margin and each layer was carefully incised to explore the peritoneal cavity.
Chief Surgeon Sun was dumbfounded the moment the peritoneum was opened.
The situation was worse than expected!
It was a big mess! He could vaguely outline the greater
omentum and transverse colon, but as for the gallbladder… it was nowhere to be seen.
He had no choice but to attempt blunt dissection.
However, staring at the clumped up abdominal viscera, he had no idea where to begin the procedure.
It looked like an intertwined flaxen thread ball with its head hidden somewhere inside. If he was merely dealing with inorganic matter, he would cut it straight away without hesitation, but unfortunately, these were abdominal organs in a human body. Once the severely edematous intestines ruptured, it would be immensely troublesome to suture it back.
Blunt separation had to be done slowly and cautiously. Chief Surgeon Liu's attentiveness was not entirely due to the patient's identity; even if this patient was an ordinary elderly man, his attitude toward this surgery would still be the same.
Five minutes had passed and yet he remained clueless.
He still did not have the foggiest notion of how to continue even at the tenth minute. The circulating nurse had wiped the sweat off his forehead twice and the disposable surgical cap had completely drenched in a cold sweat.
At the twentieth minute, a dark green patch appeared on the back of Chief Surgeon Sun's surgical gown, the result of perspiration soaking his green gown.
An unexpected event occurred as he accidentally ruptured an arteriole while lysing the adhesions, which caused fresh blood to spurt from the wound. The ruptured arteriole ligation process was risky and took him five minutes to complete the procedure.
The surgical lighthead was blinding and Chief Surgeon Sun's vision was getting blurry.
Sighing heavily, he spoke to a circulating nurse who had just arrived at the operating theater for assistance, "Call Chief Zheng and ask him to take over the surgery."
Even though Chief Surgeon Sun had spoken to Zheng Ren preoperatively, he would have never let Zheng Ren take over the operation unless absolutely necessary.
Doing so meant that he admitted defeat and that his surgery standard was inferior to Zheng Ren's.
However, he did not have the faintest idea even after bluntly dissecting the adhesions for twenty minutes, so he had no choice but to give up.
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