There were two different views on the choice of stents.
An uncovered stent had the advantage of stability. Its metal mesh formed a cylindrical structure that could be anchored by the hepatic parenchyma cells, creating strong friction that prevented it from dislodging post-surgery.
However, the robust regeneration of the liver was a complicating factor.
After a year or more, the stent and thus the tract created from the TIPS surgery could become blocked by the regenerated liver.
On the other hand, a stent graft could prevent the risk regenerated cells blocking the tract, but required more skill to secure in place due to the lack of friction between the stent and parenchyma cells.
It all depended on how the surgeon would employ it.
After repeated experimentation in the System's operating room and thorough literary research, Zheng Ren had chosen to use a stent graft.
He was certain that he could secure it in the channel made by the angiographic needle.
Professor Rudolf Wagner remained silent in the operating console room.
This could not be Zheng Ren's first TIPS surgery! If one could demonstrate such competency in their first attempt, how could TIPS surgery be referred to as the crown jewel?
He had performed this procedure so many times and understood its difficulty intimately, which was why he was flabbergasted.
How many times had he been berated when learning TIPS? How many failures had he encountered? How thrilling had his very first success been?
The professor's mind was consumed by a series of flashbacks.
Impossible. This was definitely not Zheng Ren's first time performing TIPS surgery.
Even with the professor's current skill, he was unlikely to succeed with the third puncture, especially in an emergency where the patient was vomiting blood.
However, after the third attempt and failure, Zheng Ren had remained as steady as the position of the guide wire.
And the fourth puncture was successful!
Professor Rudolf Wagner fully knew how tremendous that had been.
Zheng's hands were God's own. The man's sole purpose of existence seemed to be for interventional surgery.
Professor Wagner's decision to bring Zheng Ren to his research lab in Heidelberg University was further reinforced, rock-solid as the Alps themselves.
Zheng Ren held onto the guide wire while observing the patient's condition closely. If the patient had any intense movements due to vomiting in the next second, it would result in the withdrawal of the guide wire…
That would f*ck things up.
Su Yun inserted a 10 mm stent graft along the wire.
They both switched the position of their hands. So experienced with each other were they that their cooperation was seamless.
The stent was successfully deployed.
Since this was his first actual TIPS surgery and the patient was intermittently vomiting blood, the guide wire could deviate from its position at any time.
Therefore, Zheng Ren kept the angiography on to observe the wire and stent in real time.
Suddenly, the patient started puking intensely, filling the operating room with a thick scent of blood.
They had to stop inserting the stent. Zheng Ren and Su Yun carefully held onto the wire, fearing it would be drawn out a few centimeters and cost them the surgery.
Redoing the entire operation was not the issue.
However, if they could not resolve the pressure buildup in the portal vein and gastric varices, the patient would die of massive blood loss.
It was a race against death itself. Each detail had to be perfectly executed.
Even so, a doctor could only do so much when up against the grim reaper. Not only did the execution need to be perfect, it had to be swift!
The faster, the better.
The patient finally stopped vomiting after half a minute, seemingly exhausted beyond measure.
Zheng Ren glanced at the man's vitals on the monitor and abruptly yelled, "Put me through the phone!"
The operating console room was to the right of the first assistant's position. Su Yun had only just allowed himself some relief that the patient had stopped vomiting blood with the guide wire's position still intact.
When he heard Zheng Ren shouting, he instinctively hit the covered button on the intercom to the operating console room.
"Yanran, Yiren, put on lead aprons and come in now. The patient's suffering aspiration!" Zheng Ren roared.
Since interventional surgery required exposure to radiation, Zheng Ren preferred not to let the girls in if possible.
However… complications had arisen when he was about to insert the stent.
Due to the intense vomiting, blood had been aspirated into the patient's airway.
The monitor alarm began blaring loudly.
There was instantaneous scrambling outside the room.
Chief Xia put on a lead apron and entered the operating room with Xie Yiren and Chu Yanran.
Zheng Ren had kept the radiation active since he needed to constantly monitor the position of the guide wire.
When the door opened, there would be a certain amount of radiation let into the operating console room… but not sufficient to cause an effect on the human body.
After all, X-rays travelled in straight lines…
"Suction!" Chu Yanran called out while she put on sterile gloves.
In an unexpected emergency, not only did everyone move faster, their voices were louder as well.
Almost every word was conveyed by yelling. It was an overall risk that one's demands would be buried under another's anxiety and become overlooked.
Chu Yanran reached her hand into the patient's mouth and removed the remaining blood clots piece by piece.
Xie Yiren quickly turned on an aspirator and inserted the tube along the corner of the patient's mouth.
"Not enough," Chief Xia said loudly, "Pass it to me."
She snatched the suction tube from Xie Yiren and glanced at Zheng Ren before saying, "I'm going to insert the suction tube from the patient's nasal cavity. It might cause agitation."
"Wait, give me ten seconds!" Zheng Ren said.
A suction tube entering the nasal cavity would induce the patient's gag reflex, causing coughing and retching.
The recently-inserted guide wire was in a precarious position, like a small boat in danger of being drowned by giant waves at any moment.
Given the patient's blood pressure was at a dangerous level, Zheng Ren did not have the time for another puncture.
It was a choice between saving the patient from aspiration or blood loss.
Chief Xia looked at Zheng Ren with astonishment and confusion.
The patient was suffocating, but this man wanted to wait for another ten seconds?
Was he that confident in his success within that time?
Success or failure,
Separated by a hair's breadth.
Chapter 303 - Stent-in-stent (Part 3 of 4)
In the live surgery broadcasting room, the video feed froze. Viewers waited for a few seconds, checked their Internet connections and, puzzlingly, found no issues with the latter.
[Why aren't they moving?]
[The surgery isn't complete yet. It can't possibly be finished after the puncture alone.]
[I wanted to see if the surgeon would apply a unique method to connect the hepatic and portal veins.]
A few bullet comments passed by, confirming that it was not a connection problem. The confusion only deepened.
Were there any other surgical methods they were unaware of? Was it going to be like the previous emergency surgery broadcast, where two surgeries were aired at the same time?
[No, the oxygen saturation in the patient's blood is declining!]
It did not take long before the issue was spotted.
Due to lag, changes to blood oxygen saturation due to aspiration were only just being broadcast, but no physician observing could miss them.
Be
fore any of them had the time to process the shock, though, the operative field of the live surgery broadcast began to move again.
However, it was different from before, shaking tremendously like a doc.u.mentary filmed with a hand-held camera.
It was nausea-inducing.
Those more prone to motion sickness were more heavily affected.
What had happened?
Through the operative field, the 10 mm stent graft was moving forward rapidly, advancing to the portal vein through the guide wire to find the mark left behind by the angiographic needle.
[Damn… I can't watch this anymore. What's going on?]
[Did the patient vomit blood again?]
[Very likely! Aspiration could have happened. Still, is the surgeon continuing the surgery under such circ.u.mstances?]
The viewers quickly guessed what had transpired.
However, the horror of the situation was too much to bear; most remained in denial.
It was almost over, but the patient had abruptly vomited so much blood… Was the surgery still going on?
Even though the surgeon persisted, many watching doctors had given up hope.
It was already extremely difficult to insert a stent in a stationary patient, let alone one in this state.
In the operating room, the patient's blood oxygen saturation was rapidly falling.
Chief Xia held the aspirator in her hand, stunned. Ten seconds? Would he be able to do it? It would still be manageable if the patient was deprived of oxygen for three to five minutes.
However, under such circ.u.mstances, it was better to fix it as early as possible.
Zheng Ren was asking for ten seconds...
As Chief Xia looked on, Zheng Ren and Su Yun had their eyes fixed on the screen. Zheng Ren was at full speed inserting the stent graft along the guide wire towards the puncture site between the portal and the hepatic veins.
Su Yun was trying his best to keep the guide wire in place, adjusting for the patient's movements to buy more time for Zheng Ren.
When unable to judge the scale of movement, Su Yun pushed the guide wire further in despite the damage within the blood vessel. It was better than withdrawing the wire and having to restart the entire surgery from the beginning.
After the 10 mm stent graft was in place, it was dilated and deployed against the vessel walls of the portal and hepatic veins.
The surgery was complete!
"Chief Xia, commence suction." Zheng Ren was not relieved yet. Aspiration could be life-threatening.
At his cue, she inserted the aspirator into the patient's nasal cavity.
At the same time, she compressed its outlet periodically and removed blood clots from the patient's nasal cavity, oral cavity and airway with every pump.
It had only been a short while and the patient was not in a good condition, so the matter had not been s.u.c.k.e.d too deep into the airway.
In less than three minutes, all the dark red blood clots were removed.
The patient's blood oxygen saturation began to rise.
"Zheng Ren, is it done?" Chief Xia asked with uncertainty.
"We've completed the first part," he answered. He had no intention of packing up and leaving the operating table yet.
Su Yun was still holding the guide wire in the patient.
The first part? Chief Xia did not understand.
What was going on?
After another two minutes, the patient was visibly calmer with no signs of agitation. Oxygen saturation of the blood returned to 98%.
"You guys can leave," Zheng Ren said.
Without hesitation, Chu Yanran and Xie Yiren left the operating room with their lead aprons.
He sounded like a department chief giving orders. Chief Xia was startled for a moment before following the other two out.
"8 mm stent graft," Zheng Ren ordered.
Su Yun passed him the finer stent and he began inserting it along the guide wire.
[Damn… the surgeon's technique is incredible!]
[How did they manage to insert that? I really admire that, it's amazing.]
[I'm speechless. This surgeon managed to pull off an emergency TIPS surgery. Too bad we can't download the whole process, it's the perfect operation.]
Xinglin Garden was flooded with praise from doctors.
However…
The surgery was not over yet!
Another stent graft was inserted through the guide wire.
[What kind of operation is this? Anyone care to explain?]
[Yeah, wasn't the stent graft successfully deployed? What is this stent for?]
[Could the surgeon be so busy that they forgot about the previously inserted stent?]
Their wild speculations did not seem likely, as they were not general or interventional surgeons.
This was because specialists from both those departments had turned off the bullet screen to avoid the comments from blocking their view of the surgery.
Double-stenting, also known as stent-in-stent, was a modified method recently developed by general and interventional surgeons to help with post-operative symptoms of hepatic encephalopathy.
If they began grafting with a smaller stent, the encephalopathy would be kept under control but the tract formed between the veins would be too narrow to reduce portal pressure.
With two stents, the tract would be narrowed as well, minimizing bleeding after surgery. Removal of the second stent could be decided later depending on the degree of hepatic encephalopathy to treat pressure buildup in the portal vein.
This was the most appropriate measure.
Of course, there was also a huge obstacle.
Stent-in-stent required both stents to overlap accurately, leaving no room for error.
Any unevenness would disrupt the stability of the inner stent and risk it being dislodged by blood flow.
The consequences of that… would be very serious.
Zheng Ren had chosen to do this without hesitating.
The System's monitor at the right upper corner of his vision had reported that the patient was showing symptoms of hepatic encephalopathy. Mild though they were, they would worsen with time and could be life-threatening.
The doctors watching the broadcast stared at their phone screens silently and unblinkingly.
Stent-in-stent; this surgeon was truly ambitious!
Did they not know when to stop? Completing the TIPS surgery under emergency conditions was hard enough; yet, this doctor was already looking at the patient's postoperative hepatic encephalopathy complications?
How confident was the world's top surgeon?
Chapter 304 - Abundant Rewards (Part 4 of 4)
There were no words between Zheng Ren and Su Yun, even as they performed a procedure as unconventional as the stent-in-stent technique.
Su Yun had gotten used to Zheng Ren's methods of operation. As long as it existed, any technique could be carried out.
Would the perfect assistant still need to ask any further questions?
Never.
After a connection was established between the portal and hepatic veins, there was a clear decrease in portal pressure which also slowed down bleeding in the gastric varices.
This in turn made the surgery less difficult as the patient was no longer as restless.
The second stent graft was inserted, much more easily than the first, into the jugular vein, the atrium and then through the hepatic artery, finally resting on the previous stent graft as directed by the guide wire.
At that moment, Zheng Ren moved more gently and slowly. Since the images were overlapping, he could not verify what was happening using the venogram alone and was forced to estimate the location from his own experience.
When the stent reached the puncture location, Zheng Ren made a few minor adjustments before deploying it at the sheath.
The second stent was retractable. The operation was slightly different from the first, but not by much.
Even Su Yun and the professor could not tell if
the location of the stent was appropriate. Only Zheng Ren could.
They performed another venogram. This time, the contrast medium passed smoothly through the stent between the hepatic and portal veins. Primary imaging of the stents also revealed that they overlapped precisely, their ends not exceeding one another.
This meant that friction between the stents were maximised with minimal risk of dislodging.
The surgery was a success!
Zheng Ren turned off the equipment and removed the guide wire.
[Awesome! This guy's amazing!]
[Inclusive of the patient's fits, it all took one hour and 54 minutes. This is the shortest TIPS surgery I've ever seen!]
[I'm just a passerby who doesn't really understand TIPS surgery, but I think the surgeon did a great job.]
The doctors in Xinglin Garden began commenting via the bullet screen. Although the room had stopped broadcasting, they used it as a forum to continue discussing the surgery.
As Zheng Ren prepared to leave the operating table after withdrawing the guide wire, there was a crisp, pleasant notification of mission completion.
[Main Mission: The Crown Jewel - First Stage Completed.
[Mission Content: Complete a TIPS surgery
[Mission Rewards: Since it was the first TIPS surgery performed, in addition to it being an emergency surgery, its difficulty level was raised to 2. Duration of surgery was 1 hour and 54 minutes, 149 x 2 x 2 = 596 hours of surgery training time awarded. Luck points +2, two golden c.h.e.s.ts and 200,000 experience points.
[Mission Time: 6 hours, completed in 1 hour and 54 minutes, with remaining time of 4 hours and 6 minutes.]
The first stage of the main mission, The Crown Jewel, was complete. The rewards and experience points from the System were abundant.
Especially the surgery training time; he had been awarded over 600 hours!
That was equivalent to 25 days.
It was the largest hoard of wealth Zheng Ren had ever acc.u.mulated!
He was elated. Did this mean that he could afford to splurge once or twice in a blue moon?
He tore off his sterile surgical gown and entered the changing room, returning the special lead vest to the System and returning to the operating console room with a huge grin.
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