Auto chess in the operating room

Chapter 138 A feat achieved!Sixteen consecutive ERATs
For ectopic appendix, from a pathological point of view, it is because the patient is still developing malformation at the embryonic stage, the colon rotates abnormally or does not descend enough after rotation, and an ectopic appendix can form.

Common ectopic appendices include extraperitoneal appendix, subhepatic appendix, intramural appendix, left appendix, and pelvic appendix. Some doctors have also encountered appendix shrinkage and degeneration during the development process, resulting in congenital absence of appendix.

The case of this patient belongs to the typical subhepatic appendix.

If the subhepatic appendix is ​​searched with the conventional McBurney incision, it is difficult to find the lesion due to the limitation of the exposure range of the incision.

This time, Tang Lou passed ERAT, directly followed the colon from the inside, and entered the appendix cavity with an endoscope, which avoided the embarrassment of not finding the appendix.

This is like an intestine, mixed in a pile of intestines, it is difficult for you to tell which section is the end of the intestine.

But when you directly insert a tube into this section of intestine, no matter how curved the intestine is, as long as you push the tube along the wall to the head, you will definitely be able to touch the end of the intestine.

This is exactly the case with ERAT, but compared with the conventional appendix, the path of the ectopic appendix is ​​more tortuous, and it is more difficult to enter the appendix cavity.

In the observation room, everyone was also curious about how Tang Lou would complete such a difficult catheterization.

I saw that Tang Lou was controlling the LoopTip guide wire with one hand, while the other hand was placed on the patient's abdomen, calculating the path.

"He is this?"

In the observation room, everyone obviously did not expect that Tang Lou would insert the guide wire in such a way, completely relying on the direction of the appendix under the liver to predict the insertion angle and strength of the guide wire.

I saw Tang Lou's hand with a transparent thin glove on the patient's right iliac fossa and right paracolic groove, and began to move toward the retroperitoneum.

The fingertip of the index finger and the first knuckle of the thumb move slightly on the patient's abdomen and make gestures.

In the observation room, all the bosses are also staring intently.

"Smart! The ascending colon of the cecum of a normal person is located in the right iliac fossa and the right paracolic groove, so in the ordinary appendectomy, this is the mark. Now the patient has an ectopic appendix under the liver. The position of the fossa and the right paracolic groove is upward, and the protruding object is where the patient's cecum is."

Doctor Huang explained as he looked at Tanglou more and more. It was really a pity that this young man was in Hecheng No. [-] Hospital.

Sure enough, in the operating room, Tang Lou determined the direction of the ectopic appendix by positioning the index finger and thumb knuckles on the body surface.

With the other hand controlling the guide wire, it was passed quickly through the cecum, and the Gerlach's flap covered the cavity of the appendix.

With the guidance of the guide wire, the subsequent catheter is naturally entered very smoothly.

The next step is to routinely suck out the pus, then inject iohexol contrast, and perform endoscopic retrograde appendicography (ERA).

"Under the X-ray, the shape of the appendix cavity of the patient is shown. There is a fecal stone. It is confirmed that the appendix is ​​not perforated and gangrene. Acute appendicitis is diagnosed, and the fecal stone is removed and the appendix cavity is cleaned."

Tang Lou directly communicated the results with Ma En and others, and confirmed that ERAT could be continued, perforation and gangrene were ruled out, and traditional laparoscopic resection was avoided.

In the observation room, Professor Liu looked at Tanglou's operation process and this very typical case of ectopic appendicitis, which is easily misdiagnosed, and said excitedly:

"This is what I said before, why we want to promote ERAT, similar to this kind of ectopic appendix, if the conventional diagnosis is adopted, it is very easy to be misdiagnosed as cholecystitis, even if B-ultrasound, CT, magnetic resonance imaging (MRI) and other imaging methods are used. Examination methods. The diagnostic accuracy of CT for atypical appendicitis is 85%, and that of B-ultrasound is 82%. There is a very large possibility of misdiagnosis.”

"For each misdiagnosis, especially for the elderly and children, if the diagnosis cannot be made within 36 to 48 hours of the onset of inflammation, the incidence of perforation will exceed 65%, so early diagnosis is very important."

"So, if we want to promote ERAT, the purpose is not to perform ERAT for all patients, but to make a diagnosis first through its endoscopic retrograde appendicography (ERA). If it is just a simple acute appendicitis, then directly perform ERAT. If the diagnosis is perforation or gangrene, immediately switch to traditional laparoscopic appendectomy. Misdiagnosis can be almost avoided.”

"That's why I think endoscopic retrograde appendicography (ERA) will become the gold standard for the diagnosis of appendicitis."

With the perfect example of Tang Lou in front, the credibility of Professor Liu's remarks will naturally be greatly improved.

Several experts present nodded their heads frequently. It was Tang Lou who diagnosed a case of extremely difficult ectopic appendix cleanly and neatly, which left a deep impression on them.

Naturally, the fecal stones were removed and rinsed very smoothly, and finally the plastic bracket was placed.

Another ERAT case was completed, and the time came to [-]:[-] noon.

In the following time, Tanglou naturally worked non-stop. Except for the preparation time between the two operations, he was operating and issuing instructions in an airtight manner.

At ten o'clock in the evening, Tang Lou finally completed the last one, which is the No.16 ERAT.

Among the 16 patients, pus moss or pus was seen at the opening of the appendix under the endoscope in 14 cases, and the mucous membrane was congested and edematous. In 2 cases, purulent secretions flowed out during intubation, and in 2 cases, only fecal stones were taken out without seeing them. pus.

All cases were successfully intubated with angiographic catheter and guide wire in the appendix cavity, and filling defects (including massive and sandy filling defects) were found in 9 cases, all of which were successfully removed with stone removal balloon, and then normal saline or metronidazole The appendix cavity was flushed with injection until the outflow fluid was clean, and after re-contrast imaging showed no filling defect, the remaining cases were routinely implanted with plastic stents.

Looking at a pile of data compiled by the interns simultaneously, all the experts were shocked.

Tang Lou was really under their noses, and successfully completed 16 cases of ERAT, as well as a suspension.

Moreover, there are many very rare cases such as pinworm appendicitis and ectopic appendix.

In the observation room, Cheng Jian got up lazily and stretched his waist:
"Fortunately, everyone, is the development of our institute on ERAT okay?"

The group of experts, having drunk a stomach full of bitter coffee at the moment, really couldn't speak.

Wen Dalong lowered his head, he really couldn't understand why such a young doctor could have such strong surgical ability.Moreover, after having undergone surgery for so long, she is still in good spirits.

When Wen Dalong fell into autism, Professor Liu stood up first, glanced around in the observation room, and faced Tanglou on the screen.

"Clap clap clap!"

Hearing Professor Liu's applause, the rest of the experts also reacted and stood up to applaud together.

Wen Dalong dragged his numb feet, stood up shakily, and patted him a few times.

"Director Cheng, our inspection trip this time was very successful. Your hospital has shown us enough strength and also confirmed that your hospital has the ability to carry out ERAT surgery. At the same time, I also think that your hospital's general surgery department is fully capable. Construct a provincial acute abdomen subject point."

Professor Liu looked at Wen Dalong, narrowed his eyes, and said sharply: "Director Wen, what do you think?"

(End of this chapter)