Professor Feng lay supine on the operating bed, and the circulating nurse connected the indwelling needle in the left radial artery to maintain the intravenous channel.
Professor Ma, the anesthesiologist of Moliu, performed a puncture and catheterization of the right subclavian vein under local anesthesia, connected various monitors, and dynamically monitored electrocardiogram, heart rate, arterial blood pressure, central venous pressure, pulse, and blood oxygen saturation.
Professor Ma intravenously injected 0.2 mg of fentanyl, 100 mg of propofol, and 50 mg of rocuronium bromide. After successful induction of anesthesia, the spring stent endotracheal tube was inserted and connected to the anesthesia machine for mechanical ventilation.
After auscultation, the breath sounds in both lungs were clear and symmetrical. Professor Ma adjusted the respiratory parameters to maintain the end-tidal carbon dioxide partial pressure of 35-45mmHg, inhaled isoflurane to maintain the end-tidal concentration of 1%, and planned to add 2 mg of vecuronium bromide every 40 minutes.
After the anesthesia was satisfactory, everyone worked together to change Professor Feng to the prone position. Various position pads and restraint belts were put in place. Professor Feng's eyes were also fixed in the closed position with protective tape.
The head was fixed on the Mayfield fixator. Yang Ping installed the fixator himself. Every screw was checked several times, especially the three skull screws, to ensure that they were installed at the largest diameter position of the head and completely penetrated the outer plate of the skull.
The plate holds the head firmly.
If the installation is improper, there is not enough bone in the apical vertebrae, and head slippage occurs during the operation, which will be fatal for Mr. Feng.
Not only must the head and neck be fixed firmly, but the fixed angle must also be maintained optimally. After adjusting these, Yang Ping checks the defibrillator again.
Even the sandbag used for cardiopulmonary resuscitation in the prone position, Yang Ping personally inspected. This kind of sandbag is stuffed in the lower part of the sternum. When performing heart compressions, when the back is pressed, the lower part of the sternum is squeezed and sunk by the sandbag, squeezing the heart, which has a negative effect.
It has the same effect as supine compression.
Sandbags cannot squeeze the abdomen, and can only be placed at the lower part of the sternum. According to the principle of body positioning, sandbags cannot be placed in this position, which may easily cause pressure ulcers. However, in order to save rescue time, we cannot take care of that much.
The somatosensory evoked potential and motor evoked potential monitoring instruments of the brainstem and spinal cord work normally.
So after checking these details and repeatedly emphasizing some precautions, Yang Ping took everyone to brush their hands with satisfaction.
Drapes were sterilized and checked before surgery. The anesthetist reported vital signs: heart rate 75 beats/min, respiration (mechanical ventilation) 20 times/min, blood pressure 120/65mmHg, and blood oxygen saturation (low-flow oxygen inhalation) 100%. p>
Yang Ping wore protective glasses and held the sapphire-tipped laser knife like a pen to start the operation.
I fiddled with the laser knife a few times in my hand, looking for the feel, and started cutting the skin.
Based on the principle of two-point positioning, Yang Ping chose the posterior approach of the upper cervical spine to connect with the median occipital transmembrane medullary velum approach to form a combined approach.
There are fourteen safe zones in brainstem surgery, and there are six safe zones in the medulla oblongata. The median occipital transmedullary velum approach is one of the six safe zones.
This tumor involves the upper cervical spinal cord and medulla oblongata. It should have been a collaboration between spine surgeons and neurosurgeons, but now Yang Ping has to do it alone.
Yang Ping's research on anatomy has gone far beyond these rough concepts of safety zones. In the brainstem area, he already has a mature and complex safety map in his mind. Even in the most dangerous areas, he knows how to successfully cross them. The skin is incised, scalp clips are neatly clamped on the edges, and the laser scalpel is advanced layer by layer.
Drill two holes on the lateral side of the external occipital protuberance and on the lower edge of the transverse sinus.
The skull at the back of the head was uncovered like a manhole cover, and the annular spinal canal of the upper cervical spine was completely opened from the back, revealing the entire rhombic fossa.
With this delicate craniotomy method, the skull can be covered back like a lid after surgery, and together with the closed cervical vertebrae, they can be firmly fixed with internal fixation plates and screws.
The spinal canal and cranial cavity were opened, and the pulsating dura mater appeared in view, which contained the upper cervical spinal cord and medulla oblongata.
The entire brainstem is no bigger than a thumb, the medulla oblongata is only one part of it, only one-third the size of a thumb, and the upper cervical cord is about the same size as a finger.
It also connects various intricate blood vessels and nerves, such as vertebral arteries, cranial nerves, and spinal nerves.
Now the operation requires complex and precise incision, separation and hemostasis in this finger-sized space. There cannot be any mistakes. A small mistake will cause the patient's death.
Because the tumor only involves the medulla oblongata and upper cervical spinal cord, all approaches do not need to be used.
Yang Ping holds a laser scalpel in his right hand and a gun-shaped bipolar electrocoagulation forceps with light source in his left hand.
With extremely skilled anatomical abilities, all obstacles to surgical goals are removed.
The entire posterior cervical cord and brainstem from the scalp to the entire upper cervical cord was safely exposed to view, and almost no bleeding was seen.
The accuracy of the gun-shaped double-click electrocoagulation forceps is astonishing. Every bleeding point is solved by double-click electrocoagulation before it appears red, and the hemostatic action is completed in one go and never repeated.
"Microscope!"
Carl Zeiss neurosurgery-specific microscope was pushed to the surgical area.
Yang Ping changed his gloves and adjusted the focal length and interpupillary distance himself until he was satisfied, and then changed to new sterile gloves.
The tiny light of the laser knife cuts the dura mater in a Y-shape and opens it.
The median foramen of the fourth ventricle is open, and on the outside are the choroidal tissue, cerebellar tonsils and posterior inferior cerebellar artery.
Gentle nerve pullers pull the cerebellar tonsils and posterior inferior cerebellar artery to both sides.
Separate the choroidal tissue and inferior medullary velum to expose the entire rhomboid fossa.
At this point, the dorsal area of the brainstem exposed through the transmedullary velum approach appears in the field of view, and the safe operating area near the facial colliculus is placed in the surgical field of view.
The entire exposure was completed within a few minutes, with smooth, steady and brisk movements.
The surgeon does not want to waste time on the revealing step.
The job of Wen Rentao and Zeng Ran is just to attract and expose themselves.
The whole process was a bloodless operation. The suction device in Wen Rentao's hand did not play a big role and seemed very lazy.
"It's so fast. It's a truly bloodless operation. It's so beautiful!" Johannessen exclaimed. The success rate is indeed 80%.
The surgery had just completed the exposure phase, and Johannessen was already impressed by the superb surgical techniques, clean and clear surgical field of view, and extremely skilled anatomy.
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As the saying goes, laymen only watch the excitement, while experts watch the door. As the world's top neurosurgery expert, he has a deeper understanding than others.
However, it was hard for him to believe that this was an orthopedic surgeon performing the surgery.
"It's like he knows every possible bleeding point in advance. This is the first time I've seen this kind of bloodless operation." As an oncology surgeon, Griffin is particularly sensitive to hemostasis.
Woodhead never looked away. As a spine surgeon, his surgical scope often extends to the medulla oblongata. In the United States, spine surgery is not a branch of orthopedics, but is considered a branch of neurosurgery.
At this time, he greatly appreciated this bold and open exposure, and at the same time felt that it was difficult to replicate this unboxing technique that was very particular about bone processing.
"I'm afraid it's difficult to replicate this kind of finesse?" Woodhead was both envious and helpless.
He was thinking about what kind of surgical training Yang Ping received to acquire such sophisticated anatomical knowledge and surgical abilities.
View under the microscope, laser knife, gun-shaped double-click electrocoagulation forceps, and light source suction device in the same surgical field.
The previous exposure is just the preparation, and the subsequent surgery is the real step.
This scalpel moves the life center without any errors.
"Guys, focus." Johannessen reminded.
The three of them all sat upright, concentrated, and began to watch the video of the surgical field under the microscope.
The entire conference room was silent, and you could almost hear the breathing of your neighbors.
"Anesthesiologist, I am going to incise the upper cervical spinal cord and medulla oblongata, start to separate the tumor, and pay close attention to vital signs."
"The defibrillator begins to prepare. Remember, once ventricular fibrillation occurs, the anesthesiologist will report immediately and the defibrillator must complete defibrillation within five seconds."
Yang Ping reminded everyone that the danger is not coming so soon, so it is very necessary to get them into the state in advance.
The laser knife begins to incise along the posterior median sulcus of the medulla oblongata, which is one of the safe zones of the medulla oblongata.
The knife line is straight, just like the line drawn by a ruler.
