After multiple blood transfusions, Lu Jiangbei’s hemoglobin has increased to 70 g/L and has not dropped again, indicating that the hemodynamics have been stable.
Next, preparations for Lu Jiangbei’s surgery began. The implant used to fix the headrest and upper cervical spine has been successfully printed by a 3D printer, and the details of the surgery have also been finalized.
But there is still an unresolved question - how to safely change positions during surgery.
Lu Jiangbei's surgery required combined front and back fixation. To complete the surgery, it naturally required a front and back approach. The front approach required a supine position, while the posterior approach required a prone position. Because there was no reliable fixation, there were many difficulties in switching between the two positions, and Lu Jiangbei had multiple rib fractures.
, pelvic fracture, which makes prone position impossible to implement.
Another preoperative discussion around this issue began.
August and Robert, who were temporarily borrowed from the trauma ICU, have returned to the organization. They are indispensable for Lu Jiangbei's ability to smoothly pass the waiting period for surgery.
An animation is playing on the high-definition screen in the general surgery conference room, simulating body changes during surgery.
For this operation, it is very dangerous to change from supine to prone during the operation.
Some surgeons who specialize in upper cervical spine have encountered this fatal problem. After completing posterior surgery, the patient died unexpectedly during the turning process. Therefore, many spine surgeons used to be afraid of turning over during upper cervical spine surgery.
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In order to avoid turning over, some experts boldly use the anterior transoral approach, that is, entering through the mouth, incising the posterior pharyngeal wall, exposing the upper cervical spine, and implementing firm anterior fixation.
Unfortunately, this patient not only suffered from traumatic atlanto-occipital joint dislocation, but also had a comminuted fracture of the atlas. The fracture fragments may invade the spinal canal at any time. A combined anterior-posterior approach must be used to completely remove the atlas, and then perform combined anterior-posterior fixation.<
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"I also lack experience in this area. In the past, I relied on turning over to solve cases that required joint front and back fixation. This case is really difficult." August shrugged habitually, saying that there was no good solution for the time being.
"Is it so difficult to turn over?" A graduate student who is not afraid of tigers as a newborn asked.
This graduate student participated in several discussions, and his mind was filled with doubts as to why everyone was so cautious about turning during surgery and why they had to discuss it specifically.
No one laughed at him because he was a student and being able to ask questions showed that he was thinking deeply.
"This case must use a combined anterior-posterior approach. If we follow the conventional surgical method, the first half of the operation is completed in the prone position, and the second half is completed in the supine position. This way, the crushed atlas can be removed and firmly fixed. When changing positions,
During the process, we cannot use braces for fixation, and conventional head immobilizers cannot provide firm fixation, so we cannot guarantee that there will be no accidents during the turning process. It is speculated that the probability of death during turning over during the operation is 50%.
We doctors are not gamblers, so we must solve this problem before surgery." Yang Ping patiently explained to the student.
If the graduate student realizes something, he nods and writes it down in his notebook.
"In fact, we can use improved bracket fixation and redesign the existing head fixator to extend the fixation point back to the cervical spine. In this way, the fixation pins of the bracket are distributed on the head and cervical spine, and the head is fixed using the skull.
The cervical spine is fixed with pedicles, and you can even find fixation points on the scapula and clavicle to create a strong fixed bracket. Of course, the bracket must be designed to leave ample space for surgical operations." Xu Zhiliang spoke very fluently. p>
Song Zimo nodded, agreeing with this idea, but there was an unavoidable hurdle: "Lu Jiangbei has multiple rib fractures and comminuted pelvic fractures, and there is an external fixator left on the front of the pelvis. This bracket must be retained during the operation. Do you think about it?
I thought, even if a special bracket can be used to fix the head and cervical spine, how can he achieve the prone position? Can the thorax be supported? The pelvic external fixator will not block the prone position?"
"What about side-lying position? Can the problem be solved by using side-lying position?" Zhang Lin boldly proposed.
Song Zimo shook his head: "Not only is it difficult to implement a transoral approach in the lateral decubitus position, but it is also difficult to operate the posterior approach. What's more, it is the same as the prone position because the rib fracture and the external pelvic fixator cannot be implemented."
I really have a headache. I didn’t expect that this surgery would get stuck in my posture.
August scratched his head, Robert remained silent, and the discussion reached a dead end. This won't work, and that won't work either.
"Can you do the surgery while sitting down?"
Yang Ping has been listening carefully to everyone's speeches and now starts to speak.
Everyone cast surprised glances---Where are you seated?
"Although the surgery is a bit difficult in the sitting position, it is at least possible. It perfectly avoids the trouble caused by rib fractures and pelvic fractures, and there is no need to turn over during the operation. If you use the sitting position, the area above the shoulders is exposed to the operating table, and the operating table is exposed from the outside.
Fixed with a retainer."
"Excellent surgical position!"
August admired that in his previous surgeries, even if the front and back were jointly fixed, they only used changing positions and never considered the sitting position.
"The advantages of this position are obvious. There is no need to change positions during the operation. Due to the effect of gravity, the blood and flushing fluid in the surgical area are easier to clear, and venous return and cerebrospinal fluid return are also easier."
Song Zimo had no reason not to support Yang Ping. Experience told him that everything Yang Ping proposed could be realized.
"There are also advantages in anesthesia. I can get closer to the patient's face better, assess whether the airway is safe, whether the tracheal intubation is always in place, better monitor the cranial nerves, and in case of cardiac arrest, compression is also convenient.
Cardiac arrest in the prone position can be a lot more difficult."
Fatty Liang feels that this position is indeed more beneficial for anesthesia.
August sighed: "Although the idea is good, the operation will become difficult, and many problems may occur during sitting surgery, such as abnormal venous air embolism, intraoperative hypotension, symptomatic pneumocephalus, and acute sclerosis.
Submembranous hematoma, peripheral nerve damage, laryngeal or tongue edema, and quadriplegia are aggravated. So many neurosurgeons hate this position."
But Yang Ping is confident: "Compared with the 50% uncontrollability during the turning process, the problems faced in this position are all controllable, such as intraoperative hypotension. Dr. Liang should have a way to avoid it."
Fatty Liang crossed his legs: "Intraoperative blood pressure control technology is my unique skill, don't worry."
"Venous air embolism, we operate gently during the operation and try not to damage the veins---" Yang Ping proposed solutions to every problem.
I did the surgery while sitting down!
For this case, from a theoretical analysis, sitting is indeed the best choice.
As a master of spine surgery, August has performed countless surgeries, but he has never used a sitting position to complete this kind of combined anterior-posterior surgery. He is looking forward to seeing how Yang Ping performs this kind of surgery.
"So this problem has been solved?" Yang Ping wanted to know if anyone still has any problems.
Song Zimo murmured in his heart. Everyone was discussing how to turn over and change positions, but Yang Ping wanted to do the surgery while sitting down. Dr. Song felt that he could never keep up with the rhythm and was always one step behind.
