Fifth Vital [EN]: Chapter 202

“Doctor, the CT results are in.”

Tae-kyung’s eyes snapped to the monitor.

The homeless man, waiting anxiously nearby, was understandably nervous.

‘Ah…….’

Contrary to the homeless man’s desperate hopes, the CT scan confirmed their suspicions. The contrast agent was leaking into the abdominal cavity from the repaired blood vessel leading to the liver.

“Excuse me, could you come over here? I’d like to explain the CT scan to you.”

“Yes, doctor, what does it show?”

“This surgery……”

“Yes!? Surgery?” The homeless man’s face lit up at the word ‘surgery’.

Before Tae-kyung could explain, the homeless man exclaimed in excitement.

“Yes, actually, in most cases like this, we perform a procedure through the blood vessels rather than surgery, called interventional radiology [a minimally invasive procedure using catheters and imaging guidance to treat various conditions].”

“Through the blood vessels? I think I heard about that at the previous hospital. So, I’m getting that interventional thing, right?”

“But right now, interventional radiology isn’t an option.”

“Yes? No. Why? Don’t tell me you’re going to cut me open again with that laparotomy thing [surgical procedure involving a large incision through the abdominal wall]?”

“The situation is urgent, so we need to perform a laparotomy……”

“Ugh! Doctor, I can’t do that. I can’t have a laparotomy.”

The homeless man strongly opposed the idea, his face etched with worry.

“Do you know how painful that is?”

“You’re absolutely right. A laparotomy is very painful, and it hasn’t been long since your last surgery healed, so it must be hard to open your abdomen again.”

“No, regardless of refusal or anything, I can’t do it. Just do that interventional thing.”

“We don’t have the equipment for that here right now. If you still want interventional radiology, you’ll have to transfer to another hospital. But you need to know something.”

“What is it?”

“With this much bleeding, time is running out. We need to get you into the operating room right now and stop the bleed.”

“Patient, the doctor is right. Do you think we would have been running around looking for you for no reason?”

Lee Chan-hee, standing beside him, tried to reason with the stubborn man.

“Ha! I’m going crazy. Put yourself in my shoes, Director. They opened my stomach at that big hospital because they said I had cancer, but it was normal, and now a blood vessel burst because of that, and you want to open it again? Does that make sense? Huh?”

The homeless man was clearly angry at the hospital where he’d had the first surgery, venting his frustration.

“I understand how you feel, but if we leave this blood vessel alone, you’ll die. I’ve said it several times already, but you might not make it through tonight. Look at this image here.”

Tae-kyung pointed to the monitor.

“See this part? There’s blood filling up inside your abdomen right now. We don’t have time for this.”

“That……”

Looking at Tae-kyung’s serious and earnest expression, the homeless man paused, then announced his decision.

“Alright. I’ll do it. Do the surgery.”

“Really? Ah, that’s a good decision.”

Lee Chan-hee was genuinely relieved. But before his relief could fully register, the patient added a condition.

“But, do it with a laparoscope! Do it laparoscopically [surgical procedure performed through small incisions using a camera and specialized instruments].”

His firm words stunned everyone.

“Seriously! Aren’t you being unreasonable?”

Lee Chan-hee, losing patience, raised his voice.

“Do you think we’re doing this for our own benefit? We’re trying to save you. What laparoscope? You had a laparotomy not long ago, so your abdomen is already stuck together, and you can’t even see anything.”

Lee Chan-hee’s anger stemmed from this very point.

The reason he brought up the laparotomy was because the homeless man was currently unsuitable for laparoscopic surgery. Yet, he stubbornly insisted on it.

“And if the blood vessel ligation [surgical procedure of closing off a blood vessel] doesn’t work well with the laparoscope, then you’ll really die. A laparotomy is safer. You don’t know anything……”

“No, why are you yelling! Have you young doctors ever had a laparotomy? Do you know how hard that is? And tying off one blood vessel is nothing. If you’re a doctor, shouldn’t you be able to do that much?”

“Nothing, you say? Do you think tying off a blood vessel is like folding paper? How can you say that now……. Hey!”

Lee Chan-hee, seeing this as more than just stubbornness, was about to explode when Tae-kyung placed a hand on his junior’s shoulder, calming him down.

Then, with a calm expression and a warm smile, he said.

“If we do it laparoscopically, you’ll have the surgery, right?”

“Yes? Yes……”

“Okay, then let’s do it laparoscopically. Let’s start the surgery right away.”

“Really?”

“Really.”

“Oh……. Then I’ll have the surgery.”

“Alright! Let’s quickly prepare for surgery.”

“Doctor. That homeless patient must have been drinking and eating until just a little while ago.”

Lee Chan-hee approached Tae-kyung, who was moving busily.

“That’s true, but we don’t have time to waste. Let’s insert an L-tube [a type of nasogastric tube used for feeding or administering drugs] to remove all the food and then do the surgery.”

“But is it really possible with a laparoscope?”

“We have to try. What else can we do?”

Tae-kyung replied, looking at Lee Chan-hee’s worried expression.

“Don’t worry too much.”

“But……. Isn’t that patient too headstrong and stubborn?”

“That’s true, but it’s still the patient’s body. The patient naturally has the right to choose. Even if it’s frustrating, we shouldn’t forget that point.”

“Yes……”

“Let’s hurry and prepare before the patient changes their mind. Hurry!”

“Yes, I understand.”

After that, preparations for operating on the homeless man proceeded quickly.

After completing the surgical preparations, the patient, who had entered the operating room, had his stomach emptied of food, and then underwent thorough general anesthesia under the direction of Doctor Eui-jin.

“Anesthesia is complete.”

“Good work. Thank you, Doctor Jung. Please take good care of him until the surgery is over.”

“Of course. Don’t worry.”

“Alright! Let’s start the surgery. Scalpel, please.”

As the nurse handed the scalpel to Tae-kyung, Lee Chan-hee flattened the area below the navel.

Then, Tae-kyung, holding the scalpel, made a shallow incision of about 1.5cm.

“Tooth forceps [forceps with teeth at the end used to grab skin] and Bovie [electrocautery device used to cut and coagulate tissue], please.”

As Tae-kyung pulled one side of the incision with the instrument, Lee Chan-hee pulled the opposite side to expose the inside, then used the electrocautery device to deepen the incision.

The smell of burning skin filled the operating room. After digging down a little, Tae-kyung carefully looked inside.

“Senn [Senn-Müller retractor, a surgical instrument used to retract tissue] please.”

“Yes, Doctor.”

Tae-kyung received the instrument and inserted it into the deepened incision, spreading it to both sides. As he pulled, spreading the fat layer, white fascia [a layer of connective tissue that surrounds muscles] became visible.

“Kocher [a scissor-shaped surgical instrument with a toothed clamp] please.”

As he grabbed and pulled the fascia layer with the Kocher, the nurse handed him another Kocher. After grabbing and pulling with two Kochers, he made a very thin scratch on the fascia with an electrocautery device.

“Doctor Lee?”

“Yes, Doctor.”

“You’re going to be the surgeon later, too.”

“Yes.”

“You have to be careful here. If you do it, it becomes a habit, and it’s just a sequence of doing it quickly.”

“You’re talking about when inserting the trocar [a surgical instrument used to create an opening into the body] right?”

“That’s right. It’s dangerous when inserting it and when making a hole in the abdominal wall like now to allow the trocar to enter easily. Especially with the patient above. Do you know why?”

“It’s because I’m afraid of damaging the intestines.”

“That’s right. If you open it like this, immediately……”

Tae-kyung made a hole in the slightly scratched area with a blunt instrument, and a yellow layer was visible.

“It’s all stuck together?”

Lee Chan-hee replied after seeing the sight.

“Yes. I knew it would be like this. The mesentery [a fold of the peritoneum that attaches the stomach, small intestine, pancreas, spleen, and other organs to the posterior wall of the abdomen] is all stuck to the abdominal wall because the abdomen was opened wide once before.”

“Doctor, then isn’t surgery with a laparoscope impossible?”

“That’s not true. It’s possible.”

“Yes? No, how is it possible when it’s so rough that the trocar can’t enter……”

Tae-kyung, leaving the puzzled Lee Chan-hee behind, took the scalpel again and made an incision on the patient’s right side, below the ribs, about 10cm long.

‘Ah! That’s how you do it. As expected…….’

Lee Chan-hee nodded to himself, understanding how it was possible.

“Let’s go in here.”

“I understand.”

“And let’s make one more hole on this side and remove the mesentery with two holes first. Quickly! There’s no time.”

“Yes.”

Tae-kyung quickly made a hole in the same order as before and made a hole in his side with a trocar that was somewhat blunt.

“Turn on the CO2.”

As CO2 entered the patient’s abdomen, it gradually swelled.

“Let’s put in the scope [a medical camera that shows the inside of the abdomen].”

“Scope is entering.”

As Lee Chan-hee entered using the scope from the side, the mesentery, mostly yellow fat, was stuck to the front abdominal wall.

“Ultrasonic scalpel [a surgical instrument that uses ultrasonic vibrations to cut and coagulate tissue] please.”

“Doctor, but there are only two holes, so if you take out the camera, there’s only one hole left. Is it possible?”

“It’s just a stunt. It won’t be easy because it’s been a while, but I can do it.”

“Yes? Have you ever done it before?”

“I’ve done it. When I was at Shinhwa University, I don’t know why there were so many VVIPs [very very important people]. Because their demands were so great, I had to do everything laparoscopically, whether their stomachs were stuck together or not, and I had to make as few holes as possible.”

“Ah……”

“This ultrasonic scalpel cuts blood vessels and tissues with the vibration energy of sound waves, so there is almost no damage to the surrounding area. That’s why this is possible.”

Tae-kyung grabbed the handle of the ultrasonic scalpel and removed the tissue by releasing the end of the instrument when it was about to meet completely.

When the instrument is completely in contact, energy is applied and the tissue is cut.

To put it simply, it’s like moving things that are easy to cut with very sharp scissors, and then cutting them when there’s a place to cut.

“This is possible.”

Lee Chan-hee admired, unable to take his eyes off Tae-kyung’s hand movements.

“But it’s a dangerous method that shouldn’t be done, and you shouldn’t move tissues with this instrument. Don’t do it even if you’re confident.”

“Yes……”

After that, Tae-kyung’s quick stunt continued for about 20 minutes, and all the mesentery attached to the abdominal wall was separated.

“Put the scope back into the navel and I’ll go in from this side. Show me the screen well.”

“Yes, Doctor.”

When the mesentery hanging like a curtain in front of the intestine was lifted, blood was pooling up inside.

Shuk-

Tae-kyung quickly put down the instrument and inserted one that could do both suction and electrocautery. As he sucked in the bright red blood, a throbbing blood vessel was visible. And right next to it, blood was gushing out as if it were leaking.

“Wow! That’s amazing.”

“Fortunately, it hasn’t burst completely. Um……. Hemolock [a V-shaped plastic clip used to ligate blood vessels], please.”

“Are you going to clamp it with a hemolock?”

“I have to clamp it.”

Tae-kyung, who received the hemolock, carefully inserted it between the blood vessels, neatly grabbing the swollen area of the arterial blood where the bleeding occurred.

“That’s a relief. Now……”

“No, not yet.”

“Yes?”

“I’m not done ligating. I’m going to do a tie too.”

“Are you talking about tying arterial blood with a laparoscope?”

Lee Chan-hee asked, surprised.

“I have to. I can’t trust just that.”

The area being operated on now was the space between the liver and the stomach, where blood vessels were packed tightly, and tremendous bleeding could occur with even the slightest mistake.

Therefore, he carefully grabbed the needle and thread with an instrument and put it into the abdomen.

At the end of the long instrument, about 60cm long, was a sharp needle, and Tae-kyung pierced a very weak artery with the needle between the arterial blood, which was like a bomb.

“……Ah, it’s done.”

Unlike Tae-kyung, who was frighteningly calm, Lee Chan-hee, who was watching, was more nervous and focused.

After piercing the bleeding blood vessel, Tae-kyung grabbed the needle, tore it off, and took it out.

“You have to be careful here too.”

After piercing the needle, you have to tie a knot, and the knot has to fit perfectly around the blood vessel. If you pull it too much, the pierced blood vessel can tear.

It’s similar to piercing a thread through wheat flour noodles and tying a knot. This work is done with the end of a long instrument. It was literally like a dangerous acrobatics.

“Two ties are enough. Whew! It’s done. Scissors, please.”

Tae-kyung tied the knot, cut the long thread, and took it out.

“Let’s close it. I’m nervous after a long time.”

“You were nervous?”

Lee Chan-hee asked, surprised, Tae-kyung, who had finished the dangerous work with a focused look as always.

“I get nervous in these cases too.”

“I can’t tell at all? My gloves are full of sweat.”

“Why so much sweat? We can just open it if something goes wrong.”

“Yes?”

“Of course, the right is with the patient, but I can’t just let them die no matter what. If I get sued later or get grabbed by the collar, I have to open it if their life is in danger.”

“……!”

“You have to prioritize values. We doctors always have to do that. And the highest of those values is life. Of course, it’s even better if we can protect other things like now.”

“Yes, Doctor. I understand.”

“Okay, let’s close it up.”

Since it’s a laparoscope, you only need to close the three holes from the muscle membrane. The finishing touches were quickly completed, and the homeless man’s surgery was also completed.

“It’s over.”

“Thank you for your hard work.”

“Everyone worked hard.”

Zhiing-

Tae-kyung stretched as he left the operating room.

“What an unforgettable night.”

It was dawn, and he felt more tired than usual, perhaps because he had been running like crazy for the first time in a long time. Still, his heart was full of pride in the fact that he had saved the homeless man.