Fifth Vital [EN]: Chapter 246

246. Water Balloon in the Mud

“Scalpel, please.”

Tae-kyung, receiving the scalpel, made a 1.5cm incision just below the navel.

“Tooth forceps (10cm forceps with hooks), please.”

As the two assistants pulled the incision apart with forceps, Tae-kyung used a Bovie [electrocautery tool] to carefully widen the opening. After penetrating about 2cm deep, he inserted his index finger to probe through the fat layer.

“Fascia visible, Cocha (scissor-like instrument with hook-shaped teeth for gripping) please.”

Tae-kyung firmly grasped the white fascia [a layer of connective tissue] with the instrument.

-Drrrk

“One more, please.”

He lifted the white membrane within the fat layer with the instrument and made a small incision with the scalpel.

“Okay, trocar, please.”

Next, he inserted a blunt-tipped trocar (a large screw-shaped instrument that allows other instruments to pass through the abdominal wall) into the incision. The connected CO2 filled the abdomen through the trocar.

He then created a total of four trocar sites (locations where the trocar is placed on the abdominal wall) using the same method, and the camera was inserted through the hole just below the navel.

Shuuk-

As the camera entered, the abdomen, filled with carbon dioxide, swelled like a balloon, providing a clear view of the widened abdominal cavity.

Below, the pinkish hue of flesh, the yellowish tint of fat, and the occasional light red blood vessels were chaotically intertwined.

Tae-kyung planned to remove the fat layer covering the small intestine first.

“Harmonic (an instrument that cuts tissue and blood vessels using fine vibrations of sound waves, simultaneously achieving hemostasis and cutting) please.”

The nurse handed Tae-kyung the Harmonic scalpel, a gun-shaped clamp about 60cm in diameter. As he inserted the instrument tip into the abdomen, the tip became visible on the monitor.

Tae-kyung lifted the mesenteric fat [fat surrounding the intestines] with a simple clamp in his left hand, revealing red, pulsating arteries between the fat layers.

He clamped the instrument to simultaneously achieve hemostasis [stopping blood flow] and cutting to prevent bleeding.

Dudududuk-

As he grabbed the fat with the 1cm tip of the Harmonic, a mechanical sound was heard, and a hazy smoke spread inside the abdomen. After cutting the fat layer, Tae-kyung pushed it to one side.

Afterward, the reddish stomach came into view.

“The star of the show is here.”

The stomach, extending from the end of the esophagus to the duodenum [the first part of the small intestine], was the main stage for today’s procedure. Aggressively large blood vessels were visible on the flesh-colored stomach.

“It always has so many blood vessels.”

“Indeed.”

The stomach is an organ with a high level of activity, so it has a high distribution of blood vessels. Moreover, each blood vessel is quite large.

“Sometimes, when I look at these blood vessels, I’m reminded of earthworms.”

Lee Chan-hee was right.

The appearance of those blood vessels was like wriggling red earthworms.

Today’s surgery involves cutting the stomach in half, so most of these blood vessels need to be ligated [tied off]. Of course, even these blood vessels are not the main risk today.

An artery is like a water supply pipe.

It starts at the heart and connects to each organ at the end. The stomach also has arteries connected from the heart.

The focus today is on catching several arteries that are slightly before the branching point, rather than the arteries directly connected to the stomach.

“Chan-hee, grab the grasper and lift the liver.”

“Yes, Doctor.”

At Tae-kyung’s words, Lee Chan-hee inserted the grasper (a gun-shaped tool with a long neck, similar to other laparoscopic tools, used to grab structures) into the abdominal cavity. The tip of the instrument was visible on the monitor.

He grabbed the gauze that had been placed in the abdomen with the 2cm clamp, rolled it up, and used the gauze to lift the liver.

As the liver was lifted, the complex vascular structures beneath, surrounded by fat, were revealed.

‘There are wires everywhere.’

The blood vessels around the stomach are similar to the complex wires on a utility pole.

They seemed to be extending arbitrarily, each with its own direction. At the same time, they were extremely dangerous.

It was like finding a small water balloon buried in the mud. However, the problem was that the tool for finding it was a very sharp pair of scissors.

Gulp-

Knowing the danger well, Lee Chan-hee swallowed hard and concentrated even more.

As Tae-kyung used a sharp tool to peel away the fat one by one, blood vessels that were throbbing around the stomach outlet became visible.

“Hemo-lock (a small plastic clamp, about 1cm or 5mm, that can hold blood vessels) 5mm, please.”

As the nurse fitted the hemo-lock onto the instrument, Tae-kyung pointed to one direction of the blood vessel.

“One more.”

He secured two locations on the connecting blood vessel with hemo-locks and then simultaneously performed hemostasis and cutting between them with the Harmonic.

To the average person, fat and blood vessels are not clearly distinguished.

It is almost impossible to tell where the blood vessel starts and where the fat ends.

“Lee Chan-hee?”

“Yes, Doctor.”

“What kind of blood vessel did I just grab?”

“Ah! Was that a blood vessel?”

“Of course, it’s a blood vessel.”

In this case, even a surgical resident would not be able to completely distinguish it. So, Lee Chan-hee didn’t even know it was a blood vessel until Tae-kyung stopped him.

In fact, it was partly because Tae-kyung was good at surgery, but also because his extensive experience allowed him to recognize the outline of the blood vessels without having to remove all the fat.

Even doctors from other departments might misunderstand that he was wasting the Harmonic on mere fat.

“So, what do you think it is?”

“Um… Isn’t it the right gastric artery (Rt. gastric artery)?”

“That’s right. The stomach has major arteries that supply it. You need to know their locations and names.”

“Yes, I understand.”

“Now, let’s lift the stomach a bit. Babcock (laparoscopic babcock, an instrument with a slightly larger clamp than a grasper that can be fixed after grabbing) in.”

Lee Chan-hee inserted the instrument and grabbed just above the border between the stomach and duodenum.

“Lift.”

“Yes.”

As Lee Chan-hee lifted the stomach, fat and blood vessels buried within it were visible, as before.

There were so many blood vessels throbbing that they were visible even to the average person.

Ligating these blood vessels was the same as before. However, the appropriate extent of ligation was entirely based on experience.

Whether to simply grab it with the Harmonic or to grab it more strongly with the hemo-lock and Harmonic was solely within Tae-kyung’s domain.

‘Harmonic would be better.’

Having made the decision, Tae-kyung quickly began to grab the blood vessels with the Harmonic.

“Hmm… This is the right gastroepiploic artery (Rt. gastroepiploic artery). It’s the artery that feeds the upper surface of the stomach. You can’t just grab this one with the Harmonic.”

“Yes, Doctor.”

“Hemo-lock 10mm, please.”

As the nurse prepared the hemo-lock, Tae-kyung pushed away the fat around the blood vessel to be grabbed with the instrument. He then carefully separated the surrounding fat to avoid damaging the blood vessel.

After some space was created, he clamped the top and bottom of the blood vessel with the hemo-lock.

“Harmonic, please.”

He additionally ligated between the two hemo-locks on the straight blood vessel with the Harmonic. Then, with a hazy smoke, one of the major blood vessels of the stomach was cut off without bleeding.

“Chan-hee, grab it again and lift the stomach all the way up.”

“Yes, Doctor.”

As soon as Tae-kyung finished speaking, Lee Chan-hee lifted the entire body of the stomach, revealing an organ that was whiter and had a more ambiguous boundary than the stomach underneath.

It was the pancreas.

“Bring in one more grasper. And press down on the pancreas below with it closed, without opening it.”

“Yes, I understand.”

The current surgery is to resect [remove] the stomach, leaving only the upper part. In other words, blood vessels must also be secured on the back of the stomach.

“……!”

Lee Chan-hee looked quite surprised as he pressed down on the pancreas below to secure this view.

“Why the expression?”

Tae-kyung asked the surprised Lee Chan-hee.

“It’s just that the pulsation of the abdominal aorta [the main artery in the abdomen] felt through the instrument is too vivid.”

It was true. Even though he wasn’t directly touching the aorta, the pulsation of the blood vessel transmitted through the instrument was tremendous.

“Of course. There’s an artery with a diameter of 1cm right under the pancreas, so you’ll naturally feel it. The stronger the pulsation, the harder you’re pressing, so don’t press too hard.”

“Ah… Yes, Doctor.”

“Chan-hee? If that bursts, you’re dead instantly.”

“Yes!? I, instantly?”

“Doctor, come on. It’s not like Doctor Lee is an idiot, and it’s not like it’s going to burst just because he’s pressing with a grasper.”

Ui-jin, who was checking Hamad’s condition while looking at the monitor, said with a smile.

“Hey. Right? You’re just teasing me, Doctor?”

Lee Chan-hee, who had been startled, also thought that Tae-kyung was teasing him after hearing Ui-jin’s words. However, both of them were even more surprised by Tae-kyung’s subsequent words.

“Why? Does it sound like a joke? It’s not.”

“It’s not?”

“There was a similar incident.”

“Really?!”

“Is that true?”

“Yeah. Where was it? I remember it being in a different region than here…”

Tae-kyung continued, looking at the laparoscopic monitor.

“Anyway, the abdominal aorta was damaged while pressing with an instrument.”

“So, what happened to the patient?”

“What do you mean what happened? They died instantly. The doctor quit medicine because of it.”

“This is real, right?”

“I’m telling you, it is.”

“Wow! That’s really scary.”

Lee Chan-hee’s expression seemed to have worsened after hearing Tae-kyung’s words.

“So, you always have to be careful.”

“Of course. I’ll always be careful.”

“Okay! That’s it. Stop the instrument.”

While the conversation was going on, Tae-kyung had secured all the blood vessels on the back of the stomach.

“GI (a thick clamp-shaped stapler used for intestinal anastomosis [surgical connection between two structures]), please.”

Tae-kyung grabbed the stomach outlet with a 10cm clamp-shaped stapler and activated the machine, and a mechanical sound was heard.

Drrrkdrrrk-

When the grabbed area was detached, the grabbed surface was resected. And numerous staples were attached to the cut surface of the stomach at regular intervals and strength.

“Chan-hee?”

“Yes, Doctor.”

“As I said before, when you do surgery later, you have to look closely at the area resected and grabbed with this stapler. Not just simply looking, but also checking for bleeding and what methods to use to stop it if there is any bleeding.”

“Yes.”

“In that sense, what should we do here?”

“Wouldn’t it be enough to cauterize the outlet with electricity?”

As always, Lee Chan-hee answered the sudden question, and Tae-kyung’s slightly displeased gaze flashed by.

“Speak like a doctor. ‘Cauterize’ is not an accurate term.”

“Yes, I will correct myself.”

As Lee Chan-hee said, electricity is applied to the surface with countless stapler pins, heating it.

“One more GI, please.”

The GI was handed to Tae-kyung, and this time he placed the instrument a little higher on the stomach body.

The upper part of Hamad’s stomach body, which is being operated on now, has a diameter of about 15cm. It would take about 3 GIs to cut that length.

After resecting the stomach through repeated operations, he places a hemo-lock on the last part of the stapler to prevent the contents from leaking.

If the contents leak from the stomach, it’s a major accident. That’s because the stomach produces stomach acid.

Of course, if the contents of the gastrointestinal tract leak into the abdominal cavity, it’s all a major accident, but stomach acid is highly acidic, so it causes even more pain.

The surgery has been going on for a long time, but it’s not over yet.

“Stomach and small intestine, etc., are not finished with stapling. You have to suture them two more times.”

“Yes, Doctor.”

“CR (tool for suturing laparoscopically), please.”