medical simulator

Page 489

"The ratio of the diameter of the popliteal artery to 1/3 of the tibia is about one-seventh to one-ninth, so let's say it's 0.14mm!"

"The minimum diameter of our commonly used syringes is 0.55mm. With such a diameter, it is actually impossible to perform vascular blockade." Zhou Cheng analyzed it, and then got such a painful result.

Luo Yun and the others looked at each other.

Well, they didn't consider this before, and it was indeed their mistake.Who would count these things?

However, it seemed that Zhou Cheng would do such a thing.

"but!"

"In fact, we now have a needle for injecting insulin with a diameter of only 0.18mm, which is just suitable for the current operation."

"When I came over, I just bought a box." Zhou Cheng twisted his buttocks, motioned to put it in his trouser pocket, and asked Luo Yun to help him take it out.

Luo Yun took a deep breath and said, "When did you buy it, why don't I know?"

You are too stupid, you don't even discuss such an important matter with me?

Zhou Cheng was a little aggrieved, it wasn't you who said it, should I show it a little bit, if I discussed it with you in advance, wouldn't I lose my authenticity, these people are not stupid.

"Ms. Luo, I bought it when I went down for breakfast this morning."

"Thank you for your hard work."

Luo Yun immediately took out the so-called needle like a tool man.This kind of needle actually requires a prescription before it can be purchased.

But insulin injections are routine supplies. Zhou Cheng also tried to find a way to reveal his identity as a doctor, saying that he bought it for his family members and wrote the doctor's order on the spot!

Everything is ready, after changing the needle.

Zhou Cheng's show operation started again: "According to the mouse model built in the past, to find the popliteal artery and popliteal artery of the mouse, our reference position is still the popliteal fossa, but the structure of the mouse is quite special..."

"We probably insert the needle from here, which happens to be the position of the deviated popliteal artery. If you feel it carefully, you can feel a little pulsation of the blood vessel."

"Oh, we need to paralyze this lower limb first before we get the needles in."

"So, let's anesthetize the femoral nerve of the mouse first!"

Before the mouse was paralyzed, the direction person went numb first: "Small, the mouse's femoral nerve is blocked and paralyzed? Shouldn't it be directly anesthetized?"

Who TM operated the mice and administered nerve block anesthesia?

When a patient undergoes an operation, there may not be an anesthesiologist who is willing to perform this kind of anesthesia...

However, Zhou Cheng came here today to show the operation, and there is no psychological pressure or guilt to show the operation on the mouse. The most I can say is thank you, Teacher Mouse.

"After local anesthesia, the local capillaries will be punctured, and the blood vessels will be relatively constricted to stop bleeding, which will affect our operation."

"Nerve blocks, starting at the femur, would be more appropriate."

Chu Hanbo and Han Xiaoming were relatively calm, watching Zhou Cheng's performance slowly.

After Zhou Cheng finished the nerve block, one leg of the mouse was immediately paralyzed.

Zhou Cheng said again: "Now, the muscles of the mouse have been relaxed, but the driving force of the blood vessel beating comes from the heart, so the fluctuation of the blood vessel is more clear. You can feel it."

Fang Xiang immediately stretched out his hand suspiciously.

Zhou Cheng slapped the direction's hand, "Disinfect with alcohol!"

Fang Fang immediately retracted his hands with a little grievance, and Han Xiaoming and Chu Hanbo, the corners of their mouths under the masks twitched slightly, looked at Luo Yun complicatedly, and disinfected them in a proper manner.

After searching, it was indeed as Zhou Cheng said, the pulsation was quite strong, and it was actually not difficult to find.

This kind of blood vessel pulsation is a basic skill, and it is the kind of trick that is only used for interns and trainees to experience clinical practice. Zhou Cheng actually used this trick on them. Didn't he mean that he and others can only experience it.

Can't help with anything else?

But hold back!

Zhou Cheng then, no longer forced to escape, but looked very nervous and serious: "The tumor in the middle of the tibia mainly comes from two sources of blood."

"Periosteal Arteries and Nutrient Arteries."

"The lateral periosteum, composed of the anterior tibial artery, the anterior recurrent tibial artery, and the periosteal branches, myoperiosteal branches, and perforating branches of the posterior tibial artery, surrounds the bone surface, and consists of anterior external branches, descending branches, and adjacent arteries. The periosteal artery network and anterior chain. The medial periosteum is composed of anterior tibial artery, anterior recurrent tibial artery, medial inferior genicular artery, and posterior tibial artery. The transverse medial ascending and descending branches are interconnected with the side branches of the descending branch of the tibial nutrient artery to form a periosteal artery network. and medial edge longitudinal chain."

"It's not easy for us to directly judge where the blood vessel origin of the middle bone tumor is, so we start to block from the access end of the tumor nutrient artery..."

"Look everyone..."

Chu Hanbo really hates this sentence, what can I do if I don’t read it?

I thought in my heart, but my body stood on tiptoe honestly. In the end, I happened to actually see that Zhou Cheng blocked it, and it seemed that there was a middle part of the arterial blood flow, which caused the skin of the mouse to bulge.

However, this does not prove that the tumor in the middle of the tibia was just killed.

After completing the operation, Zhou Cheng continued: "This is the entrance to nourish the arterial network. In order to avoid other situations such as arterial backflow, we also blocked the exit. Without the supply of nutrients, we did not have time to establish collateral circulation. forward."

"The life time of osteosarcoma cells is actually quite limited." Zhou Cheng said, and he did not know where to insert the needle and completed the blocking operation.

Seeing everyone's confused eyes.

Then he said: "Oh, the artery I blocked just now is..."

Luo Yun was annoyed by Zhou Cheng's ordinary attitude, so he patted him on the shoulder: "Be normal, talk about the key points, and stop pretending!"

Chapter 2 Ninety Doing a Big Thing

In fact, at this time, Zhou Cheng can argue with Luo Yun and be a little more high-profile, didn't you confess?Stand up again?

But Zhou Cheng's purpose today is not simply to pretend to be aggressive, but has many other intentions.

Therefore, Zhou Cheng explained the relevant theories in detail, omitting some anatomical knowledge that has not been published yet, and explained them one by one.

This explanation is based on the basics, goes beyond the basics, and is easy to understand without any nonsense, but it is very profound.

Purely academic, in fact, does not have much meaning, on the contrary, whether it is listening or thinking, you need to concentrate on it.

It sounds not simple, but it is even more complicated to operate.

Fortunately, Luo Yun and the others are good students with excellent research qualities, so even though they had a lot of doubts during the listening process, they did not interrupt Zhou Cheng's explanation immediately.

Seeing that Zhou Cheng finished speaking, Chu Hanbo asked a question, "Zhou Cheng, even if you successfully block the soft tissue vascular pedicle approach and outlet of the osteosarcoma in the middle tibia!"

"But you should also know that your current operation is not universal and scalable."

"Operations that are not repeatable and scalable are not of much value. Applying what you have learned is the right way. How do you solve this problem?"

Chu Hanbo raised this question very well. He assumed that all of Zhou Cheng's operations were correct. To a certain extent, they could meet expectations, but there was a very critical problem.

Can other people do this kind of operation?

For now, with such a high level of difficulty, in theory, it is very difficult for ordinary people to clarify the relationship.

The more subtle, the smaller the operation, the more difficult it is, and a little carelessness may lead to uncontrollable accidents!

Moreover, the curative effect of this kind of operation cannot be evaluated for the time being.

Chu Hanbo was not unconvinced, he was really thinking and looking for a solution to the problem, Zhou Cheng said: "Indeed, Brother Chu's consideration is very reasonable, and it is also one of the biggest obstacles at the moment."

"However, compared with the uncontrollability of tumors, as long as such a more objective problem is solved, I think it is relatively simple."

Zhou Cheng continued: "Brother Chu, can I not answer this question of operability and repeatability? Let me talk about the follow-up treatment ideas. Let's think about the treatment ideas for tumors first, and then clarify the operation. Is it a promotional question?"

Zhou Cheng's words seemed to be asking, but in fact, he was in a dominant position to make a decision.

Although there are many problems, if we have to sort them out one by one, we will only mess up people's thinking even more.

When there are many things, it is a very scientific and effective way to divide the problems into levels and steps.

Chu Hanbo expressed his approval, nodded and said: "I was too anxious, everyone ignore my question just now, Zhou Cheng, you continue."

Zhou Cheng nodded, and continued: "I must have reviewed my review ideas by several teachers."

"Blocking the blood source and outlet of the tumor is actually only the first step. This can ensure the source of nutrition for tumor cells."

"But in fact, we all know that the composition of tumors is divided into range composition and individual composition."

"The scope composition is the tumor tissue. This part of the tissue has abundant blood vessels, which is the most basic source of energy for osteosarcoma cells."

"However, for an individual, osteosarcoma, including any tumor, exists in the form of cells and is actually spreading!"

"The detachment, entry into blood vessels, and invasion of tumor cells are an important reason for tumor growth, spread, and distant metastasis. Teachers, do you think this statement makes sense?"

Zhou Chengwei didn't say a word, let alone say it to death.

There are some things that he knows, others may not know, but the way of thinking, if you draw out the corresponding way of thinking, with the attainments of Chu Hanbo and others, it will not be incomprehensible.

Luo Yun nodded first: "There are such speculations at present, you continue."

Zhou Cheng organized his language a little bit, and said: "The remaining vascular network of the tumor does not rule out the undetectable collateral circulation of other capillary network."

"This kind of capillary is generally not detected even by inspection. Therefore, in this case, one more operation we need to do is to remove the vascular network between the entrance and exit of the vascular network that we have just blocked. , block it again, lest the blood inside flow again."

"The obstructions at the entrance and exit that we just blocked just now become two stoppers. In this way, even if there are other undetectable blood circulation networks, blood circulation can be avoided."

When Luo Yun heard this, his eyes flickered for a moment.

Zhou Cheng's backhand directly cut off all the back routes of the tumor's vascular network, basically completely blocking all the blood circulation in the tumor's general tissue.

He still had doubts before, Zhou Cheng just blocked the entrance and exit of the vascular pedicle, so how can he judge that there are only these two entrances and exits?

In fact, Zhou Cheng just blocked the entrances and exits of the two relatively large main limb arteries.And it will also block all the nutrient blood vessels of the tumor!

While talking, Zhou Cheng continued to operate, turned the syringe in one direction slightly, and then said: "The diameter of our needle is only 0.18mm. In actual operation, we can use multiple blocking channels."

"But now, because we are not prepared enough, I will use this syringe again, return to the access area, cross the stagnation point just entered, puncture and go deeper."

"There won't be a lot of permeable blood with a diameter of 0.18mm. Moreover, once we block all the pathways inside the vascular network, even if all the pathways are opened, the blood will not flow again. We It can be blocked more proximally, segmented, or ignored."

As Zhou Cheng said, he poked the syringe and needle into the posterior tibial artery again as if he had returned to his own home.

This operation is very psychedelic, but it looks very compelling, without hesitation, fast and ruthless.

Although it cannot be copied, it looks really pleasing to the eye!

After Zhou Cheng finished the operation and injected a certain amount of blocker, he still didn't pull out the syringe.

Instead, he said: "Ms. Luo, now, I have almost completely blocked the tumor body and the surrounding blood vessel network. The blood inside may not be completely filled with the blockage, but it is not harmful!"

"And as I just said, tumors have two parts: localized and individualized. We can cut off the nutrient source through the vascular network, which can only be most of the tumor tissue. This step is taken from the bone tumor treatment. Complete resection and debridement."

"However, outside of the vascular network and most of the tumor tissue, there must be free tumor cells."

"We not only blocked the vascular network of bone tumor cells, but also blocked the vascular network of surrounding normal tissues. Therefore, bone resorption will inevitably occur after surgery, forming a cavity."

"According to the debridement concept of our orthopedics department and trauma surgery, if there is a cavity left after the trauma, the possibility of bacteria remaining is almost as high as 90.00%, so we still need to find a way to seal the cavity."

"In trauma surgery, the way we close the cavity is to fill it with bone grafting or copper sulfate, bone cement, etc. However, we can't solve this kind of osteosarcoma surgery in a similar way."

"We can still replace the traditional open surgery with bone grafting, but we still have other methods, that is, in the later stage, or after bone resorption is discovered, we can inject bone formation-promoting factors!"

"At this time, although bone resorption has already occurred, the speed of resorption must not be so fast, and there is still a skeleton. If bone cells can be refilled, it can still be restored to its original state. It just so happens that our bone repair ability is extremely strong, almost as long as the bone is restored. With the blood supply, it can reach a theoretically complete repair state."

"The concentration rearrangement of osteoclasts and osteoblasts will have the effect of rebuilding bone tissue!" Zhou Cheng analyzed one by one, quoting from side to side.

Whether it is traditional tumor treatment or trauma surgery knowledge, you can use it, and there are no laymen present. Therefore, although this paragraph sounds long, in fact, everyone understands it very quickly!

Han Xiaoming sighed and said: "Xiao Zhou's clinical experience is actually stronger than ours. We just wander around in the laboratory a lot. We really never thought that after tumor cells and normal bone cells atrophy, die and lyse, the remaining The problem of reusable skeletons."

"This is indeed a very genius and novel idea, and its operability is much higher than the previous one that blocked blood vessels."

Fang Xiang also understood, but he glanced at everyone and found that no one continued to ask questions, so he slowly said: "Brother Cheng, you also said just now that tumors are divided into localized and individualized, and what you are targeting now is It’s just a range of tumor tissue, so scattered tumor cells?”

"How do you plan to deal with it? Or rely on the traditional one, chemotherapy?"

Zhou Cheng nodded: "The existing tumor treatment plan also has its uses, and it is impossible to completely abandon it, but if it is only to kill the remaining tumor cells after the operation, the amount of chemotherapy drugs required will not be too much. "

"Of course, that's just one of those options."

"There is another characteristic, which is to make good use of the survival characteristics of tumor cells. We should find that when fibroblasts form clusters, some fibroblasts will be transformed into nutrients for other fibroblasts."

"In other words, when there are a large number of fibroblasts, dying or needing a lot of energy, some of the fibroblasts will be sacrificed."

"Tumor cells also have such autophagic lysis properties. The reason why they choose to cut off the blood supply of tumor cells is also because of this."

"It can make most tumor cells kill some of their companions when they are dying, even if they still cannot escape the fate of death in the end."

"Of course, appropriate chemotherapy assistance is still required. However, at this time, the amount of chemotherapy drugs can be minimized."

"The above is the theory of the effectiveness of treatment!" Zhou Cheng summed up slowly, finishing with the first point.

He had said these words to Zeng Lao, Gui Lao and others, but at that time it was a defense and could not be practiced. Therefore, the sound was far less powerful than seeing it with his own eyes. Maybe it didn't convince them anything.

After Zhou Cheng finished speaking, Han Xiaoming applauded first.