Chapter 216

Episode 216 Crazy Guy (5)

A heart that had completely stopped.

The giant aorta, from which all blood had been drained into the heart-lung machine.

Professor Kwang-ho Ju extended his hand.

"Give me an 11."

"Here is the number 11."

The scrub nurse placed a sharp No. 11 scalpel into his hand.

Without a moment's hesitation, Ju Kwang-ho raised the tip of the scalpel and plunged it vertically, right into the most swollen area on the front of the ascending aorta.

Pook.

With a dull thud, as if piercing through tough rubber, a small incision window was breached.

Since the pump was running and all the blood had been drained, blood did not spurt out, but the chilling interior of the aorta was momentarily glimpsed through the gap.

"Give me the Potts."

"Yep."

The Potts scissors, specially angled for vascular surgery, were now held in Professor Ju's hand.

Ju Kwang-ho carefully slid one blade of the scissors into the narrow incision he had opened with the No. 11 scalpel.

Then, making a scraping sound, he started to rip open the ascending aorta long ways, top to bottom.

Jjeo-eok—

Finally, the interior of the giant pipe was completely secured within the field of vision.

The moment the core of the time bomb that threatened the patient's life was checked with the naked eye.

"Huh?"

Examining the incision surface, Ju Kwang-ho's brow furrowed deeply.

The fellow, who was standing as the first assist across the operating table and securing the field of vision, also opened his two eyes wide as if he could not believe it, and made a dumbfounded sound.

In a normal case.

That is, if it had been an aortic intramural hematoma according to the initial diagnosis, or if it had been a dissection?

The moment the blood vessel was sliced open with a scalpel, a blackish-red hematoma should have poured out, or a torn intimal tear should have been observed first.

However.

"There is no... hematoma."

Just as the fellow's dazed muttering implied, inside the aorta of this patient, neither an intimal tear nor a single drop of pooled hematoma could be found, no matter how hard one looked.

The aortic wall was not separated into multiple layers; instead, the thickness of the entire wall was uniformly thickened, as if it were abnormally, bloat-swollen.

The inner lining was turned red and ulcer-ridden due to severe inflammation, reminiscent of a festering wound.

Anyone could see it was not physical damage burst by blood pressure.

"If so... it's aortitis."

Professor Kwang-ho Ju said in a low voice, tapping the swollen incision surface with forceps.

"Professor Ju. If so, now the diagnosis is..."

When Jae-sang Jeong asked cautiously, Ju Kwang-ho let out a short sigh behind his mask.

"It's confirmed. The resident on dispatch was right."

Ju Kwang-ho turned his gaze back to the surgical site and continued matter-of-factly.

"The blood vessel wall is completely decayed. Rupture is imminent. Even if it's GCA, if the blood vessels are in this state, the operating room should have been opened immediately anyway. Thanks to the dispatch teacher, we also prevented a major accident where we uselessly tried to insert a cannula into the ascending aorta and burst it, and we saved both time and approach."

At his cool acknowledgment, I clenched my fist tightly inside.

"The original over-and-over suture plan is completely scrapped. Because the tissue is weak, it will all tear. For now, a coronary probe, please."

"Ah, yes, Professor."

Ju Kwang-ho took the slender metal probe and leaned down toward the deepest part of the aorta, the aortic root that is in contact with the heart.

"Aortic root and... Coronary ostia."

Ju Kwang-ho was seen examining something minutely through a loupe equipped with a magnifying glass, poking the probe into two very small holes alternately.

'What is that.'

Those holes located at the root of the aorta.

I know that if that place is blocked, blood does not go to the heart muscle, resulting in a myocardial infarction, but why is he poking around there now?

Is he checking if the inflammation has spread that far?

'I should ask the guys on the gallery later.'

I stood on my tiptoes and filled my eyes with that delicate technique.

Relief was buried in the voice of Professor Kwang-ho Ju as he pulled out the probe.

"Fortunately, in this patient's case, the inflammation only rode up into the upper aortic arch; the coronary ostium itself on the heart side is intact. The entrance didn't narrow, nor was it eaten away by inflammation. We don't have to do a Bentall procedure."

Bentall procedure.

An ultra-high-difficulty surgery where the aortic valve and the ascending aorta are replaced entirely, and the coronary arteries are re-attached.

If even those holes had melted away from inflammation, the surgery would have grown out of control, and the patient's survival rate would have hit the floor.

"Let's cut out the pipe."

Leaving those words, Ju Kwang-ho started ruthless yet precise scissor work.

Seogok—

The ascending aorta, severely damaged by inflammation and turned like red tree bark.

Professor Ju cleanly cut away the decayed blood vessel in a wide cylindrical shape, starting from right above the heart valve up to the origin of the aortic arch going toward the head, removing it refreshingly.

An unrealistic scene where the giant bridge that connected the heart and the whole body inside the patient's chest opened up wide and disappeared.

Ju Kwang-ho put down the bloody scissors on the operating table and glanced at the white, wrinkled artificial blood vessel and thick pieces of Teflon felt that the scrub nurse had tailored in advance.

"Gradually, we should suture."

If it had been a general aortic intramural hematoma or aortic dissection surgery, the surgical technique would have been much simpler.

Because it would have finished by just moderately trimming only the torn or blood-pooled intimal flap with scissors, and simply suturing by backing a piece of Teflon felt on the end part that meets the artificial blood vessel.

But what lay before Professor Kwang-ho Ju's eyes right now was not a blood vessel torn by hypertension, but the worst blood vessel tissue, all decayed and mushy due to inflammation.

It is impossible to just moderately trim the intimal flap and suture it with a single piece of felt like a normal IMH surgery.

Because it was clear that the moment the needle went in, unable to withstand the tension of pulling the thread, the entire blood vessel wall would crumble and burst like tofu collapsing.

The work Professor Kwang-ho Ju is trying to do now is a kind of architectural foundation work.

An artificial and robust foundation to firmly connect the fragile, inflammatory aortic tissue with the artificial blood vessel.

That is, he is trying to make a stump.

"Teflon felt and polyester strip."

As Ju Kwang-ho's instruction fell, the scrub nurse passed the white cloth pieces tailored in advance to an appropriate length and width.

Ju Kwang-ho held the forceps and very carefully lifted the mushy aortic cut surface with the sharp tip.

Then, to completely wrap the outer circumference of the remaining aortic section, he firmly backed an external strip, and on the inner circumference where the blood flow directly touches, he settled a thin internal strip in the exact position.

It was an advanced technique of wrapping the blood vessel wall from inside and outside like a sandwich, applying a splint to support the collapsing tissue.

On the surgical field where even a minute tremor of a finger was not allowed, his movement handling the rotting blood vessel looked incredibly proficient.

It was the overwhelming experience of a full-time professor of the aorta department, built up while fighting dozens and thousands of major hemorrhages.

"4-0 Prolene. The one with the double-ended needle. Nam-seok."

"Yes, Professor."

The fellow, who seemed to have the name Nam-seok, standing in the first assist position across and securing the field of vision, answered with a voice tight with military discipline.

"Look closely. Over-and-over sutures cannot distribute pressure. Because a thin thread takes all that tension and digs into inflammatory tissue like tofu, it is scrapped. Pressure must absolutely be distributed across an area so it doesn't burst."

Ju Kwang-ho briefly explained the core mechanism of the surgery and started piercing the needle in.

He appeared to carry out that suffocating process closely at regular intervals along the entire 360-degree circumference of the anastomosis without a single error.

Every time the thread was pulled, the white felt tightly bit the blood vessel wall, perfectly distributing the destructive force applied to the needle hole.

'This is... the department of surgery.'

I captured that process in my eyes without even making a breathing sound on top of the footstool.

Even in emergency medicine, opening a patient's chest happens occasionally.

But that was nothing more than an emergency thoracotomy where one breaks ribs to save a patient right before cardiac arrest, mindlessly blocking a bleeding aorta with clamps, or massaging the heart with bare hands.

To my eyes, which could only encounter about an emergency thoracotomy even if the chest was opened, all of this—newly creating a broken part of the human body with errorless sewing—looked so wondrous and cool.

'Internalizing the surgeon's mindset and thought process......'

The advice I heard from the medical center director while drinking chocolate milk on the bench in front of the hospital hovered around my ears.

"Give me the Metzenbaum."

"Yes, Professor."

After dozens of stitches of horizontal mattress sutures were completed, Ju Kwang-ho accepted the rounded scissors.

With the tip of the scissors, Ju Kwang-ho trimmed the extra white felt protruding upward and the red, inflammatory aortic tissue remaining jaggedly, very smoothly and sleekly.

Seogok.

Seogok.

The messy edge of the aorta became neat.

The most dangerous and precarious foundation work was finished.

Putting down the scissors, Ju Kwang-ho slightly raised his gaze beyond his blood-splattered goggles.

"Now, it's becoming a surgery done thanks to the resident on dispatch."

"?"

"?"

In an instant, the air in the operating room froze oddly.

The fellow on the opposite side of the operating table, the 2nd year Jeong Jae-sang who was holding the retractor, and the scrub nurses who were organizing instruments simultaneously sent a huge question mark.

For a full-time professor of the aorta department, who is a lump of pride, to suddenly openly credit a resident on dispatch from another department at the most decisive turning point of the surgery.

It was an impossible thing.

However, Professor Kwang-ho Ju did not care about the surrounding gazes at all and raised his voice.

"What degree is it?"

"It's 24 degrees."

Meaning it has reached an extreme state of deep hypothermia where brain cells and organs can endure even without blood.

"Let's do total circulatory arrest. Keep the pump flow under 800 mil."

"Yes, Professor!"

The perfusionist immediately turned the main dial of the heart-lung machine.

"Since the inflammatory thickening of the aortitis is riding down the lesser curvature of the aortic arch, we will go beyond a simple ascending aorta replacement to do a hemiarch replacement."

Simultaneously with those words, the machine sound dropped dead.

The pump blood flow going to the lower body stopped completely.

From now on, the flow of blood heading to all organs except the patient's brain is zero.

The patient has entered a medically controlled death.

The allowed time is around 30 to 40 minutes at the longest.

Within that time, one must cut out half of the rotten aortic arch and connect an artificial blood vessel to open the path of life again.

"Anesthesiologist teacher?"

"Ah, yes. I will watch the NIRS."

Confirming that the notification sound of the equipment monitoring oxygen saturation going to the brain rang regularly, Ju Kwang-ho tightly gripped the forceps he was holding.

And.

"Good. Thanks to the resident on dispatch, we were able to do..."

Ju Kwang-ho turned his head and looked straight at me, standing on the footstool behind the operating table.

"Let's start the real surgery. Give me the Mayo."