Chapter 259

Episode 259 Anatomical Variation (2)

"Give me a 10."

The moment Professor Park Seung-woo's words dropped, a sharp No. 10 blade was placed into his hand.

Swwish—

Professor Park carefully started cutting into the skin.

'Next up is... the scalp connective tissue.'

And then, almost immediately after passing the connective tissue, the incision slashed straight through to the galea aponeurotica covering the skull.

'So this is a surgeon's speed.'

I had no idea what kind of "surgeon's mindset" the chief had been drumming into me since my rotation in Thoracic Surgery last year, but for now, I was trying my best to internalize it while watching this.

I tilted my head slightly to look at the comment window.

[Comments]

Latte is Mine: Speaking of brains, that brings back deep memories.

oo (39.7): Like what?

Latte is Mine: Actually, none.

Ignoring the trolling from these old men...

CrackTheHead: Hell Slave, hey, Hell Slave.

?

'Why is this phantom calling me?'

Korean Slave 1 (Male): Yeah?? What, what?

The moment I replied, CrackTheHead shot back with a lightning-fast response, as if he had pre-typed it.

CrackTheHead: Give us a live broadcast.

CrackTheHead: Pictures would be nice.

'…?'

So this phantom wanted me to give him a live report of the action breaking out in the operating room on my very first day of rotation?

'Well, it's not like I can't...'

Korean Slave 1 (Male): Yeah, will do that way.

It would be a bit tedious, but I decided to relay information to the phantom by using the system window to even send pictures. After all, that person must have been a legendary doctor when he was alive, and since he possessed that much expertise, he could navigate the current gallery without any trouble.

What if an experienced neurosurgery expert could tag along in real-time and offer advice during surgery on a patient with such a rare anatomical variation? It could only be a plus for the patient, never a minus. And I would also be able to understand the surgery a little better.

Korean Slave 1 (Male): By any chance, if the surgery goes horribly wrong, would you consider possession?

If a major problem arose during the surgery currently being performed by Professor Park Seung-woo, simply copying and pasting comments might not allow for proper intervention. However, in the case of possession, using the guidance mode allowed for a 2-hour possession. During that time, CrackTheHead could float around the void, examine the affected area, see even the slightest slip of the mes, and point it out to me directly. All I would have to do is pass it along.

CrackTheHead: Well, that’s up to you. If you think it’s necessary, let me know.

'Okay…'

The phantom seemed to agree with my plan.

With that, I quietly returned to my spot in the gallery and watched the scenery of the surgery unfolding.

"Raney."

At Park Seung-woo's word, something made of metal was clamped onto both sides of the incision.

'Raney?'

Unable to help myself, I immediately opened the window in the void.

Korean Slave 1 (Male): What's a Raney?

LaunchTheCatapult: Her name?

'Look at them go.'

Lately, it felt like the phantoms from Internal Medicine were joking around more often. True, since this was a Neurosurgery rotation, there wasn't much room for them to shine. Resolving to appease the Internal Medicine phantoms next time, I looked at the comment left by CrackTheHead.

CrackTheHead: It’s to stop the bleeding along the incision line.

CrackTheHead: He’s applying hemostatic clips.

'Ah.'

That made it a bit easier to understand. As expected, you really need an expert around.

Korean Slave 1 (Male): (Picture)

CrackTheHead: He’s separating the scalp flap from the skull.

'Ah-ha.'

It felt completely like... I was cheating or something. With that feeling lingering, I continued to observe the surgery.

"Give me a 15."

"Here is the 15."

Professor Park Seung-woo only opened his mouth when changing the blade number or when a surgical instruction was required.

'Professor Han Ihyun from Thoracic Surgery was basically a question machine.'

It didn't seem to be a difference between departments. Was it a difference between people? Park Seung-woo from Neurosurgery seemed to be the type of surgeon who focused and operated in a relatively quiet environment.

'If so, I should stay quiet.'

In fact, this might be better. Since I didn't have to answer questions one by one, I could study the parts I wanted to focus on more properly.

"Periosteal elevator."

"Yes sir."

Taking the elevator, Park Seung-woo pushed the instrument inside and dissected the temporalis muscle entirely along with the periosteum. The dissected temporalis muscle mass was folded downward, completely exposing the bone up to the lateral orbital wall and the root of the zygomatic arch.

"Give me a retractor."

"Retractor... here it is."

Creak.

"Fix it. Monopolar bovie."

Using the monopolar electrocautery, Professor Park burned away all the residual soft tissue that had been adhering to the bone surface.

"There's a bit of bleeding."

After cauterizing the bleeding areas to achieve hemostasis, he was handed a drill fitted with an attachment.

Korean Slave 1 (Male): (Picture)

Korean Slave 1 (Male): ?? What is this?????

CrackTheHead: It’s a high-speed pneumatic drill. He’s got a cutting burr attached and is going to drill a MacCarty burr hole right behind the fronto-zygomatic suture.

CrackTheHead: Tell him to watch out because if the burr hole angle tilts forward, it can slip into the orbit.

'I see.'

I nodded to myself and watched the surgical scene, carefully observing in case Professor Park accidentally misjudged the drilling angle and plunged the drill tip into the orbit.

'I know he’s a nice person, but…'

Skill is a separate matter. In the end, deciding whether a person lives or dies depends on the surgeon's hand skills. It was necessary to keep that in mind and watch closely.

Professor Park went on to create two additional burr holes.

Korean Slave 1 (Male): Why is he drilling more burr holes?

CrackTheHead: Something called a craniotome, which cuts the skull... anyway, that needs to be inserted into a burr hole too. There’s a reason for it.

It was just as I was looking at that comment.

"Penfield No. 3."

"Yes sir."

The Penfield dissector was inserted through the burr hole. The inner surface of the skull and the dura mater began to be meticulously separated.

"Give me the craniotome."

Professor Park carefully inserted the craniotome into the burr hole and started the cutting.

"Periosteal elevator."

"Here it is."

Using the elevator, he carefully pried up the completely cut free bone flap using leverage to separate it.

"Wrap this in gauze and store it."

"Ah, yes! Understood."

At Professor Park's instruction, Hwang Seong-hun wrapped the free bone flap in gauze soaked in sterile normal saline and placed it on the back table.

Turning his head back, Professor Park finally noticed me, and an "oh, right" expression washed over his face.

"?"

"Ah. The resident on rotation. Dr. Han Hyeonjae."

"Yes sir."

At my response, Professor Park turned his head back toward the patient and continued speaking.

"By any chance, do you know what to watch out for when elevating a bone flap?"

'Ah. He just didn't realize I was here.'

This person was simply so focused on the surgery that he had forgotten a resident on rotation was standing right there. Then again, how could someone who asked so many questions before entering the operating room suddenly become completely silent?

I tilted my head slightly.

Korean Slave 1 (Male): What do you need to be careful of when removing a free flap with an elevator?

CrackTheHead: The patient is on the older side, right? The dura mater could be adhered to the bone.

CrackTheHead: If that happens, stop, slide the scissors in, and cut the adhered part. Use Surgicel. You can patch it up later during suturing.

After reading the comment, I turned my head back to the patient.

"Ah. Is it alright if I answer?"

"It's fine. Go ahead."

"Given the patient's advanced age, I thought the dura mater might be strongly adhered to the inner surface of the bone, meaning it could tear and pull up along with the bone."

"Naturally."

Perhaps because Professor Park was one of the gentlemen present at the exam site that day, instead of reacting with surprise like Professor Han Ihyun from Thoracic Surgery, he responded as if it were obvious.

"This can lead to variables like cerebrospinal fluid leakage and cortical damage. In that case, the elevation must be stopped immediately, scissors inserted into the bone gap to cut and separate the adhered dura from the bone, and the torn area covered with an absorbable hemostatic agent to stop the bleeding, to be repaired later during the suturing stage."

"You know it well. The answers come right out."

Professor Park Seung-woo spoke casually while using bipolar electrocautery to coagulate the branches of the middle meningeal artery, which were pouring out pulsatile bleeding.

'Surgeons really don't pay much attention to this kind of thing.'

They rarely get flustered, even when there's major bleeding.

"What about venous bleeding oozing from the bone cut surface?"

Ah. This was something I knew.

'Thank you, CrackTheHead.'

"You firmly apply bone wax using a wax applicator or a finger to plug it."

"This is it."

Startled by his sudden outburst, I asked back, "Pardon, sir...?"

"This is exactly it! Why doesn't Neurosurgery have residents like this? Good grief. Seriously. Even if they don't know, if they just think about it for a second, the answer comes right out like Dr. Han's!"

Um. No, sir. It's probably because those people don't have access to a gallery of dead experts. Even if you gave them a bit more time, it wouldn't change things that much, would it?

However, those words didn't make it out of my mouth.

'I'm sorry, resident doctors.'

I looked at Hwang Seong-hun with a look of pity in my eyes.

"Cut."

Thump—

"Cut."

Thump—

Park Seung-woo was suturing the dura mater to the bone along the edge of the skull.

'Why is he doing that?'

Korean Slave 1 (Male): He’s suturing the dura mater to the bone, what is that?

CrackTheHead: Highly likely to prevent a hematoma from forming in the epidural space.

Reading that comment, I could roughly understand the principle.

'By completely eliminating the space, you don't even give the blood a chance to collect.'

Indeed. The human body and medicine still hold many mysteries.

"Diamond burr."

"Here it is."

I uploaded the scene exactly as it was to the comments.

Korean Slave 1 (Male): (Picture)

CrackTheHead: Oh, can you see that? You can even see the meningo-orbital band over there.

CrackTheHead: He’s grinding the bone down to the absolute limit.

Drilling deep downward, he exposed the meningo-orbital band and ground the bone right down to the limit of the visual field.

"What we're doing now is flattening," Professor Park said.

I asked in return, "Flattening, you say?"

"Grinding down enough bone near the base of the anterior clinoid process. That way, we can secure the maximum view of the skull base without having to retract the brain too hard."

"Ah...!"

"Then do you know what I'll do next?"

Having a rough guess, I gave voice to it. Back during my Thoracic Surgery rotation, I had failed to answer even an easy question because I was busy cheating off the gallery phantoms.

"Cover the entire exposed area with Gelfoam and cotton pads...?"

"Why do you think so?"

"Because we have to prevent microscopic bleeding."

Professor Park, who was palpating the dura mater with his finger, nodded.

"We won't need to give any more mannitol."

He had clearly checked the brain pressure.

...So why wasn't there any comment on my answer? Was I wrong?

"And doctor on rotation. You were right."

Oh yeah.

While I was marveling at how I had managed to get the answer right, Professor Park picked up the knife again.

"Give me an 11."

"No. 11 mes."

Laying the tip of the mes flat, Professor Park made a microscopic incision in the outer layer of the dura.

Korean Slave 1 (Male): (Picture)

CrackTheHead: If you mess up and stab too deep here, it can cause brain edema. That was decent.

"Dural scissors."

"Yes sir."

With that, the dura was completely swung open. Perhaps due to the effects of the subarachnoid hemorrhage, the brain surface was stained red with blood.

'Hooh…'

To be honest, seeing a sight like this... almost never happens. As an emergency medicine doctor, that is.

'We rarely get to see the actual brain of a brain hemorrhage patient.'

Unless it's on a CT screen, that is.

"Cover it."

"Yes sir."

To protect the cortex from drying out due to air exposure, a cloth thoroughly soaked in normal saline was draped over the exposed frontal and temporal lobes.

Then, an instrument was inserted, slightly lifting the frontal lobe.

"Hmm, okay. Visual field. Hmm."

"Please wait just a moment."

Hwang Seong-hun seemed to be taking a bit of time to set up the surgical microscope.

"It's ready."

Now the surgical microscope entered the field. Professor Park turned his head, looked at me, and said, "From here on out, it's microsurgery. Watch closely."

"I'll keep that in mind."

Moving to an area that was relatively close but didn't interfere with the surgical field, I observed the scene.

Korean Slave 1 (Male): (Picture) What is he doing here?

CrackTheHead: He made a hole to lower the brain pressure.

Mes of the God (Male): The brain is damn hard.

Red cerebrospinal fluid mixed with blood began to flow out through the hole.

"Get the suction tip ready."

"Yes sir."

The neurosurgery team began to position the suction. As the fluids were gradually sucked away, the swelling of the brain cortex noticeably subsided.

'Did he relax the brain by draining the cerebrospinal fluid?'

Prompted by sudden curiosity, I posted a comment.

Korean Slave 1 (Male): What happens if you can't drain the cerebrospinal fluid? Can't perform the surgery?

Mes of the God (Male): Dunno?

CrackTheHead: Yeah, dissecting the skull base itself becomes impossible. In that case, you have to touch the lamina terminalis, but since it’s going well right now, let’s talk about it after the surgery is over.

CrackTheHead seemed to be far more interested in the current situation. Then again...

'There's no need to dwell on negative 'what ifs'.'

"Give me a hook."

"Yes sir."

Using the hook, Professor Park tore away Liliequist's membrane located deep inside. As he did, a large amount of cerebrospinal fluid and old hematoma debris began to pour out.

"Suction."

"Suction."

'This is damn fascinating.'

Korean Slave 1 (Male): What’s this?? (Picture) A hematoma came out when he tore it.

CrackTheHead: That’s the basal cisterns. The stuff trapped inside came out.

After a brief moment passed, Park Seung-woo spoke up.

"It’s relaxed enough. You see it?"

"Yes, I see it," Hwang Seong-hun replied.

Having confirmed the relaxation, the two officially began the dissection of the Sylvian fissure—the cleft that traverses the frontal and temporal lobes.

"Mes."

"Yes sir."

Digging in along the Sylvian fissure to proceed with the dissection, Park Seung-woo finally exposed the main stream of the right internal carotid artery.

"It's the PCoA."

"Yes. It's the origin."

"And... the anterior choroidal artery."

Having confirmed the origins of the two arteries, the pair continued their ascent and finally reached the end of the internal carotid artery—the bifurcation.

"The M1 segment of the middle cerebral artery courses laterally."

"Okay, check."

Checking the M1 segment of the middle cerebral artery, Park Seung-woo turned his gaze anteriorly.

And then, he suddenly went quiet.

'...What? Did something happen?'

"...Doctor on rotation?"

"Yes, Professor."

Park Seung-woo let out a dry chuckle and lifted his head.

"How did you know? You predicted this just by looking at the CTA...?"

"Pardon?"

As I asked back in confusion, Professor Park let out a deep sigh and continued speaking.

"Just as you predicted, the A1 segment doesn't exist in its normal trajectory. It's a total wasteland."