I Am Diagnosed as a Medical Titan

Chapter 297: Chapter 202: Top-Level Prediction

The large demonstration classroom.

Yang Xu came in and started handing out oranges.

Everyone discussed business while eating the oranges.

Yang Xu said, "Bed 42, Bismuth type IV hilar cholangiocarcinoma. Total bilirubin is down to 85, and the FLR calculation is within the safe range. For today’s operation, I’ll be the lead surgeon. Jiang He is first assistant, Lin Haibo is second, and Xu Chen is third. Old Lin from Anesthesiology, and Chen Jing as the circulating nurse."

He paused. "A posterior approach with major vascular reconstruction. You all know how difficult this is. Jiang He, go over the preoperative plan first."

Jiang He picked up the laser pointer and aimed it at the 3D CT reconstruction.

"The core risks for this surgery lie in two areas. First, the right branch of the portal vein is involved. Imaging shows a faint, low-density shadow here. If we use a conventional anterior approach and dissect this area, there’s a high probability of a portal vein tear leading to massive hemorrhage."

Yang Xu: "Countermeasure?"

"We’ll avoid the minefield at the front and take a posterior approach. We’ll first mobilize the retrohepatic inferior vena cava, ligate the short hepatic veins, and flip the entire liver to the left side. This will expose the portal vein bifurcation from behind. If we find intraoperatively that the tumor is densely adhered to the right wall of the portal vein and forced dissection is not feasible, we’ll immediately apply a non-crushing vascular clamp, resect the involved portion of the vein wall, and repair it with a continuous 6-0 Prolene suture."

Yang Xu nodded. "Acceptable. Clamp time must be kept under twenty minutes. Before clamping, Old Lin needs to coordinate volume expansion to prevent a sharp drop in blood pressure from intestinal congestion."

Lin Peidong jotted a note in his notebook and nodded. "No problem. I’ll push vasopressors beforehand to maintain circulatory stability."

"The second difficulty is the right hepatic artery. It must be resected. For reconstruction, my plan is to mobilize the gastroduodenal artery, or GDA, and perform an end-to-end anastomosis by flipping it upward."

Lin Haibo raised a question, "Jiang He, what if the GDA’s diameter doesn’t match the right hepatic artery’s? Also, the tension from flipping it up could be significant. If the anastomosis tears post-op, the patient would immediately suffer a fatal intra-abdominal hemorrhage."

Jiang He immediately laid out the contingency plan. "If the diameter difference is more than one-third, we’ll switch to a beveled anastomosis. As for the tension, when mobilizing the GDA, we must dissect all the way down behind the pancreatic head and ligate some branches of the superior pancreaticoduodenal artery to free up enough length. If the length is still insufficient, the backup plan is to harvest a segment of the great saphenous vein for an interposition graft."

Yang Xu suggested, "If the GDA isn’t long enough, what about using a branch of the splenic artery instead? We could do a preoperative splenic arteriogram to confirm the vessel’s course. That would be more reliable."

Jiang He nodded. "I agree with Teacher Yang’s plan."

Throughout the demonstration classroom, the questions and answers flew back and forth.

Lin Haibo could still manage to get a word in,

but Xu Chen was already completely lost,

unable to keep up with the pace at all.

In the end, all he could do was twirl his pen.

It was a new pen. As for why he’d bought a new one, don’t ask.

Yang Xu: "Anything else to add?"

Everyone shook their heads.

"Alright, the plan is set. Let’s get ready for surgery."

...

The changing room.

Jiang He took off his ring, unclasped his necklace, and threaded the ring onto the chain.

He then placed it against his chest and said a silent prayer.

’May everyone, on and off the table, be safe and sound.’

He closed his locker and went to scrub in.

Operating Room 1.

The patient, Zhao Youcheng, was already lying supine on the operating table, the general anesthesia having taken effect.

Lin Peidong gave a thumbs-up. "Vitals are stable. You can begin at any time."

The circulating nurse, Chen Jing, was quickly counting the instruments. After confirming everything was in order, she looked toward the surgeons at the table.

Yang Xu stood in the lead surgeon’s position, with Jiang He opposite him as the first assistant.

Lin Haibo and Xu Chen stood at their respective sides.

The halo of the surgical lamp focused on the patient.

Yang Xu extended his right hand. "Number 22 blade."

The scrub nurse immediately slapped the scalpel into Yang Xu’s palm.

The surgery began.

The blade sliced through the skin, the incision quickly taking form.

The electrocautery knife followed, cutting through the subcutaneous fat layer by layer.

Entry into the abdominal cavity.

The state of the liver was exposed to view.

Prolonged, severe jaundice had turned the liver a dull, cholestatic green, and its texture was somewhat firm.

"Exploration complete. No abdominal metastasis, consistent with preoperative imaging. Jiang He."

"Understood."

Retractors in, gauze packed.

Jiang He’s movements were exceptionally fast.

Yang Xu: "Ultrasonic scalpel."

Mobilizing the perihepatic ligaments.

Jiang He held the suction, moving it almost in contact with the tip of the scalpel.

Any oozing blood was suctioned away by Jiang He the moment it appeared.

The surgical field remained clear from start to finish.

Cut, suction, suture, snip.

The pair’s movements were as smooth as flowing water.

Instruments were exchanged in a dizzying rhythm.

Standing in the second assistant’s position, Lin Haibo was a bit dazed.

He had thought that as a senior attending in the department, even if he couldn’t be the lead surgeon for such a difficult operation, he could at least serve as a key supporting pillar.

But the reality?

He couldn’t get involved at all!

Lin Haibo suddenly felt like he did back when he was a new intern, standing by the operating table feeling as insignificant as an ant.

’I thought that once I became an attending, I’d never feel this way again. Was I just kidding myself?’

Meanwhile, Xu Chen, in the third assistant’s spot, was in a completely different state.

He had completely given up on the idea of participating and had instead started to study their every move.

He had only heard about this posterior approach technique during theoretical discussions in the department.

Now, seeing Yang Xu and Jiang He flip the liver and strike at the core of the problem from behind with his own eyes, he felt it was a truly eye-opening experience.

’Getting to see a Level 4 Surgery of this caliber, and a brand-new technique at that, is a huge win!’

The surgery progressed extremely quickly, soon reaching the most treacherous part of the hepatic hilum.

"Vessel loop."

Dissecting the right branch of the portal vein.

Just then.

The situation deep within the surgical field suddenly changed.

Beneath the connective tissue.

An accessory right hepatic duct emerged from behind the portal vein, completely encased in fibrotic tumor tissue.

This kind of anatomical variation was completely invisible on the preoperative CT scan!

Xu Chen’s heart instantly started racing.

He subconsciously glanced at Yang Xu and Jiang He, only to see that their expressions were unchanged.

"Jiang He."

"Understood."

Jiang He lifted the edge of the variant tissue, and a clamp passed precisely behind the main portal vein trunk.

CLICK.

It clamped perfectly on the borderline between the variant tissue and the normal portal vein wall.

Yang Xu followed immediately, his Metzenbaum scissors gliding along the edge of Jiang He’s clamp and cutting cleanly.

SNIP.

The fibrotic tumor tissue, along with that section of the variant bile duct, was excised in one piece.

A spindle-shaped defect was left on the main portal vein, but thanks to the clamp, not a single drop of blood escaped.

"6-0 Prolene." Jiang He was already passing over the needle holder.

Yang Xu took it and began a continuous suture.

The needle tip weaved through the tiny space.

Suturing complete, he released the clamp.

The defect didn’t leak a single drop of blood. Flow in the portal vein was instantly restored.

The entire process took less than two minutes.

Xu Chen was dumbfounded.

They... solved it? Just like that?

They solved it just like that?!

Don’t they need to stop and think? How are they not panicking at all?!

In truth, because Xu Chen had been spacing out during the preoperative meeting, he had no idea.

Though this variation was rare, Jiang He had already included it in the contingency plan for extreme scenarios during the preoperative simulation.

Jiang He had not only considered routine adhesions but had even factored in the potential for traction on the main trunk caused by a posterior bile duct variation.

So, when this crisis actually occurred, Yang Xu and Jiang He didn’t even need to communicate.

They had long since anticipated it.

Everything was under control.

Even the anesthesiologist, Lin Peidong, was breaking out in a cold sweat just watching.

"These two... they’re incredible..."

Jiang He was brilliant, especially in diagnostic prediction, special pancreatic surgeries, and new surgical techniques that were ahead of their time. His abilities were world-class.

Yang Xu was also brilliant. In terms of pure general surgery dissection and suturing, he was absolutely among the top tier in the country.

It was the combination of these two powerhouses that created the overwhelming surgical rhythm they were witnessing.

The surgery continued.

The extended left hepatectomy, including the caudate lobe, was completed smoothly.

Now, they entered the final cleanup and reconstruction phase:

Biliary-enteric anastomosis.

"Prepare for anastomosis," Yang Xu said.

Due to the patient’s prolonged, severe jaundice, even with preoperative PTCD for biliary drainage, the bile duct wall was still edematous.

Yang Xu gripped a PDS suture with his needle holder, placed the needle, and passed it through the bile duct wall.

The moment he tied the knot and tightened the line,

the fragile bile duct wall, unable to withstand the suture’s tension, was torn, creating a small slit.

Jiang He immediately pressed down on the edge of the tear with the toothless forceps in his hand, preventing the opening from widening. At the same time, he extended his right hand to the scrub nurse, his voice calm and decisive:

"Give me the fine needle holder! And a 7-0 Prolene suture, double-armed needle!"

Then, Jiang He said, "Teacher, switch needles. The PDS suture is too stiff. Let’s change to a 7-0 vascular suture. We won’t do a continuous stitch."

Yang Xu immediately took the 7-0 Prolene suture Jiang He handed him.

Jiang He: "Parachute technique."

Yang Xu understood instantly.

He placed needles at multiple stress points but didn’t tighten them, letting the sutures hang in the air like the lines of a parachute.

After all the sutures had been passed through the walls of both the bile duct and the intestine,

"Tighten."

Yang Xu called out softly.

Jiang He coordinated his actions with him. The two simultaneously applied even tension in all directions.

Under the evenly distributed force of the numerous fine threads, the fragile walls of the bile duct and intestine slowly came together.

The tension was perfectly distributed, and no further tearing occurred.

Knot, secure.

A potentially tricky complication was once again resolved in seconds.

Standing on the side, Lin Haibo and Xu Chen no longer felt any intense shock.

From the initial scalp-tingling awe, to being utterly dumbfounded, and now... they had grown somewhat accustomed to it.

This was probably what they called "going numb."

Watching others perform a Level 4 Surgery as if it were a simple appendectomy, they now just thought:

’Oh, standard procedure. It’s the Director and the River God, after all.’

In the lead surgeon’s position, Yang Xu was thrilled. The experience was absolutely exhilarating!

This surgery felt so damn good!

Every possible complication had been discussed in the preoperative meeting, and every move was executed with perfect synergy.

It was pure enjoyment!

Especially this new posterior approach. Logically, he should have felt at least a little nervous applying it in a real clinical battle.

But the truth was, he hadn’t felt a shred of panic the entire time.

Because Jiang He was standing across from him.

With Jiang He there, it felt like he could cut with his eyes closed and someone would be there to reliably cover his back.

’Fucking hell, is my student even human?’

Yang Xu cursed inwardly.

Afterward, his reliance on Jiang He went up another notch.

Meanwhile, Jiang He was also marveling to himself.

’Teacher Yang truly is the master.’

He had only discussed the brand-new posterior approach concept a few times preoperatively, yet on the table, he was able to execute it so perfectly.

Especially the tension control during the biliary-enteric anastomosis just now. A typical attending, even using the parachute technique, would have very likely caused a second tear due to uneven force.

’But Teacher Yang’s touch is just incredible. I’m impressed.’

"Check the abdominal cavity, confirm no bleeding points." Yang Xu irrigated the surgical field with warm saline and observed carefully for three minutes. "Place the drains."

Chen Jing handed over the drainage tubes.

Jiang He secured the drains near the biliary-enteric anastomosis and under the right hemidiaphragm.

"Count the instruments and sponges."

"Thirty instruments, twelve needles, twenty gauze pads. Count is correct."

"Alright. Xu Chen, you close the abdomen."

"Got it!"

Xu Chen was ecstatic.

Even though it was just closing, this was a radical resection for a Bismuth type IV hilar cholangiocarcinoma!

Being able to have his name on the record for this surgery made him feel fully involved.

But Lin Haibo fell silent.

’Damn it, how do I feel even more useless than Xu Chen?’

’At least he gets to close the abdomen.’

’What about me?’

’What did I even come to this surgery for?’

’To witness a miracle?’

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