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"The surgical incision for anterior communicating aneurysm clipping is very important."

Looking at the screen Tian Lu was marking both sides to inject lidocaine, he said coldly to Dean Liu Ming: "Because whether the surgical field is exposed appropriately is related to the safety and difficulty of the subsequent operation. Just like this surgery, the classic Yasagir pterygis approach is used, where the scalp incision generally starts from the upper edge of the zygomatic arch, one to 1.5 cm anterior tragus, and then perpendicular to the zygomatic arch, from the front of the ear upwards, along the hairline to the frontal hairline, one to two centimeters from the midline, and ends at the frontal hairline. Of course, the shape of the specific incision can be adjusted appropriately according to the patient's hairline height. ”

Nodding, Liu Ming didn't speak, but watched with all his attention as Tian Lu picked up the scalpel and slashed it without hesitation.

This time, compared to Taji's previous surgery, the movement was relatively slow.

"When incorporating the scalp, it is necessary to pay attention to protecting the main trunk of the superficial temporal artery, especially the posterior branch, and not to damage the anterior and posterior branches at the same time, because special circumstances during the operation may require superficial temporal artery and middle cerebral artery bypass surgery."

Perhaps because he felt that the operation speed of Tian Lu was a little different from what he had mentioned to Liu Ming, he explained with a cold smile: "In addition, when reversing the cutaneous muscle flap or interfascial temporal muscle flap, it is necessary to pay attention to the maximum retraction of the temporal muscle, while not damaging the frontal branch of the facial nerve innervating the frontalis muscle, so as to avoid the disappearance of frontal lines and atrophy of the temporal muscle after surgery, so the operation should be more cautious." ”

He nodded again and did not speak. Although I don't know much about the specific situation, and there is indeed some gap between the operation of Tian Lu and Leng Yan's description, there is no problem in Liu Ming's eyes. He only noticed that there was no pause when Tian Lu laid down the knife!

It's slow, but there's no hesitation!

The things I saw with my own eyes must be a lot more than the cold description, so Liu Ming felt that this cold explanation was a bit redundant.

Of the two conventional methods of exposure, the field road adopts interfascial separation and walks along the incision. Separate the subgal layer of the glandular aponeurosis anteriorly and inferiorly to the fat pad, then cut the superficial layer of the superficial temporal fascia and turn it anteriorly and inferiorly with the flap.

It's easy to say. It's just a few words, but when it comes to doing it, it's very cumbersome and delicate, and the cooperation between Tian Lu and the two assistants is a little rusty. From time to time, I had to stop to coordinate the synchronicity of the three of them, and it took a lot of effort to finally reveal the superior orbital border, frontal angle, and sphenoid bone. Of course, a fascial muscular margin was left on the skull for temporal muscle reduction and suturing during cranial closure.

"Next is the craniotomy."

Leng Yan continued to fulfill his obligation to explain, stared at the display screen and said: "It's still a conventional drill two holes, milling the cutter to mill down, and then free the bone flap." ”

The first foramen is the foramen guanjian, which is located posterior to the zygomatic process of the frontal bone, revealing the base of the anterior cranial fossa, and the second foramen is located in the temporal part behind the sphenoid crest. Tian Lu's movements are gentle and resolute, and they are all one-time successes. The bone flap is then milled with a milling cutter. Because of the thick bone at the sphenoid crest, Tian Lu used a grinding drill to grind the skull cortex and then flip the bone flap. And because Li Dashan is a little old, it is very likely that there will be adhesions with the dura mater under the bone flap. In order to avoid damaging the dura mater, Tian Lu used a bowl to separate the bone flap before opening it, and the operation was careful and very cautious.

Liu Ming pursed his lips tightly and looked at it seriously.

As before, this involves drilling holes in the bone margins around the bone flap next. The gelatin sponge is padded under the edge of the bone flap, and the speed of these operations on the field road is obviously much faster than just now, and there is still no hesitation and hesitation!

After the bone flap was lifted, the dura mater was revealed, and some blood vessels in the submembranous brain were clearly exposed in the surgical field.

Pointing to the ongoing operation of Tian Lu on the screen, he said coldly: "In order to avoid the reduction of intracranial pressure during the operation, the epidural hematoma caused by dural detachment requires a routine suspension of the dura mater. The middle meningeal artery traveled through the surrounding area, and where the effect of simple pressure and hemostasis might not be satisfactory, Oda deliberately suspended two or three more needles. ”

In the operating room, Tian Lu, with the cooperation of his assistant, began to use small rongeurs and high-speed drill to grind one-half of the sphenoid crest until the skull near the anterior bed process. Fully smoothing the sphenoid crest can maintain a good vertical field of view and reduce the traction of brain tissue during surgery, but because the dura mater and bone of the sphenoid crest are prone to bleeding, Tianlu seals the skull plate barrier with bone wax.

However, when doing this step, the coldness in front of the display screen couldn't help but sigh slightly.

"What's wrong?"

Although the voice was very soft, Liu Ming still heard it and couldn't help but ask.

"It's okay, it's okay!"

Leng Yan hurriedly smiled and waved his hand, but there was a slight doubt in his eyes when he looked at the screen.

Just when he used the bone rongeurs, Tian Lu's movements had small pauses and mistakes several times. Of course, this kind of pause and mistake is not very obvious, and it has not caused any adverse consequences, at least Liu Ming can't see it. But in Leng Yan, he can see it clearly: this is definitely not Tian Lu's usual style, Leng Yan has seen several of his surgeries, and this is the first time this situation has appeared!

"Is it because you know that the dean is watching the operation?"

The cold brow couldn't help frowning slightly.

In fact, the cold observation was not wrong, when he used the bone rongeurs just now, Tian Lu was indeed a little distracted!

But this situation occurred definitely not because he knew that Liu Ming was watching, but because Tian Lu couldn't help it for a while, and remembered the set of device patents that had just been handed over to Weisen Company.

It's still easy to use。。。。。。

Fortunately, this loss of consciousness was only a moment's work, and Tian Lu quickly put away his divergent thoughts and refocused on the operation. The three doctors worked together and began to rinse, suction, and insert gelatin sponges to thoroughly clean the surgical field.

Next, the dura mater is cut.

Cut the dura mater in an arc with the sphenoid crest as the center, and use the silk thread just worn to flip it and hang it on the edge of the bone window, and then open the arachnoid membrane next to the saddle according to the operation specification to release the cerebrospinal fluid. Reduces intracranial pressure and increases the amount of space to be exposed. On the one hand, excessive traction of brain tissue, especially temporal lobe brain tissue, can be avoided, and on the other hand, bleeding from the tear of the draining vein leading to the sphenoid parietal sinus can be avoided.

Leng Yan's heart was slightly raised, and he quickly put it back. At least on the screen, the field road has returned to normal levels, the operation is clean and clear, fast and stable. No bleeding was caused.

After the dura mater was treated, the lights in the operating room dimmed instantly.

Only one lamp was still on, and the light was concentrated on the field. The patient's brain has been revealed. After the microscope is fixed above, the surgery is about to enter the micromanipulation stage.

Outside the operating room, the image on the display goes under the scope. And Liu Ming and Leng Yan also sat up straight at the same time!

Covering a large part of the exposed brain with soaked noodles, Taro began the operation to separate the revealed aneurysm.

Traditionally, the method of exposing the aneurysm is to first expose the proximal end of the aneurysm-bearing artery according to the location of the aneurysm, then expose the aneurysm neck, then separate the aneurysm neck, and finally select a suitable aneurysm clip to clip the aneurysm neck after it is satisfied.

This part of the operation is also very simple to say, but it is extremely complicated to operate. The surgeon can even be said to be walking on thin ice!

This is not a second-level or third-level surgery performed by the previous Tian Lu chief surgeon, and the anterior communicating aneurysm is not just below the spinal cord like a spinal ependymoma, which can be seen through an incision.

The lesion is deep in the brain tissue!

Because the aneurysm is located in the subarachnoid space, it does not have a transparenchymal fistula but follows the normal anatomical site of the aneurysm-bearing artery. In the process of reaching the aneurysm ♀ from near to far, because there are normal perforating blood vessels, in order to avoid bleeding, it can only be sharpened under the microscope, and not blunt tearing!

In other words, the surgeon must be in an extremely small deep space. Under the microscope, use those delicate surgical instruments to operate: peel open the delicate and fragile brain tissue of the patient, probe in, avoid those dense blood vessels, little by little, trace by free out of the lesion!

In words, it is difficult to describe the precision of this surgery.

The blood vessels in the anterior communicating artery area are very complex and have important perforating arteries, and there may be as many as 14 blood vessels that may be involved in the treatment of the anterior communicating aneurysm! And instead of operating on the surface of the brain, the surgeon goes deep into the inside, getting smaller and narrower, and finally only the top of the slender metal rod sticks in!

As Leng Yan said at the beginning, this step has extremely high requirements for the basic knowledge and operation ability of the operator! He must have a clear understanding of the structure of this part of the brain tissue, including the distribution and direction of blood vessels, the tissue structure of the lesion site, etc., and the operation under the microscope must also be very stable, the feel should be soft, and the action should be clean!

Little by little, not in a hurry or impatient, the field road operated slowly and firmly, but there was still no pause or hesitation!

The most important thing in aneurysm surgery is the control of bleeding, and blind exploration of the aneurysm body should be avoided before the aneurysm is fully exposed, which can lead to the occurrence of intraoperative rupture of the aneurysm. Once the aneurysm ruptures, the aneurysm artery is temporarily blocked, and then the aneurysm is separated and clamped.

It wasn't until the aneurysm neck was finally isolated that Tian Lu turned on the fluorescence imaging function of the microscope to observe the morphology, location relationship and blood flow of the aneurysm, aneurysm-carrier artery and other normal branch blood vessels, and suddenly realized that there was not a single bleeding in the whole process!

This kind of operation can definitely be called perfect!

When Tian Lu clamped the aneurysm neck with titanium alloy, and then turned on the fluorescence imaging function again to observe the clamping effect, the cold mood was finally completely relaxed!

Turning his head, he smiled coldly: "Dean, do you continue to watch the back?" ”

"What, it's over?"

Liu Ming was slightly stunned and asked strangely.

He nodded with a cold smile and said, "It's almost, let's deal with it now, and then close the skull." There's no difficulty in the next one, it's all routine operations, so I asked you if you still want to watch it? ”

"Let's read it!"

When Liu Ming heard this, he immediately relaxed, and said quite happily: "And I think about meeting Xiao Tian after surgery, let's go to lunch together, and then have a good chat, what do you think?" ”

"Of course that's good!"

Leng Yan hurriedly agreed. He understood what Liu Ming meant to come to see Tian Lu for surgery today: first, Tian Lu had just become the youngest deputy chief physician of the Second Affiliated Hospital, and second, he tried his best to put him in the position of deputy director, which made Liu Ming a little curious at the same time!

But after a clean and beautiful operation, Liu Ming must have understood everything.

Liu Ming naturally didn't know about the cold and careful thoughts, he just smiled slightly, and after nodding, he still habitually turned his gaze to the direction of the screen.

Indeed, as Leng Yan thought, after seeing this operation, Liu Ming has fully recognized Tian Lu's ability!

Liu Ming naturally can't say that he understands the operation of neurosurgery, but as a general surgeon, he can still see the level of a surgeon!

Not to mention anything else, although Tian Lu's speed was sometimes fast and slow throughout the operation, it was smooth and smooth, and there was basically no hesitation or hesitation. Through this alone, Liu Ming understands that such an operation is not difficult for him!

A complex operation, Tian Lu, who is only in his early thirties, can be completed almost perfectly, is this ability still worth Liu Ming's doubts。。。。。。

In the operating room, Tian Lu's operation continued.

The results of fluorescence imaging showed that the aneurysm clamped well, and Tian Lu quickly made the decision to close the cranium. In order to prevent the tail of the clip from compressing the normal brain tissue, Tian Lu and his assistants applied sponges and hemostatic fibers around the clips to provide support and protection. Moreover, the whole operation was unusually clean, and there was no obvious wound in the surgical field, so there was no electrocoagulation to stop bleeding, and the surgical field was routinely flushed with a one-to-ten dilution of nimodipine solution, and the cranium was ready to be closed.

Conventional skull closure is naturally still layered by layer.

First, the dura mater is sutured. Tian Lu used absorbable threads to suture the dura with non-dense continuous sutures, and before the last stitch, Tian Lu injected normal saline into the subdural to avoid postoperative pneumonia.

When he saw this, Leng Yan got up and stood up, and couldn't help but stretch slightly.

He really didn't want to read the following content. As long as the neurosurgeon knows that in these most basic technical operations, it is impossible for Tian Lu to make any mistakes, and the speed is definitely beyond the reach of ordinary people!

"Huh?!"

Sure enough, just when Leng Yan got up and moved his neck, which was a little stiff because he had been sitting for too long, and wanted to move his hands and feet further, Liu Ming's suspicious cry came from behind him.

With a smug smile in his heart, he turned around coldly, and was about to explain Tian Lu's strong performance to the dean, but the moment the corner of his eye swept over the display screen, the smile on his face suddenly froze!

"What's going on?!" (

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