medical simulator

Page 346

After the posterior approach for shoulder arthroscopy is completed, the core of the arthroscopic sleeve is inserted into the glenohumeral space, and the arthroscopic sleeve is inserted behind the lens under the protection of the sleeve.

The first step is to find the position of the biceps tendon. In this position, first observe the upper part of the shoulder joint or the articular cartilage part of the biceps tendon and glenoid.

Su Mincheng put the camera into the glenohumeral space, first adjusted the angle, and then moved forward slowly. His operation seemed to be very familiar with the operation he was going to do next, observing the humeral head and the cartilage part of the glenoid.

Then rotate the shoulders internally and externally, fully observing.

Proceeding forward, observe the upper and lower surfaces of the biceps tendon, the insertion point of the biceps tendon, and the superior labrum for partial tears.

When he got here, Su Min's operation was still very smooth, without any intention of stopping.

This is the basic skill, so! ?

but! ?

As soon as the camera is pushed in, all that can be seen at the time is the long head tendon of the biceps 'sleeping' there.

The reason why it is called sleep!

It is because the insertion point of the long head of the biceps tendon is completely disconnected from the lower part of the tendon.

Insertion point and tendon seem to be separated.

Each play their own way.

Seeing this scene, Zhou Cheng stopped the operation and was stunned!

Except for Zhou Cheng, Su Min, who was the chief surgeon, was in a daze at the time, and Yu Heng, who was in charge of the first assistant, had erratic eyes and a blurred mind.

The expressions of the 'bladder' person - Zhen Xing and Zhou Muyun changed drastically immediately. Zhou Muyun's eyes widened and he covered his mouth with his hand, while Zhen Xing next to him immediately moved his eyes to Peng Peng's body, as if Asking why?

Then, Zhen Xing saw it.

Peng Peng was also 'stunned' on the spot, but his blankness was different from theirs, like a wooden stake, he just stared and didn't respond to their strange expressions, as if he didn't know these people As if looking at him.

Mental quality is very strong!

"Mr. Peng, what is the preoperative diagnosis for this patient??" When Peng Peng, Zhou Cheng, and everyone else could sit still, Su Min couldn't sit still right now!

Now, he is the chief knife.

But now?

The intraoperative diagnosis does not match the preoperative diagnosis, and the intraoperative surgical method will also change. What should I do?

It's impingement syndrome that has worn out the long head tendon of the biceps!

But the tendon did not separate too much, and because of the interference of other soft tissues on the MRI, the ruptured end could not be seen! ? ?

This is not a simple shoulder injury surgery!

This is a major operation, and it is simply not something that ordinary students can do!It can even be said that it can be regarded as one of the most difficult teaching operations in the department.

"You continue." Peng Peng continued to order Su Min.

However, Peng Peng's words made Su Min's scalp tingle a little.

No?

Mr. Peng Peng, do you not understand the current situation?

This patient, the current diagnosis, he is wrong!

The technique of the preoperative talk is also wrong, you should find someone to come, right?

I continue?

I switch to open surgery now?

Once it was opened, it became a level IV operation, and Su Min did not dare to continue.

He laughed and said: "Mr. Peng, the actual condition of this patient is much more serious than expected. I think the difficulty of the current operation is beyond my operating ability, so I may not be suitable to continue to perform the operation. .”

"Teacher Peng, why don't you come to be the chief surgeon?"

Biceps tendon rupture is a condition requiring open surgery.

Cerclage fixation under shoulder arthroscopy is a technique that requires extremely high operating skills. In his own professional group, there are not many such patients.

Because if such patients are discovered before the operation, most of them will be sutured openly for the sake of insurance.Or it was closed by open sutures in prefecture-level cities.

Plus, this patient is again.

It is extremely rare that there is no way to see the rupture of the long head of the biceps tendon on the MRI.

The pre-operative conversation, pre-operative diagnosis, and intra-operative diagnosis were inconsistent. Does Su Min dare to continue to perform the surgery at this time?

Su Min didn't dare, because no matter how you put it here, it was the third hospital in Kyoto, not Ruijin where he was. His teacher, his team, and everyone he could rely on were not around.

Alone, even though she came here as a student, Su Min dared not do such a thing like tyrannical operations that were beyond her ability.

Peng Peng smiled, then looked at the others with great satisfaction, and asked, "All of you, has anyone read the informed consent form signed by the patient before the operation?"

"Has anyone carefully checked the specific information on the patient's plain film and MRI?"

This is not their job content, because they are here to study, not to be a bed doctor, and after a class, there is only such a short time, so it is impossible to complete the process of talking and signing, and naturally it is impossible to get the medical records to read This kind of thing.

They have long been used to managing patients without medical records, but what about reading films?

Who would have imagined that Peng Peng would deliberately dig a hole for them?

Even, Zhen Xing and Zhou Muyun once again glanced at the patient's preoperative MRI scan from a distance.

The result is still!

The shape of the long head of the biceps tendon seen on the MRI is very smooth, without any loss of continuity. It is almost impossible to diagnose such a patient through auxiliary examinations!

However, the gold standard for diagnosis in sports medicine is not plain MRI scans, but arthroscopy!

Look at the scene on the display screen of the arthroscope: the rupture of the biceps tendon far from the insertion point...

This shit?

Who could have imagined such a routine?

Moreover, such a diagnosis is inconsistent with the diagnosis of other patients in this section, unless the MRI of the next patient is replaced by this patient, and then the MRI of this patient is transferred to the next patient.

But it doesn't make sense. This group of patients should only have simple rotator cuff injuries?

So where is the patient's MRI?

"Come and try?" Peng Peng tried his best not to underestimate the strength of the five little ones this time.

He knew a general idea of ​​Zhen Xing and Yu Heng's abilities. Now that this operation has left Su Min in Bengbu, but there are still Zhou Muyun and Zhou Cheng, so he can look forward to it a little bit.

Zhou Muyun was in the same group as Zhen Xing, and Zhou Cheng formed a group with Su Min and Yu Heng. Of course, priority was given to those in the group.

Zhou Chengcheng asked: "In such a situation, Mr. Peng, do you still think we can be the main surgeon?"

This diagnosis and treatment procedure needs to be clarified. When Peng Peng spoke, it was Su Min who had already said that he was unable to do what he wanted. It must be confirmed that Peng Peng has already made an assessment of what they can do.

In this way, it can be called authorization.

What if there is a misunderstanding?

"If you feel confident, you can try." Peng Peng said.

Both Su Min and Yu Heng looked at Zhou Cheng, Su Min looked both expectant and fearful.Yu Heng was rather skeptical.But amidst the doubts, there was also a trace of fear.

Yu Heng knew Yang Yifeng, so after he learned that Zhou Cheng was from Hunan Province, he asked why Yang Yifeng didn't come.

Who is Zhou Cheng?How could it be possible that Yang Yifeng from Hunan Province did not come, but Zhou Cheng came instead?And it has never been heard of before, it shouldn't be!

After Zhou Cheng took over the position of chief surgeon, he didn't delay much, because Yu Heng and Su Min next to him were both knowledgeable people, and their kung fu was not weak.

Therefore, showing that he knows arthroscopic skills in front of them will not seem awkward at all, but only feels natural. Even, if Zhou Cheng knows nothing, that would be a strange thing.

Under such circumstances, that week's achievements were well played.

After Zhou Cheng took Su Min's position as chief surgeon, he politely said to Su Min and Yu Heng: "You two, thank you for your hard work."

Su Min and Yu Heng just opened their eyes to respond, and didn't speak, but the meaning was obvious, you go to work, what are you talking about?

Holding the arthroscope, Zhou Cheng checked the anterior portion of the inferior glenohumeral ligament and the middle glenohumeral ligament further downward.

Normally, the anterior bundle of the glenohumeral ligament attaches to the glenoid neck between two and four o'clock.The anterior joint capsule contains 3 separate ligaments with different attachment points.These ligament attachments are fairly normal, with only a small amount of synovial attachment.

Immediately afterwards, Zhou Cheng controlled the arthroscope to enter the inferior recess, and rotated the arthroscope toward the upper glenoid to inspect the glenohumeral ligament and labrum.The integrity of the glenohumeral ligament and labrum is also acceptable.

However, even at this moment, Zhou Cheng did not rush to open the next hole, but gently rotated his upper limbs outward. If the arthroscope can easily move forward in the joint, this phenomenon is called "Warren's passing sign". There is extensive ligament laxity.

Fortunately, this kind of situation does not exist. Peng Peng and others may not be able to know what they are doing, but Zhou Cheng, as the chief surgeon, must also pay attention to all the details that should be paid attention to.

But even so, Zhou Cheng frowned deeply!

Peng Peng walked out of the laboratory at this time, without saying a word, and didn't know what he wanted to do.

Zhou Cheng and others noticed Peng Peng's departure, Zhou Cheng frowned slightly, what does Peng Peng mean?

But in the end, Zhou Cheng continued to do it. With Peng Peng's authorization, he did not stop. The current situation is not beyond my expectation.At least according to the conventional process, restore all the operation steps of shoulder arthroscopy one by one.

I looked at the glenohumeral space before, but now I have to look at the subacromial space.

Immediately afterwards, Zhou Cheng took the arthroscope slightly out of the glenohumeral joint, inserted the prying core, and entered the subacromial space obliquely upward!

The arthroscope is re-entered from the arthroscopic sleeve, and the subacromial space is viewed again!

The subacromial gap turned out to be a mess!

There is a large amount of synovial hyperplasia inside, and the specific structure cannot be seen clearly at all. Moreover, when the arthroscope entered, the synovium was punctured.

A lot of bleeding red mirror.

"Back piercing!" Zhou Cheng shouted to the handwashing nurse.

Peng Peng washed his hands and came in. Seeing that Zhou Cheng was still operating, he raised his eyebrows, but he immediately understood what Zhou Cheng meant!Started to put on my clothes.

Then an assistant, Su Min, immediately inserted a lumbar puncture needle into the subacromial space from the front entrance to drain the water. Zhou Cheng immediately put the flushing fluid, and then washed the blood clean, restored the arthroscopic field of vision, and then Zhou Cheng moved up and down with the waist needle.

The needle for the lumbar puncture was found in view.

"sharp knife!"

After Zhou Cheng received the sharp knife, he punctured the needle along his waist and made another incision. After expanding it with straight forceps, he immediately started cauterizing with the plasma electric knife.

Clean up the joint cavity until only a small part has been cleaned and the shoulder joint capsule can be seen clearly, then Zhou Cheng called the hand washing nurse to bring the probing hook.

At this time, Peng Peng also finished washing his hands again, and walked to the side of the stage.It also seemed a little uneasy.

Moreover, Zhen Xing and Zhou Muyun, who were watching by the side, also washed their hands, put on their clothes, and came to have a close look.

Then Peng Peng found that Zhou Cheng suddenly ran to the gap between the shoulders again, frowned, and asked, "Zhou Cheng, what are you doing?"

The tone was exactly the same as before, as if he was simply asking Zhou Cheng what to do.

Zhou Cheng was operating: "I suspect that this patient also has rotator cuff damage. Generally, when the type 3 acromion has worn out the biceps tendon, the supraspinatus muscle closest to the acromion will definitely not be special. it is good."

"However, this patient's situation is a bit special."

"He doesn't have a type III acromion." Zhou Cheng calmly told Peng Peng what he saw, and moved the arthroscope to a position where he could see the acromion.

Zhou Cheng then looked at Su Min: "Does this patient have a history of trauma?"

"I remember that he has a history of trauma." During the ward rounds, Su Min asked about the medical history. Although everyone has heard it, Su Min must have the deepest memory.

"Yes! It was the fifth day after the trauma when I was admitted to the hospital. I came to the outpatient clinic only after the pain was unbearable, and then I was admitted to the hospital. The patient is currently 52 years old. He took an MRI in the outpatient clinic and showed acromial impingement syndrome. He is also suitable for his age. Then I took it in." Su Min quickly nodded and replied.

In the previous diagnosis process, it was only thought that the patient had acromial impingement syndrome, and a rotator cuff injury was suspected.

But, when you open it up, the first thing you see is a ruptured biceps tendon!

This made Su Min a little suspicious of life.

"However, I also saw just now that the biceps tendon injury of this patient is fresh, not old. And during the physical examination, no muscle atrophy was seen!"

"And the patient's MRI showed no edema in the tendon. Therefore, the patient is likely to have a problem with the MRI."

Peng Peng stretched out his hand and took over the patient's shoulder joint capsule. He only probed for the deformity of the supraspinatus muscle, and suddenly saw the contracted supraspinatus muscle.

Then continued: "You continue to talk. Now you are the chief surgeon, and we are your assistants."

Peng Peng was very open-minded, and didn't say anything professionally related to disturb Zhou Cheng's thoughts.

Zhou Cheng said: "I also looked at the patient's supraspinatus muscle just now. It is a huge rotator cuff, and the retraction must exceed 5cm. This patient may eventually undergo biceps tendon transposition!"

"Yes, you are right, you continue. We have prepared the corresponding equipment. Tour, open the equipment bag!" Peng Peng immediately said to the patrol nurse in the operating room.

"????" Zhou Cheng raised his head and looked at Peng Peng.