Nineteenth Century Medical Guide

Chapter 503, Page 499: Choosing a Path
Until the second half of the 19th century, progress in urology was still very limited, even far less than that in abdominal surgery, which has a more complex anatomy.

The latter has a large patient base and pioneers like Bill Roth. Although the success rate of the surgery is very low, thanks to the more diverse and convenient surgical approaches available for the abdominal cavity, the surgical techniques are constantly being innovated, which has laid the foundation for future optimization.

In contrast, the urinary system is located in the retroperitoneum, and surgical treatments involving the kidneys are extremely rare.

The only surgical procedures available were occasionally incisions for perirenal abscesses and pyonephrosis, and bladder surgeries were limited to lithotomy and lithotripsy.

Although Carvi has performed several bladder tumor removals in the past two years, compared to cesarean sections and gastrointestinal surgeries, removing tumors while preserving bladder function is still too complicated.

The closest to Kavi's level was a nephrectomy reported in Prussia last year, performed by a doctor named Simon from Heidelberg.

A sizable mass could be felt in the patient's lower back. Coupled with long-term hematuria and severe lower back pain, Simon diagnosed it as kidney cancer. Upon opening the lower back, a huge tumor was found. After careful dissection proved fruitless, the entire tumor, including the kidney and most of the ureter, was removed.

The surgery was successful, and the patient is recovering well.

Dr. Simon, the surgeon, immediately submitted the article to the surgical journal Carvy. After several revisions and ten months of correspondence, it was finally published.

Historically, nephrectomy was a remarkable innovation.

Later, some people wanted to use this surgery to perform kidney lithotomy to treat kidney stones, but unfortunately, many attempts ended in failure.

It wasn't until the late 19th century, with the further standardization of surgery and the gradual clarification of anatomical structures, that the development of urology accelerated.

With Klavey's groundbreaking work preceding it, the nephrectomy, which should have been widely publicized, failed to generate much buzz. The surgery was already niche, with limited applications and not particularly challenging, so it was quickly overshadowed by other surgical procedures.

Compared to Simon's fleeting success, Ju Yong, who was at the main hospital back then, received more attention from the surgical community.

After Kavi left Paris, he and his student Albaran began to study many prostate surgery techniques.

This was partly due to Kavi's suggestion, and also thanks to Mosier, who went to Vienna for "further studies" back then.

Mosier lived in Austria for two years, creating numerous atlases of bladder and prostate surgeries. The finest examples were the bladder cancer removal surgery performed on Edm, which became a significant driving force behind the two men's dedicated research on the prostate.

Through tireless efforts, Ju Yong and Albalan advanced the two-step perineal bladder incision radical prostatectomy, a procedure they pioneered, by a full eleven years.

In modern times, surgery is no longer the absolute gold standard for treating benign prostatic hyperplasia (BPH). Internal medicine medication is just as effective and easier. Even if surgery is necessary, open surgery is a last resort; minimally invasive procedures that can be performed transurethral are the preferred option.

But more than a hundred years ago, without antibiotics and advanced technology, surgery was considered successful as long as there was a chance of a complete cure.

Of course, whether the surgery is successful or not has never been an admission criterion for the Cavite Surgical Journal.

Kavi wants not only innovation, but also to perfect the technology and make it an industry benchmark worthy of being included in textbooks.

This procedure originally required nearly 20 years of technical optimization to not only reduce intraoperative bleeding and postoperative infection, but also to overcome the disadvantage of slow recovery.

Like many urological surgeries, radical prostatectomy only truly matured in the late 19th century. Only a truly mature radical prostatectomy can greatly alleviate the suffering of elderly men with chronic benign prostatic hyperplasia (BPH) and avoid the inconvenience and infection risks of long-term catheterization.

But now, with the atlas brought by Mosier and the guidance of Kavi himself, the time to master the surgery has been drastically reduced to less than two years, and it was included in Kavi's surgical journal at the beginning of this year.
Even before Ugo's surgery began, Kavi had discussed the prostate and praised Juyong and Albalan's innovative surgical approach.

Bergett was initially a little impatient: "We're having kidney surgery, why do you keep bringing up the prostate?"

"Think about it again."

Bergert had witnessed the initial stages of this surgery and even assisted them during the procedure, but unfortunately, he was not in Paris when the final surgical summary and report were prepared, and thus his name was not recorded.

Of course, the reason I can remember it so clearly is not because of these things, but because Ju Yong used a double perineal bladder incision, which was very bold.

Bilateral incisions result in double the risk of bleeding and infection, and a slower recovery. However, bilateral incisions also mean double the surgical field, allowing for easy dissection of the prostate and the removal of bladder stones, a common problem.

At first, Bergett didn't understand, but as Kavi explained in more detail, he finally realized Kavi's intention:
"You mean, we're now like Ju Yong and his team, needing to solve two problems with one surgery?"

"That's right."

Kavi hesitated for a moment, but still wanted to be as precise as possible: "Although I am skeptical of their idea that the cause of benign prostatic hyperplasia is bladder stones, the purpose of the two surgeries is the same."

Due to the unique location of Ugo's injury, the surgical incision needed to be longer than that for a typical kidney surgery, in order to maximize the area to be explored.

"The incision needs to be long enough, but where should it be placed?" Bergert asked curiously.

"That's a question for you," Kavi said, having already made up his mind. "If you were to perform the surgery, what would you choose?"

The surgical approach is the path taken to enter the human body, encountering skin, fascia, muscles, blood vessels, and nerves. Which parts to avoid, which to cut, which are irrelevant, and which will require suturing post-surgery all determine the risk of post-operative complications and the speed of recovery.

Choosing the approach is like deciding the route of an army's attack; it may seem insignificant, but sometimes it can determine the success or failure of the entire operation.

Having been by Kavi's side for so long, Bergett was well aware of the importance of the surgical approach and appeared very cautious, washing his hands while considering several possibilities.

He needs to mentally recreate the anatomical structures he will encounter at each approach point, and after repeated attempts and selections, he can get the answer he wants.

In comparison, Antonio's level is several levels lower.

He had no concept of approach, and his thinking was straightforward. He just thought that he would find the nearest place to make an incision, and then suture it to complete the operation.

What he really cared about was the white powder used when washing his hands.

In fact, Anders had already used these powders in his surgery, and he was certain that they were not the phenol that Kavi mentioned in the magazine.

However, he was extremely nervous because it was his first time assisting Kavi on stage. In addition, the scene was too chaotic, and his attention was entirely focused on the surgical procedure, so he didn't have a chance to speak even if he had questions.

Now that the surgery was long over and he had some free time, Antonio, despite knowing full well that it was a disinfectant solution, pretended not to understand and asked, "Dr. Cavill, why does this water taste strange?"

Unlike the established surgical history, phenol's dominant position in disinfection was challenged from the outset. Over the past two years, the use of bleach for disinfection had become common practice among FAO surgeons. Therefore, Kavi didn't immediately grasp the situation: "Oh, it's just disinfectant."

"Disinfection? It's the preoperative step to prevent postoperative wound rot?" Antonio was somewhat surprised, and deliberately leaned down to smell it. "This doesn't smell like phenol, does it?"

"phenol?"

Just as he was about to put his wet fingers in his mouth, Kavi quickly stopped him, saying, "We're using bleach, not phenol."

"What about phenol? I remember you mentioned using phenol for disinfection in your magazine."

“That was just the initial suggestion. The key is the concept of disinfection. Phenol is toxic, and we stopped using it a long time ago.” Kavi picked up a brush and carefully brushed his fingernails. “Bleach is used in small quantities and is cheaper than phenol. You can find it in any textile factory.”

"No???"

He had been requesting phenol from the hospital for six months, a substance that could determine the success or failure of the surgery, only to find that it was already a product that others had discarded. The shock this brought him was far greater than the delicate and brilliant intestinal repair surgery he had just witnessed.

Antonio was puzzled: "Preoperative disinfection is so important, why haven't so many surgical journals mentioned bleach?"

Kavi dipped his hands into the pool of clear water and thought for a moment: "Perhaps it's already common sense."

"."

“But you’ve reminded me that common sense can’t be confined to the surgical circles of Vienna and Paris; it needs to be disseminated further.” Kavi dried his hands and walked towards the operating table. “So, has the surgical approach been chosen?”

Begot stood beside him, following the disinfection process step by step, from bleach and brush to soaking in clean water: "Let me think about it some more."

"What about you?"

Antonio was a little confused, unsure whether it was because of the bleach or the question: "I... I've never had kidney surgery, so I don't know anything about the approach."

“It doesn’t really have much to do with whether I’ve done it or not, I haven’t done it either,” Kavi explained repeatedly. “The underlying logic of surgery is the same, you can definitely draw some inspiration from other surgeries.”

That's about it for Antonio; in fact, he knew very little about kidneys.

Spain is a country that has been in decline for two hundred years, and its surgical teaching level is far behind that of other major European countries. This is something that no one can change.

Maintaining the intensity of his anatomy training after graduation was already difficult, and Antonio was also very "picky." His training was very targeted, focusing on the gastrointestinal tract, and by the time the training ended, the corpses were almost completely decomposed.

Even if he were to suddenly decide to dissect the urinary system, he would stop at the bladder due to the difference in the amount of surgery performed, and almost never go up to the kidneys.

Actually, this is to maintain the feel of the lithotomy procedure, since there are just too many patients with bladder stones.

Antonio's knowledge of kidney anatomy was already poor enough, he wouldn't even consider the choice of approach, and he didn't have time to make a judgment in that short time.

Like millions of other surgeons, he was concerned with the surgical process itself; the pre- and post-operative aspects were merely secondary.

But seeing Cavie's eager eyes, Antonio couldn't refuse: "Just do it along the side of the midline, or the center incision will do, just like we did with Anders' internal bleeding earlier."

Kavi said thoughtfully, "This way, you'll encounter the gastrointestinal tract first before you can enter the retroperitoneum, which is a complicated process."

“But the surgical field is easily exposed, and we won’t encounter those annoying ribs. The patient’s bed position is also the most stable,” Antonio explained. “Moreover, we cannot be completely certain that other organs are intact.”

Having served as the head of surgery for so many years, he has all the necessary experience.

Unfortunately, the concept was still in the mid-19th century and had not yet caught up with the rapidly developing level of French and Austrian surgery.

"What do you think?"

Bergert shook his head: "There are many options for the renal approach. As Antonio said, the anterior approach has many advantages, such as a wide surgical field and the ability to see many major blood vessels. However, the disadvantages are also obvious: the approach is too far from the site of trauma, the thoracic cavity is not easy to operate, and there is a risk of intestinal adhesions after surgery."

Intestinal adhesions?
What is intestinal adhesion?
Antonio heard another technical term he'd never heard before, and before he could ask about it, Bergett had already shared his opinion: "I choose the posterior approach."

"The back." Kavi, fully dressed and wearing an apron, walked to the operating table and asked, "Why?"

"It allows for easy exposure of the renal pelvis and upper ureter without the various complications of the anterior approach."

Bergert also wiped his hands and changed his clothes: "It seems that Simon's kidney removal surgery used a posterior lumbar incision, choosing the fascia approach, avoiding many important muscles, resulting in very few postoperative complications and a very fast recovery."

I heard that patient was supposed to be discharged in a little over two weeks, but I wonder how he is doing now.

“I’m perfectly fine,” Kavi replied.

"You know that too?"

“Simon asked a question inadvertently in his letter,” Kavi said, changing the subject. “Back to the path of entry, your idea is not bad.”

Bergert knew he wasn't right: "It seems you have a different idea."

“I prefer the lateral approach.” Kavi pointed to Ugo’s ribs. “It’s closer to the kidneys here, so we can locate them immediately and determine whether the diagnosis of diaphragmatic hernia is correct.”

"It is indeed closer to the kidneys, but furthest from the damaged renal pelvis!"

Bergert felt this was inappropriate: "The surgical field of the intercostal incision is extremely limited, and repairs are very difficult. Besides, the intercostal spaces have abundant nerves and blood vessels, so damage during surgery is inevitable."

“Yes, there are indeed many risks,” Kavi readily admitted. “Therefore, my approach is not a typical lateral approach, but rather an extension.”

Having said that, he had already put on gloves and asked them to help push Ugo into a side-lying position, using a cushion to immobilize him. Then he picked up a pair of hemostats, and the jaws moved along the intercostal spaces forward to the front of his abdomen.

“Make a combined thoracoabdominal incision,” Kavi said confidently. “If there are other issues within the chest cavity, the incision can be extended further back.”