Chapter 33: ‘appendicitis Surgery’
“Xiao Lu, don’t be nervous later, appendicitis is a beginner surgery for many surgeons.”
“Although you were in orthopedics standardized training before, once you generally understand the surgical procedure, operating will be much simpler than suturing tendons.”
“If you really want to let go, even an intern can handle this type of surgery for the first time. You already have chief surgeon experience, so there’s no need to be nervous,” Chen Song said as he walked alongside Lu Cheng into the emergency operating room.
Orthopedics and general surgery are different specialties. Lu Cheng was previously in orthopedics standardized training, and Chen Song feared Lu Cheng would be particularly nervous.
The incandescent lights overhead approached and receded one by one, making Lu Cheng’s eyes flicker, but Lu Cheng’s mindset was relaxed: “Teacher Chen, it shouldn’t cause any problems, right?”
“I really haven’t performed an appendectomy before. During my orthopedics standardized training, when I rotated to general surgery, I didn’t encounter a single case, because Zhongnan Hospital’s general surgery department doesn’t admit appendicitis patients, and the emergency department rarely admits them.”
“There won’t be any problems, don’t worry…”
“Actually, appendicitis is best done laparoscopically; the incision will be smaller. However, at your county hospital, you don’t need to be so particular.”
“Just make a small incision and go in…”
After helping the patient into the supine position, Lu Cheng went out to wash his hands, then routinely disinfected the abdominal skin, draped sterile towels, and exposed the surgical area…
Lu Cheng waited until Chen Song had also put on a sterile surgical gown and mask before glancing at his skill panel.
【 General Surgery Basic Procedures: Appendectomy（ Beginner 1/5）……】
I haven’t practiced surgery, nor have I properly watched many tutorial videos, so my operational proficiency certainly won’t increase, but that doesn’t prevent Lu Cheng from remembering the surgical procedure for appendectomy and then proceeding step by step with his basic skills.
Lu Cheng had watched tutorial videos, and he also had a certain level of basic skills for incisions, so he very proficiently found McBurney’s point.
After using tweezers to outline the incision line, Lu Cheng then asked Chen Song with his eyes.
After receiving a nod from the other person, Lu Cheng immediately made an oblique incision about 5 cm long, aligned with the line connecting the umbilicus and the anterior superior iliac spine on the right.
He incised the skin and subcutaneous tissue without much deliberation. After Lu Cheng finished operating, Chen Song wiped the incision with gauze; there was very little bleeding.
He then praised: “Not bad, your basic skills for incision are solid, and you have a good grasp of the depth for the first cut.”
“Next, use the electrocautery.”
“Circulating nurse, adjust the electrocautery flow rate,” Chen Song said.
“It’s already adjusted.” The circulating nurse was experienced and was busy preparing the saline for irrigation.
After using the electrocautery for local hemostasis, Lu Cheng bluntely separated the external oblique aponeurosis along the direction of the muscle fibers. He then continued to proficiently and alternately bluntely separate the muscle layers along the direction of the muscle fibers with vascular clamps.
Lifting the peritoneum and confirming no intestinal adhesions, Lu Cheng made a small incision and then cut the peritoneum upwards and downwards…
“Teacher Chen, there isn’t much pus or exudate. The appendicitis is likely localized. We’re quite lucky,” Lu Cheng explained, trying to create more opportunities for himself to operate.
He wanted to explain to Chen Song that he was very familiar with the surgical procedure; even if he hadn’t operated before, his basic skills were enough to support him!
Assessing the grade of appendicitis is also a manifestation of cognitive ability.
If it’s an appendiceal abscess, an appendectomy is not suitable.
“Okay, continue. First, find the colon, and then find the appendix at the intersection of the taeniae coli,” Chen Song instructed.
The point where the three taeniae coli converge at the cecal cul-de-sac is where the appendix is attached.
Lu Cheng found it easily.
After confirming the location, Lu Cheng immediately clamped the mesenteric border of the appendix tip with an appendix clamp and gently pulled it out of the incision.
The process was smooth, with no adhesions. This is most suitable for beginners to practice on, and interns with rich theoretical knowledge can also perform it.
However, Lu Cheng still cautiously asked: “Teacher Chen, can I continue?”
Learning surgery requires a step-by-step approach. Even the simplest surgical technique is still a technique, and there needs to be a fallback.
Chen Song was Lu Cheng’s greatest confidence as chief surgeon; Lu Cheng would not get carried away!
“Continue. Finish it directly,” Chen Song nodded.
Lu Cheng held a physician qualification certificate, his practice location was this hospital, and his scope of practice was surgery. This is just the simplest Level 1 surgery, not an over-level surgery.
With Lu Cheng’s basic skills, even if he wasn’t there, Lu Cheng could complete it as long as he didn’t mess around.
Lu Cheng meticulously handled the appendix root mesentery with a curved vascular clamp, opened a window, and clamped the appendix mesentery and the contained appendiceal artery with two vascular clamps.
After cutting the mesentery, the proximal end was ligated twice with absorbable sutures.
After completing local hemostasis, Lu Cheng continued to gently clamp and compress the appendix about 0.6 cm from the cecal wall with a straight vascular clamp, thinning the tissue, and then performed a purse-string suture on the cecal wall before continuing to clamp the appendix…
The appendix was cut with a surgical knife close to the proximal vascular clamp and then routinely sent to the pathology specimen bag.
Lu Cheng treated the mucosa of the appendix stump with an iodophor cotton swab, released the proximal compression clamp, then clamped the stump with a mosquito hemostat and gently inserted it into the center of the purse-string suture on the cecal wall.
At this moment, Chen Song simultaneously tightened the purse-string and tied the knot.
Then, he began to check if the embedding was satisfactory and if there was any bleeding or oozing.
After being satisfied with everything, Chen Song smiled: “Not bad, very standard, step-by-step. You basically operated according to the textbook, which proves you’ve read the book and watched the tutorial videos seriously.”
Lu Cheng replied: “Teacher Chen, an appendectomy is also a serious surgery, not a joke.”
“I did watch some, after all, it’s a routine diagnosis and treatment for the emergency department.”
“It’s possible I won’t have the chance to perform it, but I can’t be completely ignorant,” Lu Cheng said without too much humility.
Chen Song didn’t praise him excessively: “Continue to finish it…”
In fact, for Lu Cheng to perform an ‘appendectomy’ with his current basic skills is a bit like using a cannon to swat a fly; he doesn’t need such robust basic skills to complete it.
“Okay.” Lu Cheng then irrigated the local area and continued with the suturing operation…
The surgery was completed without any unexpected incidents, as anticipated.
There was a certain change on the panel: 【 Appendectomy（ Beginner 2/5）……】
【 Independently completed appendectomy, relieved the patient’s acute abdominal pain, and provided professional postoperative guidance, gaining 1.2 skill points】
The gains were significant. Performing one surgery directly increased the proficiency of appendectomy by 1 point due to his sufficient basic skills.
He also received an additional 1.2 skill points, a true win-win.
It’s actually easy to understand; basic skills are an external manifestation of overall surgical ability, analogous to a person’s literary attainment.
A literary scholar proficient in writing novels who then decides to learn to write poetry might not be proficient, but they wouldn’t need to start from scratch, learning bit by bit.
Their inherent literary talent would allow them to improve rapidly in the early stages.
The difficulty of performing an appendectomy is not high, and the operation is simple. With basic skills as a fallback, one doesn’t need skill points to improve; skill points should still be used for more critical surgeries.
For example, key procedures such as splenectomy, spleen preservation surgery, gallbladder removal, and gallstone removal with gallbladder preservation.
