Translator: EndlessFantasy Translation Editor: EndlessFantasy Translation
“Insert a 10-0 surgical silk thread.” During the suturing process, Ling Ran gave instructions without even looking up.
The scrub nurse answered without hesitation. She immediately opened a 10-0 surgical silk thread pack and installed it into a needle-holder. Subsequently, she placed the needle-holder gently onto Ling Ran’s palm. The contact produced a light sound, and it caused a red flush to appear on her fair cheeks.
Ji Tianlu raised his head immediately. He realized something and asked, “What’s wrong?”
In repairing an Achilles tendon, the 10-0 surgical silk thread was considered a thicker thread, but it was still three times finer than the 4-0 surgical thread that Ling Ran had used before. So, there must be a reason for the chief surgeon to change the thread suddenly.
Ling Ran was always willing to share more when it came to discussions of skills.
Ling Ran directly pointed at the bottom of the microscope with a forcep while he sat at one end of the two-head microscope. He said, “The rupture ends were not uniform enough. If we sutured it using the 4-0 surgical thread, there will be some defects after we trim it.”
The pulling force of a fine thread was not high. If all fine threads were added into one of the severed ends densely, the total pulling force would be increased. However, if the fine threads were scattered in groups of two or three threads, the pulling force would be much lower than a single 10-0 surgical silk thread.
Meanwhile, while tendons were elastic, the Achilles tendon was even more elastic. This flexibility would cause a problem in the surgery. When a surgeon tried to pull the ruptured Achilles tendon together, it would go along the flow and allow itself to be pulled. However, once the surgery is finished, the Achilles tendon could return to how elastic it was. Therefore, it would pull back in a stronger and more powerful manner.
If the length of the two ruptured ends of the Achilles tendon were the same, the pull-back force would be similar. Thus, the functionality of the Achilles tendon would still be maintained. But if the structure of the two ruptured ends of the Achilles tendon was irregular, then the length of the Achilles tendon when pulled back would be different… The longer Achilles tendon would be pulled back with less force compared to the shorter Achilles tendon. The difference would make the Achilles tendon be exposed to an even higher risk of rupturing again.
This was just like suturing five rubber bands of the same length compared to suturing five rubber bands of different lengths together, the former option would lead to a better suturing effect and stronger endurance.
The solution was quite simple. With the use of different threads of varying strengths, the strength of the threads could complement the weakness of the tendon’s strength in order to ensure that the postoperative tension of the tendon would be comparable.
However, the solution that Ling Ran considered normal had shocked Ji Tianlu. His solution even astonished everyone in the demonstration room watching the screen, including Doctor Qu.
A resident doctor could not hold his curiosity and asked, “Did you all see uneven ends?”
Another resident doctor next to him sneered and said, “There’s so much blood. You can’t even clearly observe the surgical field. At most, you can only see the tips of some of the hair on the skin.”
“Maybe the judgment is based on other requirements? The view under the microscope can’t be clearer than ours. Our screen is huge and we don’t have to operate,” the resident doctor said while moving closer to the screen. He stared at the screen like he was scanning over it to slowly in search for the signs.
“Maybe he made his judgment from the MRI scans,” said Zhu Tongyi. He thought for a second and explained again, “If we consider the vascular distribution, there is a possibility… but it’ll be more complicated.”
“It is a matter of metaphysics now.” The group of doctors turned around and looked at Doctor Qu after he said his words.
Doctor Qu felt slightly regretful. He coughed twice and said, “What I meant was, he sutured the tendons so quickly just now that it’s impossible he saw it more clearly than we did. Besides, even if he really noticed the frayed ends, how could he know which suture should be used to replace it? This is totally a gamble, or it’s just his intuition.”
Doctor Qu forcefully swallowed his comment of Ling Ran’s choice being totally unreliable, and it choked him slightly.
He did not want to talk at first, that was the reason why he stood at the back of demonstration room. He planned to observe the situation and leave the room quietly. Still, Doctor Qu did not expect Ling Ran to be able to operate at such a speedy rate and came to the peak of the operation in such a short time, making the doctors unable to take their eyes off him.
Doctor Qu himself was a doctor in charge of Achilles tendon repairs. He was reluctant to leave when he observed the way Ling Ran performed the surgery.
In certain aspects, Doctor Qu was slightly impressed by Ling Ran’s surgical techniques. However, the operation of changing threads was something that Doctor Qu could not understand, and it was not one he would acknowledge.
But just like how Doctor Qu thought Ling Ran’s judgment in the operating theater was unreliable—even though he did not say it because he forced himself to not say them—Zhu Tongyi’s explanation was also unreliable.
He himself was a surgeon who performed with the Kessler suturing technique. He could not believe that someone was able to observe the full state of the Achilles tendon from the vascular distribution. Not even from the MRI scans could allow the surgeon to receive such fine details. At least, the surgeon could not be make the judgment on-the-spot; the judgment would be more appropriate after the postoperative analysis was done, or a mortality analysis after a patient accidentally died.
The surgeons should be very clear on the strengths of the suture threads right then and there.
Currently, Ling Ran had changed the 10-0 thread to a 4-0 thread, which meant that he knew the Achilles tendon that would be sutured by the 10-0 thread was much shorter, and therefore needed a greater pulling force. But neither the vascular distribution nor the MRI scan could possibly provide information like this.
At the very least, Doctor Qu himself did not know the ways to gauge information like this, and neither had he ever heard of any medical imaging expert who could do this.
Zhu Tongyi looked at everyone, smiled, and said, “Since we couldn’t get it, we’ll try to ask. Just treat it as a surgery for educational purposes.”
Zhu Tongyi pressed on the call button without any hesitation right after he finished talking. He said, “Ling Ran, how did you determine the uniformity of the rupture ends and what sort of tensile strength in the thread was required?”
Compared to the first question, the second question had a clearer direction.
If you wanted to pull a shorter rubber band, you would need a greater pulling force. This was a simple question for an engineering experiment. There were devices that could measure the pulling force, tensile strength, and the sheer strength of a material. However, the Achilles tendon of a living person could not be tested this way. There was also no device that could perform a task like this in the operating theater.
Therefore, how did Ling Ran judge the amount of strength needed in a thread? If Ling Ran had just made the judgment that the ruptured ends were frayed without any corresponding proof, it would not mean anything.
In fact, when general doctors performed surgery like this, they did not care about the pulling force of the thread; they would just complete the suturing. When they encountered problems of frayed ends, most of them would just solve it with replantation, such as the case in free gracilis muscle transplantation and the autogenous bone grafts from the ilium. The shorter Achilles tendon could be sutured with a fragment of the tendon to make the length of both tendons the same. A longer tendon could also be used in the replantation to reduce the possibility of ruptures.
Doctors who were able to complete this kind of surgery were no longer called general practitioners. They were doctors of Doctor Qu’s caliber, who was considered a doctor that was the backbone of a famous medical institution in the country.
Ji Tianlu’s standard was slightly higher than Doctor Qu’s, but he, too, could not understand Ling Ran’s surgical procedure, so he watched Ling Ran doubtfully as well.
Ling Ran did not answer immediately. Only when the 10-0 suture he had just obtained was strung up did he reply slowly, “I felt it with my hand when I pulled it.”
“Feeling?” Doctor Qu laughed. He could not help but move forward. Then, he pressed on the call button and said, “How did you use your feelings as the reference for the surgery?”
Ling Ran hummed and said, “I always massage other people’s tendons, fascia, and muscles. I can roughly estimate the strength of the pulling force with my hands. It shouldn’t differ much.”
“You must be kidding me, right?” Doctor Qu said before he remembered that he forgot to press the button. So he pressed it and said it again.
Ling Ran answered simply, “No.”
This skill belonged solely to Ling Ran, and he had gradually developed it on his own.
Osteopathic massage was composed of pushing and poking techniques which targeted the muscles. More specifically, it targeted the tendons and ligaments that lied within the muscles.
When Ling Ran performed finger replantations or used the M-Tang technique, the tendons that he touched were so weak that he could not accurately calculate the strength needed even with the Master Level Osteopathic Massage. Or rather, he should say that it was useless even if he managed to calculate it. The tendon in the thumb was thinner than a chopstick. If it was ruptured into uneven ends, the best way was not to suture it separately, but to cut it uniformly and then suture it.
But the Achilles tendon in the foot could not be repaired this way. The Achilles tendon was the thickest tendon, and its length could greatly affect athletic ability. Furthermore, the rupture degree was not the same. If the shorter Achilles tendon was used as the standard and both ends were cut to the same length as the shorter Achilles tendon, the Achilles tendon could basically no longer be used. Another tendon would need to be transplanted.
But the muscles held by Ling Ran were not that much thicker than the Achilles tendon, they were a close correspond to each other. The Achilles tendon was the thickest tendon in the human body, therefore, if he could understand the other tendons by pushing and poking at them, he could also confirm the pulling force of the Achilles tendon.
Ji Tianlu looked up and glanced at Ling Ran. “Did you really feel it?”
Ling Ran replied again, “Yes.” His hand reached out and he said, “3-0.”
He wanted to suture the other ruptured end of the Achilles tendon.
Ji Tianlu stared at Ling Ran’s confident expression and said, “If you can really feel it, that’s really amazing.”
Ling Ran made a humming sound. He did not reply. Ji Tianlu watched his operation and almost fully trusted in Ling Ran in his heart.
Doing things based on feelings might sound ridiculous from the patients’ point of view. They would think, ‘How could my precious body be manipulated by your feelings?’ And yet, this was really how human technology had progressed. The more high-end the surgery was, the more doctors relied on their feelings in a surgery, especially when the surgery involved internal organs.
When Ling Ran stopped the bleeding with his bare hands during the liver surgery, it was completely based on his feeling. Naturally, that feeling was backed by his experience in the study of human anatomy, but at the end of the day, they were not something that could be seen or calculated.
Similarly, a heart surgery was always filled with the surgeon doing things based on an extraordinary “feeling”, and that was why it led to the birth of so many miracles. In neurosurgery, the brain functions categorized by humans were not always correct, but when it came to surgery, there was no hesitation in surgeons.
There were even more internists who made judgments based on feeling. Take the great ward rounds in Peking Union Medical College Hospital as an example, every internist could provide their suggestion with sufficient proof, but at the end of the day, there was only one truth.
In the end, the talented internists were doctors who always had better intuition.
When Ji Tianlu performed the Achilles tendon surgery as the chief surgeon, he also did it based on his own feeling. If he felt that the elasticity on an Achilles tendon was too strong, he would transplant it longer. If the elasticity was weak, he would forcefully pull it and suture it.
They could not really perform surgeries without relying on feeling. Until now, there was no device that could help surgeons test the pulling force of the Achilles tendon. To be more exact, what else could they do even if the pulling force was measured? The Achilles tendon differed among people. Take the length as an example, since it was the easiest example to be provided. The Achilles tendon in Asians was typically 5.9 inches long. The Achilles tendon of Allen Iverson was said to be 9.8 inches long, while Michael Jordan had 11.8 inches. So, the pulling force would be totally different.
However, when Ji Tianlu used his feeling to perform the surgery, he would not spell it out deliberately. Not that anyone had asked him about it before, anyway. At that moment, Ji Tianlu admired Ling Ran a little for his straightforwardness.
Right now, Doctor Qu, who never “felt” anything during surgery, was fuming. He huffed angrily as he pressed on the call button, and said, “Doctor Ji, shouldn’t we stop the surgery now?”
Academician Zhu Tongyi was in the demonstration room, while the young and capable Chief Physician Ji Tianlu was in the operating theater. Doctor Qu, who was still wise, did not dare to make demands. He only asked inquiringly.
Ji Tianlu did not even pay any attention to Doctor Qu. He spoke bluntly, “You can just follow and learn.”
Doctor Qu’s face turned red instantly.
Both of them were similar in age, but their statuses were totally different. If the senior doctor Ji Tianlu chose not to be good to Doctor Qu, Doctor Qu would definitely be humiliated.
Doctor Qu silently walked away from the microphone he used for the conversation and moved to the back of the demonstration room.
He did not want to leave immediately, especially when Liu Weichen was still there. Doctor Qu would not give up willingly until he saw the final result.
“4-0 surgical silk thread,” Ling Ran suddenly asked for a thinner suture. He did not even raise his head and continued to suture. In this simple Achilles tendon repair suture, he only cared about how good the suture can be without considering the failure rate.
