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Chapter 106: Perineurium Anastomosis

Translator: EndlessFantasy Translation Editor: EndlessFantasy Translation

“Li Huamin, right?”

“Yes. Thirty-one years old, female, her palm was pierced by a hard object when she fell…”

Ling Ran entered the operating theater, asked a question, and craned his neck to look at all kinds of scans while listening to Lu Wenbin’s report.

He did not usually make such a request, but ever since he began asking to have a look at the scans, the Emergency Department had specially added a large portable backlit board into the operating theater.

This was how hospitals were like as institutions. If you were skilled enough, you would get whatever you wanted; if you could not get what you wanted, it meant that you were not skilled enough. To put it in simpler terms, how much does one need to spend to buy a life, and how much does one need to pay to retain his hand?

Hospitals had always spared no expense investing in highly-skilled doctors. The leaders who were qualified to become the decision makers of the hospital also knew clearly that the worth of a highly-skilled doctor could not be calculated purely based on surgery fees and hospital bills.

Of course, to be considered a highly-skilled doctor, a doctor’s standards must indeed be extremely high—far exceeding the average level of doctors. When it came to this, doctors were quite similar to athletes.

An average doctor was like an average athlete. To become high performance athletes or elite athletes, they would have to work so hard that they would feel like they were going to die from exhaustion. It was extremely strenuous, but who would care about them? Who would know about the hard work they put in? Who would show them solicitude?

Outsiders would not care about whether the athletes had trained for five, eight, or even ten years. People in the industry would also only see them as cornerstones. They were worth about as much as pebbles.

A highly-skilled doctor was more like a highly-skilled athlete who was at least qualified to be ranked in the provincial games.

The requirements were even higher in larger tertiary grade A hospitals. You would need to be qualified to participate in the national games. Or at the very least, you needed to have the potential to be able to grow to such a level in the coming years.

Ling Ran obviously had that kind of potential. The fact that he had performed more than a hundred surgeries using the M-Tang technique was proof to that.

The leaders of the hospital did not even need to spend too much energy making comparisons. They could gauge Ling Ran’s worth just by comparing him with Department Associate Director Pan.

Department Associate Director Pan was a renowned hand surgery specialist in the province. Even though he was not extremely famous, he was still considerably so. He was someone who would definitely be invited to any conferences related to hand surgery in the province; when it came to any national conferences related to flexor tendons and tendons, he would most likely receive an invitation letter too.

If you only looked at the M-Tang technique, Department Associate Director Pan was one of the top specialists in Changxi Province, and was the first choice when people in the industry were to transfer their patients to a hand surgeon.

Because Ling Ran had only been in Yun Hua Hospital for a short time and his status was a rather awkward one, Yun Hua Hospital’s administration had yet to begin discussing about it and come to a final decision.

But internally, Ling Ran was already treated very well in the Emergency Department. He had the right to use the operating theaters at all times, received the surgery fees in full, received the profit made from medicine and medical consumables in full, and had assistants and housemen who spent half their time working solely with him.

Of course, the ability Ling Ran displayed was even more of a pleasant surprise. For a doctor to have a steady stream of patients discharged with a ‘good’ rating would be an astonishing feat in any hospital in the country. Even Lu Wenbin felt a surge of dread when he watched Ling Ran right then.

“The ulnar nerve is damaged, right?” Ling Ran had looked at the film before this, but he asked again just to be sure.

Lu Wenbin froze for a moment and quickly said, “There’s indeed damage to the ulnar groove.”

Even though Lu Wenbin was quite accustomed to the way Ling Ran did things, he rarely saw Ling Ran pay any attention to the patients’ nerve damage.

Some of the nerves that suffered minor damage did not need to be sutured. For slightly more serious nerve damage, doctors could choose whether to suture them or not. Patients with even more severe nerve damage like the so-called associated neurotmesis would not have been sent to Yun Hua Hospital’s Emergency Department.

All the specialized departments of modern hospitals screened patients to begin with, and they would send those with complicated conditions to more well-equipped hospitals. To increase the success rate, ordinary hospitals would only take on cases they were familiar with.

Because Ling Ran did not know how to suture nerves in the past, he used to screen out cases with serious nerve damage. Similarly, he also screened out those with associated fractures.

Now that he knew how to suture nerves, he could take on patients with these kinds of surgical indications.

Ling Ran quickly came to a decision. “After I suture her tendon, I’ll be suturing the perineurium of her ulnar nerve.”

The fact that a patient fulfilled the surgical indication meant that the condition of a patient tallied with the standards set by conventional surgery. It was actually very easy for patients with nerve damage in the hands to fulfil the surgical indication, because primary suturing (when it came to wounds that healed well in the early stages) was very effective when used on patients with nerve damage.

Aside from that, it was better to suture the patient’s nerve than to leave it like that. This was a self-evident fact.

However, very few doctors liked to suture nerves. Doctors, especially those in departments other than the Neurosurgery Department, would always choose not to suture the patient’s nerve should it be a viable option.

The main reason was naturally because it was difficult to suture nerves. To put it simply, the number of doctors outside tertiary grade A hospitals who knew how to suture nerves could be counted on one hand. There were even fewer doctors who could suture nerves well, and it was better to leave a damaged nerve as it was than to suture it badly.

This was also what Ling Ran did in the past; one would not undertake a difficult task without the necessary equipment. Now, he had the necessary equipment.

Lu Wenbin began to hesitantly make the preoperative preparations. Ling Ran continued to look at the scans.

A lot of MRI scans and X-ray films were placed on the backlit board. Even though it would look rather chaotic to outsiders, Ling Ran enjoyed it very much.

For a clinician, the experience of having Master Level Magnetic Resonance Reading was similar to the opening of one’s third eye. Once one had a taste of the clarity that was comparable to what one would get after dissection without the need to dissect, one would then be unable to live without it. This was much more useful than the bits and pieces Ling Ran got from the doctors in the Medical Imaging Department. Without knowing the field well, even the doctors from the Medical Imaging Department themselves would not be able to obtain the vast quantities of information Ling Ran had access to.

In the future, the medical environment would definitely grow more and more demanding when it came to a doctor’s ability to read scans. But right now, it was still very difficult to make this universal.

For medical students who had finished their undergraduate studies and did not undergo specialized training in medical imaging, MRI scans were as illegible as hieroglyphics.

The Master Level Magnetic Resonance Reading Ling Ran possessed made him even better at reading MRI scans than most doctors in the Medical Imaging Department. To be able to perform his first perineurium anastomosis well, Ling Ran looked carefully at the film for a very long time.

Ling Ran thought carefully about the order in which he would suture the patient’s flexor tendon and nerve, and at the angle whereby he would make the incision.

When he performed surgeries using the M-Tang technique in the past, there was a fixed surgical method and order, without any other things involved. He only had to follow the steps.

Things were different after the addition of the perineurium anastomosis.

It was the difference between building a bridge and a flyover. Even though you could design a bridge according to fixed steps, you would have to take the circumstances into consideration when designing a flyover.

Even though Lu Wenbin and the others were quite puzzled, they stayed very quiet.

“Let’s get started.” Ling Ran returned to the operating table and said indifferently, “Flexor tendon reconstructive surgery together with anastomosis of the ulnar nerve perineurium. Since today’s surgery is different from the ones we usually do, we’ll have to be focused.”

After giving that special reminder, Ling Ran began the surgery by holding the scalpel in a fiddle bow hold and slowly made a large, five-inch incision.

When Lu Wenbin saw this, his gaze froze. After working a long time, resident doctors could often guess a lot of things just by looking at the incisions made by chief surgeons.

Disregarding personal habits, when the same chief surgeon performed surgery using the same surgical method, the larger the incision they made, the harder the surgery would be.

Ling Ran was a doctor who put a lot of attention into the aesthetics of the incision. Hence, when he made the incision so large it was exemplary, Lu Wenbin got such a shock he was wide awake.

Ling Ran did not need to say anything; Lu Wenbin immediately picked up a gauze with a pair of forceps and got into action.

Slowly and steadily, Ling Ran cut open the patient’s muscle layer. He did not strive for speed at all. Lu Wenbin joined in proactively and with a competitive spirit.

Because Ling Ran was very familiar with suturing flexor tendons, he quickly finished suturing the patient’s flexor tendon even though he was deliberately being slow about it. The next step was anastomosing the perineurium.

The nervous system of the human body was a wire mesh-like structure.

There were many bundles of nerve fibers at the center of the nervous system. They were surrounded by sheaths of perineuria, and they were the ones who did all the work in the nervous system—like twisted pair cables in a wire network. The epineurium was more like the outer sheath of the wires. The difference was that due to the biological property of nerves, they had the ability to heal themselves.

Built on this basis, there were usually three types of nerve anastomosis: epineurium anastomosis, perineurium anastomosis, and the simultaneous anastomosis of the epineurium and perineurium. The most widely applied one was epineurium anastomosis—suturing the outer sheath of the nerves and letting the interior regenerate by themselves.

Although doctors could control how well the interior would regenerate, they did not have full control over it.

Perineurium anastomosis allowed doctors a greater control, but it was a much harder procedure to perform. Even though doctors were often able to perform epineurium anastomosis with the naked eye, it was totally impossible for perineurium anastomosis.

Quite worried, Lu Wenbin looked at Ling Ran, who wore surgical magnifying glasses. Because he himself was not wearing the same glasses, he could not really see what Ling Ran was doing with clarity. He could not even see the thread clearly. No one could see a 10-0 suture clearly when it was being moved.

“The perineurium really is pretty tensile,” Ling Ran suddenly said.

Lu Wenbin froze for a moment before he asked, curious, “More tensile than pig’s skin?”

Ling Ran thought about it and said, “A lot more tensile, like the skin of pig legs.”

Lu Wenbin understood what Ling Ran meant.

“I’m done.” After quickly making a knot with the needle-holder, Ling Ran announced that he was done suturing.

Lu Wenbin was surprised. “You are done? There are quite a few perineuria, right?”

“I’m done with all of them.” Ling Ran breathed a sigh of relief and started closing the patient’s incision.

Lu Wenbin had been prepared to be the one to close the incision. When he saw Ling Ran’s actions, he froze for a moment. He had no choice but to obediently continue playing second fiddle. He consoled himself internally, ‘Doctor Ling is placing more emphasis on today’s surgery because it’s relatively important. Don’t be scared, it’s a technical adjustment. Don’t be scared.’