Chapter 8: An Unconventional Surgery

Words : 2403 Updated : Mar 13th, 2025

The gallbladder was located in the upper right abdomen, while the appendix was in the lower right abdomen. The patient was experiencing pain in the lower right abdomen, which led Elliott to firmly believe it was acute appendicitis. Decades ago, acute appendicitis required surgical removal, but with medical advancements, appendicitis could even be managed with medication and conservative treatment. Walter didn't want to argue with Elliott publicly, so he turned his gaze to Andy. Andy didn't immediately decide but instructed Raina to take the patient to the ultrasound center. Minutes seemed to drag on as they waited. Elliott noticed Walter was calmer than expected, wondering where this intern got his confidence. "Mr. Tibbert, if Walter's diagnosis is wrong, should we consider changing the lead surgeon? Isn't it too risky for the patient to be in the hands of a doctor unsure of the condition?" Elliott spoke to Andy, adopting an earnest demeanor. Andy saw through Elliott's intentions, "Do you want to do this surgery?" Elliott blushed and quickly said, "I'm not insisting on doing the surgery; I just think it should be given to someone reliable for the patient's sake. Otherwise, the patient's family might not agree either, right?" Andy was displeased by Elliot's behavior of beating around the bush and replied coolly, "I'll give you a satisfactory answer once the ultrasound results are out." The emergency department's urgent orders were not to be delayed, and the ultrasound results came back shortly. Andy took the images from Raina, glanced at them, and his wrinkled face relaxed slightly before handing them to Elliott. "Can you read this?" From Andy's tone, Elliott sensed trouble, and as he studied the ultrasound, sweat formed on his nose, his mind going blank. "Thickened gallbladder wall, enlarged gallbladder, deposits inside the gallbladder—acute cholecystitis!" "No way, could the images be wrong? The gallbladder is in the upper right abdomen, the appendix in the lower right—I wasn't wrong!" Elliott actually questioned the accuracy of the ultrasound. Andy glanced at Walter and sighed. "Tell him the reason." Walter knew Andy was testing him, so he patiently explained, "Pain in the lower right abdomen, especially fixed pain, is generally considered acute appendicitis. However, typical appendicitis pain starts around the navel and later shifts to the lower right abdomen. I asked the patient earlier, and she didn't experience navel pain." "Additionally, while the gallbladder is in the upper right abdomen, it can cause lower right abdominal pain if it perforates. Not only appendicitis but a perforated gallbladder can leak bile into the lower right abdomen, causing irritation and pain." Elliott was in disbelief! Andy looked grave. "If it's gallbladder perforation, the patient is in serious danger and needs immediate surgery!" Just then, Raina shouted, "The patient has lost consciousness!" Walter's eyes fell on the blood pressure monitor, showing only 70/40 mmHg. He quickly checked the patient's abdomen, which was rigid, and stated solemnly, "Gallbladder perforation can cause diffuse bile peritonitis. We must operate as soon as possible!" In such a situation, laparoscopic minimally invasive surgery was not an option—they needed to perform open surgery! Andy nodded at Walter. Walter's consistently correct judgments gave Andy more confidence, and he decided to entrust the surgery to him fully. ***** Gallbladder perforation was a severe complication of acute cholecystitis, occurring in ten percent of cases. The key to successful treatment was timely diagnosis. The patient had already shown signs of shock, indicating the critical stage of the illness. Fortunately, the time from onset to diagnosis was not too long. However, if treated as appendicitis with conservative management, it would have delayed treatment. Andy was intrigued, though. Doctors needed ample experience to determine where a patient's problem lies quickly. High-level physical examination involved more than textbook steps; it included assessing breathing rate, heart pulse, pupil state, and muscle response. Like a sniper on the battlefield, they had to consider factors like wind speed and humidity before firing a bullet. Though a novice, Walter relied on his sharp instincts to diagnose beyond appendicitis. The only explanation was his extraordinary diagnostic talent. The medical department intervened, and Walter and Andy explained the situation to the patient's parents. The mother tearfully signed the consent form after accepting the advice. ***** Gallbladder removal wasn't a major surgery in emergency surgery, but this one was special due to the gallbladder perforation. Elliott volunteered to stay in the operating room, smiling but feeling frustrated inside. He still believed it was outrageous for Andy to let Walter lead the surgery. Andy took on the anesthetist role, as being a good anesthetist was fundamental to successful surgery. His gentle and precise technique, evident even in drug administration, showed his high skill level. Soon, Walter began making the incision. Everyone's attention was on the cut. The incision was small, about 1.2 inches—the size typical for laparoscopic surgery. And the position seemed wrong! Had he made a mistake? Andy felt uncertain but decided to trust Walter and observe. Walter started bluntly separating the subcutaneous tissue and muscles, opening the peritoneum. Because the incision was so small, only a tiny clamp could be inserted. Before anyone realized it, Walter suddenly clamped out the gallbladder. Andy's eyes brightened, realizing Walter had just performed a high-level maneuver—by touch alone! Normally, one needed a visual aid or a laparoscope to locate the gallbladder, but Walter accurately pinpointed it by feel. Andy might have managed it, too, but not at such speed! No wonder he dared to make such a small incision at a non-traditional site; he had the skill for blind operation. Walter's abilities were clear to an expert like Andy, who had previously considered assisting. Now, it seemed unnecessary—Walter was steady. "Small curved clamp," Walter requested, and Raina handed it to him. The woman had spent over a decade in the operating room and seen many gallbladder removals, but today's surgery was different. Everything seemed off, yet it was remarkably smooth and successful. When Walter raised his hand, the instruments were precisely placed in his grasp. He was secretly impressed with Raina's coordination, a testament to her experience as an instrument nurse in a major hospital, achieving seamless teamwork even on their first collaboration. In a blink, Walter removed the swollen gallbladder and began suturing the artery. Next came flushing the abdominal cavity with saline. Despite the perforation, because it was discovered early and the patient was young and strong, the inflammation hadn't spread extensively with no other complications. He meticulously flushed the area until it was spotless. Soon, it was the final step. "5-0 suture!" Walter's request lifted the fog, unraveling the mystery for Andy and Raina. No wonder Walter made such a small incision! The patient was a young woman who was unmarried and childless. A large abdominal incision could affect aesthetics and cause unnecessary misunderstandings in some situations. Andy usually used 4-0 absorbable sutures, rarely using the higher standard 5-0. The finer the suture, the finer the needle, and the smaller the suturing window, exponentially increasing difficulty. Yet, the recovery result was superior, often leaving no scar after healing. Walter's meticulous planning covered all the considerations from when he made the incision. "All done." In just thirty seconds, Walter finished suturing the 5-0 gut line, snipping the suture. Andy instinctively glanced at the digital clock—it had taken eight minutes and thirty-five seconds from start to finish! A standard gallbladder removal takes ten to twenty minutes. It was astonishingly fast. Walter exhaled with relief, suddenly noticing the atmosphere seemed off. Andy started clapping, followed by Raina. Stunned, Elliott reluctantly joined in the applause, a forced smile masking his disappointment. He had to admit defeat to an intern. Pablo also stood from a corner, joining the applause! Having heard Andy allowed Walter to complete a surgery independently, he had quietly entered the operating room out of concern after the surgery began. This was an atypical gallbladder removal surgery. The main controversy lay in the incision site—most would choose the "right costal margin" (gallbladder surgery point). Still, Walter chose "McBurney's point" (appendix surgery point), enabling quicker abdominal cavity cleaning and addressing post-perforation infection. The controversial choice was also the highlight. Without any auxiliary tools, to blind-operate and extract the gallbladder from McBurney's incision was a daring decision. Of course, all this was grounded in Walter's formidable skill.

Chapter 8: An Unconventional Surgery

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