In support of Application for Chief Surgeon
Since the resumption of professional journals and academic activities after the Cultural Revolution in 1979, I have published dozens of papers in journals such as Southern Anhui Medicine, Journal of Bengbu Medical College, Lectures of Provincial Medicine, Domestic Medicine (Surgery) and Jiaotong Medicine. In 1979 and 1980, I participated in the preparation and re-founding of Anhui Orthopedic Society and Surgical Society respectively, and attended the annual meetings (1-6 sessions) of the two societies. I also participated in many academic activities of surgery in China and the Ministry of Transportation.
In 1994, I was involved in the planning and organization of a symposium on orthopedics in the Yangtze River Basin area, helping to compile a special issue of Orthopedic Clinic for Journal of Southern Anhui Medical College, Vol-13 supplement, 1994) under the guidance of Professor Jingbin Xu, editor of Chinese Journal of Orthopedics, carrying over 100 published papers, with participants and contributions from all over the country.
In September, 1995, I published two papers at the National Academic Conference on Acute and Severe Surgery (Guilin, 1995), among which “Problems in the Treatment of Liver Trauma” (0190) won the certificate of excellent papers. I have also published papers in the First International Academic Conference of Chinese Naturopathy (Chengdu, 1991) and Naturopathy (published in Taiwan Province).
1 Professional path and deputy chief physician performance
(On evolution of several theoretical problems in surgery)
1.1 In the early 1960s, a large number of patients suffered from acute volvulus, ascaris lumbricoides intestinal obstruction and cholelithiasis. Carrying out a large number of related operations for these cases consolidated my mastering the basic surgical skills. In addition, for the treatment of toxic shock in late cases, we practitioners underwent an arduous zigzag path from vasoconstriction and pressure increase to volume expansion and improvement of microcirculation, which proves to be an epoch-making change and progress both theoretically and clinically.
1.2 In Southern Anhui, there used to be a large number of patients with portal hypertension, hypersplenism and upper gastrointestinal bleeding in the early years of late-stage schistosomiasis and late hepatitis cirrhosis. The medicine community has also experienced a process of repeated debate and re-understanding of the choice between shunt and devascularization. In this regard, as early as in 1975, I performed splenectomy, splenorenal vein anastomosis and other various shunts. Due to the high rate of postoperative embolism, the blood supply to the liver was reduced and hepatic encephalopathy was easily induced. Later on, I switched to various types of portal-azygous devascularization, and obtained many lessons and various experiences for improvements from the treatment of this difficult problem.
1.3 Biliary lithiasis still bothers the surgical community. With the development of hepatobiliary surgery and improvement of monitoring methods, surgical procedures for this challenging problem of intrahepatic calculi are constantly updated and improved. I started the surgery of regular resection of the left lateral lobe of the liver for this disease in 1980 (the paper on five early cases was published in the Annual Meeting of the Provincial Surgery in 1980 and in Journal of Southern Anhui Medicine (80, 13; 51, “Regular resection of the left outer lobe of the liver for the treatment of intrahepatic stones”). Also starting in 1980, various types of choledocho-intestinal drainage (Finster, Longmire, Roux-en-Y, etc.) were successively performed. In 1992 and 1995, three cases were treated with intrahepatic bile duct incision, stone removal and plasty, and “basin” biliary and intestinal drainage (The first case was reported in “Communication Medicine”, 93,7; 91, “A case of hepatobiliary basin type biliary enteric drainage”). This work advanced the operation to the treatment of intrahepatic lesions, leading to improved clinical efficacy.
1.4 In recent years, the incidence rate of acute pancreatitis has increased. All severe pancreatitis patients in my department were cured by measures such as focus removal, pancreatic bed drainage, intraperitoneal lavage, 5-Fu, somatostatin and other measures to inhibit exocrine, anti-shock and anti-infection. In recent years, one patient was rescued in my department despite the complicated stress ulcer bleeding after operation was performed in another external hospital.
1.5 On the basis of treatment and operation for various thyroid diseases, hyperthyroidism operation was performed after 1980, and two cases of radical thyroidectomy (neck-mimicking surgery) were performed in 1994. One case was re-operated due to recurrence 3 years after the initial surgery was performed in an external hospital. No further recurrence was observed during follow-up.
1.6 In addition, there are surgeries such as excision and anastomosis of cervical aneurysm, thymopharyngeal duct cyst, thyroglossal duct cyst and cystic hygroma resection, etc.
1.7 Over the past 30 years, more than 1,000 cases of breast cancer, gastric cancer, colon cancer and rectal cancer have been treated, and many of them have survived for a long time.
1.8 The prevention and treatment of short bowel syndrome after large intestinal resection as a surgical method of interposition of distal reverse peristaltic bowel loops, the observation shows no diarrhea and malnutrition for 21 years. This paper was published in the Journal of Bengbu Medical College (82; 7: 214, PEUTZ Syndrome) and Traffic Medicine (91; 1: 41, “Surgical treatment of short bowel syndrome”).
1.9 The management of duodenal injury has its particularity and complexity, and its retroperitoneal injury is especially prone to missed diagnosis and misdiagnosis. The prognosis of patients who underwent surgery more than 24 hours after injury is grim. In a case report from 1994, following the principle of “rest transformation” of duodenum, I performed a Berne-like operation 28 hours after injury, and the recovery was smooth. My paper was published in Communication Medicine (“Experience in Diagnosis and Treatment of Closed Retroperitoneal Duodenal Injury”, by Mingjie Li).
1.10 Subdiaphragmatic total gastrectomy, jejunostomy, supradiaphragmatic esophagectomy, thoracic esophagogastrostomy, lobectomy, mediastinal thymoma removal, diaphragmatic hernia repair, etc. which started years ago.
2. Work involving various medicine disciplines
The two hospitals I have served are both base-level primary hospitals. The “major surgery” department covers general surgery, orthopedics, urology, chest surgery, obstetrics and gynecology, ophthalmology and otorhinolaryngology, anesthesia, radiation, laboratory test and other related work. As professional subject leader, I have long been engaged in the work of all of the above areas, outlined below.
2.1 Orthopedics is one of my key areas, only second to general surgery. I have performed all major surgeries in this area, and participated in academic activities at all levels, including publication of numerous papers, professional talks and compilation of a special issue on Orthopedics. My representative operations treating bone injury and bone disease include closed nailing of femoral neck (for the paper, see Orthopedics Clinical 1994, 13:37, Closed nailing treatment of femoral neck fracture in 45 cases), surgical paraplegia (paper in Anhui Province Medical Lectures 1982;, 4:21, Surgical paraplegia analysis of 14 cases), spinal tuberculosis surgery (paper Spinal tuberculosis a surgical therapy in Proceedings of First Provincial Orthopedic Annual Conference, 1979), lumbar disc surgery, spinal cord tumor enucleation, bone tumor removal and orthopedic surgery, etc.
2.2 Urological surgery: nephrectomy, stripping of renal pedicle lymph nodes, removal of various segments of ureteral calculi and Urethral trauma realignment repair, ureteral transplantation, vasovasostomy, spermatic vein–inferior epigastric vein anastomosis, hypospadias repair, radical resection of bladder cancer and penile cancer, etc.
2.3 Gynaecology and obstetrics: I founded the department of obstetrics and gynecology of our hospital, having operated Cesarean section (lower segment and extraperitoneal operation), hysterectomy (abdominal type and vaginal type), oophorectomy, repair of vesicovaginal fistula and cervical cancer resection, etc.
2.4 Ophthalmology and otorhinolaryngolog: parotid gland, tonsil, maxillary sinus, mastoid, cataract, artificial pupil, enucleation, nasolacrimal duct anastomosis, strabismus correction, etc.
2.5 Anesthesiology: various segments of epidural block, cervical plexus block, brachial plexus block, intubation general anesthesia and intravenous compound anesthesia, etc.
2.6 Radiology: I founded the department of radiology in 1960, and concurrently served as the head of the department for 2 years (1960-1962). Very familiar with its routine work and related angiography.
Environment trains people. A wide range of issues encountered in the long-term work of grass-roots hospitals enabled me to dabble in many subjects. The knowledge and skills of these relevant areas complement each other, contributing to and deepening the improvement of my surgical expertise. Various Level-4 and Level-5 surgeries have been performed to keep placing me at the forefront of contemporary surgery.
3 Continuous innovations and some experience to share
Over the past 40 years, with high technological development, diagnosis and monitoring methods are constantly updated. With the change of social life, diseases are also changing. In an aging society, geriatrics takes a prominent position. Many factors make the clinical work evolve too. This requires physicians to constantly hunt for scientific and technological information, learn from the experience of others, study hard and embrace the courage for innovation, in order to improve the service quality for our patients.
3.1 Improvement and innovation
3.1.1 The key to the control of traumatic infection is complete debridement at the first diagnosis, rather than relying on drainage and antibiotics. Techniques involve a large quantity of water washing, elimination of foreign objects and inactivating tissues, disinfection, and no suture. When postoperative inflammatory reaction occurs, apply local wet compress with alcohol, supplemented with with or without antibiotics. Following this strategy, surgery within 6 hours of trauma is almost completely free from infection.
3.1.2 Over the past 30 years, based on the experience of over 1,000 cases of gastrectomy I have performed, the preset gastric tube has basically been abandoned except for special needs, and there were no cases of failure. This requires excellent anastomosis, perfect hemostasis, intraoperative emptying of the residual stomach, and attentive postoperative monitoring.
3.1.3 For extensive peritonitis, after the nidus and infectious substances are removed, abdominal cavity drainage can be abandoned to reduce postoperative adhesion. The key for this to work is to wash it thoroughly during the operation. As the drainage is quickly blocked by fibrin glue in the abdominal cavity and soon stops working, it only increases the pain of the patient. To be sure, however, in cases such as pancreatitis, abdominal abscess, etc., if continuous overflow is expected, double-cannula negative pressure drainage is still required.
3.1.4 For any surgery, regardless of scale, its success or failure makes a big difference to the health and safety of patients. As a surgery practitioner, I attach importance to the technical improvement of each and every “small” surgery. Some of my technical innovations and experience are outlined below.
For inguinal hernia repair, the focus is the transverse abdominal fascia, the traditional Bassini method should be replaced by the modified Madden procedure, which greatly reduces the pain of postoperative tension suture for patients, and is also conducive to healing, with the recurrence rate greatly reduced.
For circumcision, the conventional routine procedure has plagued both doctors and patients with the poor alignment of the inner and outer plates, hematoma, edema, as well as difficulty in stitches removal. I modified the procedure, using local venous anesthesia to support neat cutting under a tourniquet, with perfect hemostasis, accompanied by careful sutures with human hair or absorbable thread. The benefits include no pains during the operation, good alignment, fast healing, and avoiding stitches. (see my paper published in Jiaotong Medicine 90; 4（3)：66, Several improvements of circumcision）
Anal fistula seton therapy or open resection both make patients suffer from postoperative pains with a long recovery period. I used long-acting anesthesia (with local injection of diluted methylene blue) to ensure the primary resection and suture. Most cases receiving this treatment result in primary healing, with the course of treatment greatly shortened.
3.2 Some General Experiences
Based on what I have learned from my 40 years of hands-on surgical practice, I feel that in order to be a qualified surgeon, we need not only consolidate the basic knowledge with continuous updating, but also exercise meticulous working methods with a high sense of responsibility, supported by logical thinking and practical orderly working style. It is very difficult to just follow a unified norm or standard procedure when the real-world surgery scenario involves so many moving parts to be weighed and considered, factors like the ever-changing condition, physical differences, positive and negative effects of drugs, advantages and disadvantages of the techniques in consideration, the reserve function of body organs, the length of the course of the disease, and even the natural environment, mental and material conditions, and so on. One must be equipped with high adaptation wisdom. It is not an exaggeration to say that the adaptation ability determines a surgeon’s diagnosis and treatment level and the clinical effects.
3.2.1 The entire process on the operating table involves struggles between personal fame and the interests of patients. The so-called following “safety first, and draw the line accordingly” principle is often not a feasible practice. A competent physician must have the courage to take risks for his patients. It is often the case to be placed in the position in fighting for patients’ good chances of rescue that can be missed because of a small mistake in one’s thinking. I have countless memories of such incidents in the past, one of which is as follows. In the fifth operation of the biliary tract, cavernous blood vessels caused by portal hypertension due to biliary cirrhosis were distributed all over the hepatic hilus, and in addition, the inflammation was thickened. After struggling for 8 full hours of operation, I finally managed to open the biliary duct and save the life of the patient. This was a victory of perseverance.
3.2.2 Adjust measures to real-world conditions, and keep an open mind to break the routine to save a patient. The key to life-saving in case of liver and spleen trauma and massive hemorrhage of ectopic pregnancy in the countryside lies in the rigorous transfusion of the abdominal blood. To wait for the blood supply in these scenarios means to wait for death. I remember a case of liver trauma in which 1700ml of liver blood was transfused locally to support the successful operation. (See paper Related issues in the treatment of liver trauma (review), in Proceedings of the National Academic Conference on Acute and Major Surgery, 95; 190）
3.2.3 For difficult surgery and new surgery, one must accumulate the relevant knowledge and operation skills, by reviewing the literature, consulting experienced experts for guidance, and visiting and studying surgery scenes, before embarking on the operation, to minimize potential misses or accidents. In my first case of hepatobiliary-pelvic internal drainage operation, I asked for direct guidance from a professor of surgery. The subsequent two cases were successfully completed all by myself.
Looking back on my 40 years of career in surgery, I deeply feel that clinical surgery is a combination of science, perseverance, determination, and a sense of responsibility. It is like a small boat that ups and downs in the forefront of the waves. Walking on thin ice, one can hit hidden rocks at any time. The hardships and risks of our career are among the highest in all trades. Fortunately, I have not failed the society. Along the journey, there have been countless joys of success, together with many sleepless nights and panic moments. For the rest of my career years, I am determined to maintain the service spirit of “healing the wounded and rescuing the dying”, to complete the journey to the end.
Appendix 1, Publications
Appendix 2, Relevant Materials and Records of Level III and Level IV surgeries
In Commemoration of Mingjie Li’s 66 Years of Medical Practice