Level 4 Surgery

Education Campus

Level 4 Surgery

Six Sample Cases  

[Editor’s Comments] This part of Education Campus is where the six representative cases of high clinical difficulty are presented, with detailed operation records.  They are: 1. Extended total gastrectomy; 2. Simulated radical surgery for thyroid cancer; 3. Simulated Berne surgery for duodenal rupture; 4. Left lateral hepatectomy, intrahepatic lithotomy and hepatobiliary basin internal drainage; 5. Focal clearance and drainage for acute pancreatitis; 6. Radical surgery for rectal cancer.

Level 4 Surgery: Six Sample Cases

Case 1: Extended Total Gastrectomy

Single Operation Record for Surgery Case 1 from Wuhu Changhang Hospital

  • Patient Information:

    • Name: Yao XX
    • Gender: Female
    • Age: 74
    • Bed Number: 34
    • Hospitalization Number: 19052
    • Date of Operation: April 21, 1995
  • Diagnosis:

    • Pre-operation: Gastric cardia cancer with esophageal invasion
    • Post-operation: Cancer of the gastric fundus, cardia, and esophagus
  • Procedure:

    • Type of Surgery: Total gastrectomy + splenectomy, esophagojejunostomy (Schlatter's method)
    • Operation Time: 9:00 AM to 4:00 PM
    • Blood Transfusion Volume: 1200 ml
  • Medical Team:

    • Surgeon: Dr. Mingle Li
    • First Assistant: Dr. Yang Zonghua
    • Second Assistant: Dr. Wu Maowang
    • Surgical Nurse: Qian Weilin
    • Anesthesia: Continuous epidural block
    • Anesthesiologists: Dr. Chen Qibin and Dr. Wang Yisen

Gross Examination of Specimens

The primary cancer was located in the posterior wall near the cardia, extending 1 cm into the lower end of the cardia and esophagus, and penetrating the entire layer. Pathological specimens submitted for examination included the whole stomach, distal esophagus, and spleen.

Detailed Surgical Procedure

The patient was placed in a supine position, and the chest and abdominal areas were disinfected and draped. A midline incision measuring 25 cm in length was made between the xiphoid process and the navel, and the xiphoid process was excised. A layered laparotomy was performed, and the incision was isolated.

Upon examination, the abdominal cavity was free of ascites. No hepatic lesions were found. Minor adhesions were noted between the pancreas, spleen, and the lesion. The tumor was identified on the posterior wall of the gastric fundus at its small curvature, extending into the serosal layer. The tumor dimensions were 10x7x5 cm, and it was spatially separated from the liver. No metastasis was observed in the pelvic floor or other abdominal regions.

A total gastrectomy and splenectomy were planned. A double-tube jejunostomy was created anterior to the colon, followed by a side-to-side anastomosis with the esophagus. Additionally, a Bauwn short-circuit procedure was performed between the jejunal afferent and efferent loops.

The stomach was mobilized, and the left gastric artery was ligated at its origin. The greater and lesser omenta were excised, as well as the anterior layer of the transverse mesocolon. The duodenum was severed 3 cm below the pylorus, and the stump was sealed. Adhesions between the pancreas and stomach were separated from under the pancreatic capsule, and the spleen was excised. Acute dissection was performed in the space between normal tissues surrounding the pericardial mass. The peritoneum at the esophageal hiatus was incised and folded back, and the left and right vagus nerve trunks were severed. The esophagus was bluntly dissected and mobilized downward for 7 cm. At this point, the stomach was entirely mobilized, and the cancerous mass was wrapped and set aside for traction. Lymph nodes from groups (1), (2), (3), (4), (5), (6), (7), (10), (11), and (15) were excised, constituting a radical level 2 surgery.

The jejunum, 20 cm proximally, was lifted anteriorly to the colon and anastomosed laterally with the esophagus, 5 cm above the cardia. The posterior wall was fixed with five intermittent seromuscular layer sutures. A 3 cm incision was made in the mesangial margin of the jejunum opposite to the esophagus and sutured intermittently with the whole layer of the posterior wall of the esophagus. At 4 cm above the cardia, the esophagus was severed, and the entire stomach and spleen were removed from the surgical field.

The anterior wall was then sutured in full layers in a circular pattern. Given the fragile inflammatory condition of the esophagus, tension-reducing sutures were carefully placed. A two-layer suture secured the anastomosis into the jejunum slightly, with no leakage. Further away from the anastomosis, the jejunum was sutured to the septal muscle near the hiatus to reduce tension, and the hiatus was slightly repaired to prevent internal herniation without causing constriction.

Seven cm below the anastomosis, a Braun short-circuit anastomosis was performed between the double loops of the jejunum, measuring 8 cm. A gastric tube was inserted into the proximal jejunum to facilitate postoperative suction and decompression.

The abdominal cavity was thoroughly rinsed, and careful examination revealed no bleeding or leakage. There was no torsion or compression of the intestinal loop replacing the stomach. The abdominal cavity was soaked in distilled water for tumor eradication. After cleaning the abdominal cavity, a double cannula was placed under the septum for wound drainage. The abdomen was closed in the standard sequence. The procedure was uneventful with a blood loss of 400 ml. The patient was safely returned to the ward.

Surgical Conclusion

Despite the extensive surgical intervention, including a total gastrectomy, distal esophagectomy, and splenectomy, as well as the removal of both the greater and lesser omentum and the anterior layer of the transverse mesocolon, the prognosis remains guarded. The surgery achieved radical level 2 but given the advanced stage of the gastric cardia cancer involving extra-gastric organs such as the pancreas, spleen, and distal esophagus, both short-term and long-term prognoses are not optimistic.

Surgeon and Recorder: Dr. Li Mingjie
Date: April 21, 1995

Additional Notes

  1. Postoperative pathology report (952343) identified a poorly differentiated adenocarcinoma at the lateral aspect of the lesser curvature of the cardia, with portions classified as mucinous adenocarcinoma. The lesion measured 10x7 cm and involved the esophagus, cardia, and stomach fundus, penetrating all layers. Out of seven lymph nodes at the lesser curvature, six showed metastatic carcinoma, while none of the five lymph nodes at the greater curvature had metastatic carcinomas. Mild acute inflammation was observed in the spleen.

  2. The patient has survived for six months post-operation and is relatively frail.

Case 2: Simulated Radical Surgery for Thyroid Cancer

Single Operation Record for Surgery Case 2 at Wuhu Changhang Hospital

Name: Gao XX
Gender: Female
Age: 47
Bed No.: 34
Hospitalization No.: 18639

Operation Date: August 30, 1994

Pre-operation Diagnosis: Metastatic Carcinoma of the Right Thyroid Gland
Post-operation Diagnosis: Metastatic Follicular Adenocarcinoma of the Right Thyroid Gland

Surgery Operated: Modified Right Cervical Lymph Node Dissection + Isthmus Resection and Left Thyroidectomy

Operation Time: Started at 9 am, Ended at 2 pm

Blood Transfusion Volume: 400 ml

Surgeon: Mingle Li

Assistant 1: Yang, Zonghua
Assistant 2: Shi, Lianghui
Surgical Nurse: Gao, Qingjie
Anesthesia: Cervical Plexus Block
Anesthesiologist: Chen, Qibin

Post-operative Gross Examination and Pathology:

The resected tumor was dissected and found to be a typical enlarged lymph node. The intraoperative rapid frozen section pathology report (Pathology No. 944346 from the Second Municipal Hospital) indicated metastatic thyroid cancer, specifically follicular adenocarcinoma, with the possibility of papillary adenocarcinoma not being ruled out.

Specimens sent for further pathological examination were labeled as follows: Nine nodes from both superficial and deep cervical lymph nodes on the right side, along with thyroid tissue.

Surgical Procedure:

Step 1: Under cervical plexus anesthesia, the patient was placed in a supine position with the head and neck hyperextended and slightly turned to the left. Standard skin sterilization and draping were performed. An "inverted L-shaped" incision was made in the right anterior neck region, starting from below the right mastoid and ending 2 cm above the sternum. The incision extended leftward to the outer edge of the left sternocleidomastoid muscle and was 18 cm in length. Another incision extended to the right supraclavicular fossa. The original surgical scar was excised, and subcutaneous flaps were carefully elevated to expose the outer edge of the right trapezius muscle, the left sternocleidomastoid muscle, the lower edge of the jaw, and down to the sternal notch.

Step 2: The platysma was incised, and the anterior neck muscles were separated from the midline and transversely cut to expose various nodules and the thyroid gland. No residual traces of the right thyroid lobe were observed. The right common carotid artery, vagus nerve, and internal jugular vein were displaced superficially by the tumor mass. Nine lymph nodes of various sizes were identified in the right subclavian triangle, right sternocleidomastoid muscle region, supraclavicular fossa, and anterior cervical triangle. The largest node had a diameter of 5 cm, while the smaller ones were approximately 1 cm in diameter. The nodes were hard, smooth, and not densely adhered. The trachea was shifted to the left but was not connected to the tumor mass. The left thyroid lobe was slightly enlarged but had no palpable nodules.

Step 3: The right sternocleidomastoid muscle was transversely incised at its middle-to-lower third to improve exposure. A 2 cm lymph node was initially excised from the superficial aspect of a cluster of nodules for rapid pathology, which confirmed metastatic follicular adenocarcinoma of the thyroid. A modified right cervical lymph node dissection was performed, and a total of 9 lymph nodes were excised during the surgery. Care was taken to protect the right common carotid artery (CCA), internal jugular vein (IJV), vagus nerve, and accessory nerve, all of which remained undamaged.

Step 4: The dissection of the thyroid gland continued, and its isthmus along with the major part of the left thyroid lobe was removed. A small piece of glandular tissue, roughly the size of a fingertip, was preserved on the posterior and medial aspect. The residual thyroid tissue was sutured.

Step 5: The surgical cavity was thoroughly irrigated, and hemostasis was meticulously achieved. A Penrose drain was placed, and an additional incision was made for its exit. The anterior neck muscles and the severed right sternocleidomastoid muscle were sutured. The incision was closed in layers with interrupted sutures.

Step 6: Anesthesia was satisfactory throughout the surgery. The anatomical dissection was clear, and there were no injuries to major blood vessels or nerves. Blood loss was minimal, and there were no occurrences of voice hoarseness or coughing. The patient was safely returned to the ward.

Step 7: Despite being a well-differentiated adenocarcinoma, the patient had already experienced cervical lymph node metastasis, requiring re-operation. Unfortunately, the surgery may have been too late for curative intent, making the long-term prognosis less optimistic.

Surgeon and Recorder: Li Mingjie Date: 1994, August 9


  1. Post-operative regular histopathology report on 1994/9/2 (City Second Hospital pathology number 944355):

    • Papillary and follicular thyroid carcinoma.
    • Small foci of metastasis found in the "normal" thyroid tissue.
    • Metastasis in most lymph nodes.
  2. Post-operative follow-up has been ongoing for over a year. The patient shows no signs of recurrence and is asymptomatic.

Case 3: Single Operation Record of Wuhu Changhang Hospital

Patient Details:

Name: Li XX
Gender: Male
Age: 29
Department: Surgery
Bed No.: 22
Hospitalization No.: 18158

Operation Details:

Operation Date: October 7, 1993

Pre-operation Diagnosis: Duodenal rupture, peritonitis
Post-operation Diagnosis: Injury to the descending part of the duodenum behind the peritoneum, peritonitis

Surgery Performed: Berne-style procedure (intestinal repair, external drainage of the common bile duct, antral gastrectomy, gastro-jejunostomy, duodenostomy, peritoneal drainage)

Operation Time: Started at 7 PM, ended at 11 PM

Blood Transfusion Volume: 400 ml

Medical Team:

Surgeon: Li Mingjie

Assistant 1: Shen Yaping
Assistant 2: Wu Maowang
Surgical Nurse: Qian Weilin


Type: Continuous epidural block
Anesthesiologist: Chen Qibin

Surgical Procedure:

  1. Initial Preparations: The patient was placed in the supine position. The abdomen was routinely disinfected and covered. An 18cm-long midline incision was made on the right side of the abdomen, followed by hemostasis and draping.

  2. Abdominal Examination: Upon opening the abdomen, approximately 100 ml of pale green fluid was found in the peritoneal cavity. The stomach and duodenal bulb appeared normal. The liver was smooth, with a normal color and texture, and no nodules were found. The spleen was slightly hard and weighed around 500 grams. Some bile-like fluid was accumulated around the omental foramen.

  3. Pathological Findings: Extensive edema and thickening were observed in the hepatoduodenal ligament region, as well as around the descending part of the duodenum and the right renal area. A Kocher incision was made to mobilize the descending part of the duodenum. Extensive necrotic tissue and bile-like fluid were found in the retroperitoneal space. A 1.5 cm rupture was found on the right posterior side of the descending duodenum, with mucosa protruding outward.

  4. Repair Work: The common bile duct was opened for decompression. The injury was located 1.5 cm anterior and superior to the papilla. Under direct vision, the ruptured intestinal tube was trimmed and carefully repaired with double-layer suturing, covered by the omentum, without tension. The repair was satisfactory and did not involve the opening of the common bile duct.

  5. Bile Duct and Gastric Work: The common bile duct was flushed to confirm that there were no leaks. A T-tube was placed for external drainage. Antral gastrectomy was performed, along with duodenal ostomy for decompression, and gastrojejunocolic anterior anastomosis, with an anastomotic opening of 4.5 cm.

  6. Final Steps: Following the Berne procedure, except for the vagus nerve of the stomach, which was not severed, the injured part of the duodenum was made into a diverticulum to facilitate successful repair. The abdominal cavity was thoroughly cleaned again, and drainage tubes were placed at the Winslow's foramen and the pelvic floor. The duodenal ostomy tube and the T-tube were both brought out through separate incisions in the abdominal wall and secured.

  7. Closure and Conclusion: The abdomen was closed layer by layer. The operation went smoothly, with no accidental bleeding or collateral damage.

Surgical Conclusion:

The descending part of the duodenum had retroperitoneal injuries and extensive inflammatory edema. Surgery was performed 28 hours post-injury. The condition was critical, but a thorough diverticulum-like treatment was done at the repair site, which is expected to heal well.

Surgeon and Record Keeper:

Surgeon: Li Mingjie
Operation Date: October 7, 1993

Additional Notes:

Postoperative Complications: None reported. The patient recovered smoothly.

Hospital Stay: The patient was discharged after a 34-day hospital stay in good condition.

Follow-up: Two-year follow-up indicated that the patient was living and working normally, with no need for additional medical consultations.

Case 4: Liver and Biliary Duct Stone Disease

Personal Details:

Name: Shui XXX
Gender: Male
Age: 46
Ward: Surgery
Bed No.: 10
Hospitalization No.: 16502

Operation Details:

Operation Date: April 18, 1991

Pre-operation Diagnosis: Liver and biliary duct stone disease
Post-operation Diagnosis: Liver and biliary duct stone disease

Surgery Performed: Major resection of the left lobe of the liver + biliary stone removal + residual gallbladder removal + hepatic duct-to-intestine pelvic internal drainage

Operation Time: Started at 2 pm, ended at 8:40 pm
Blood Transfusion Volume: 1200 ml

Medical Team:

Surgeon: Li Mingjie

Assistant 1: Yang Zonghua
Assistant 2: Shi Lianghui
Nursing Staff: Gao Jieqing

Anesthesia: Intravenous combined intubation general anesthesia
Anesthesiologist: Chen Qibin

Postoperative Gross Examination:

Stones found in the left liver, common hepatic duct, common bile duct, and residual gallbladder.

Pathological Samples Sent:

Left outer lobe of the liver

Surgical Procedure:

Anesthesia and Initial Incision:

  • The initial epidural anesthesia was ineffective, so intravenous combined endotracheal intubation general anesthesia was administered.
  • The patient was placed in the supine position. The chest and abdominal areas were disinfected with iodine and alcohol, and sterile sheets were laid in three layers.
  • A curved incision was made in the right upper abdomen, starting from the left side of the xiphoid process and ending at the tip of the 11th rib on the right, touching the right anterior axillary line. The incision was 30 cm long. The original surgical scar was excised. After achieving hemostasis, sterile towels were placed, and the abdomen was opened layer by layer.
  • Extensive adhesions were present in the abdomen. After separation, the edge of the peritoneum was sutured to the towel to isolate the incision.

Exploration and Stone Removal:

  • Adhesions along the liver edge were separated both bluntly and sharply, exposing the common bile duct. The duct was found to be dilated to 2.5 cm and contained multiple stones.
  • A residual gallbladder from a previous surgery was found, measuring 2.0 cm in diameter and containing stones.
  • Stones were also palpated in the transverse part of the left hepatic duct.
  • The liver appeared normal in color and texture, with no occupying lesions or fibrous atrophy. The stomach, intestines, pancreas, and spleen were also normal.
  • A decision was made to perform a partial resection of the left outer lobe of the liver, remove stones from the liver and bile ducts, remove the residual gallbladder, and conduct hepatic duct reshaping with pelvic hepato-intestinal internal drainage.

Higher-Level Hepatic Duct Incision:

  • The common hepatic duct was incised at a higher level to remove the stones and to further probe the biliary tract.
  • The common bile duct and I and II levels of the intrahepatic ducts were filled with stones.
  • The left hepatic duct had a narrow ring and stones in the deeper parts were difficult to remove, so it was decided to proceed with the resection of the left outer lobe of the liver.

Detachment and Resection:

  • The falciform ligament, round ligament, left coronary ligament, and left and right triangular ligaments were cut to loosen and lower the liver.
  • A suture was placed 1.5 cm to the left of the hepatic portal to pre-ligate the left hepatic vein. The hepatoduodenal ligament was then clamped for 25 minutes, and a large portion of the left outer lobe was removed to expose the transition area of the left hepatic duct.
  • The blood vessels on the cut surface were clamped and ligated to stop bleeding. The tourniquet was released, and the left hepatic duct was opened, revealing 3 grams of bile pigment stones.

Further Exploration and Stone Removal:

  • Glisson's capsule at the hepatic portal was opened, and the first-level branches of the hepatic duct were separated upward. Stones weighing 4-5 grams were removed from the convergence area of the hepatic ducts.
  • The "small gallbladder" was then excised, and the distal common bile duct was cleared. The Oddis sphincter was probed with a No. 9 probe, and the gallbladder duct was sutured and repaired without leakage.

Duct Reshaping and Draining:

  • The common hepatic duct, along with the left and right first-level hepatic ducts, was fully exposed. While suturing, traction was applied to directly expose the second-level hepatic duct openings, clearing them of stones and dilating any narrow parts. Hydrogen peroxide was used for rinsing.
  • The edge of the hepatic duct basin was reshaped to a diameter of 4.5 cm.

Intestinal Drainage:

  • The jejunum was cut 15 cm below its starting point, and its mesenteric vascular arch was trimmed. The distant end of the intestinal tube was lifted to the edge of the basin without tension.
  • A full-thickness, mucosa-to-mucosa, one-layer suture was made at the basin mouth with a stitch spacing of 3 mm. After testing for leaks by squeezing, the anastomosis was further reinforced by covering it with peritoneum.
  • To reduce tension, the intestine was suspended from the liver bed with several stitches. The lifted intestine took a path anterior to the colon without causing any compression.

    Hemostasis and Open Treatment:

    • The liver's cut surface was examined, and hot saline-soaked gauze was applied to control bleeding. Once there was no more bleeding or oozing, the area was left open without further covering. This was done with the expectation that any minor postoperative leakage would be beneficial for peritoneal absorption.

    Intestinal Anastomosis:

    • A side-to-end anastomosis was performed 40 cm from the distant end of the biliary-intestinal loop to the proximal end of the jejunum. Full-thickness interrupted sutures were placed internally, and reinforcing sutures were added externally. An additional synchronous 5 cm suture was made to form a 'Y-shape' to resist reflux.

    Final Checks and Drainage:

    • The surgical field was thoroughly cleaned. Both anastomotic sites were inspected and found to be satisfactory, with no twisting or compression. Double drainage tubes were placed under the liver and led out through a hole in the right abdomen, where they were sutured in place.

    Abdominal Closure and Recovery:

    • The abdomen was closed in layers, as is routine. Dressings were applied to cover the wound. The surgery went smoothly, anesthesia was satisfactory, and the patient was returned to the ward.

    Surgical Conclusions:

    1. Complete Biliary Clearance:

    • All gallstones within the liver were removed. The residual gallbladder was excised, and a No. 9 probe confirmed that there was no stricture in the distal common bile duct.

    2. Partial Hepatectomy of the Left Lateral Lobe:

    • The left lateral lobe of the liver was partially removed, eliminating gallstones and stricture in the left hepatic duct. Hemostasis was adequately achieved on the cut surface of the liver.

    3. Reconstruction of Hepatic Duct System:

    • The main hepatic duct and the left and right first-level hepatic ducts were collectively reshaped into a "basin" with a diameter of 4.5 cm. All second-level hepatic ducts were dilated and cleaned of stones.

    4. Hepaticojejunostomy:

    • The hepatic duct was anastomosed to the jejunum in a "basin" fashion. The diameter of the anastomotic site reached 4.0 cm, offering resistance to reflux.

    5. Anastomotic Integrity:

    • Both anastomotic sites were sutured in an orderly manner. There were no leaks, tension, twisting, or compression.

    Surgeon and Record:

    • Li Mingjie
    • Date: April 19, 1991

Ultrasound Follow-up:

  • Postoperative ultrasound re-examination and a 4-year follow-up showed no residual stones or recurrence.

Case 5: Surgical Record from Wuhu Changhang Hospital

Patient Information:

Name: Tang (Surname withheld)
Gender: Male
Age: 60
Department: Surgery
Bed Number: 38
Hospital Admission Number: 15539
Surgery Date: November 20, 1989

Preoperative Diagnosis:

  • Acute severe pancreatitis
  • Peritonitis
  • Cholecystolithiasis (Gallbladder stone disease)

Postoperative Diagnosis:

  • Pancreatic lesion removal
  • Pancreatic bed drainage
  • Cholecystectomy (Gallbladder removal)
  • T-tube drainage of the common bile duct
  • Abdominal drainage

Surgery Details:

  • Start Time: 9 PM
  • End Time: 1:30 AM (next day)
  • Blood Transfusion: 400 ml

    Lead Surgeon: Dr. Li Mingjie

    Assistant 1: Huang Hongcheng
    Assistant 2: Shi Lianghui
    Surgical Nurse: Gao Qingjie

    Anesthesia Method: Continuous Epidural Block
    Anesthetist: Wang Yisen

Postoperative Gross Findings:

  • Diffuse edema and bleeding of the pancreas
  • Focal necrosis
  • Large amount of hemorrhagic exudate in the abdominal cavity
  • Extensive saponification spots
  • Gallbladder stone, edema, and congestion.

Pathology Samples Sent for Examination:

  • Pancreas
  • Omentum
  • Gallbladder

Case 5: Surgical Procedure (First Part)

Initial Steps:

  • The epidural anesthesia was effective. The patient was placed in a supine position, and the abdomen was disinfected with iodine and alcohol. Sterile drapes were applied in three layers.


  • A vertical incision approximately 20 cm long was made along the right rectus abdominis muscle. The incision started at the xiphoid process and extended 3 cm below the navel. After achieving hemostasis in the subcutaneous tissue, the layers of the abdominal wall were opened sequentially.

Initial Observations:

  • Upon opening the abdomen, a large amount of cloudy, blood-tinged fluid, estimated at about 2000 ml, gushed out and was suctioned away.

  • Widespread edema, congestion, and bleeding were observed in the abdominal cavity, along with soapy spots scattered throughout.

  • The omentum appeared inflamed and clumped together.

  • The pancreas was severely swollen, exhibiting signs of bleeding and necrosis.

  • The lesser omental sac contained about 500 ml of fluid.

  • The gallbladder was congested and swollen, containing multiple stones, with the largest measuring 3.5 cm, along with an abundance of amorphous biliary sludge.

  • No stones were palpable in the common bile duct or within the liver.

  • Both liver and spleen appeared normal, as did the appendix.

Further Steps:

  • Incisions were made at the upper and lower edges of the pancreas' fascial envelope to decompress and drain the pancreas. A small amount of necrotic pancreatic tissue was cleared. A Kocher incision was made to mobilize the head of the pancreas.

  • Cholecystectomy was performed. The common bile duct was incised and found to have a diameter of 0.8 cm with no stones or parasites visible. The distal end was probed with an 8-number probe, and a T-tube was placed for external drainage.

  • Part of the omental mass was excised, and the lesser omental sac was opened for better drainage.

Draining and Cleaning:

  • The abdominal cavity was thoroughly washed and cleaned. Double drainage tubes were placed in the Douglas pouch at the pelvic floor, and single drainage tubes were placed in the retro-pancreatic space and lesser omental sac. These, along with the T-tube, were brought out through separate incisions in the abdominal wall and secured.

Surgical Difficulties:

  • The surgery was challenging due to significant fluctuations in blood pressure and inconsistent anesthesia depth. However, no accidental injuries or bleeding occurred. During surgery, 3000 ml of fluids, 400 ml of whole blood, and 500 ml of 5% S.B. were administered.

Final Steps:

  • All surgical instruments and gauzes were accounted for, and the abdomen was closed layer by layer. The patient was safely returned to the ward.

Surgical Conclusions:

  1. The patient had severe acute pancreatitis, which carries a high risk of mortality and an uncertain prognosis.
  2. The surgical procedures, which included decompressing and draining the pancreas and common bile duct, are beneficial for disease control. However, the possibility of further pancreatic necrosis remains.
  3. The gallbladder has been removed, eliminating concurrent gallbladder pathology.

Surgeon and Record Keeper: Dr. Li Mingjie

Date: November 21, 1989


  • Fourteen days post-surgery, the patient experienced a major hemorrhage and shock due to stress-induced ulcers. Emergency intervention stabilized the patient, and a second surgery was not required.

  • The patient was discharged after full recovery.


  • Six years of follow-up showed no recurrence of the condition.

Case 6: Surgery Record from Wuhu Changhang Hospital

Patient: Xue Somerong
Gender: Female
Age: 44
Department: Surgery
Bed No: 38
Hospital Admission No: 13533

Surgery Date: April 2, 1987

Pre-Operative Diagnosis: Rectal Adenocarcinoma
Post-Operative Diagnosis: Rectal Adenocarcinoma, Dukes Stage B1

Surgical Procedure: Anterior Resection of the Rectum (Dixon Technique)

Surgery Duration: 9am to 1:30pm
Blood Transfusion: 800ml

Surgeon: Dr. Li Mingjie

Assistants: Cai Yalun, Shen Yaping
Surgical Nurse: Gao Jieqing

Anesthesia: Continuous Epidural Block
Anesthetist: Chen Qibin

Post-Operative Gross Examination: Cauliflower-like cancerous mass of 6 cm, involving the entire layer of the intestinal wall.

Pathology Specimen Sent: Rectal cancer tumor along with 25cm above and 5cm below the intestinal tract, and lymph nodes at the root of the mesenteric artery.

Surgical Procedure Details

Surgical Steps

  1. Positioning: The patient was placed in the supine position with the head down at a 15-degree angle and the buttocks elevated. The perineum was disinfected, and a catheter was inserted and kept open at the bedside.

  2. Incision: The abdomen was disinfected in the usual manner. A longitudinal incision of 25cm was made through the left rectus abdominis muscle, extending from two fingerbreadths above the navel to the upper edge of the pubic bone. Hemostasis was achieved in the subcutaneous layer, and the surgical drapes were placed.

  3. Exploration: No ascites were present. The liver appeared normal with no signs of metastasis. There were no enlarged lymph nodes around the root of the inferior mesenteric artery or near the aorta. The entire colon appeared normal, and no adhesions were found in the abdomen. Multiple soybean-sized lymph nodes were present on the small intestine mesentery.

  4. Tumor Identification: A 6cm tumor was identified at the junction of the sigmoid and rectum, involving the entire layer of the intestinal wall but not causing obstruction. The colon was empty.

  5. Procedure Choice: It was decided to perform an anterior resection of the rectum (Dixon Technique). The lumen above and below the tumor was occluded, and 500mg of 5-FU was injected into the bowel at the site of the lesion. A lymph node biopsy was performed at the root of the inferior mesenteric artery.

  6. Vascular Management: The descending branch of the left colic artery was ligated and cut, preserving the marginal artery network. Blood supply to the colon 10cm above the lesion was good.

  7. Dissection: The pelvic reproductive organs appeared normal, with a slightly enlarged uterus in the postmenopausal stage. The appendages were not involved with the cancer. Tubal ligation was planned for the end of the procedure.

  8. Resection and Anastomosis: A segment of the rectum 25cm above and 5cm below the tumor was removed. End-to-end anastomosis was performed in two layers, with no leakage and good blood supply.

  9. Cleaning and Drainage: The abdomen and pelvis were soaked and cleaned with distilled water, 0.1% Cetrimide, 500mg 5-FU, and saline. Hemostasis was carefully achieved.

  10. Closure: The peritoneum was repaired, and the pelvic floor was reconstructed. Double drainage tubes were placed near the anastomosis and brought out through separate stab wounds. A cigarette drain was placed in the Douglas pouch.

  11. Final Count and Closure: All sponges and instruments were accounted for. The abdomen was closed in layers. Blood loss was minimal, and the procedure was completed smoothly. The patient was returned to the ward.

Surgical Conclusion and Follow-up 

Surgical Conclusion:

  1. Diagnosis: The tumor at the upper end of the rectum was an adenocarcinoma that was well-differentiated. It had invaded the entire circumference and all layers of the intestinal wall. Despite the prolonged stage of the disease, no extra-intestinal metastasis was found.

  2. Procedure: A standard Dixon radical surgery was performed, and the prognosis is expected to be relatively good.

  3. Anastomosis: The anastomotic site was free of tension, had good blood supply, and the sutures were satisfactory. The risk of postoperative leakage is considered low.

  4. Sterile and Tumor-Free Principles: The surgery was conducted following sterile and tumor-free principles, making the chance of iatrogenic implantation and dissemination extremely low.

  5. Postoperative Treatment: Chemotherapy is recommended post-surgery to enhance the therapeutic effect.

Surgeon and Record Keeper: Li Mingjie
Date: April 2, 1987


  • The patient recovered well post-surgery, with no complications.
  • Length of hospital stay was 26 days, and the patient was discharged in good health.
  • Eight-year follow-up showed no signs of recurrence or symptoms. The patient's quality of life is comparable to that of a healthy individual.
  • Rectal examination indicated that the anastomotic site had soft mucosa and the bowel lumen was unobstructed.





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