Surgical paper II

PEUTZ syndrome

A 14-Year Case Study of Three Surgical Interventions Due to Complications

Surgical paper I

Regular resection of left lateral lobe of liver for intrahepatic calculi

Introduction

Intrahepatic calculi, otherwise known as stones within the bile ducts situated above the left and right hepatic ducts, are an often underdiagnosed but significant clinical entity. Over the past five years, our hospital has recorded 368 cases of primary bile duct stones, which constitute 83.4% of the 441 cases of cholelithiasis surgeries performed during the same time frame. Of these, 112 cases were identified as intrahepatic stones, accounting for 30.4% of primary bile duct stone cases. These statistics align closely with domestic literature on the subject [4, 5]. However, it should be noted that the actual incidence is likely higher, given the limitations in diagnostic capabilities. The distribution of intrahepatic stones within the liver is further detailed in Table 1.

Table 1        Distribution of 112 Cases of Intrahepatic Stones

Intrahepatic calculi present a unique challenge in diagnosis and treatment, often leading to misdiagnosis and unsuccessful interventions. Until recently, the condition has been marked by a cycle of recurrent episodes, multiple surgeries, and repeated failures in treatment.

In a concerted effort to enhance the treatment outcomes for intrahepatic calculi, our hospital initiated a new surgical approach. Between 1975 and 1976, we performed resections of the left lateral lobe of the liver in five patients. Following a period of 3 to 4 years of postoperative surveillance, the long-term therapeutic outcomes have been promising. This innovative approach has not only yielded good long-term curative effects but also provided valuable insights that have significantly improved our treatment protocols for intrahepatic calculi.

Clinical Data

The study sample comprised a total of five patients: two males and three females, ranging in age from 21 to 40 years. Among them, two patients presented with residual stones. Intraoperatively, all cases were complicated by choledocholithiasis—stones in the common bile duct. The primary location for the intrahepatic calculi was identified as the left lateral lobe of the liver, where varying degrees of fibrous atrophy were also noted.

Surgical Procedure

All surgeries were performed under general anesthesia with abdominal incisions. Resection of the left lateral lobe was the principal surgical intervention. A "T"-shaped tube was employed for external drainage of the common bile duct, or additional intrahepatic calculi were extracted using a "joining forces" technique.

Postoperative Outcomes

Two cases experienced complications, specifically delayed hemorrhage and abdominal infection. The hospitalization duration for these patients varied between 14 and 72 days. However, all patients recovered fully and were discharged. Postoperative recurrence of choledocholithiasis was noted in two cases, necessitating further surgical intervention supplemented by a choledocho-duodenal lateral anastomosis. Subsequent examinations revealed no presence of intrahepatic bile duct stones.

Long-term Follow-up

All patients were followed for a period of 3 to 4 years postoperatively and showed no signs of recurrence. Overall health status was reported as good. (For a detailed summary of the original medical records, please refer to Table 2). 

Diagnosis of Intrahepatic Calculi

The majority of surgeries for intrahepatic stones are performed to address biliary obstruction. Among the 112 cases in this group, 95 were complicated by common bile duct stones (84.9%). Previously, the removal of extrahepatic stones and restoration of biliary tract patency were considered sufficient for a "cure," supplemented by general treatment. However, this approach failed to account for potential adverse reactions arising from persistent intrahepatic infections. This oversight often resulted in repeated episodes and surgeries.

Diagnostic Methods

1. Intraoperative Indicators: If the common bile duct is expanded by pigment stones or filled with sediment and the gallbladder is clear of stones, this suggests hepatogenic stones, warranting further examination of intrahepatic lesions.

2. Visual and Tactile Examination: The liver's surface may exhibit localized hardness, paleness, and dome-shaped prominence, along with localized atrophy. In contrast, healthy liver tissue may show compensatory hypertrophy.

3. Liver Abscesses: Multiple bile duct-derived liver abscesses often indicate intrahepatic calculi.

4. Angiographic Evidence: "T" angiography may reveal negative shadows, such as a bean-and-pod pattern, suggesting intrahepatic stones.

5. Postoperative "T" Tube Drainage: The presence of sediment-like stone deposition in the drainage bottle indicates a reduction in postoperative intrahepatic stones.

The Role of Left Extrahepatic Lobectomy in Treatment

1. Minimal Surgical Trauma: This procedure inflicts moderate damage on liver function and minor disturbance on the body overall. When executed correctly, it solves most treatment challenges related to intrahepatic stones, ensuring short-term recovery and long-term satisfaction.

2. Complete Elimination: It eradicates lesions and prevents ongoing infections and stone reformation due to poor drainage and bile retention.

3. Alternate Exploration: The surgery allows for the exploration and removal of stones from other hepatic lobes, offering a different vantage point for tackling intrahepatic lesions.

4. Convenience: Compared to intrahepatic cholangiojejunostomy, left lateral lobe hepatectomy is technically easier to perform.

However, it's crucial to note that simpler surgical interventions are more suitable for patients with toxic shock, severe systemic infections, or extremely compromised liver function. Relief of obstruction is better achieved with "T" external drainage.

Surgical Indications

The following cases are considered appropriate candidates for the surgical resection of the left lateral lobe of the liver for treating intrahepatic calculi:

1. Multiple Intrahepatic Stones in the Left Lateral Lobe: Particularly when accompanied by fibrous atrophy, and when other hepatic lobes either have no stones or have stones that can be completely removed by other methods.

2. Calculus in the Outer Lobe with Poor Drainage: Cases where the outer lobe has calculus, along with bile duct stenosis and poor drainage, making it likely that stone regeneration will occur if only the liver parenchyma is cut open for stone removal.

3. Inaccessible Calculus at the Junction: Cases where there is calculus at the junction of the left inner lobe hepatic duct that cannot be removed through other means.

4. Left Lateral Lobe Calculus with Abscess: Cases where an abscess is present along with the calculus in the left lateral lobe.

5. Necessity for Roux-Y Longmire Surgery: Cases where the extrahepatic bile duct cannot be located due to inflammation or adhesion, or is too narrow to be shaped, thereby necessitating a Roux-Y Longmire procedure (anastomosis between the intrahepatic bile duct and jejunum) for drainage.

   Implementation Technique of Regular Left Lateral Lobectomy

   Preoperative Preparations

   • Anesthesia: Continuous epidural anesthesia is recommended.
   • Positioning: Patients should lie on their back with their right side elevated.
   • Incision: A right rectus abdominis longitudinal incision is advised. The xiphoid process is sufficient, and if necessary, the seventh costal arch can also be cut off and exposed through extrapleural enlargement.

   Hemostatic Techniques

   1. Local Blocking Method: After freeing the left lateral lobe, an assistant holds it or presses it against the costal arch, and the surgeon performs resection with minimal blood loss. This was the method used in all 5 cases.
   2. Hepatic Portal Block Method: The hepatoduodenal ligament is freed, and the hepatic artery and portal vein are blocked for 15 minutes, then relaxed for 5 minutes. This can be done safely and repeatedly.
   3. Other Techniques: Liver forceps, rubber bands, and the mattress suture method were not used.

   Surgical Procedures

   1. Ligament Resection: Cut several ligaments like the ligamentum cirrhosae, falciform ligament, left triangular ligament, left coronary ligament, and hepatogastric ligament.
   2. Vein Ligation: Place a needle 1 cm to the left of the second hepatic portal and ligate the left hepatic vein. Be careful not to damage the middle hepatic vein.
   3. Liver Capsule and Parenchyma: Cut the liver capsule 1 cm along the left side of the suspensory ligament and sever the liver parenchyma with a knife handle. The cut should be flat, not in a "V" shape, to avoid damaging the left inner vein.
   4. Vessel Ligation: Each vessel should be ligated individually.
   5. Stone Removal: The hepatic duct and common bile duct are jointly opened to remove the stones, followed by internal and external suturing or drainage.
   6. Final Steps: The mattress suture is limited to not crossing the suspensory ligament. Turn over the suspensory ligament to cover the liver section and fix it. Use subhepatic siphon drainage or negative pressure drainage.

Discussion

Stone Distribution and Diagnosis

The distribution of intrahepatic stones is not random but follows patterns influenced by anatomical and dynamic factors, particularly favoring the left lobe. Direct imaging techniques are ideal but may not always be practical, making clinical judgment during surgery crucial.

Left Lobe Calculus

Calculus in the left lobe often undergoes significant fibrous atrophy, losing much of its function. However, the anatomical boundary of this lobe is well-defined, facilitating a safer and more convenient hepatectomy.

Treatment Efficacy

Left lateral hepatectomy is effective in treating most hepatolithiasis issues. Chinese reports show a success rate of around 90%. There were recurrence cases, but these were not related to the liver, suggesting that more comprehensive internal drainage strategies might prevent such outcomes.

Treatment Goals

The key to treating intrahepatic calculi is to remove the focus, ensure drainage, and prevent new stone formation. Surgery alone may not be sufficient, and a multi-pronged approach involving other treatments may be needed to prevent recurrence.

Infections

Hepatolithiasis often comes with serious infections, which can lead to abdominal infections. Aseptic techniques should be strengthened to mitigate this risk. The use of intraoperative bile duct irrigation should be carefully considered as it can spread infections.

Blood Transfusion

The necessity of blood transfusion is not emphasized; for generally healthy patients, it can often be avoided.

Etiology

The high frequency of intrahepatic stones, particularly bile pigment sediment-like stones, is not yet fully understood. However, it appears to be linked to biliary ascariasis and subsequent infections by Gram-negative bacteria. These factors contribute to the formation of stones with various cores, like parasite cadavers, making it an important subject for preventive medicine.

Summary

The paper summarizes the treatment and follow-up of 5 patients who underwent left lateral lobectomy to address intrahepatic stones. It delves into the surgical indications, the benefits of this particular surgical approach, the techniques employed, and the precautions that should be taken. One of the key takeaways is the recommendation to combine left lateral lobectomy with other methods like "reunion" for stone removal or incisions in the liver parenchyma. Coupled with the establishment of "valveless" internal drainage, this multifaceted approach aims to eliminate infection and prevent the recurrence of stones. The paper concludes that this strategy offers a viable treatment alternative for the complex issue of intrahepatic stones.

References  

1. Qian, Wenzhi.  Preliminary experience in treating hepatolithiasis by intrahepatic cholangiojejunostomy. Chinese Journal of Surgery 18221- 1965
2. Meng, Xianmin. Hepatectomy. Shanghai Science and Technology Press, Shanghai 1965
3. Han, Yongjian. Liver Surgical Anatomy.  Shanghai Science and Technology Press, Shanghai 1963
4. Huang, Zhiqiang. Hepatolithiasis and its treatment. Chinese Journal of Surgery. 91716-1961
5. Ran, Ruitu. Surgical treatment of intrahepatic bile duct stones. Chinese Journal of Surgery, 9:216-1961
6. Zhou, Hongquan.  Discussion on etiology and treatment of hepatolithiasis. Chinese Journal of Surgery 50(8):501-1964

Li Mingjie, Department of Surgery, Nanling County Hospital

This article was published in Journal of Wannan Medical College, Wannan Medicine, 1980, 13:51  and Domestic Medicine Surgery Volume (Part 1), 1981, 39

from 肝左外叶规则性切除治疗肝内结石

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

In support of application for Deputy Chief Surgeon, 1987

Editor’s Comment: This piece of writing submitted by my father 35 years ago is a review of the achievements and hard work in his first 30 years of medical practice. This stellar and unique report card explains how a doctor in a grass-roots hospital has been tempered into a powerful ‘iron man’, becoming an all-skill expert practicing almost all major medicine areas, extremely rare in a modern society.  In helping compile the collection of his own medical papers and in reviewing the 66-year journey, my father feels extremely grateful and proud. Dad said, his growth depends largely on “one book and two mentors”. This book refers to Maingot's Abdominal Surgery, which is a biblical surgical masterpiece. Dad said: At that time, the price of this book was 10 yuan, which was 25% of my monthly salary. It was a treasure of all my belongings! 

One of the two tutors was Dr. Meixian Min, the surgical authority in Wuhu superior hospital, whose theory, technology, character and demeanor were praised by everyone!  The other is Dr. Jingbin Xu, an authoritative professor of orthopaedics in China. My father studied orthopaedics with him at the 127 Hospital of the People's Liberation Army and became his accomplished disciple. About Dr. Min, Dad recalled two episodes he has cherished most.  Dad said: 

Once, he had me preside over an extremely challenging operation. When I came to the operation table ready for the surgery, he said, "Maybe you can't get off the table successfully. Everything off the table  is mine!"  It means all the aftermath, I do not need to worry about, and he will take care of everything. Who can match this spirit of responsibility! Another thing he said is also very memorable.  Before I moved to Wuhu, I came to see him, he said, "Knowing your recent situation, I suggest that you come to join me, in department of either surgery or orthopedics, better in surgery as it has a wider range and would benefit your further development. As long as your current employerNanling agrees to let you leave, I’ll take care of all logistics on the accepting side, including the health bureau, personnel bureau and hospital authority. Ours will be the Second Affiliated Hospital of Anhui Medical University, the provincial level hospital, which should be beneficial to your future promotion! "  He was very sincere and his favor was out of pure treasuring for talents. Apart from the career relationship as my mentor, there was not much personal relationship between us. Along the journey of practicing surgery, I always turned to him for advice once I came across challengies, and he acted always as my direct supervisor. It was also his key evaluation that helped my smooth promotion to the title Attending Physician.  He was the chief examiner in the promotion committee, and he evaluation was decisive. At that time, he said to me: “you can apply for either surgery or orthopedics for this promotion”.  The implication was that I was qualified for both subjects. That was 1981, not long after the Cultural Revolution. The entire Nanling had only seven people promoted to Attending Physicians, that is, less than half of the applicants made it.  Your mother and I both succeeded in the promotion list, which caused a stir effect in our community. At that time, professional titles were highly respected in the society. With the title of attending physician, one can enjoy all kinds of preferential treatments.

Mingjie Li, a full-time worker, graduated from the medical class of Wuhu Medical School in 1955.  In March 1956, he joined Nanling County Hospital. In 1960, he was sent to study radiology in Wuhu District Hospital for one year, and then returned to the hospital to establish the radiology department.  Since 1961, he has been mainly engaged in clinical surgery (during which he had worked concurrently in radiology for two years).  Since 1968, he has been the principal surgeon of major surgery in the hospital.

In 1973, he took part in an advanced training course in orthopaedics, and studied orthopaedics for more than one year under the guidance of Professor Jingbin Xu, an expert in orthopaedics at the 127 Hospital of the People's Liberation Army and editor of the Chinese Journal of Orthopaedics.  He obtained a certificate for the completion of the course.  Meanwhile, he was selected by the Foreign Affairs Bureau of the province as preparatory personnel for the foreign aid medical team waiting to be sent abroad.  On December 1, 1981, he was promoted to the title of Attending Surgeon. At that time, he served as Director of Nanling Branch of Medical Society.  In August, 1985, he was transferred to Wuhu Changhang Hospital, where he worked as an attending surgeon and orthopedic surgeon.

Since the medical association resumed its activities after the Cultural Revolution, I have participated in, and submitted papers to, the first, second and third annual conferences of orthopaedics and the first and second annual conferences of surgery in Anhui Province.  My papers were printed in the conference proceedings for research exchange.  I have also submitted papers to the first academic conference of obstetrics and gynecology in Anhui Province.  I have been involved in a variety of academic activities at the prefecture, city and county levels.  I have served as a lecturer in the county health school, teaching courses in anatomy, physiology, surgery and orthopedics.  I have been supervizing numerous medical college interns for many years.  I have been studying professional English for more than 10 years.  In 1980, I took part in the correspondence course of "Clinical English Learning" administered by Jiangsu Health Department for one year. Upon graduation, I won the first prize for the National Translation Competition.  I have translated a number of professional papers.  I can read and translate English books and journals, and write English abstracts for my own papers.  I have published numerous papers in medical journals at all levels, and in 1980 I was awarded the title of advanced scientific and technological worker in our county.

In the past two years since I joined Changhang Hospital, according to the limited cases encountered in our hospital, I have performed subtotal thyroidectomy, superficial parotidectomy, radical gastrectomy for gastric cancer, rectal cancer and breast cancer, and numerous cases of gallbladder, biliary tract and intestinal operations.  In addition, I have treated cases with spinal canal decompression, spinal cord exploration, myelography (Amipaque), closed penetration of triangular nail under fluorescence of femoral neck fracture and other osteopathy operations in orthopedics.  All these cases have achieved good results.

Earlier in my career, I served in Nanling County Hospital surgical department for nearly 30 years as a front line   physician of clinical practice. As a principle, all kinds of cases should be solved on the spot. Therefore, my practice covered a wide range, including orthopedics, urology, thoracic surgery, obstetrics and gynecology, ophthalmology and otorhinolaryngology, which are described below.

General surgery:

Surgeries performed include epatectomy, liver repair, ligation of proper hepatic artery, and a large number of biliary surgery and various biliary and intestinal drainage,

Additionally, a comprehensive array of biliary surgeries and assorted drainage techniques for both the biliary system and the intestine have been performed. These techniques include sphincterotomy and plasty of Oddi's sphincter, as well as various forms of anastomosis involving the common bile duct and duodenum. Procedures such as Roux-en-Y jejunostomy and multiple subsequent operations for recurrent hepatolithiasis are also among the interventions undertaken

such as Oddi's sphincterotomy and plasty (括约肌切开、成形术), side-to-side and end-to-end anastomosis of common bile and duodenum and its low hole anastomosis, Roux-y jejunostomy, second, third and fourth operations for recurrent hepatolithiasis. Incision and stone removal of liver parenchyma, intrahepatic bile duct stricture plasty, intrahepatic bile duct bypass, a large number of cases for gastrointestinal surgery, radical gastrectomy for gastric cancer (R1R2), total gastrectomy, radical resection for rectal cancer (Miles Bacon Dixon operation), intestinal obstruction, colon cancer, hernia, hemorrhoids, appendix, etc. A case of Hirschsprung's disease, congenital omphalocele and Pcutz-Jegher Syndrome underwent three operations in 14 years, including hyperthyroidism surgery, radical mastectomy (including super radical mastectomy), splenectomy (including giant brand 含巨牌), splenorenal vein anastomosis, portal azygos disconnection, internal drainage of pancreatic cyst, focus clearance and drainage of abdominal adenitis, PTC and retroperitoneal oxygenation.

Extrathoracic:

Resection of carcinoma in the middle and lower esophagus (including supraarch anastomosis and thoracic roof anastomosis), lung repair, pneumonectomy, septal hernia repair, and closed thoracic drainage.

Urological surgery:

Surgical procedures on the kidney such as removal of the kidney, stripping of lymphatic vessels in the kidney, removal of stones from the kidney through an incision in the renal parenchyma, removal of tumors in the kidney, removal of stones in the ureter and bladder, realignment of the urethra in case of trauma, vasectomy, transplantation of the ureter, removal of one or both testicles, treatment of cancer on the penis, and repair of a congenital defect of the urethra called hypospadias.///Nephrectomy, renal lymphatic stripping, pyelolithotomy, renal parenchyma incision to remove stones (肾实质切开取石), renal embryonic tumor resection, removal of ureteral and vesical urethral calculi, urethral trauma realignment, vasectomy and anastomosis, ureter transplantation, orchiectomy, penis cancer radical cure, hypospadias repair.

Obstetrics and gynecology:

All operations involved, including Cesarean section (classical, lower segment, extraperitoneal surgery), total hysterectomy (abdominal, vaginal), tubal ligation (abdominal, vaginal), vaginal wall repair, uterine isthmus incision to obtain the fetus, induction of labor, fetal debris, ovarian tumor resection, vesicovaginal fistula repair, cervical cancer pelvic cleaning.

Orthopedics:

Manipulation and surgical treatment of limbs’ bone, joint and spinal trauma, including reduction steel plate internal fixation and bone grafting for spinal fracture and dislocation, internal fixation (opening and closing) of femoral neck fracture with three-wing nails, and lesion removal of bone and joint tuberculosis, including surgery for tuberculosis of neck, chest, waist, sacral vertebra, hip, knee, ankle, shoulder, elbow and wrist joint, one-time operation for thoracic vertebra tuberculosis through pre-thoracic approach,  with lesion clearance, spinal canal decompression and anterior bone grafting, spinal cord tumor extraction, lumbar intervertebral disc extraction, myelography (iodine oil and iodine water), bone tumor (benign and malignant) surgery, meningocele repair and some orthopedic operations.

Ophthalmology and ophthalmology:

Tonsillectomy, radical correction of maxillary sinus, turbinectomy, nasal polypectomy, mastoid incision, cataract, artificial pupil, dacryocystectomy, nasolacrimal duct anastomosis, enucleation and strabismus correction, trichiasis, pterygoid excision and burial, etc.

Professional growth and innovation efforts

The original county hospital where I worked for nearly 30 years is a medical center with a population of 500,000 in the mountainous area of southern Anhui, and its surgery has an exclusive market. Although in the early 1960s, when I entered the early clinical stage of surgery, the conditions and my skill level were both very limited, I had to work hard to face all kinds of diseases related to surgery. There were many surgical opportunities and a wide range of operations. Environment trains people, pressure urges them to advance.  I managed to study hard and practice hard, and made rapid progress in practice.

The famous Maingot’s work "Abdominal Surgery" has benefited me a lot with intensive reading and digesting.  At that time, the incidences of intestinal obstruction were widespread, especially in the years of famine.  There were hundreds of such cases in a year, which laid the foundation for me to break through the basic theory of surgery and practice of lower abdominal surgery.  In 1964, I marched into the upper abdomen practice.  On the basis of dozens of stomach and gallbladder operations, I was appointed to lead a team for rural roving medical treatment in the countryside in 1965.  In 100 days, more than 600 operations of various scales were performed, including 121 laparotomy operations, in which 25 were upper abdomen operations, including stomach, gallbladder and uterus operations.  By this time, I had mastered the epidural anesthesia technique in advance, which created favorable conditions for these operations.  In the following year, I was sent to lead a team to set up two medical branches in Yijiang and Hewan successively, serving as business leader and continuing to carry out surgical operations.  In 1968, I was appointed as the head of the major surgery department of our county hospital, in charge of the treatment of all surgical patients. According to statistics, nearly 100 cases of gastric and biliary operations were performed in our hospital every year in that period.  Over the past decades, I have accumulated experience from both positive and negative aspects through a large number of operations, which also involves a process of continuous exploration and innovation.

In 1973, I participated in the restoration and reconstruction of Wuhu District Hospital after the early tubulance of Cultural Revolution.  While studying orthopedics, I also helped to perform numerous surgical operations, under the guidance of the director of surgery. Orthopedic specialty was also systematically studied and mastered.  I learned the most from Director Meixian Min and Professor Jingbin Xu, who were my two mentors in surgery and orthopedics.

Learn to swim in swimming

The recurrence and reoperation of cholelithiasis prompted me to be eager to update my examination methods and operation methods.  Inspired by the literature, I shifted my focus from simply dealing with extrahepatic bile duct problems to paying special attention to the discovery and examination of intrahepatic stones, hence a better understanding of intrahepatic bile duct stenosis.  Shortly after the 1980 Provincial Surgical Annual Meeting, I administered PTC, which dramatically improved the blindness in the past practice.  The operation methods also expanded to hepatectomy and liver incision for stone removal.  Combined with Finster operation plus Oddi sphincterotomy, Roux-en-y operation, posterior duodenal choledochoduodenectomy, hollow anastomosis of distal common bile duct and other internal drainage methods, the curative effect was greatly improved and the re-operation rate was reduced.

In our county, early local schistosomiasis portal hypertension was very common, our treatment ranged from early gastric circle and omentum to liver and kidney, to portal azygos disconnection, and finally to splenorenal venous shunt in 1976.  In order to prevent short bowel syndrome after a large number of bowel resection, I performed intestinal anastomosis with interposition of reverse peristalsis segments, resulting in good effect.

I had frequent on-call visits to the countryside to rescue liver and spleen injuries and ectopic pregnancy.  In order to solve the critical problem of blood source difficulty, my innovative and careful self-blood transfusion approach played a positive role.  For example, in 1969, I was sent 60 miles away to visit a 13-year-old child with rupture of the central liver, which needed to be repaired through the chest.  During the 4-5 hour interval while waiting for the ambulance’s return from the county hospital to bring the anesthesia machine, I practiced rein fusion of up to 1000 ml of abdominal liver blood repeatedly for the first time, and finally won the operation opportunity.  The postoperative recovery was fairly smooth, but 16 days later, the patient was complicated with massive hemobilia, treated with ligation of inherent hepatic artery, also for the first time.  Finally it was cured.  Having followed up to now, all is well with the case.

    Following the experience reported by provincial hospital in the First Annual Meeting of Obstetrics and Gynecology in 1980, I helped the Department of Obstetrics and Gynecology in our hospital to carry out the first 10 cases of extraperitoneal approach cesarean section and gained practical experience.  This became standard operation in our hospital.

After further study in the orthopedics trainee class, I changed the posterior approach of vertebral tuberculosis to the anterior approach for one operation, which greatly shortened the course of treatment, including one-time treatment through chest of thoracic tuberculosis complicated with paraplegia.  At the same time, interbody bone grafting was performed. In addition, lumbar tuberculosis was also treated with a trial operation to remove bilateral abscesses, together with bone grafting.  It was a success.  I also performed cervical tuberculosis surgery. This experience was reported at the first annual meeting of orthopaedics in our province.

Femoral neck fractures are common, complicated to handle and often ineffective. The original open triangular nail fixation led to   damage, easy to cause shock to the elderly, and often requiring blood transfusion.  After learning the experience from the Tianjin peers in 1979, I changed to closed nailing under fluorescence.  The patients had little burden, resulting in less pain, faster recovery and less cost. This experience was reported in the third provincial orthopaedic annual meeting.

I also advanced the spinal cord lipiodol angiography in the past to iodohydrography, which provided the basis for the diagnosis of intervertebral disc surgery, beneficial to the identification and monitoring.

In addition, I assisted the Ear, Nose, and Throat (ENT) department in performing a procedure called subchondral tamponade to help treat a condition called atrophic rhinitis by filling under the mucous membrane of the cartilage nose.  My report of this practice received rave reviews at the first annual meeting of the ENT in the province.

In summary, my professional growing process is primarily through improvement in massive practice and advance in technical pursuit. Long-term independent work facing all sorts of clinical practical cases, short of good conditions and nearby mentors, enables me to have developed the habit of independent thinking and turning to books and literature for help and insights.  Every time when a new operation is carried out, I feel it necessary to collect extensive information and review all relevant knowledge for contingency. This way, although the road has not been easy, the experience accumulated from practice proves to be fairly profound.

Mingle Li, Attending Surgeon, Wuhu Changhang Hospital, 19??

业务自传和工作报告

【李名杰从医66年论文专辑（英语电子版）】

Editor’s Comment: I have always felt that Dad is the modern Hua Tuo created by the times, which is basically unprecedented (except for Hua Tuo himself maybe) in terms of extensiveness in medical practice, the number of patients treated and the long service time.  Dad has been practicing medicine at the grass-roots hospital for more than 60 years (he is still on the job for half a day although he is in his eighties now).  In his long career, Dad has encountered various complicated situations. With his extraordinary intelligence, dedication and ingenuity, Dad demonstrated his expertise and professionalism to the fullest extent.  Dad has been both bold and cautious, knowing how to adapt to local conditions case by case, having saved countless lives with his comprehensive skills.  In a community where more than 300,000 people in the county had access to  only two or three surgeons, there was no clear division between surgery, gynecology, orthopedics and so on.   My dad made himself to be a general practitioner involving all major areas of clinic practice.  As my father said in his memoire, "My surgical life is the longest, with a large number of operations involving a wide range of surgical  areas (general surgery, orthopedics, urology, obstetrics and gynecology, nerves, facial features, chest, etc.)."  This is one piece of his more works written in 2011 covering his amazing undertakings in clinic visits beyond his hospital.  These stories can enlighten young doctors and encourage them to strike for their best. 

My surgical career has lasted for more than 50 years since the early 1960s.  Besides the three hospitals I have served as full time practitioners (Nanling County Hospital, Wuhu Changhang Hospital, and China Railway Bujiadian Hospital), I have been involved in dozens of external hospitals in "guest practice", including hospitals at all levels in Nanling and Wuhu, such as the Fourth Hospital, the Sixth Hospital, Xinwu Hospital, Matang Hospital, Jiangdong Hospital, Clinic at Smelter, etc.  My engagement also includes  on-call house visits, tour medical treatment in rural areas, various on-site surgeries and remote consultation as a visiting doctor.  This achievement is hardly heard of in terms of the number of number of operations and a wide range of subjects involved (general surgery, orthopedics, urology, obstetrics and gynecology, neurology, facial features, chest, etc.).  In fact, the number of operations performed beyond my own hospitals may well exceed the sum of the operations I have practiced in the three hospitals I have served. 

This situation of work overload continued until June, 2007, when my health entered an inflection point, with a red light on.  I was rushed to Wuhan Union Hospital for stomach cancer with massive bleeding, and had a total gastrectomy.   My gallbladder was also removed in the surgery  due to gallstones.  My postoperative recovery was reasonably smooth. Postoperative pathology: gastric Ca, poorly differentiated, involving deep muscle layer, all 18 lymph nodes around the stomach were negative, which can be described as "early stage". The operator said: no radiotherapy or chemotherapy is needed.  With this diagnosis, for the  sake of dealing with the cancer monster, it's a perfect ending, it's all over.  But my health was still hit severely with a long list of consequence.  I suddenly lost 15kg (from 70Kg to 55Kg). Although there were no common complications such as stenosis, reflux, dumping, indigestion, I felt sudden aging effects now that I have no bile and stomach.  Life entered the countdown, and energy and physical strength are much worse.  Physiologically, there is always something occurring of annoying discomfort or minor symptoms one after another.  Fortunately, I still can maintain the lowest level of normal "healthy" daily activity: I have been working in the first half of the day, and from time to time, I still manage to perform operations at the table for 3-4 hours non-stop.  From June to August last year, I made a trip to Silicon Valley, USA, where I visited my two sons and their families,  who both have a PhD background and serve the IT industry.  I endured the 14-hour flight journey fairly well.  So far, it has been more than 4 years since my operation, so I think I was lucky enough to have escaped the cancer.  However, what it left behind is a downhill path in life, and I know my future is limited.  So I need to cherish life more in the remaining time. 

After that incident, besides emergency call for surgery rescue several times, basically I stopped the out-of-hospital consultation practice, but the operations in my hospital have not stopped.  Nevertheless, surgery operations beyond my own hospitals accounts for more than half of my surgical career.  Here, looking back on the external visiting practice or on emergency calls to help rescue in the middle of other’s operations, there are some remarkable episodes worthy sharing.

It is said in the scientific and technological circles that scientific and technological talents should be encouraged to take more external posts or jobs, in order to fully tap the valuable human resources to serve the society.  But the current "practice" following the on-going policy is to stick to one post, in the fixed discipline for fixed jobs, with no felxibility allowed.  However, in today's market economy, it is not uncommon for experts to take advantage of the needs for undertaking multiple external jobs for extra financial benefits,  making visiting experts or guest doctors lose their original glory.  I have experienced the social transformation and different needs of various times in different periods over a much longer time.  In contrast, my guest practice was quite unique. 

During the 29 years (1956-1985) of working for Nanling County Hospital, the expert human resources of the society were extremely scarce, with very few doctors and even fewer surgeons serving a large population.  In fact, for many years there were only two or three surgeons who were counted on to meet the needs for solving the difficult surgery problems in a county with a population of more than 300,000 residents.  That is to say, all the surgical patients in this population basically need to be treated by these two or three people.  Prohibited by the economic and traffic restrictions at the time, there was very little possibility to outflow the patients elsewhere.  Furthermore, in addition to those who manage to come to the hospital, there are many of them who cannot make to the hospital in emergency.  It is inevitable to make numerous house visits, consultations and on-site operations.  Especially after 1968, as the head of our surgery department, I had to make more frequent house visits and all kinds of consultations for diagnosis. 

Here's a fun episode.  At that time, there was only one ambulance in our hospital, driving within 20 miles an hour at its best on those rural sandy roads. Many times, it was only me and our driver heading for an emergency house visit to the rural area.  Over time, although I didn't attend any driving class, I managed to have learned to drive, without a license (at that time, the traffic rules were lax and there were few vehicles on the country road anyway). Over the subsequent few decades, I drove at least 10,000 kilometers to make house calls, with a driving experience of more than 30 years, comparable to a full-time driver.  It is mainly my health and age following my last operation that makes me miss the emerging driving era as a legit licensed driver. 

That was the era of "serving the people", and there was never a personal benefit of house visiting and consultation for any out-of-hospital surgery. When we needed to invite experts from the superior hospital to come for consultation on difficult cases, it was the same.  Their coming to support was counted as a business trip then, only to reimburse their travel expenses.  They needed to leave 20 cents to cover the cost of the meal. In Mao’s era, no matter how famous a doctor is, there was no way of having any extra-salary income. 

1. Rural itinerant medical treatment 

During the last three months for 100 days in 1965, as captain leading a rural itinerant medical team of 5-7 people, I performed 612 operations, major or minor, in Yandun Commune, Nanling.  Among them, 121 people underwent laparotomy, including stomach, intestine, gallbladder, uterus, hernia, hemorrhoids, thyroid, kidney, ureter, bladder, orthopedics, ophthalmology and dentistry.  One afternoon, while there was availability of an anesthesiologist on site, I operated on three consecutive cases of vaginal hysterectomy plus pelvic floor repair and reconstruction.  The high rate of this disease, often third degree uterine prolapse (or pelvic floor hernia), was in fact incurred as side effects of sustained malnutrition from the notorious great famine in 1960 China.  This is unbelievable work efficiency, not to mention that everything was operated on a temporary "operating room" in a remote commune clinic.  That day, operations lasted non-stop until three o'clock in the morning, and more than ten other operations were also performed. 

There is a middle-aged woman who suffered from intestinal perforation of typhoid fever complicated with peritonitis (such infectious diseases were prevalent at that time, but very rare in recent years).  I treated her with intestinal resection.  She was penniless and there was no charge on her treatment.  Furthermore, after she was discharged from hospital, I rode my bike to pay her a house visit in her rural home in Qingyangmu town for the follow-up and condolences, with some donated gifts gathered from physicians ourselves. This was a trend in answering the call from Mao on serving the “poor and lower-middle peasants”.   It also reflects the original holy glory for medical practitioners as "angels in white". 

There was a case of incomplete abortion with massive bleeding, facing a crisis every minute.  I and a midwife rushed to her home at Sanxing Brigade to give an emergency uterus cleaning with rapid fluid replacement, which saved her life. 

Another case of vesicovaginal fistula was repaired by my operation, and discharged with recovery after 12 days.  This success initiated this kind of operations.

2.   First aid visits

Here are a few cases of first aid visits to share. 

That was 1968.  A 13-year-old boy from a remote mountainous village Yashan fell from the back of a cow, and his right liver ruptured, causing massive abdominal bleeding.  I rushed in our ambulance to the Hewan health center where I had to open his chest to complete the operation.  There was a need for blood transfusion.  I had to send the ambulance back to the county town (at that time, this was the one ambulance we had) to fetch the anesthesia machine and a blood donor.  This mountain road was in a very poor condition, about 30 miles away, and it happened to be foggy day in the mountainous area.  It ended up taking more than 4 hours for the return trip.  I simply could not wait any more.  As a last resort, I decided to have the accumulated blood boldly extracted from the patient’s  abdominal cavity for the first time to save the case.  The self-transfused blood amounted to 1700 ml.  Here it also involves a theoretical question whether the blood mixed with bile can be re-transfused safely, which  was debated in the community and also finally affirmed in subsequent literature later on.  The transfusion helped to maintain the hemodynamic operation during the “waiting" time, and enabled the general anesthesia thoracotomy and liver repair surgery on the spot.  The postoperative recovery was fairly "smooth".  But 9 days after the operation, just as he was supposed to be discharged the next day, the complication of intrahepatic biliary tract hemorrhage occurred.  The hemorrhage attack was typical: with a burst of biliary colic, blood pressure came down, a list of symptoms followed: pale face, anemia, shock, and repeated attacks. Conservative treatment failed, so after one day's observation and measures, I decisively transferred this case to the county hospital to perform the proper hepatic artery ligation and external drainage of common bile duct.  The operation was a success. This entire procedure is very typical based on classical operation theory: the hepatic artery tremor was felt during the operation, which showed bleeding.  After ligation, the tremor disappeared immediately, and the common bile duct hemorrhage was delayed and stopped (as noted in the literature). Life was finally saved. This was an absolute "miracle" for the surgical level of a county hospital at that time, and I was pioneering frontier of surgery. 

At that time, our monthly salary was less than 50 yuan.  This case cost more than 1,000 yuan in the entire treatment,  so he was nicknamed as "1,000 yuan".  How can a poor farmer afford this astronomical amount of money?   Fortunately, in the era of Mao's "curing the wounded and saving the dying", the poor lower middle peasants’ medical charges could be simply written off following some logistics, which has been passed from mouth to mouth with approbation in the society. 

Another example is the splenic rupture at Donghe. My colleague and I were called for the urgent house visit.  We performed splenectomy successfully on the spot on a desk of the commune.  The wonder in this case was our use of 800ml abdominal blood for self-transfusion to overcome the problem of no blood source. 

Although it is defibrinated blood, it is without anticoagulation, yet it does not need to be anti-coagulated (thereby solving another difficult problem of no anticoagulants on hand) as it is the self-blood on the spot.  This was a first bold attempt forced out by the emergency in innovation.  Life was saved.  The road paved out, as it is so-called "the times make heroes”.   This innovative practice was later supported and theoretically recognized by the surgery community.  Its efficacy report gradually appeared as legit rescue in the literature. 

There was a difficult labour case at Xinlin, in Fanchang, with intrauterine transverse position of fetus， and uterine aura rupture, too critical to transport to county hospital.  Cesarean section had to be performed on the spot.  An office desk was used as the operating table, a cloth was pulled on the top to block the ash, with disinfectant sprinkled on the ground, I performed the operation with an infusion under local anesthesia, which saved two lives.

3.  Surgical practice during special period of “civil fighting”

During the Cultural Revolution, there was a special period of chaos when the various factions were armed fighting with real fire arms.  Traffic was interrupted, and hospitals were shut down.  Bullets had no eyes, and gunshot wounds ensued.   They had to be operated on the spot to repair the damaged liver and lungs, kidney, intestines and stomach, etc.  At that critical period, I was forced to take the challenge of practicing these urgent surgeries for rescue, like in a war.  Many lives were saved and most of the cases were successful.  It was a special war-like time, so in case of accidents during operations, there was no strict accountability check.  It was also a unique period when my surgery skills advanced rapidly with tons of urgent surgery practice demanded then.  Indeed, practice generates expertise.  

This is an era of serving the people, and all this will not bring economic benefits, nor will we pursue benefits at that time. 

4.  AS guest surgeoN

After joining Wuhu Changhang Hospital in August, 1985, this affiliated staff hospital did not demand a full work load, so I had some extra time to serve as a guest surgeon for other hospitals. 

4.1 I served as surgical consultant for Xinwu District Hospital for three years, until the hospital was restructured and turned private.   Every Saturday morning, I administered an expert clinic.  I was also responsible for managing the patients’ ward.   During that period, all surgical operations were conducted by me, and for almost all daily operations I would be present. Mr Chen, the president of this hospital, suffered from gallstones, and I performed the operation right there in the hospital. 

4.2  The Municipal Tuberculosis Hospital, later named as Municipal Red Cross Hospital (Sixth Hospital), is located in  suburban Yueya Road. This hospital is also responsible for some comprehensive medical treatment for the people in its neighborhood.  However, this is a specialized hospital, and the surgery expertise is zero.  The hospital leader came to me and asked me to take over the surgical work in this hospital. I was at the time also with "excess energy", so I organized a queue of surgical directors of various hospitals from all districts and factories in the city, and requested the director of radiology department of our hospital to be the chief shift supervisor (equivalent to the chief resident).  The day shift and night shift watchmen came from 4 or 5 hospitals.  Where there was a need for operation, I would take my anesthesiologist, Mr. Chen, together with me to the hospital in the hospital car.  In this way, in more than a year, we performed hundreds of operations, involving various areas of surgery, gynecology, orthopedics and urology, related to stomach, gallbladder, appendix, lumbar intervertebral disc, uterus, fracture, etc.  Meanwhile a number of surgical new talents were also trained there.  During this period, a rare case of pyometra was encountered.  In order to clear the focus at one time, hysterectomy was performed for the first stage, and the recovery was smooth.  That was also the first such operation in this hospital. 

4.3 For No 4 Hospital and Municipal Psychiatric Hospital, surgery, orthopaedics, obstetrics and gynecology are not their forte, and there was a lack of related talents.  However, as a hospital, their comprehensive medical care is still indispensable.  Therefore, when they encountered problems in these area, I was the support they relied on.  From time to time, I went on visits to have performed cesarean section, choledocholithiasis and other operations for this hospital. 

4.4  Matang District Hospital, located in the south of the city, is a connecting part of urban and rural areas.  Although it is a class 2 hospital, there is insufficient technical strength and it often calls for diagnosis guidance.  With my anesthesiologist, I served for their surgery emergency rescue.  One case with acute suppurative obstructive cholangitis was treated right there by an emergency operation successfully . 

4.5.  Zheshan Branch, Jiangdongchang Hospital, is a class one hospital in the city, close to Hongmei New Village where I live.  So it is convenient for me to be called for help any time. Basically, I took care of all the surgical matters there, which lasted for many years.  It's my “backyard”, sort of.  Although they all have deputy chief physicians, they still lack the experience and ability to support all the comprehensive surgeries needed independently.  It's a "win-win" and mutually beneficial for me to support them on call.  When my hometown acquaintances and old patients turned to me for treatment, for convenience and economy, I could solve most of their problems there. Hence I have done a lot of operations on the spot.  

My child’s fifth uncle had rectum cancer and came from Hefei to me for help.  I had a radical operation on him in Zheshan.  It took him 7 hours to get through this critical stage because of massive bleeding before sacrum.  He was cured 

A case of thoracic vertebra fracture with high paraplegia from Nanling had my operation of spinal canal exploration and decompression in Zheshan too. I also performed a caesarean section for a doctor in this hospital,.  I also demonstrated vaginal hysterectomy for the training of the surgeons there. 

A large number of routine operations are performed there, often dozens of surgeries in one month.

5. Numerous weekend house calls 

Over time, I have become their perennial consultant in numerous hospitals such as Sanli, Yijiang (the second and third branch hospitals of Nanling), Family Planning Station, Schistosomiasis Station, Hewan, Xuzhen, Chengguan.  Almost every weekend, I was on my way back and forth to help with their operations. 

Lumbar disc herniation and lumbar spinal stenosis are common diseases in orthopedics, which belong to the Level -3 and Level-4 operation of high difficulty.  My confidence in performing such surgeries comes from my many years of clinical experience and my studying orthopedics under Professor Jingbin Xu, the top orthopedic master in China.  Not long before my own serious illness and operation in 2007, I drove out in the morning to Nanling schistosomiasis control station, and performed the operation on three cases within one day.  The key to ensure success is to completely loosen the compressed nerve root and spinal meningeal sac.  The curative effect is then definitive.  That afternoon after three surgeries performed, it was still not too late for me to drive home for dinner.  

There is another case of Wang XX, a young driver and also a family friend of mine, who also suffers from this disease.   She is restless day and night, and cannot move.  Dr. Lin, the president of the Second Hospital of our city (who is my junior fellow), and I performed an operation on him in Zheshan Hospital.  After decompression of the vertebral lamina, he was able to drive a car again three months after the operation.  For more than ten years now, he has had no symptoms and has enjoyed normal activity in work and life.  He has made himself a billionaire today. 

6. Save the performance at operation table any time 

6.1.  Once in a private hospital of Guniushan, Nanling,  they had a surgery on-going but could not find the expected bilateral ureteral stones during the operation.  Their dean gave me an urgent call for rescue and he was waiting outside on the parkway.  I immediately took a taxi, and in less than an hour, I went on the operation table, taking out the bilateral stones and smoothing the urine flow to have saved the surgery. 

6.2. Once there was an urgent case of subacute perforated peritonitis of a transverse colon cancer in Yijiang Hospital.  At three o'clock in the midnight, they called for my help.  I had to get up to rush for a taxi.  It also took me one hour to get onto the operation table, and I stepped down at dawn with the first stage excision and radical cure of the lesion.  It has achieved long-term curative effect, saving the patient as well as the doctor initiating this surgery.  In fact, they are all my disciples and trainees in the past.  Of course, I feel the responsibilities to be on call to help them any time needed, without hesitation.

7.  Tangshan  Earthquake 

In the July 28, 1976 Tangshan Earthquake, the official death toll was 240,000.  On August 3rd, I was called to go to Tangshan for earthquake-related medical treatment and rescue.  Before getting on the bus in Wuhu, the central authorities gave us a telex: the wounded are being transferred to the south so we do not need to go northfor their treatment.  As the appointed team leader, I organized a medical team of 25 people from Fanchang, Jingxian, Nanling counties plus 25 additional logistics security guards.  The task given to me was to receive and treat 100 wounded people.   Of course, all expenses are covered by the state. It is ordered as a serious political task for us to accomplish.  We set up a temporary treatment site beside the railway at a small town Eqiao. Then I led the team to the Nanjing station in a specially assigned emergency train to take over the patients in orthopedics. About three months after our treatment and care, we had completed this glorious task and sent all of them back to their hometown safely.  It is a historical monument. 

Most of these patients involved fractures, peripheral nerve injuries and spinal cord injuries with paraplegia.  There were not many operations, most of the treatments are of rehabilitation.  This large-scale urgent medical activity involves dozens of sites like ours in Wuhu area, whose leaders include authorities of orthopedics like Jingbin Xu, director of the 127 Hospital of the People's Liberation Army, and Naiyi Chou, director of the former Yijishan Hospital (the medical captain who led medical teams to South Yemen twice).   We medical team leaders meet regularly and discuss all clinical problems and measures.  I am both the captain and the backbone of orthopedics, having participated in the entire process of this rare undertaking. 

8.  Remote consultation and diagnosis 

During an online chat,  my son Wei in the U.S  said that he had severe "heartburn" from time to time, as he said, “it comes and goes, but when it strikes, it is unbearable.” His family physician asked him to have a gastroscope and checked his heart, but he never thought he was suffering from biliary colic.   A healthy middle-aged man, with sporadic pains striking and leaving, what could have been the cause?  On this side of the ocean thousands of miles away from him, I remembered that he had mentioned one year earlier that his annual physical exam found gallstones but it was asymptomatic then.  It must be biliary colic kicking in!  But he didn't agree with my suggestion. He was convinced that it had nothing to do with gallstones because the pain was from the heart area.  I am professionally sensitive and experienced, insisting on my diagnosis: this is gallstone colic, and it can be cured by surgery.  He then followed my advice to see his doctor again, reminded him of this possibility, and then had an ultrasonic examination, coming back with a definite diagnosis.  A laparoscopic operation was performed, and it cured him instantly.  He has been amazed by this experience of my remote diagnosis and has enjoyed a healthy life since.

There have been many similar incidents.  One day, our head nurse called me and said that her husband suddenly had severe abdominal pain.  I knew that he had a history of bleeding from gastric ulcer, so I naturally thought that it must be related to perforation complicated with peritonitis.  I told him to go to the hospital immediately and make preoperative preparations, such as taking an abdominal fluoroscopy, checking blood, etc.  At the same time, I went to the emergency department.  Although no "gas layer" was found under the diaphragm, I still went on with a decisive surgery and managed to perform radical gastrectomy for him.  It is more than ten years now, and he has enjoyed a healthy life.

Many of my out-of-hospital practice and visiting operations, and my being so interdisciplinary in medicine, are the special products of my era.  According to today's standards of high specialization, such practice is neither standardized nor rigorous.  Nevertheless, my special skillset has managed to save many lives and cured many diseases.  It is an indelible mark in the career of my medical practice, demonstrating a significant contribution to society. It has made a difference to my patients and hard for them to forget.  In my life, I have had countless sleepless nights, with eating and sleeping in total disorder, but the sense of self-satisfaction in saving lives is more than enough to comfort me with deep pride and joy.   Nothing could have been better, I have no regrets!

More recently, with the rapid development of science and technology, medicine is also making great strides, evolving with each passing day.  In the ascendant, medical instruments and drugs also see revolutionary development, especially striking to me are the new drugs and the orthopedic equipments, such as stapler, occluder and repair mesh, etc.  As I have been on duty all the time, I feel extremely fortunate to have got on this "last bus", although most peers in my generation are now blocked at the door.  However, the currently popular techniques like laparoscopy surgery, minimally invasive technology is still a blind spot for me, due to the equipment requirements beyond my reach. 

In recent years, a large number of new concepts and terms have appeared in medicine, such as translational medicine (TM), targeted therapy (TT), evidence-based medicine (EBM), etc. I keep up with the times, continuously update my knowledge and keep on following up.  Both in theory and clinical practice have been undergoing changes. 

According to the requirements of fine division of labor in modern clinical medicine, in the past five years after my own gastrectomy, I have basically given up other related professional work outside general surgery, such as orthopedics, obstetrics and gynecology and even urology. This, too, is a way to help create bigger room for new talents to be superior to masters, and shows the progress of society.  My professional title is "General Surgery" chief physician, and I will stick to this area for the remaining path of my career, never fall behind in my lifetime and stay young and energetic! 

My eldest granddaughter is a senior with the 8-year medicine practitioner curriculum in Tongji Medical University, Wuhan.  She is expected to follow me to become the next doctor in my family.  Well-educated, standing from a high starting point, she came to my hospital as a trainee and intern during the Spring Festival holidays last year. When she wore a white medicine costume, she looked like a brand-new doctor in the 21st century.  This baton is passed down to her, and I feel that it is a perfect legacy carry-on for my medicine career,  there’s nothing more I could have asked for.  Admittedly, this profession calls for enduring dedication, involving huge risks and hard work.  However, it also provides a platform where the value of life is most experienced and demonstrated!

October 2011

《李家大院》7: 我的外科生涯—-院外集锦

【李名杰从医66年论文专辑（英语电子版）】

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. techniques. The medicine community has also gone through a process of repeated debate and re-evaluation of the choice between shunt and devascularization techniques.  In this regard, as far back as in 1975, I performed splenectomy, splenorenal vein anastomosis and other types of shunt surgeries. 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 can cause patients to suffer from postoperative pain and a prolonged recovery period post-surgery. 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 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 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 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

《李家大院》6: 业务自传和工作报告

【李名杰从医66年论文专辑（英语电子版）】

Before writing my debriefing report in support of my application for Chief Surgeon, let me start with three unforgettable orthopedic cases that I experienced in my medical practice. 

In 1970, my old schoolmate and close friend from junior high school, Mr. Gui from Fanchang No.1 Middle School at that time, brought his son’s case to my attention.  His son, aged 16 then, suffered from cervical vertebra 5 tuberculosis with cold abscess, which severely oppressed esophagus and trachea. He was unable to eat, and had difficulty breathing, with hoarseness, dehydration and hypoxia, in a critical condition.  

They had visited Yijishan Hospital, the largest hospital in Wuhu, but the director there Dr. Chen of the Department of Orthopaedics could not admit this case, saying that a few days before, a similar case, died during the operation.  He made the suggestion for the patient to be sent to the provincial Hospital of Hefei, which required 800 yuan then.   However, Mr. Gui’s monthly salary was only 52 yuan, and he had to support a family of six with this income.  How could he afford it?  Besides, nobody knows whether the chief hospital in Hefei could treat him.  In a hurry, Mr. Gui turned to the No. 127 Army’s Hospital located in the suburb of my town Nanling, to try their luck there.  The corresponding department of the hospital was administered by Dr. Xu Jingbin, the nation-wide orthopedic authority, and this military hospital located in a small place long had a tradition of helping the poor.  Unfortunately, Dr. Xu was on a business trip to Nanjing, and several of his subordinates there were too afraid to accept this high-risk patient.   

Feeling helpless, Mr. Gui came to me in Nanling County Hospital (the two hospitals are only 5 miles apart) to discuss possible rescue plans with me.  I was not sure about how best to treat this condition either.  However, I had studied in No. 127 Hospital, with Dr. Xu as my supervisor, familiar with the personnel there.  I immediately called an ambulance. We went back to No.127 Hospital, found doctors in orthopedics and surgery, and asked them to work together for the treatment of this urgent case.  Mr. Gui as patient’s family and I jointly signed the required paper for willing to take the risk of the operation, and discussed the detailed rules.  However, this plan was still not approved by the hospital.  Instead, the hospital asked me to help them out of this embarrassing predicament, and promised a free car to be used for transferring the patient to big city hospitals in Hefei or Nanjing.  The patient's life was in danger at any time. Far water cannot put out the near fire, so it's not advisable to transfer to hospital far away. 

I decided to take on the challenge myself.  At that time, I thought, at least I could give pus discharge for saving life first, relieving the oppression of esophagus and trachea, and making it possible for hime to eat and breathe.  So the patient was brought back to the county hospital where I worked.  Without even getting off the stretcher, I ordered to first give fluid replacement and antituberculosis.  At this point in the evening, Mr. Gui didn't get any food for a whole day, so he was given dinner at my home.  I could not afford the time to have a dinner.  I took the time to review the related literature and anatomy.  Half an hour later, the patient was sent to the operating room under local anesthesia. After my careful dissection, the patient’s pus cavity was cut to release a large amount of pus.  The patient immediately started making sounds, could sip the water, and breath smoothly, indicating him finally put out of immediate danger. 

The operation continued, exposing the focus of cervical vertebra 5 by anterior approach, I removed the dead bone, scraped off the granulation of tuberculosis, flushed the pus cavity, inserted streptomycin and isoniazid, put the drainage piece in, with suture.  The operation was smooth and very effective.  The fever came down 3 days after operation.  The patient went to get a haircut, ate normally and recovered well. 12 days after the operation, he was discharged from hospital, and his medical expenses were 32 yuan.  He continued anti-tuberculosis treatment for half a year and recovered well.  For more than 40 years now, the patient has been working and living normally, now enjoying a family of his numerous children and grandchildren. 

In addition to the complicated anatomy of the neck, such as dense blood vessels, nerves, thyroid gland, trachea, esophagus, etc., this type of cervical tuberculosis debridement operation is of high difficulty also due to the fragility of the cervical spine and the destruction of tuberculosis.  If there is a slight mistake in the cervical spinal cord, it will lead to being paraplegic at a high level or even death.  It's an orthopedic high risk level 4 operation.  Even in big hospitals, the directors are extremely cautious in treating such cases.  I was still a newcomer in orthopaedics then, but I needed to save lives, knowing that transferring to another hospital at that time was basically a dead end.  The patient was on the verge of an abyss.  But I also had some of my own strength and preparedness for this success.  I had had many years of experience in neck thyroid surgery, familiar with anatomy, and had accumulated specialized knowledge in orthopedics.  This solid foundation finally enabled me successfully complete this rare problem in a grass-roots hospital.  Life threatening symptoms were treated by relieving oppression immediately.  And the disease was cured, with the lesion eradicated.  It proved to be a cure for life.  

Another case, at the end of 1980s, named Xiao Wei, a 14-year-old junior student in Wuhu No.1 Middle School, suffered from right humeral neck tumor.  He had undergone two operations in Yijishan Hospital and Shanghai Zhongshan Hospital respectively.  Now, the disease struck at the right scapula.  The director of orthopaedics in a hospital of our city said, it is malignant tumor recurring and metastasizing, amputation is necessary, and it is challenging to save his life!   The family was in a desperate situation.  The patient’s grandfather, Mr. Wu, was my junior middle school teacher.    Mr.  Wu knew about the case of cervical tuberculosis treated  well by me on Mr. Gui’s son, so he came to me for consultation.  I carefully examined the medical records and the X-ray films before and after, and diagnosed it as a new critical tumor, neither a recurrence nor a metastasis of the original disease.  I personally performed a half-excision of the right scapula in my own hospital, resulting in his full recovery.   More than 20 years have passed, and Xiao Wei has enjoyed good health ever since.  He has become a Dr. Yang in the west later on, and is now a high-end international talent in his field.  From time to time, he and his father still come to visit me with appreciation. 

The third case, in the fall of 1975, a 35-year-old female patient, who had lost 40 kilograms, was admitted to our hospital for tuberculosis of thoracic vertebrae 6 and 7 with paraplegia.  Under general anesthesia, through the chest, the focus was cleared, and the dead bone and the necrotic intervertebral disc were removed.  The tubercle granulation in the spinal canal was 8cm long, which pressed the thoracic spinal cord, resulting in spinal canal obstruction and paraplegia.  After curettage, it could be seen that this segment of spinal cord was throbbing again.  The focus area was thoroughly washed, with antituberculosis drugs added in.     The ribs cut during thoracotomy were trimmed and embedded in the intervertebral defect area, and the anterior bone graft was completed in one single stage. After operation, the patient recovered well and was cured.  The patient’s husband was a blacksmith, who gifted me with  a stainless steel kitchen knife and a spatula of his own craftsmanship, which are still in use in my home today.  In orthopedic surgery, this belongs to the top level-four category.  With thoracic tuberculosis complicated with paraplegia, the cure was one-time lesion clearance and bone grafting through the anterior thoracic approach, definitely having reached the peak in county-level hospitals. 

Such cases have brought me a great sense of pride and accomplishment, and they form the motivation for my lifelong dedication to saving lives and relieving pains for my countless patients.

《李家大院》5: 我的外科生涯

【李名杰从医66年论文专辑（英语电子版）】