Chapter 2404: Tools and Hands
The xiphoid process is at the lower end of the sternum, and for most people, it is cartilage.
With cartilage, there’s no need for a power saw; surgical scissors will suffice. In many tasks, it’s a common strategy to tackle the areas of least resistance first and save the tougher parts for last. This is also true in medical procedures. Clearing the xiphoid process before sawing the sternum serves as an important breakthrough point. Just like before, the most crucial task is to clean the things attached around the bone.
This time, to assist the Chief Surgeon, the First Assistant does not use the Separation Clamp. Instead, they use forceps to clamp the small shield-like xiphoid process and clean out the heap of "debris" behind it. It’s akin to dismantling a mechanical arm—without cutting the wires and such connecting the arm, it’s not possible.
The Chief Surgeon, holding the Electrosurgical Unit, zizzes through the xiphoid process, coagulating as they cut, revealing the rectus abdominis muscle beneath. This location is near the abdominal cavity, requiring extreme caution to prevent excessive dissection. If fluid intended for the thoracic cavity or pericardium flows into the abdominal cavity, it could lead to complications in the abdominal organs.
After cutting, a gap is revealed behind the xiphoid process. The Chief Surgeon puts down the Electrosurgical Unit, extends a finger from their right hand into this gap, reaching the left posterior side of the sternum. This area is adjacent to the pericardium, and the surgeon’s finger gently pushes, spreading the pleura on both sides of the mediastinum, performing a blunt dissection.
If the patient were younger, the doctor’s finger might directly separate up to the upper posterior end of the sternum. If older, one finger wouldn’t reach the upper sternum, so like in other engineering tasks, the only solution in this case is to use tools in place of fingers, following the finger’s direction forward. Doctors commonly use the Changping Forceps, aligning them closely to the sternum for blunt dissection.
Whether using a tool or simply fingers, the goal is to verify where it has reached and whether it has made the intended connection. Therefore, once the Changping Forceps are inserted, the end needs to be connected from below to verify the separation’s target direction is correct.
For analogy, human tissue is like a Mysterious Great Cave in the mountains, with numerous interlaced cave networks. The Changping Forceps act as a rod inserted into one of these cave openings. To ensure that the string emerges at the designated opening, one needs to connect with the rod’s end at that specific cave opening.
On the operating table, the Chief Surgeon needs to free up another hand to reach into the cut at the top end of the sternum. With the right hand occupied, they have to use the forefinger of their left hand, inserting from the upper end, trying to connect with the Changping Forceps untangling the tissue from below upwards.
This separation path follows along the sternum’s posterior end; thus, the doctor’s view is blocked by the bone, making it invisible, thereby called the Mysterious Great Cave. Sometimes, the finger from the left hand might not contact the end of the Changping Forceps for quite some time; one is unsure if the separation is complete. In such scenarios, the doctor can only withdraw the Changping Forceps to measure the inserted length against the sternum length, determining if the depth reached was adequate.
You may find it curious, assuming the upper and lower openings of the sternum are not far apart. Even when invisible behind the bone, the short distance should logically allow for connection through sensation, so why can’t the ends connect repeatedly? General surgery taught blunt dissection early on, and blunt dissection isn’t like the Electrosurgical Unit for hard cuts. As in another analogy, the doctor’s finger and tools are like tiny tadpoles swimming through caves finding their mother, unable to forcefully cleave the cave walls. They must find the correct path to connect with the surface.
The ideal is indeed that they connect, and the tiny tadpole finds its mother.