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Black Pean Information #18-20
Medical commentary on episode 5 (1)
In episode 5, we saw the appearance of the surgical support robot Darwin. Also, Ms Makino had a pulmonary thromboembolism and was on the verge of death.
This time, before commenting on the medical treatment scenes, I’ll try writing down my thoughts on surgery in general.
People, robots, art and science
When I was starting out as a heart surgeon, a little above Sera’s position, my boss at the time often told me “heart surgery is art and science!”
So could we call it a combination of art and science? First-class heart surgeons often refer to “performing surgery” as “completing a work” instead. Just like an artist puts their soul into their work, we put our souls into our surgeries as if we were creating a work of art.
However, heart surgery has a time limit. No matter how far techniques for preserving the heart muscle progress, we can’t expect to be able to stop the heart forever. We could say that limit is about three hours, and it’s kinder on the heart muscle to keep that time as short as possible.
At the same time as creating a work of art, we have to do only the necessary things as quickly as possible, i.e. it requires a technique that eliminates wastefulness as completely as possible. Also, the heart is like a place where if you take one wrong step you’ll fall to your death, so surgery must generally be performed while keeping risk management in mind. You need to work with no wasted movements, like trying to carefully run across a stone bridge without hitting the stones - that is, you need artistry.
I have talked about adult heart surgery before, but there aren’t that many different variations. However, there are several different approaches to the heart (where to make the incision and how to treat it), including the orthodox midline incision (cutting open the centre of the chest vertically), right thoracotomy (cutting open the right side of the chest to reach the heart) and left thoracotomy (cutting open the left side of the chest to reach the heart). There is a plank-like bone called the sternum in the middle of the chest, and with midline incisions the sternum is cut with an electric saw to reach the heart. With practice, you can reach the heart in under two minutes, starting from the skin incision. There are also methods that do not involve cutting the sternum, i.e. performing surgery by cutting open the left or right side of the chest and operating between the ribs, which is called MICS (minimally-invasive cardiac surgery).
Surgeons performing any of the above-listed midline incisions, left or right thoracotomies stand by the patient’s side to operate. They work from a position where they can put their hands on the patient at any time.
With the robotic surgical assistant Darwin that appeared this time, the robot is by the patient’s side. That means the surgeon controlling the robot is some distance from the patient (sitting in a control chair and controlling the robot). As our robotics supervisor Dr Watabane said, the robot's controller has to be a surgeon, and the robot doesn’t make any decisions or operate by itself. We could say that to control this F1 machine, you need a surgeon in the cockpit.
Whether a human hand or a controlled robot performs the surgery, the aim is still to cure the patient and complete a work of art. In that sense, the existence of robot-assisted surgery may just be a logical progression from surgery performed by humans, and there may be no real justification for treating human and robot-assisted surgery as opposing concepts... Do you want to eat sushi made by a super efficient robot or sushi from a Ginza sushi chef with decades of strict training? When you actually eat it, you might not really be able to tell the difference. The human representative, Dr Tokai, referred to patients’ bodies as “objects”. In some sense, he has some robot-like characteristics too.
After thinking about various issues, in the end I don’t really know. This is a deep and difficult subject, so maybe that’s why it became this main theme of this episode of the drama.
In Dr Tokai’s room, there are surgery articles stuck all over the walls. Well, rather than surgery articles, they’re surgical records with drawings of the patients' hearts and pictures (diagrams) of their form after the surgery, so you can understand what type of surgery it was just by looking at them. The boss I mentioned before always said “drawing beautiful surgical diagrams is the first step towards becoming first class!” I liked drawing, and had been drawing pictures of animals and so in sketchbooks since I was in kindergarten, so I was good at making surgical diagrams - I feel like my surgical reports were the only thing he praised (other than that, he got angry at me just like Dr Tokai gets angry at Dr Sera).
The diagram below is a surgical record of a thoracic aortic aneurysm. A prosthetic blood vessel is being sewn to the aorta with a needle and thread, which is called suturing. You could call Dr Tokai a suturing genius, and the way he completes his surgeries is like the highest art. With feelings of respect and reverence for the heart, an organ that is the foundation of human life, he artistically puts his soul into performing surgery.
“We dream and dream and dream of achieving the absolute, and that’s romantic, but we can’t reach it. That unattainability is art...” (Mishima Yukio) It reminded me of that quote. Dr Tokai really is the absolute heart surgeon.
Surgical diagram of a thoracic aortic aneurysm [Image at http://www.tbs.co.jp/blackpean_tbs/information/18.html]
I always get goosebumps from something awesome happening about twice an episode, but this time it happened about five times, so I even ended up calling Dr Tokai “the absolute”.
Next time, I’ll discuss pulmonary thromboembolism.
Medical commentary on episode 5 (2)
This time, I’ll discuss Ms Makino’s pulmonary thromboembolism.
The flow of blood through the body
Here, I’ll refer to blood that flows through the body after being oxygenated in the lungs “arterial blood” and blood that has provided oxygen to the cells “venous blood”. Venous blood in the upper half of the body flows through the superior vena cava, and venous blood in the stomach and lower body flows through the inferior vena cava into the right atrium. This blood goes from the right atrium to the right ventricle, then into the pulmonary arteries, reaches the left and right lungs through the left and right pulmonary arteries, takes in oxygen, then flows through the left and right pulmonary veins, the left atrium and the left ventricle before being sent (as arterial blood) to the rest of the body.
Arterial blood is sent to the body by the strong contraction (pumping ability) of the left atrium of the heart. Venous blood enters the heart by the expansion of the right atrium, but the right atrium’s expansive strength is not that strong. Gravity still acts on the venous blood in the upper body, so it drops down into the heart, but in the lower body and particularly in the legs, venous blood has to move against gravity to go up to the heart, which is quite difficult. For that reason, the veins in the legs have valves to prevent blood from flowing in the wrong direction so that it only flows towards the heart, but even that doesn’t make it move up. Fortunately, the human body seems to be really well made, because when you move your legs (walking, running), the arteries and muscles around the veins squash them and push the blood inside them towards the heart.
Economy-class syndrome
This means that venous blood in the legs is returned to the heart by moving the legs. You might be wondering what happens when you are asleep, but people actually move a lot while sleeping, you know. We unconsciously twitch and jiggle our legs.
However, there are also times when we don’t do this. You’ve probably heard of a disease called economy-class syndrome. At times, you go for many hours without moving, for example during a disaster or other times when you have to remain lying down in a car for a long time and can’t really move around much in the narrow car, or when you sit in an economy-class seat in an aeroplane for a long time without moving. When that happens, the venous blood in your legs doesn’t flow into the heart, so it gradually hardens. The blood can’t flow so it hardens into a clot. In bad cases, the veins in the legs are filled with clots.
Then, when you get out of the car in the morning and walk around, or when the plane lands at its destination and you start moving again, the clots flow towards the heart and reach the right atrium and pulmonary arteries, blocking the pulmonary arteries. To prevent this, please keep moving your legs from time to time. There are also drugs that help prevent blood clots.
There are mild cases like just having clots in the legs or in part of the pulmonary artery, and there are severe cases too. Ms Makino’s case was particularly severe.
Ms Makino was hospitalised for orthopaedic surgery on a broken femur, so she was probably unable to move for a long time. A large number of clots formed in the veins of her legs and clots blocked her pulmonary arteries on both sides. That completely prevented any blood from reaching her lungs, so her blood couldn't take in any oxygen. She developed oxygen deprivation, which is very painful, and lost consciousness. In the end, even her heart didn't have enough oxygen and couldn't move properly, so she went into shock.
We treat this condition with drugs that break clots apart, using a drip and putting filters in the inferior vena cava to prevent the clots from reaching the heart.
In very severe cases like Ms Makino’s, we have to either set up the heart-lung machine, insert a catheter and break up the clots or surgically remove the clots from the pulmonary arteries. This surgery usually starts with a midline incision, but Ms Makino had heart surgery as a child (for tetralogy of Fallot - this disease is difficult to explain, so I’ll leave it out) and had a lot of adhesions, so doing another midline incision would cause problems.
What is circulatory arrest?
During his time abroad, Dr Takashina had some experience with an operation to remove blood clots from the pulmonary arteries through a left thoracotomy, so they decided to perform the surgery in this way. With a left thoracotomy, it is easy to remove clots from the left pulmonary artery, but the right pulmonary artery is at a long distance.
“Dr Sekikawa, please set up the heart-lung machine and bring it down to 18 degrees.”
“Please stop her circulation.”
The reason for lowering the temperature to 18 degrees is that it puts the body into a sort of hibernation. Just as a hibernating bear doesn’t need to eat, the body doesn’t need the blood to flow. Artificially preventing the blood from flowing is also called “circulatory arrest”.
When removing clots from the pulmonary arteries, if blood keeps flowing through the body, more and more blood will leak from the pulmonary arteries. In circulatory arrest, the body’s flow of blood is stopped, so the flow from the lungs (backflow) stops. This means that the blood leaves the operating field (referred to as a bloodless field), making it much easier to remove the clots. At 18 degrees, circulatory arrest can be safely continued for 15 minutes. We use a repeating pattern where we stop the circulation for 15 minutes, remove clots, restore the blood flow with the heart-lung machine for 10 minutes, then stop the circulation for another 15 minutes and remove more clots. This method of using circulatory arrest to operate with a bloodless field can also be used for aortic surgery.
Clots in the pulmonary arteries stick to the artery walls, and if removed carelessly this can cause the arteries to tear, so the clots must be removed carefully and accurately. This operation showed Dr Takashina’s true power. In contrast with Dr Tokai’s operation on Koharu, this one was performed calmly.
When Dr Takashina used the Cooper surgical scissors to cut the drapes, Dr Tokai was clicking the tweezers in his left hand, a common scene showing a surgeon’s irritation. This was an ad-lib too! At the end of the surgery scene, when he spit out “You look like you're about to die”, the original line was “Okay, I’m done”! Dr Takashina really did look exhausted to his very soul!
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Next time, I’ll discuss Koharu’s surgery.
Medical commentary on episode 5 (3)
Koharu’s second surgery
For the last part of my commentary on episode 5, I’ll discuss Koharu’s second surgery.
Koharu had mitral surgery with the new SNIPE model,which was thought to have been completed without problems, but a septal infection was spotted and she needed more surgery.
The septum is the interatrial septum, and Koharu was born with a defect in hers, so her mitral valve replacement surgery was performed by passing the SNIPE through this defect to the mitral valve. I explained this in a previous commentary too, but this kind of defect is called an atrial septal defect. These can safely be dealt with by catheter embolisation or by surgical closure.
Her septum was closed up by the SNIPE, but that stopper came loose and the cells became infected. It is very unusual for that kind of thing to happen with septal catheter techniques, so please don’t worry. It is very uncommon for an infection to spread into the heart and reproduce unless the internal structure of the heart is abnormal in some way or the patient has a blood disorder. In people with infective endocarditis, valvular regurgitation steadily increases and holes can open up in the septum (please see the medical commentary on episode 4).
To remove the part of the septum where the germs have reproduced (the focus of infection), they performed robot-assisted surgery with the Darwin. Robot-assisted surgery can be performed with a large or small incision of the skin, minimising bleeding, making it possible to operate on Koharu despite her difficulties with infusions. Teika’s Dr Matsuoka starts the heart-lung machine and uses the Darwin to cut open the right atrium and remove the focus of infection from the septum, but its arms suddenly stop moving and she starts bleeding from around the septal focus of infection. Usually, with the heart-lung machine running, this machine would collect the lost blood by suction and return it to the body without too many problems. As I mentioned previously, when operating inside the heart (on the valves or septum), after starting the heart-lung machine the aorta is clamped and all of the blood inside the heart is removed by suction, leaving no blood inside it (bloodless field) while performing the surgery. Because of the problems with the Darwin’s arms this time, the clamp on the aorta was out of place and blood leaked from the aorta into the heart (aorta→left ventricle→left atrium→septum→right atrium). We often refer to this kind of thing with phrases like “the clamp on the aorta was loose”, and since she started bleeding a lot, the heart-lung machine’s suction couldn’t remove all of the blood and she kept losing more and more.
This was shown on screen a bit too, but Dr Tokai readjusted the aortic clamp. Then he treated her at very high speed, but compared to the surgeries he has done so far, this wasn’t a very complicated surgery. He removed the septal focus of infection, sutured the septum and then sutured the right atrium. However, he did this with limited time and demonstrated the power of Tojo while rebuking Dr Sekikawa and Dr Kakitani.
Episode 5 also had many cool scenes, but the part after finishing Koharu’s surgery where he said “Then you do the rest.” while pointing at Dr Sekikawa and Dr Kakitani gave me goosebumps!
Focus on Nekota’s movements too
Ninomiya and the other actors are very good at portraying the atmosphere of surgery, but Shuri, who plays Nekota, is also superb at playing a scrub nurse (instrument nurse). She checks the order of instruments to pass to Dr Tokai before filming starts, passing the DeBakey forceps to his left hand, then the Metzenbaum scissors to his right hand, then two sheets of felt, holding 4-0 suturing thread in a needle holder and passing it to his right hand, placing gauze nearby, taking back the 4-0 thread once suturing is finished, providing water for his hands while the knots are being tied (particularly during heart surgery, surgeons often put water on their hands to make the thread move more easily and make the knots easier to tie, using a large dropper), passing the Metzenbaum scissors to his right hand again, taking back the scissors once the thread has been cut, etc. What’s more, she can do it perfectly after checking just once. Her timing when passing the instruments is also superb; when watching on the monitor, I was worried, thinking “it’s the Metzenbaum scissors next, but they’re at the edge of the instrument tray, so will she be okay?” but when the time came, she smoothly stretched out her hand and took the Metzenbaum scissors to pass to Dr Tokai. A capable scrub nurse usually watches the operating field, and she did that naturally. She also remained calm at all times and was able to look at the operating theatre objectively. She sometimes even gives instructions like bringing a drip or setting up the heart-lung machine - I’d really like an amazing nurse like her in my operating room.
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In episode 7, we’ll see the explosively brilliant combo of Dr Tokai and Nekota again, so please look forward to it!!
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Thanks for this!! AHHH Nino's adlib was great!! He really showed his impatient gesture to Takashina who performed the surgery xD
So in the re surgery the suction's blood is transfused back to the patient?? I kept wondering in the drama who show all those blood loss why not the blood is transfused back to the patients lol. Moreover it seems more efficient effort too lol.
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I might be wrong but in the paragraph just before "Focus on Nekota's movements too", should it possibly be "while rebuking Dr Sekikawa and Dr Kakitani" instead of "while being rebuked by Dr Sekikawa and Dr Kakitani"?
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I think you're right about that part - sorry about that!
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No worries, I just vividly remember that operating scene because of how rudely Tokai bossed the other surgeons around
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Thanks for pointing it out!