Black Pean Information #28

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Medical commentary on episode 8 (2)

The main surgery in episode 8 was Mr Kobayashi’s surgery for mitral valve incompetence.

From Caesar-based mitral surgery to the MICS Saeki method

Dr Nishizaki performed surgery using the Caesar. As I discussed previously, mitral valve surgery usually involves clamping the aortic valve to close it off tightly and sucking out the blood from inside the heart so that the inside of the heart is empty during the operation. The device used to close the aorta tightly is called an aortic cross-clamp.  There are several different types of clamp used to close off the aorta from the right side of the chest, one of which is the Chitwood clamp. This was developed by an American surgeon called Chitwood who was an expert in performing heart surgery through the right side of the chest.

Blood flows strongly on the other side of the clamp (the opposite side from the heart) (through the heart-lung machine). This time, that part of the aorta (where the blood is flowing) was damaged, causing major blood loss. If the aorta is clamped, there is no blood flow in the part of the aorta nearest the heart, so this could be repaired even if it was damaged. However, it is quite difficult to repair the side of the aorta where blood is flowing.

This time, when Dr Tokai was trying to repair it, Dr Saeki came in and sutured the lesion through a small chest incision. It is difficult to suture with the clamp in place, so he removed the clamp first. When he said “flow down” at that point, he meant that the heart-lung machine’s blood flow should be stopped (by the medical engineer). If you removed the clamp with the heart-lung machine still running, a large volume of blood would suddenly be pushed into the heart, and the pressure on the walls of the previously-empty aorta could be ruptured by the sudden blood flow. In bad cases, the aortic wall could tear (rupture), so it is necessary to stop the heart-lung machine before removing the clamp. When removing a clamp from its place, you always say “flow down” to stop blood being sent from the heart-lung machine.

At this point, he used the word “MICS”, which means not making a midline incision. There is a plank-like bone called the sternum in the middle of the chest, which is normally cut with an electric saw to perform surgery. In contrast to the midline incision, operating without cutting the sternum but working between the ribs on the left or right is called MICS. That is, mitral surgery performed through the right rib cage is called MIC mitral valve surgery.

My honest thoughts on watching this scene were “Dr Saeki can perform the Saeki method using MICS?! He only used midline incisions so far, but he can do MICS too! And the Saeki method as well!”

While Dr Saeki was suturing and tying knots, he used different instruments from usual, namely the MICS needle holder, MICS tweezers and knot pusher, which are specialist tools for MICS operations. When operating through the right rib cage, the distance to the heart is long, so long-handled tweezers and needle holders like these MICS instruments are needed. When tying knots, you can’t reach with your fingers, so these long stick-like instruments are needed too.

This is very picky, but while Dr Tokai had Nekota follow his movements when doing the Caesar simulation in the medical office, this time Dr Saeki tied the threads by himself. When using the knot-pusher to tie the knots, some people have someone else follow them with the thread (holding it for them), while others tie it by themselves. Technically speaking, tying it by yourself is harder, but Dr Saeki had no problems doing so.

That surgery made everyone think “Dr Saeki is a god”.

“This is who I am. The black pean.” was an intense line too.

I understand why Dr Kurosaki cried so hard there too. After that, Tojo’s medical staff came to cheer Dr Saeki on and applaud him in the hallway, and the scene of them complimenting him was moving too.

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There are only two episodes left.

With all kinds of mixed feelings about Dr Saeki, we’ll unravel the mystery of the black pean.

Working hard to save a single life creates such a rich space between people. As each scene goes past one by one, I look back at them over and over and I feel more and more passionate. With all these amazingly rich scenes coming one after another, a final line will be drawn at the end and we will be able to cry and be refreshed. Please look forward to it.