Outrageous Practice

The pregnant woman was lifted onto the operating table, which was then angled downward 15 degrees to the left.

It provided better access to the appendix as the gravid uterus shifted to the left. At the same time, this position was better for reducing agitation to the uterus during the operation and minimizing the risk of miscarriage or complications.

Preoperative preparations were swift and Xie Yiren was already in position.

Zheng Ren scrubbed and gowned up. The sterile surgical drapes were in place as he stood before the operating table.

"0.5% lidocaine and half a syringe of milk," Zheng Ren said.

Milk was the nickname for propofol—an intravenous anesthetic commonly used in the induction of general and continuous epidural anesthesia. It was not as useful as a local anesthetic agent.

Shocked, the anesthesiologist considered protesting, but the determined look on Zheng Ren's face made him think twice.

This surgeon was going to operate on a case of appendicitis in pregnancy without general anesthesia. Nothing else in the world could faze him.

"Five-milliliter syringe, but use a one-milliliter syringe needle tip." Zheng Ren's profile loomed under the shadowless surgical light. His every order was firm and left no room for doubt.

A smaller needle tip meant less pain for the patient but made it more difficult to deliver the anesthetic.

Local infiltration anesthesia began and the anesthesiologist watched with rapt attention as the needle rhythmically and expertly pierced the patient's skin.

After each injection, there was a pause to allow the mixture of lidocaine and propofol to take effect before moving on to the next site. Zheng Ren's technique was attentive but accurate. Judging from the patient's vitals, there was no sign of any pain response from each injection.

Amazing! No wonder he chose local anesthesia for this appendectomy.

The anesthesiologist recognized talent when he saw it. His eyes remained fixated on the scene.

In the surgical demonstration classroom, Old Chief Physician Pan and Chief Surgeon Liu exchanged a look.

Old Chief Physician Pan put down his copy of Limited Views when he realized the ongoing appendectomy was on a pregnant woman.

At the sight of Zheng Ren prepping for local anesthesia, anxiety rose in Old Pan.

"Old Chief Physician Pan, you have sharp eyes." Chief Surgeon Liu felt victory in his hands already. This time, Zheng Ren's suicidal attempt had nothing to do with him. Chief Surgeon Liu felt more relaxed as he began to denigrate his competitor, who had bitten off more than he could chew.

"Appendectomy on local anesthesia; it's been many years since my last one. Old Chief Physician Pan, you must be familiar with the procedure, especially after your time at county-level hospitals. Today, I shall watch and learn."

Satisfied, Chief Surgeon Liu shifted into a more comfortable position and continued watching the projection with a small smile on his lips. Zheng Ren had started local anesthesia.

Old Chief Physician Pan wanted to fire back, but now was not the time.

It was already midnight when over a hundred Xinglin Garden accounts came online and rushed to watch the livestream.

[My my, what am I seeing, a case of appendicitis in pregnancy? And operating on local anesthesia! Is the god livestreaming a shortcut to death?]

[What do you know? Just sit down, you're blocking my view.]

[I've never done locally anesthetized appendectomy before. This is a good opportunity to learn. Hopefully our god operates slowly, I'm gonna tell others to come and watch.]

[Have any of you done a local anesthesia appendectomy before? Not me. Sit down and learn from the god.]

[Nope +1]

[Never +2]

[...]

[Never +10086]

Behind each Xinglin Garden account was a physician. It was a website for professionals and came with strict requirements—one's real identification and legitimate, verified physician's certificate—for user registration.

A routine appendectomy called for continuous epidural anesthesia.

Those staying up for this livestream were young physicians around thirty years of age. None of them had ever performed an appendectomy on local anesthesia before, despite being professionals.

[Why is the syringe so turbid?]

[I think I heard something about propofol just now. Is there an anesthesiologist in this room? Can you shed some light on this outrageous practice?]

[I'm the deputy chief anesthesiologist from one of the Class Three Grade A Hospitals. I am dumbfounded, no idea what's going on.]

As the surgery commenced, the professionals entered a collective state of confusion.

Local anesthesia appendectomy was an uncommon surgery to begin with, but the surgeon was pushing his luck if even an anesthesiologist could not make sense of the anesthetic being used.

The comment section started to overflow.

[Why does he pause after each injection? What's the reasoning behind this?]

[My guess is that it allows the local anesthetic to take effect and avoid agitating the patient. Infiltrative 0.5% lidocaine will take effect around 12 seconds post-administration, though, so why is he spacing out the injections at three-second intervals?]

[Don't tell me that's the use of propofol?]

[I'm kneeling. Please accept my reverence.]

[Oh please, stop commenting. Watch the surgery! Watch!]

The last call for silence was futile and was quickly lost in a sea of incoming comments.

[I remember the textbook incision for an appendectomy in pregnancy starts at the McBurney's point1 on the right side of the rectus abdominis. Isn't the god's incision point a bit high? Or am I remembering it wrong?]

[It's possible that the position has been confirmed through palpation.]

[A five-centimeter incision on a pregnant woman for an appendectomy. How gutsy he must be!]

Although it was just an appendectomy, everyone watched hungrily. The live comments dwindled as the first layer of skin was peeled open.

…

…

Zheng Ren drew the scalpel across the skin and proceeded to perform a blunt dissection on the tissue and muscles underneath. The peritoneum was the last layer.

Every move required the administration of local anesthesia. The surgery was not a quick one but his movements were steady.

The anesthesiologist looked at the surgery, then at the patient's vital signs, and then back at the surgery. They were at the peritoneum now, and the patient's blood pressure, heart rate and breathing remained stable. 

This indicated that Zheng Ren's local anesthesia technique was effective and the patient did not feel any pain.

'This man is a daredevil,' the anesthesiologist thought.

Zheng Ren's performance was of the highest caliber. Even a professional anesthesiologist would not have done as well. Was this the effect of the propofol? Could it perhaps be tested in the next surgery?

The anesthesiologist shook his head to clear the outrageous thoughts from his mind. He should keep to standard protocols for anesthesia. If something were to go wrong, he would not be able to shoulder the responsibility.

After cutting through the peritoneum, Zheng Ren looked inside and promptly located the appendix with the curved surgical forceps.

The swollen appendix was gently clamped between the forceps. There was not an ounce of unnecessary force in Zheng Ren's grip.

With one hand on the scissors, Zheng Ren motioned for Xie Yiren.

A smaller pair of curved forceps was placed in his hands.

"Not this." Zheng Ren rejected the instrument. "The syringe."

With a start, Xie Yiren realized her mistake. This was not the standard appendectomy she was used to, but a local anesthesia appendectomy. The clamping of the ligaments and arteries surrounding the appendix had to be prefaced with administration of anesthetic.

Xie Yiren's eyes twinkled as if a new toy was before her—Zheng Ren's procedure had her full attention. All the routine appendectomies she assisted in had bored her to tears.

A quick round of local anesthesia later, Zheng Ren continued separating the ligaments.

Zheng Ren considered himself unlucky to be saddled with a case of appendicitis in pregnancy at such a precarious moment, and to operate with only local anesthesia.

Although he had practiced local anesthesia appendectomy in the System, he still prefered to avoid such outrageous practices as the risk of accidents was high.

However, there was some luck on his side as this case was not as complicated.

Due to the pregnancy, the patient's uterus was enlarged and the greater omentum which usually covered the appendix had been pushed away. If the appendix ruptured without the greater omentum's protection, the patient would suffer severe complications and the surgery would have been even more troublesome.

It was unclear to him how the swollen appendix was still intact. He chalked it up to a quick and timely diagnosis. The patient's youth and general good health also likely contributed to the cause.

The inflammation around the appendix was also mild.

Zheng Ren thanked his lucky stars.

He removed the appendix and tied up the appendicular artery, then closed up the residual stump with a purse string suture, adding an extra stitch at the end.

The whole process was clean and beautiful.

It was a success that stunned everyone into silence—from the surgical demonstration classroom to Xinglin Garden.