Acute Phlegmonous Appendicitis with An Ectopic Appendix

Zheng Ren used the scalpel to make a five-centimeter incision—the standard incision size in an appendectomy. Xie Yiren—the scrub nurse—watched his hand movements attentively so that she could predict the next procedure and hand over the necessary instrument in advance.

Very professional coordination, it was standard for a surgeon.

Electrocauterization for hemostasis, the small curved forceps for blunt dissection… Slowly but surely, the surgery for the 'misdiagnosed' case began.

In the surgical demonstration classroom, Cen Meng was grinning delightfully while staring at the screen. "That's a small incision. He must be very confident of himself."

"That's true. It's rare to make such a small incision in a standard appendectomy."

"Well, we learned something this time."

The deliberately ambiguous comments were like numerous palms slapping Chief Physician Pan's cheeks with all their might.

Lowering his head shamefully, he prepared himself mentally to lose every bit of dignity he had left.

The only thing supporting Chief Physician Pan's belief in Zheng Ren was the impressive performance of the latter had given with the pancreaticoduodenectomy last time.

Xinglin Garden was livelier than the surgical demonstration classroom at the moment.

None of them knew each other since it was just a live broadcast. There was no conflict of interest, only pure academic discussion.

Thus, their comments were more straightforward and harsh.

[Exploratory laparotomy on the right hypochondrium region with just a five-centimeter incision? What is the surgeon thinking?]

[He figured that the inflammatory stripe in the gallbladder area was actually an abscess in the appendix, hence the diagnosis of acute appendicitis. Just keep quiet and watch the surgery.]

[This is the most ridiculous surgery that I've seen in my entire life. It's a miracle that this surgeon is able to survive until now without getting killed.]

Regardless, no comments—in Xinglin Garden or the surgical demonstration classroom—reached Zheng Ren's ears.

It was quiet inside the operating theater. Zheng Ren used a small gauze to cover the incision and upturned his palm. A medium-sized curved forceps was immediately placed on it.

"Aspirator with suction tube," said Zheng Ren coldly as he put the forceps on the surgical drape while staring attentively at the operative field.

This was the first time Xie Yiren had made a mistake in her judgment. She quickly connected the suction tube to the aspirator and put it on Zheng Ren's outstretched hand.

The hissing sound produced by the aspirator broke the silence in the operating theater.

Zheng Ren held the aspirator in one hand and separated the peritoneum with the blunt end of the curved forceps with the other hand. The aspirator was inserted as soon as the peritoneum was opened.

"Cen Meng, prepare to perform a surgical scrub," instructed Chief Surgeon Liu when he heard Zheng Ren's request for an aspirator before opening the peritoneum.

His voice was soft but loud enough for Chief Physician Pan to hear him very clearly.

Derision. This was undisguised contempt.

Zheng Ren's surgical technique—from making the first incision until now—had been flawless. If anyone attempted to find fault on purpose, their authority would have been questioned.

However, Chief Surgeon Liu was convinced Zheng Ren had made a mistake in his diagnosis. Thus, he had instructed Cen Meng to scrub up and prepare to take over the operation before the peritoneum had even been opened. That was exactly what he had in mind all along to humiliate both Chief Physician Pan and Zheng Ren.

Watching the scene progressed as his script made Chief Surgeon Liu smile in delight.

His presence in the operating theater was not required at all. Even if this was a complicated case of acute cholecystitis, Cen Meng—a chief resident—alone was more than enough to handle it personally.

He just needed to sit there and give Chief Physician Pan a contemptuous gaze.

On the other hand, numerous comments started flooding the live broadcast in Xinglin Garden.

[F*ck! He was really performing the surgery as if it was an appendicitis case. It's rare to find such an awesome doctor nowadays.]

[How confident was he to perform a surgery without an assistant?]

[An aspirator? Is this live broadcast a joke? If he can aspirate any pus out of that incision, I'll start a live stream and drink all the pus myself.]

…

The aspirator was quickly inserted into the small opening in the peritoneum, which fit perfectly without any visible leakage of pus.

Thick yellowish-green pus was drawn into the suction tube as soon as it entered the peritoneal cavity.

There was a huge amount of pus and it took almost thirty-two seconds to complete the drainage.

In the surgical demonstration classroom, Cen Meng, who had been instructed to perform a surgical scrub, merely stood rooted to the spot while the wide smile on Chief Surgeon Liu's face stiffened into a rictus instantly.

Pus? Suppuration was normally absent in acute cholecystitis and the most common clinical case with pus collection was actually acute appendicitis.

This patient was really suffering from acute appendicitis? This was actually a misdiagnosis?

Impossible! Both Cen Meng and Chief Surgeon Liu desperately tried to recall B-scan ultrasonographic findings for acute phlegmonous appendicitis. There had to be a clue hidden in the B-scan that they missed even if the appendix was in an ectopic position.

Cen Meng stood still at the doorway, caught up in a dilemma between staying or leaving.

His faith was shaken. If he appeared in the operating theater after scrubbing up and the diagnosis of acute appendicitis was proven correct, it would be extremely humiliating, right? How embarrassing it would be if that really happened under the live stream.

In Xinglin Garden, the chat room was completely overwhelmed by comments.

[What the f*ck! He really aspirated pus out of that. That wasn't a gallbladder perforation, right?]

[Is the brother who wanted to start a live broadcast still okay? Was the pus delicious? I'm still waiting for your livestream.]

[Damn… It really was a case of acute appendicitis? Why haven't I encountered such cases before?]

[The surgeon must be very confident to make a five-centimeter incision on a patient with phlegmonous appendicitis. Who is this demon in the live stream?]

Thirty-two seconds later, there was no pus in the suction tube any more.

Zheng Ren placed the aspirator on the sterile gauze Xie Yiren had positioned in advance to prevent contamination to the operating field.

He then continued separating the peritoneum.

Then, a thick, huge, blackish-purple wormlike thing emerged from the three-centimeter opening in the peritoneum. 

The peritoneum separation continued to approximately five centimeters when the blackish-purple thing popped out of the opening.

It was engorged, edematous, and had pus collections on it.

No matter what that wormlike thing looked like in the end, every surgeon would recognize it at first glance. That was an appendix.

It could only be an appendix.

It must be an appendix.

Dead silence reigned in the surgical demonstration classroom in that instant.

The smile froze on Chief Surgeon Liu's face and there was an uncontrollable quiver in his orbicularis oculi muscles, as if he was undergoing electrical nerve stimulation.

Chief Physician Old Pan straightened his back and tightly clenched his fists as he fixed his full, attentive gaze on the screen.

There was a temporary halt in comments on the live stream as every viewer finally realized that this was indeed an appendectomy with an incision made on the right hypochondrium region.

The comments started flowing again forty-seven seconds later.

[What the f*ck… What an awesome surgeon.]

[How did he come to that diagnosis when none of the preoperative investigations showed evidence of an ectopic appendix? I'm convinced that the surgeon must have hidden some investigative results.]

[You say it like you'd have the courage to diagnose such after performing a lower abdominal MRI scan. Mortals, tremble before your God.]

Zheng Ren's hands were stable, with slow but precise movements.

Since the appendiceal artery was engorged and edematous, Zheng Ren chose to perform stitch ties instead of a conventional ligation technique. His hands started dancing again, weaving the needle within the five square centimeters with ease.

The purulent appendix was resected and thrown into a specimen container along with the forceps.

Zheng Ren held his hand out again but this time, Xie Yiren's movement was sluggish, as if she was hesitating.

Zheng Ren, who was staring at the operative field attentively, seemed to understand the cause of her hesitation. Thus, he said without looking at her, "Small curved forceps and surgical scissors."

"The peritoneal cavity should be irrigated with normal saline after the resection of the appendix. What does he want to do with those instruments?" asked a random observer in the surgical demonstration classroom.

It was a question thrown without the blatant contempt that hung in the air before the surgery had even begun.

The surgery aside, that an ectopic appendix was accurately diagnosed was enough for any surgeon to gloat for a lifetime. 

Moreover, the operation was done very beautifully. The whole process from the incision to the current procedure took only three minutes, and that included half a minute of pus aspiration.

Anyone with a doubt in their mind in that instant fought the urge to ask questions to prevent themselves from being humiliated. Even if an inquiry was made, its voice would be so soft that it would almost sound like unspoken criticism.

[Small-sized curved forceps? Surgical scissors? What for?]

[The appendix was resected, so what is he going to do now? Demon, that's a marvelous performance. Please give us a classic memory and don't screw it up.]

[What do you even know? He's much better than you.]

Xinglin Garden was indeed a website for adepts. Once they witnessed the mind-blowing skills of the surgeon, more than half of the viewers started expressing their admiration.

Birds of a feather flock together, and those willing to spend time on this website were experts who valued skills and professionalism.

It was their nature to worship anyone who could execute such a high-performing surgery.

[He is debriding the abscesses on the wall of the gallbladder!]

[Oh my God, is he not worried about damaging the edematous gallbladder?]

[Worship! Which hospital is this daemon working? I'm going to go further my studies!]

The operative site had a very limited field of vision. Back in the day, Zheng Ren definitely would not have completed a surgery under such circumstances.

A restrictive line of sight increased the degree of difficulty of surgery tremendously.

However, after continuously performing more than two thousand appendectomies in the intensive training provided by the System, he had acclimatized the operative view of a tiny surgical opening.

It was impossible to attain the perfect standard required by the System with a large incision anyway, as it was simply too messy and amateurish.

If this was an ordinary surgery, the operation would have been declared successful once the inflamed appendix was resected. The following steps would be peritoneal cavity irrigation with normal saline, topical administration of antibiotics and finally, surgical wound closure.

However, that was nowhere close to perfection. At the upper right corner of Zheng Ren's vision laid a surgical progress bar which stated [86 percent].

Excellent rating only. Not enough yet.

What Zheng Ren needed to do right now was to debride the abscesses on the surface of the gallbladder wall so that antibiotics could take effect as soon as possible.

The gallbladder was edematous due to bacterial infection and caused its surrounding walls to be fragile, like a delicate porcelain vase.

It was beyond question that the 86 percent shown in the progress bar would reduce to negative instantly if there was an iatrogenic perforation of the gallbladder wall.

This procedure put not only the patient's life at risk, but also Zheng Ren's. Thus, extreme vigilance was compulsory and negligence was not an option in this situation.

Both the medium-sized curved forceps and the surgical scissors were in his right hand, with the finger holder of the scissors hanging on his right thumb. Depending on what was required, the positions of these two instruments could be swapped easily with a gentle flick of his fingers. 

His hand movements were gentle and proficient as he dissected the abscesses from the surface of the gallbladder wall using the blunt end of the surgical scissors, which hung on his thumb most of the time.

Sea City General Hospital was well-equipped with advanced demonstration hardware for learning purposes. There were two monitors in the surgical demonstration classroom—one for the panoramic view of the surgical field, and the other connected to the camera in the surgical lighthead. The camera was able to capture everything the light touched, and so blindspots were essentially nonexistent as the surgery was projected onto the classroom screens.

Zheng Ren's hand movements were displayed very clearly when the second screen was set as the main view of the surgical field.

"That is skillful, but why does it look so familiar?"

"The way he uses the surgical scissors and medium-sized forceps…"

Chief Surgeon Liu's expression darkened instantly upon hearing the discussion behind him.

On the other hand, Chief Physician Old Pan was not in a good mood, either. He believed Zheng Ren was simply gilding the lily in debriding the abscesses from the surface of the gallbladder wall, since the patient's immune system could deal with them postoperatively with no issue.

At least the risk of surgical failure would be minimal even if the patient had to be discharged a few days late. The game was not worth the candle if surgical complications arose because of this unnecessary procedure.

The chat room in Xinglin Garden was overwhelmed with comments.

The view of the surgical field in the live broadcast was much clearer and direct than the projector screen used in Sea City General Hospital's surgical demonstration classroom.

[The surgery and live broadcast are amazing and professional. Is it possible that some live broadcast platform is going to start livestreaming surgeries and came here to test the waters?]

[Don't be ridiculous. There are less than a hundred surgeons in this country who can perform such an outstanding surgery. No matter who he is, it's impossible that he would visit any live broadcast platform to livestream his surgery.]

[The blunt dissections were done beautifully. My fifty-meter surgical sword is craving blood. Fortunately, I have surgery this evening. I'm going to try it out later.]

After worshipping a god, it was time for reassessment, amelioration, and experiments.

Every doctor… Well, most doctors possessed this insatiable hunger for knowledge.

Each and every comment transformed into specks of light, invisible to the naked eye, which passed through the dimensional barrier and flew right into the fox statue in the System.

Slowly but surely, the spacial distortion in the System stabilized.

"Warm normal saline and gentamicin irrigation." Zheng Ren sighed in relief as the last abscess was dissected. Staring at the transparent screen on the upper right corner of his vision which showed 97 percent, his initial anxiety was slowly replaced with calm.

Based on Zheng Ren's experience, that number would reach 100 percent as long as he followed basic surgical steps—irrigation and abdominal surgical wound closure, which meant that he had performed this appendectomy surgery perfectly.

Success!

After the warm normal saline was handed over, Zheng Ren started pouring it along the tiny surgical incision into the peritoneal cavity and waited for twenty seconds before aspiration was initiated.

Meanwhile, Xie Yiren filled the syringe with gentamicin and removed the needle before passing it to Zheng Ren.

He injected gentamicin into the peritoneal cavity slowly before starting abdominal wound closure.

Some liked to use powdered antibiotics from the cephalosporin family while others preferred to use old-fashioned gentamicin for intraperitoneal administration of antimicrobials.

Zheng Ren belonged to the latter group.

There was a subtle difference between these two options. Based on Zheng Ren's experience after thousands of surgical practices in the System, he concluded that gentamicin was more suitable for this patient's current condition.

The abdominal incision was small so its closure could be done in a short amount of time.

However, Zheng Ren dared not loosen up or let his guard down because he was unsure whether he was given only ten surgeries to perform perfectly or if ten perfect surgeries were required from a hundred. God only knew what the System actually wanted with him…

He had no choice but to put pressure on himself. He needed to perform ten operations and all of them had to achieve perfection.

Each layer of the abdominal cavity was sutured accordingly. Once Zheng Ren reached the skin layer, he hesitated for a while before asking for a 3-0 absorbable suture for a running subcuticular suture technique.

This surgery was officially complete, according to Xie Yiren.

She relaxed and smiled. "Doctor Zheng, the patient is a forty-year-old man. I don't think an abdominal scar is a concern to him at all."

"I just want to do everything perfectly," replied Zheng Ren while continuing closure of the surgical wound.

"Young female patients will feel blessed under your care in the future," Xie Yiren smiled in response.

"Yes. I can make it woundless if it's just a simple appendicitis case," replied Zheng Ren.

Xie Yiren was stunned momentarily. Woundless? Doctor Zheng must be joking with her.

Yes… it must be a joke.

Even though Xie Yiren did not assist Zheng Ren in the operating theater frequently, it was perfectly normal for a surgical team to tell funny stories or make dirty jokes in order to maintain a joyful and tension-free atmosphere in the operating theater.