“Whoo…”
Kim Cheolsu cut the distal common bile duct where it entered the pancreas with the scalpel.
If he hadn’t mobilized the duodenum earlier, the surgical field would never have been visible.
The duodenum had been blocking the distal common bile duct.
Now it was time to check if the tumor had metastasized beyond the duct he just cut.
Kim Cheolsu let out a relieved sigh and spoke to Shin Seyoung.
“I’ll check if the tumor has metastasized to the resection margin using a Frozen Section Biopsy. Please assist.”
“I’m on it!”
Thirty minutes later, the Pathology Department returned the test results. Kim felt a twinge of guilt for relying heavily on Shin Seyoung’s connections.
She smiled and said,
“The results are in. There’s no tumor metastasis at the resection margin of the duct on the portal side, so there’s no need to cut any further duct. Major. You can proceed as is.”
“Getting help from the Pathology Department… If this goes wrong, many people will be affected. I will make sure this surgery succeeds.”
“Don’t carry the burden alone. You can do this, Major.”
Encouraged by Shin Seyoung, Kim began occluding the cut bile duct.
Since the duct was cut in the middle, two ends needed blocking.
Kim personally sutured the duct on the hepatic side, and on the proximal side, he used hemostatic forceps to clamp and stop bleeding.
He carefully occluded the critical pancreatic side duct with much tighter control.
Next, he moved the cavernous lymphatic tissue, which had been dissected earlier alongside the lymph nodes, toward the right side of the portal vein.
This was to secure a better surgical view.
He also moved the resected common bile duct upward to clearly expose the hepatic hilum.
Using the scalpel, he cut the branches of the portal vein leading to the caudate lobe, mobilizing these branches similarly to how he mobilized the duodenum earlier.
There were many organ mobilizations during today’s surgery because all the “roads” connected to the right liver—where the tumor was—needed to be blocked and separated.
He couldn’t make incisions on the liver, which was hanging with blood vessels and ligaments.
The key point of today’s operation was to preserve the intact left liver while resecting the tumor-ridden right liver.
Next were the vessels connected to the liver.
He temporarily clamped the right portal vein (the vessel transporting blood from the stomach to the liver’s right side) and sharply cut it with the scalpel.
Blood naturally gushed from the severed vessel.
To stop the bleeding, Kim clamped the right portal vein with vascular clamps and sutured it tightly with thread.
On the left portal vein, he also cut branches leading to the caudate lobe and severed the portion where the venous ligament connected.
Since both the right and left portal veins were cut, blood flow toward the area to be resected (the tumor-bearing part) was completely blocked.
Kim, tense, said,
“We’ve blocked most of the tissues connected to the liver. Now, we will mobilize the right liver.”
Kim cut the falciform ligament connecting the right liver and dissected the cavernous lymphatic tissue to secure the surgical view between the left hepatic vein and the middle hepatic vein.
Similarly, he cut the broad ligament of the right liver to separate it from the diaphragm.
He also separated the right adrenal gland from the liver and cut the right inferior vena cava ligament, fully mobilizing the right liver.
The right liver, filled with tumors, could now move somewhat more freely.
Kim pulled the right liver forward and to the left, severing the connecting hepatic veins and slightly lifting the liver upward.
Now, the right hepatic vein was visible, and Kim cut it with the scalpel.
The surgery was already lengthy just from cutting the vessels connected to the liver.
Sweat beads formed on Kim’s forehead; his breathing was heavy and cold sweat broke out.
Seeing this, Lieutenant Shin Seyoung anxiously wiped the sweat from his forehead with a white towel.
“Thank you.”
“You can’t let sweat obstruct your view. We’re almost done with the liver resection. Stay strong, Major!”
“Yes. With the right hepatic vein cut, I’ll proceed to cut the smaller branches of the hepatic veins.”
After blocking the large vessels, it was time for the smaller ones.
Kim cut the branches of the hepatic veins and severed the ligament of the inferior vena cava along with the Arantius ligament (the vessel connecting the umbilical vein to the inferior vena cava).
Finally, the caudate lobe of the liver separated from the inferior vena cava.
Blood flow to the future remnant liver (the part to remain after surgery) was completely blocked.
With both sides clamped, Kim could now proceed fully to the liver resection.
This was the critical moment.
A slip of the hand could send the patient’s liver flying away, creating an irreversible situation.
A mistake here could be fatal.
Lowering the liver back down after lifting it, Kim cauterized the Cantlie line (the imaginary line connecting the gallbladder and inferior vena cava) on the liver surface using electrocautery to make it clearly visible.
At last, it was time to cut the liver parenchyma.
To briefly explain the hanging maneuver he was about to use: it’s a surgical technique that uses a medical tube called a Nelaton catheter to lift the liver whole and facilitate the cut.
Since the catheter is used, the liver is lifted even higher than before, securing the surgical field and making right hepatectomy easier.
This was the very reason the liver had been mobilized earlier.
The liver fixed by several vessels can’t be lifted high otherwise.
Kim folded the caudate lobe to the right and passed the Nelaton catheter straight under the liver before lifting it upward.
Nurse officers on the side held the catheter in midair to assist.
“CUSA, please.”
“Here it is.”
Kim dropped the scalpel and picked up the CUSA (ultrasonic aspirator).
It’s essentially a vibrating cutting device for surgery.
–Eeeeng!!!
Using the CUSA, he cut down the liver following the line marked earlier with electrocautery.
Right now, Kim was performing surgery to remove the gallbladder, spread with tumors, and the right liver all at once.
As he cut through the liver parenchyma and moved downward, the middle hepatic vein appeared.
He cut its end and attached it to the left liver.
Although ultrasound is sometimes used to confirm the visibility of the middle hepatic vein, Kim relied on his visual “X-ray,” and it was sufficient.
He continued cutting the lower and posterior parts of the middle hepatic vein while completing the parenchymal dissection.
He completely removed the right liver and caudate lobe, then cut the left hepatic duct.
Hepatic duct = the bile duct network spreading inside the liver
“The right liver has completely detached, and the right hepatectomy has been successfully completed. Now, I will check the condition of the left liver.”
Even after removing the right liver, the left liver must remain viable.
Kim checked whether blood flow through the vessels leading to the left liver was normal.
He also performed another Frozen Section Biopsy on the cut surface of the protruding left hepatic duct.
This was to double-check whether the tumor had metastasized to the left hepatic duct.
If so, more resection might be necessary, and the surgery couldn’t simply end here.
It was a truly nerve-wracking moment.
Kim and the surgical staff anxiously awaited Shin Seyoung’s return from pathology.
If the tumor had spread this far, the surgery would have to restart, further decreasing the patient’s survival chances.
Moreover, since the tumor-laden gallbladder was already removed, the biliary reconstruction surgery would need to use the remnant left hepatic duct.
If the cut surface of the left hepatic duct was tumor-positive, that would be impossible.
Thirty minutes later, Shin Seyoung burst into the operating room smiling.
“There’s no tumor metastasis here either, Major!”
Kim let out a sigh of relief.
“Good. Then, let me visually confirm the surgery’s completion. The soft tissues, including the right liver and common bile duct, have been removed… Blood flow into the patient’s left portal vein is adequate. The cut surface of the middle hepatic vein is well preserved with no issues. I will now irrigate with saline and control any bleeding.”
After all hemostasis was complete, Kim performed hepaticojejunostomy (connecting the intrahepatic bile duct to the jejunum).
Since the gallbladder connected to the liver was removed during the right hepatectomy, the left liver had to be connected to the jejunum again.
Jejunum = a part of the small intestine located below the duodenum
First, Kim checked whether the left hepatic duct’s condition was suitable for suturing.
Fortunately, the surface was clean with no apparent issues.
He then cut the proximal jejunum, passed the distal jejunum through the mesocolon, and sutured it to the hepatic hilum’s bile duct.
Luckily, the final anastomosis was completed successfully.
The biliary reconstruction had succeeded.
After finishing the hepaticojejunostomy, Kim reconnected and fixed the falciform ligament to the left liver and inserted drainage tubes beside the liver resection surface and the anastomosis site.
“… It’s all over. I’m really exhausted. Now, I’ll close the patient’s abdomen. How is the patient’s condition?”
Closing the incision, Kim nervously listened to the pounding of his own heart.
He silently prayed that nothing had gone wrong as he looked toward Lieutenant Shin Seyoung, who stood by the patient monitoring device.
She stared at the monitor anxiously, then soon cheered and clapped her hands.
“Very healthy!! The surgery was a complete success! Congratulations, Major!! You really saved the patient! All tumors were completely removed!!”
–Wahhh!!!
The staff gathered late at night to save one patient erupted in cheers.
No one had expected Kim Cheolsu to successfully complete this operation.
But the 37-year-old genius doctor had made good on his word, performing a difficult surgery and saving the patient.
Excited staff shouted,
“I’m proud I decided to participate in this surgery!! I’ve been part of many surgeries, but I’ve never seen one so perfect. To successfully remove hilar gallbladder cancer in a military hospital?! No one in other military hospitals will believe this. This was impossible without Major Kim Cheolsu! Who else, whether a department head or hospital director, could perform such surgery? Even the capital hospital, the best military hospital, couldn’t pull this off!!!”
“Remarkable, Major! The surgery took only two hours. That’s unbelievable. You truly are a genius!! A genius!!”
At the staff’s praise, Anesthesiology Captain Oh Hajin nodded in agreement.
“Clearly, someone from S University stands out. Honestly, the general surgery chief’s surgeries always feel slow and frustrating, but this was completely different! Hands were fast… the judgment perfect. A genius is a genius after all. Major Kim Cheolsu, your surgery was astonishing enough to impress anyone. I will serve you with all my heart from now on! Loyal—!!!”