Chapter 13: 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.]

2…

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.

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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.]

1Zheng 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!]

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