Now do the same thing to the subcutaneous fat that you did to the skin; incise at the same angle, clamp bleeders, cauterize, remove clamps, and wipe clean. Again, be sure to go to the very corners for your incision, but be careful not to cut _beyond_ the corners to the skin above. Retract the fat to reveal the oblique muscle tissue.
The oblique muscle (and the transversus muscle below) has no blood vessels and will not cause bleeders. Cut the oblique muscle layer exactly as in the last two layers, going from corner to corner and making a straight, neat incision. The next layer -- the transversus muscle -- is striated in the oth direction. Don't cut at the usual angle; cut "with the grain" from upper right to lower left. Keep making those incisions as long as possible. Retracting the transversus will reveal the peritoneum, through which you can vaguely see the end of the large intestine (which covers the appendix).
The peritoneum calls for very delicate incising. Unless you have version 1.03 of the program (or better), forget what the manual tells you about incising the peritoneum and listen carefully. You're going to cut diagonally from upper left to lower right with the scissors. FIRST, pick the spot where you're going to start the incision. Pick up the scalpel and click once just at that point; you're scraping the peritoneum but not cutting it. Don't draw a line, just click once and let go. Put the scalpel down and get the forceps; clamp the forceps just a pixel or two below where you just scraped. With the forceps in place, pick up the scalpel again and click once more on the same point you scraped; a large black dot should appear. Drop the scalpel, remove the forceps, pick up the scissors and start clicking. Make each click a little farther down and to the right of the last, but not too far or the program will think you've started a new incision. Don't make your first snip right on the black dot; make it a bit further down/right. Continue all the way to the lower right corner and use the skin retractor.
Voila! There's that lovely large intestine, covered with infected fluid (the black shading). From the bottom drawer, take the test tube, and click it on the abdomen to get a fluid sample. Close the drawer and get the suction tube start to suction off the liquid, and it'll come right up. Put down the hose.
Click the fingertips at the bottom of the large intestine. Provided you've made the incisions long enough, the cecum will flip up into sight. If the incisions aren't as large as they need to be, you won't be able to get at this area, and you'll have to abandon the operation. But let's hope for the best.
Open the top drawer and get the roll of gauze. Click the gauze at the base of the cecum, and the cecum becomes packed and immobilized. Close the drawer. I assume you're still watching the IV and the EKG? Of course you are.
Once again, click the fingertips at the base of the cecum to expose more intestine. Click the fingertips at the base of this new intestine, and the appendix pops up, pointing to the right. Take a clamp, the L-shaped object in the center of the tray. Clamp the tip of the appendix, all the way to the right and just above the bottom edge. If you clamp in the wrong spot, the appendix may rupture; in that case, take the drainer from the top drawer (the red bulb) and drain the appendix before continuing. If you've clamped the appendix correctly, it will be lifted and the underside exposed. You're doing great if you're still with me; put the game on pause and play some golf.
You're going to nick the mesoappendix membrane. Pick up the scalpel. There's a red line, or shadow, running the length of the appendix. You'll nick -- a quick click -- at a point slightly to the right and about a fifth of the way up that red line. If you mess up, you'll know it...and they'll show you in class the proper place to nick. Assuming you've clicked in the right place, you'll get another big black dot with a small white dot in the center. Put down the scalpel and take the needle and thread. Click once at the center of that dot to suture the mesoappendix artery.
Get the scalpel. To sever and remove the artery and membrane, you click once directly on that long red shadow, a pixel or so below the bottom edge of the clamp. The clamp appears spread; use the lower of the two clamp ends as a reference point. Click just below that end, and the membrane vanishes. Now get another clamp and clamp the base of that long, red shadow; Danielson should confirm that the LOWER clamp is in place. Get another clamp and clamp at about the middle of the shadow; Danielson will remark that the HIGHER clamp is in place. Get the needle and thread, click once between the two clamps, and a small "purse string" suture should appear. Click the scalpel just above the suture, and off it goes. The appendix is gone. All the clamps except one will vanish. Remove that clamp and click the fingers on the cecum to tuck in the wound. A small hole appears on the cecum; click the needle on that once to make a Z-string suture across the hole. Put away the needle, and click the fingertips on the base of the cecum. That'll instantly remove the gauze and tuck everything back into place. You're ready to close!
To close each layer, pick up the skin retractor. Move it all the way to the right of the window; it will be almost entirely off the screen. Click it once and the peritoneum closes. Put down the retractor, pick up the needle, and place sutures along the closed incision. They don't have to be touching, but they should be fairly close together. You'll need to make a lot of them.
Once you've finished suturing the peritoneum, take the spreader and click it all the way on the right as you did just before. The transversus muscle layer closes; suture it the same way. Now close and suture the oblique muscle layer and the subcutaneous fat layer. Close the skin layer, but don't suture it. Secure it with the X-shaped skin clips in the upper left corner of the tray. Put them close enough together to touch. Turn off the gas, and let the patient go to Recovery. Congratulations! This was the hard part.
When the program evaluates the surgery, you'll be told to go to Medical School if your performance was not perfect. If it was perfect, you'll be congratulated for having performed an appendectomy and sent to medical school anyway! But now you'll be promoted to deal with a different set of problems, and appendectomies will become a thing of the past.
LIFE & DEATH Part 3
Your new crop of patients will have one of three possible conditions: arthritis, immature aneurysms, and mature aneurysms. The diagnosis is just nearly as straightforward as in the previous part of the game. Carefully palpate all areas of each patient's abdomen. Be certain to palpate several times just below the navel. If the patient has pain all over the abdomen, take an X-RAY. You'll probably find that the spine is practically a solid white mass; this indicates arthritis and requires MEDICATION. If the patient's response to palpation under the navel is "That feels like a lump" or some mention of a lump, that's probably an aneurysm. Do an ULTRASOUND SCAN to determine its size. If it's less than "5 cm" in diameter (use the ruler up above the ultrascan screen to judge), it's immature and should not be operated upon. Check OBSERVE. If the aneurysm is 5 cm or larger (as it probably will be), you'll have to OPERATE!
Before you go into the OR, though, you'll want to readjust your staff. Be sure to include Laurelee Menzies, the resident expert on aneurysms. Your other assistant should be either Kim Brewer, Bev Kabes, or Ken Shepherd. Head into the OR. You'll note a few new items on the trays, but don't be intimidated. Next to conquering the appendix, this one's almost a cakewalk.
Open the bottom and top drawers. Use the soap and the gloves (in that order please!). Apply the antiseptic (this time you have a whole abdomen to work with). Put on the drape, and as before, you're going to leave as much room to operate with as possible. Close the top drawer, turn on the gas, inject with the "B" hypo (there's a new one marked "H" for Heparin, which you'll need in a bit). Hang a bottle of blood on the IV and pick up your scalpel.
This time you won't be making any McBurney's incisions. Cutting smoothly, incise the abdomen straight down the middle from as far on top to as close to the bottom as you can without touching the drape. There shouldn't be much drape there, anyway...only a line or two on top and bottom. Work quickly to clamp all the bleeders with the forceps. The cauterizer is gone; we now have a ligator -- a pretzel-shaped loop on the tray. Pick it up and center it over each bleeder; click once to ligate each bleeder. When you've gotten them all, remove the forceps and wipe the area clean. Separate the skin with the skin retractor. Do the same with the rippling subcutaneous fat layer. Always be vigilant for problems with the EKG; act quickly with Atropine, Lidocaine, and Dopamine when necessary.
Now you're down to the muscle layer, the rectus abdominus. This one won't bleed. Cut down the linea alba, the thick white portion at the center. Spread using the retractor. You'll be looking at the preperitoneum, which is incised the same way the peritoneum was: Click with the scalpel to scrape, elevate just below with forceps, click again with scalpel to nick a hole, remove forceps and snip all the way down with the scissors. Be cautious not to make your snips so