godfather of surgery

Chapter 1405 Only through repeated practice

Chapter 1405 Only through repeated practice

The surgery lasted two hours and twelve minutes. Every step was successful on the first try, without any rework, hesitation, or unnecessary "let's take another look" procedures.

Gao Yuan took off his surgical gown and gloves, and moved his fingers. There were several deep marks on his fingers, left from holding instruments for a long time.

Robert also took off his surgical gown, and the two stood side by side in front of the operating table, looking at the last frame on the screen. The reconstructed anterior and posterior cruciate ligaments were clearly visible in the joint cavity. The two pink, cord-like structures crossed at the center of the knee joint, with full shape, precise position, and moderate tension.

The door to the observation room opened.

The experts filed out, their expressions varied. Some were still watching the video playback on their phones, some were hurriedly jotting something down in their notebooks, and some were shaking their heads as they walked—not in denial, but in disbelief.

A middle-aged expert walked over, shook Gao Yuan's hand, and said, "I've been doing this for twenty years, and I've never seen anyone get such a fast location without navigation. How did you do it?"

Gao Yuan looked into his eyes and replied, "Experience and intuition!"

The expert paused for a moment, probably expecting a more technical answer, specifying the angle, reference, and calculation method. But Gao Yuan gave him the least "technical" answer.

Experience and intuition—this answer might sound like a perfunctory response, but what the expert saw in Gao Yuan's eyes was not perfunctoriness, but a realm he had never reached before. In that realm, surgery was no longer a mere accumulation of techniques, but became an instinct, an intuition, something as natural as breathing.

An elderly professor with a full head of white hair walked over. Gao Yuan recognized him as the director of a long-established medical center on the East Coast, one of the founders of anterior cruciate ligament research, and a figure written into textbooks. As the old man approached, the people around him automatically made way for him.

He stood before Gao Yuan, offering neither a handshake nor pleasantries. He simply looked at Gao Yuan.

“I’ve done antero-crunchy cruciate ligament reconstructions for forty years, and I thought I’d seen it all. But in today’s surgery, I’ve seen something I’ve never seen before. Your tibial tunnel localization for the anterior and posterior cruciate ligaments—I haven’t seen this method described by anyone in any literature. Is that your original creation?”

Gao Yuan shook his head: "It wasn't me, it was my teacher, Professor Yang Ping."

The old professor nodded, "I see."

In the locker room, Gao Yuan sat on a bench to rest.

“In the afternoon,” Robert said, his voice a little hoarse, “they will have a lot of problems.”

“Hmm!” Gao Yuan said.

Have you thought about how to answer this?

"To be honest," Gao Yuan said, "I'll just say what Professor Yang taught me."

The two rested for a while and then had lunch at the hospital's restaurant.

At 2 p.m., the small conference room was full of people.

It wasn't a formal academic report; there was no podium, no nameplates, and no agenda. Robert simply sent an email—"Dr. Gao is here; feel free to ask him any questions." Then everyone who was free came, even the old professor who had sat silently in the observation room the previous day. There weren't enough chairs in the meeting room, so some stood, some leaned against the wall, and some simply sat on the floor.

Gao Yuan sat at the front, with no notes, no PowerPoint presentation, only a bottle of mineral water in front of him. He acted very casually, looking more like a neighbor visiting than a surgeon who had just silenced the nation's top sports medicine experts.

Robert sat beside him, legs crossed, twirling a pen in his hand. He wouldn't answer Gao Yuan's questions, but he would translate technical terms for Gao Yuan when needed. However, he was prepared that Gao Yuan might not really need his translations. Gao Yuan's English was good enough that he could discuss any technical detail with anyone in English.

A young resident physician sat in the corner, raised his hand, and before Gao Yuan could even call on him, he couldn't wait to speak.

"Dr. Gao, during yesterday's surgery, the femoral tunnel location for the anterior cruciate ligament—you didn't use any navigation equipment. How did you ensure the accuracy of the tunnel's location? What anatomical landmarks did you use?"

Gao Yuan didn't answer immediately. He stood up, walked to the whiteboard at the front of the conference room, picked up a black marker, and drew a simple side view of a knee joint. He spoke as he drew, his pace slow, but every word clear and forceful.

"Textbooks tell you that the femoral insertion of the anterior cruciate ligament is located on the medial wall of the intercondylar fossa, behind the intercondylar crest. This statement is correct, but not precise enough. Because the intercondylar crest is often worn down in patients with chronic injuries, you can't find it. Moreover, even if the intercondylar crest is intact, it only provides an anterior-posterior reference, not a superior-inferior reference."

He drew an arrow on the whiteboard, pointing to the medial side of the lateral femoral condyle.

"I used the most common 'resident's ridge.' This is a bony prominence located on the posterosuperior aspect of the medial wall of the intercondylar fossa, proximal to the intercondylar ridge. This structure is more constant than the intercondylar ridge because it is outside the joint capsule and is not affected by intra-articular lesions. No matter how damaged the patient's joint is, this ridge is still there. Find it, then move it forward seven millimeters and downward two millimeters, and that is the center of the original footprint. Actually, my description is not very accurate. I only described it this way so that everyone can understand. When I actually operate, I don't need seven or two millimeters to locate it. Instead, I rely on the feel of the probe. The footprint of the ligament and the non-footprint look different under the probe, and their mechanical centers are also different."

He paused, turned around, and looked at the young doctor who had asked the question.

"What I mean is that the millimeter number is just for convenience. Every patient is different. Seven millimeters and two millimeters are average values, not absolute values. After you find the 'resident's ridge,' you need to use a probe to confirm it. Within a one-millimeter range around the predetermined tunnel location, gently press with the probe. The bone of the original footprint is slightly denser than the surrounding area, so the feedback when you press the probe will be different. You need to find that hardest point; that point is the true center."

In the conference room, some people were taking notes, some were staring at the simple diagrams on the whiteboard, and some were gesturing with their hands to indicate the direction of "seven millimeters, two millimeters." The old professor sat in the corner, his arms crossed over his chest, his eyes slightly narrowed, revealing no expression, but his right hand rested on his knee.

A middle-aged attending physician sat in the second row, leaning forward with his hands crossed on the table.

“Dr. Gao, the tibial tunnel localization for the posterior cruciate ligament. You used a curved guide to directly locate it from the posteromedial approach, which is a very high-risk procedure. The popliteal artery is only a few millimeters behind it. How can you ensure that the popliteal artery will not be damaged?” Gao Yuan added the course of the popliteal artery to the knee joint diagram, a curve running vertically downwards from the back, closely following the posterior edge of the tibial plateau.

“The risk exists, but the risk comes from uncertainty. If you are unsure of the exact location of the popliteal artery, then it is dangerous. If you are sure, then it is no longer dangerous.”

He picked up a red marker and drew a thick line at the location of the popliteal artery.

"The popliteal artery follows a regular course behind the knee joint. It lies at the joint line level, approximately seven to ten millimeters posterior to the tibial plateau, and about five millimeters medial to the exit of the tibial tunnel. When you enter via the posteromedial approach with a guide, as long as you keep the tip of the guide pointing anteroinferiorly to the tibial plateau and not deviating posteriorly, you will not encounter the popliteal artery. The key is..."

He tapped his fingers on the table three times to emphasize what he was about to say.

"The key is that you need to familiarize yourself with the course of the popliteal artery on the patient's MRI images beforehand. During the procedure, you can't just rely on your eyes. You need to 'listen' with your hands. When the guide moves through the soft tissue, the resistance it encounters will tell you what kind of tissue you're touching. Fat has the least resistance, muscle has moderate resistance, fascia has slightly more, the resistance of the blood vessel wall is elastic, and the resistance of the ligament is tough. The popliteal artery wall has a unique tactile feel; it pulsates. When you gently push the tissue apart with a blunt dissector, if you feel a periodic, slight pulsation synchronized with the pulse, it means you're too close to the popliteal artery. Step back and adjust your direction."

"A surgeon's hand is a second pair of eyes, and the probe is an extension of that hand."

The meeting room fell silent for a moment. Some people were processing what he had said, while others were comparing it with their own experiences. The old professor seemed to be deep in thought.

The third question came from a female attending physician, who sat in the front row with her arms crossed and a serious expression.

"Dr. Gao, yesterday you and Dr. Robert adjusted the tension of the two grafts at the same time. There was no communication between you, but you stopped adjusting at the same time, and the tension seemed to be matched. How did you do that?"

Gao Yuan glanced at Robert, who shrugged, meaning "You answer for yourself."

“We use the same set of standards and learn from the same teacher,” Gao Yuan said. “Professor Yang Ping, my teacher, has a theory about ligament tension matching. He believes that the tension of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) is not two independent parameters, but two variables of a system. When the knee joint is in a neutral position, the tension ratio of the ACL to the PCL should be 6:4. The ACL bears 60% of the load, and the PCL bears 40%. This ratio is not fixed; it changes with the flexion and extension angle of the knee joint. But in this change, the tension curves of the two ligaments should be mirror-symmetrical; if one rises, the other falls; if one falls, the other rises. The axis of symmetry of the two curves is constant.”

He picked up a marker and drew two curves on the whiteboard, one rising and one falling, intersecting in the middle.

"This axis of symmetry is the signal for us to stop adjusting at the same time. When the absolute values ​​of the slopes of the two curves are equal, your feel will tell you that the force of the pullback felt by your left and right hands is the same. The left hand feels the same amount of force as the right hand. At this point, the tension is matched."

He put down the marker and dusted off his hands.

“This process cannot be coordinated with words. Because words are too slow. You say ‘tighten it a little more,’ I tighten it, and you think it’s enough, but a fraction of a second or even a few seconds have already passed, and the position of the joint may have changed. So you can only rely on feel. You and your partner must have the same feel, the same standards, and the same judgment. This requires a high degree of tacit understanding.”

Someone in the conference room nodded slightly. The attending physician's expression changed from serious to thoughtful. She didn't press further. Not because she had no more questions, but because she realized that Gao Yuan's answer wasn't technical; it was something beyond technology. You can replicate a person's skills, but you can't replicate the tacit understanding between them and their partner.

The questions continued: some asked about graft selection, others about postoperative recovery timelines, some about managing bone tunnel expansion in revised cases, and still others about surgical strategies for cases involving posterior and lateral complex injuries. Gao Yuan answered each question concisely, precisely, and directly, just like his surgical procedures. He didn't beat around the bush, didn't pile up jargon, and didn't try to mystify. He could explain the core of a complex question in just three sentences. This ability to express himself wasn't innate; it was "forced" out of him by Yang Ping at the Sanbo morning meetings. Yang Ping wouldn't allow him to speak for more than three minutes; if he did, he would be interrupted, saying, "If you can't condense it, it means you haven't truly understood."

Two hours later, the problems gradually subsided.

The old professor remained silent, sitting in the corner in the same posture, like an observer. But everyone knew he was no observer. He was the most senior person in the room; his name appeared in the references of every sports medicine textbook, and his paper on anterior cruciate ligament biomechanics had been cited over ten thousand times. If he were to speak, the question would certainly not be technical; technical questions were ones he had asked himself countless times over the past forty years.

He spoke up now.

"Dr. Gao."

All eyes turned to him. Gao Yuan turned to him too, his gaze calm, without tension, without flattery, and without the deliberate "neither humble nor arrogant" often seen when facing authority. He simply looked at the old professor as if he were looking at anyone else asking a question.

"I'd like to know, how long does it take your teacher to perform an anterior cruciate ligament reconstruction surgery?" the old professor asked.

Gao Yuan didn't expect him to ask this: "Half an hour."

"I don't doubt what you say, but I'd like to know, how did he do it? Half an hour means that every step was done without any unnecessary movements, every judgment was made without hesitation, and his hand speed had to be extremely fast. How did he train to achieve such efficiency and accuracy?"

This isn't a technical question. It's a question about "becoming." The old professor wasn't asking about Yang Ping's surgical methods; he was asking about Yang Ping as a person—how did he become that kind of surgeon? How did his skills develop? How did he achieve that state of mind during surgery, free from hesitation, rework, and unnecessary movements?

Gao Yuan thought for a moment and then spoke.

"Actually, there's no secret. Let me answer with my teacher's words—it's all about practice!"

He paused for a moment, looked into the old professor's eyes, and the old professor was taken aback.

“Only through repeated practice”

Robert stood up to translate.

The old professor was taken aback again and frowned.