Director?
We finished Sakuma-san's pericardial tap—
Director...
Director!
Dr. Sakurai?!
He collapsed after giving Sakuma-san
chest compressions.
Sir, you're safe now.
You're going to be okay.
Can you hear me? Sir.
Sir?
Sir.
His BP spiked during the chest compressions...
His aortic arch aneurysm is about to rupture.
That triggered a rupture of his basilar tip aneurysm.
Sir.
Dr. Sakurai!
Sakurai Shuzo, male, age 68.
A doctor by trade.
Previously diagnosed with an aortic arch aneurysm
as well as a basilar tip aneurysm...
Let's secure a CV line.
Got it.
Prepare the echo.
Have a PCPS on standby.
Make sure he's sedated!
It's been confirmed.
Both aneurysms have ruptured.
In the aortic arch,
two out of three layers of the aorta have ruptured.
Only the adventitia is holding right now.
If that also ruptures,
it'll become a true aneurysm,
and he'll die.
His cerebral aneurysm has also ruptured,
but bleeding is minimal.
But he'll die if there's another rupture.
Dr. Asada.
We'll have to do the simultaneous operation now.
But who's going to operate on the brain?
Dr. Baldwin isn't even here!
Arase, hit up all the L&P neurosurgeons!
Now that they've both ruptured,
the operation will be even more difficult than we previously thought.
And you want one of our doctors—
If we don't do it now, we won't be able to save Dr. Sakurai!
Arase!
All right.
I'll try asking all the neurosurgeons.
Prep for surgery!
Take him to the OR!
Hey, make Mizushima from neurosurgery come here.
You've got to be kidding.
You want him to be Dr. Baldwin's subst—
That's our only option!
What's the status?
The aneurysms in his heart and brain have both ruptured.
Dr. Asada's team will do the simultaneous operation now!
It's a no-go.
All of our neurosurgeons say they can't do it.
It'll have to be...
me.
I'll operate on his brain!
Are you serious, Asada?
Just listen to yourself.
You can't possibly operate on a basilar tip aneurysm while you operate on his hear—
I can't just have us stand here wringing our hands while he dies!
You've made miracles happen many times over on the heart.
But the brain is a different story!
It'd mean...
Dr. Sakurai might die by your own hand!
You have a call from Dr. Fujiyoshi.
"Dr. Fujiyoshi"?
I heard.
There is one neurosurgeon in Japan
who can save Dr. Sakurai.
We've done an exhaustive search of all neurosurgeons in Japan!
There's no one—
He's not...
a doctor anymore.
But he's a genius neurosurgeon
who previously topped Mike Baldwin
in the Best Surgeon in the USA rankings.
Better than Mike?
Reverse Mullet mentioned it before
that there's a neurosurgeon who was ranked first in 2004 but then retired.
Who is it?
The neurosurgeon is...
Okamura Tadashi.
I've talked to Okamura.
He'll be there soon.
Dr. Sakurai can't be saved through
the power of business economics anymore.
He can be saved only by doctors with the best skills.
Do whatever it takes to save his life.
Okamura-san was a neurosurgeon better than Dr. Baldwin?!
Come to think of it,
his medical knowledge is incredible.
Right.
But Dr. Noguchi fired Okamura-san.
Dr. Noguchi would never permit a simultaneous operation with him.
So what if he doesn't?
Now that L&P's announced their global-expansion plans,
they're getting a lot of attention from the press.
Okamura-san hasn't operated in 10 years, right?
Dr. Noguchi'd never allow something that dangerous—
He's the only one we have.
Well...
I know that.
But if Dr. Noguchi finds out—
Oh.
Oh!
No!
Dr. Noguchi,
we just received the highest quality tea leaves from India.
Do you know how to make chai?
You don't?
Then allow me to enlighten you.
First,
you fill a pot with water and bring it to a boil.
Then...
I've come to return the favor.
I...
want to save Dr. Sakurai, too.
It's now more difficult than we thought it'd be for the simultaneous operation.
Given the circumstance, can you repair a basilar tip aneurysm—
I'm the only one you have...
who can.
Let's do this.
You steep the tea at low heat.
And, here is the critical step...
You pray to the gods that you'll make good chai—
Stop!
What are you babbling on about?
Oh, um...
I'm just studying up for when I go to India.
You're going to India?
Yes.
I'm part of Team Dragon, right?
If not their director,
I'm at least their supporter.
I'm one of them, right?
Okay, stand.
Yes, sir.
We will save you.
We'll make sure you can go back to being a doctor.
1...
2...
3...
4...
5...
6...
7...
Air leak's gone.
Hook him up to the brain monitor.
Got it.
Anesthesiologist Arase Monji
Scrub Nurse Inohara Kaoru
First Assistant Kato Akira
Second Assistant Ijyuin Noboru
Basilar Tip Aneurysm Repair Operating Surgeon Okamura Tadashi
Aortic Arch Repair Operating Surgeon Asada Ryutaro
He's ready.
Praying to the gods for making good chai?
There's an emergency operation.
Hurry.
It sounds like a pipe dream.
A simultaneous operation on the brain and heart?
Stop!
What'd you say?
"A simultaneous operation on the brain and heart"?!
Why's Okamura here?
Okamura was a genius neurosurgeon.
He's the only possible substitute for Dr. Baldwin—
How long's it been since he's last held a scalpel?
Ten years.
"Ten years"?!
I can't allow such a dangerous operation!
Do you want to kill Dr. Sakurai?
We can only stake our hopes on two genius surgeons.
We'll now perform clipping to repair
the ruptured basilar tip aneurysm.
Scalpel.
Here.
We'll now repair
a ruptured aortic arch aneurysm.
Scalpel.
Here.
Let's do this.
Forceps. Gauze.
Bovie.
Here.
Time to open him up.
Sternal saw.
Here.
Harken clamp.
Cell saver tube.
Here.
Bring blood transfusion packs.
10 units of MAP and 20 units of FFP.
Please.
Got it.
Proceeding with craniotomy.
Perforator.
Here.
All right.
Let's do this.
Yes, sir.
Brain monitor shows him stable below 40.
Rib spreader.
Here.
Dissecting pericardium.
Dissecting dura mater.
Dura scalpel.
Here.
Metz.
Sternotomy complete.
Craniotomy complete.
Budde halo retractor set.
Here.
You can't even tell he hasn't touched a scalpel in a decade.
Has he really been away from the OR for that long?
Dr. Kihara, how are things going?
Let's put in the microscope.
Yes, sir.
Metz.
Here.
Tube clamp.
Cannulae insertion, complete.
I don't see additional bleeding.
Arase, give him heparin.
Heparin, IV push.
Got it.
It's the first simultaneous operation on the heart and brain in the world.
You normally need heparin for cardiac procedures.
But if you use heparin in brain surgery,
and there's another rupture in the brain,
it'll result in lethal bleeding.
That's why they've induced hypothermia and induced circulatory arrest?
That's right.
If you induce circulatory arrest when the body temperature is 20 degrees,
you can mitigate the risk of bleeding
and make a simultaneous operation like this possible.
Core temperature has reached 20 degrees.
Stop circulation.
Got it.
The imminent rupture extends to the descending aorta.
I guess it won't be easy.
The maximum time we can maintain circulatory arrest
is 30 minutes.
Thirty minutes is the limit.
They're going to repair both the brain and heart in 30 minutes.
Pump off.
Got it.
Circulatory arrest.
Start countdown.
Yes, sir.
Countdown's started.
Let's do this.
Metz.
Here.
Forceps.
Here.
Increase pump suction.
Got it.
Put the head on ice.
Lower the A/C setting.
Yes, sir.
Opening the Sylvian fissure.
Scissors.
Here.
The temporal lobe's been retracted too far.
Don't put any tension on the sphenoparietal sinus.
Bayonet scissors.
Here.
Cutting through liliequist membrane.
Already?
Accessing posterior circulation.
Raspatory.
Here.
Felt strip.
Here.
The blood's coagulating.
All right, we're at the main basilar artery.
The basilar tip
is located in the deepest part of the brain.
He'll have to trace the main basilar artery
through the sea of blood,
Main Basilar Artery
while skirting the left and right
Superior Cerebral Arteries
superior and posterior cerebral arteries,
Posterior Cerebral Arteries
to reach the basilar tip and do the clipping.
There's the left SCA,
the superior cerebral artery.
I can see the right SCA, as well.
Careful with pressure on the brain spatula.
Got it.
He's fast.
Asada's team has also finished trimming the proximal vessel
and is resecting the distal end.
Metz.
Here.
Something wrong?
There is an aneurysm developing in the distal arch.
If we use this site for anastomosis
the aneurysm may eventually grow
and rupture after the operation.
But if we repair that on top of everything else,
we won't be able to finish the aortic arch repair in time.
Even if everything goes as planned,
it's impossible to repair the aortic arch in 30 minutes.
If they spend additional time dealing with that,
they won't be able to attach the trifurcate graft in time.
Hey.
What if we switch to an elephant trunk graft?
If a distal arch aneurysm develops in the future,
that'd make it easy to repair via a left thoraco-abdominal approach.
But that'd mean making more sutures.
We don't have that kind of time.
Sorry.
We'll use a stent graft.
"A stent graft"?
They want to do endovascular repair?
That's not possible unless they're in a cath lab.
So you want us to prepare a C-arm?
That won't be necessary.
We'll insert a stent graft right from here into the aorta.
Right.
We can prevent further dilation into an aneurysm
if we implant a stent graft,
and we won't need to place additional sutures.
The time loss will be minimal.
Open stent-graft placement.
Get a stent graft, now.
Please.
Got it!
Here's the stent graft.
Nice job, Reverse Mullet.
Please save...
Dr. Sakurai.
Trimming complete.
Ijyuin, you take over.
Got it.
We'll place the open stent
in the descending aorta.
Wire's out.
These guys just might be able
to pull this simultaneous operation off.
Deploying.
Open stent-graft placement complete.
We'll proceed to distal anastomosis of the synthetic graft.
Synthetic graft.
Here.
4-0 thread.
I see the oculomotor nerve.
SCA, PCA locations confirmed.
Dr. Sakurai will make it, right?
He'll come back.
Dr. Asada's team won't let us down.
Metz.
Distal anastomosis complete.
We'll proceed to prepare the synthetic vessels.
Metz.
Here.
Left PCA.
Right PCA.
All right, I've located the basilar tip.
So fast.
Despite the acute rupture,
he found the basilar tip in just ten minutes.
We'll proceed to clipping the...
This is...
What's wrong?
I can't do the clipping for this!
Why not?
There's extensive calcification of the neck of the aneurysm.
If I force it,
the aneurysm might tear right off the artery.
And if the tear occurs in the calcified area,
there's nothing we can do.
Without clipping,
there's no other way of treating the cerebral aneurysm.
They'll have to just close up his skull.
It was a fool's errand from the start.
There is one way.
Flow control surgery.
We'll do a bypass in the brain
to control the blood flow.
"A bypass in the brain"?
The neck of the aneurysm
is too calcified to permit clipping.
So he'll place the clip before the calcified area
and stop the high-pressure bloodflow from the heart.
Then, he'll use a graft from the patient
to connect the superficial temporal artery with the PCA
and preserve bloodflow.
But this bypass is an order of magnitude more challenging than a bypass for the heart.
There's...
another issue to consider.
In order to perform this bypass,
I'll need a subtemporal approach.
"A subtemporal approach"?
It requires the patient to be rotated 30 degrees,
which will increase the difficulty of the cardiac procedure.
Can you handle that?
Who do you think you're talking to?
This team...
can.
Arase.
Right.
Rotating 30 degrees to the left.
Got it.
First, we'll harvest the graft.
Take the RA—the radial artery—from the left forearm.
Got it.
Wait.
The RA won't do.
We need the best graft.
The "best" graft?
We'll use the ITA,
the internal thoracic artery.
But...
we'll have to stop the aortic arch repair
while the ITA's being harvested.
We have only 15 more minutes.
Not even you will be able to finish in time.
Given the circumstances,
it's better to use the RA, since the aortic arch repair can continue—
No.
But if we want to save Dr. Sakurai—
Saving him is not enough!
We need to make sure he can be a doctor again,
so that he can safeguard the healthcare of this region.
For that, he needs a bypass with the best graft possible,
the ITA graft.
Ryutaro-chan.
We have the best team here.
I have faith in our abilities
if all of us work at...
one-hundred percent.
Harvest...
the best graft.
I will ensure that the cerebral bypass is a success.
IMA.
Here.
All right,
we'll put a permanent clip between the SCA and PCA.
One seven-millimeter straight clip.
Here.
Bovie.
Here.
It's common for cerebral bypass
to harvest the RA from the wrist.
But since blood vessels in the brain are narrow,
Blood Vessel in the Brain
the wider RA can be a mismatch,
Radial Artery
resulting in a rupture even if the anastomoses at first succeed.
In comparison, the ITA is narrow and flexible,
and is a good fit with vessels in the brain.
It's only even an option
because of the ongoing open chest surgery
so that the ITA behind the sternum can be harvested.
They're eating into their time limit for the aortic arch repair
in order to harvest a graft for cerebral bypass?
They made that decision because it's the best option for the patient.
But they're going to use up any time they saved with the stent-graft—
Dr. Asada's team can do it
within the time limit for the circulatory arrest!
But...
they have only 12 minutes left.
Bovie.
Here.
Once this is done,
we'll proceed to the temporary clipping.
Two five-millimeter clips.
Got it.
Graft harvest, complete.
Let me handle the trimming.
You go back to the aortic arch repair.
Thanks.
Potts scissors.
Rib spreader.
Here.
Permanent clipping, complete.
This should significantly reduce blood flow to the aneurysm.
Trimming, complete.
Ten more minutes.
Proceeding to proximal anastomosis.
Let's step up the pace!
4-0 thread.
Temporary clipping of P1 and P2.
We'll start with the proximal vessel.
Got it.
The director's going to be okay, right?
He'll be okay.
He'll get better.
Put it here.
I hope Dr. Sakurai will get better
Write Get-Well Messages to Dr. Sakurai!
Temporary clip.
Here.
Get better, Dr. Sakurai
We'll be done with proximal anastomosis soon.
Then it'll be just the trifurcate graft.
Five more minutes.
It typically takes five minutes just to anastomose one vessel.
But doing it for three?
They've done well.
But if they're just now getting to the trifurcate graft,
not even Asada can do it in time.
Metz.
Here.
Proximal anastomosis, complete.
What's Asada doing?
Once he cuts the synthetic graft,
he can't use them.
Wait a minute...
We'll use the en block method.
"En bloc method"?
The en bloc method:
the three vessels in the aortic arch
are resected as an island patch
that is anastomosed to the synthetic graft.
En Bloc Method Typical Trifurcated Graft Method
This allows for one anastomosis site,
as opposed to three separate sites,
thus reducing the time requirement.
He made that split-second decision based on the fact
that Dr. Sakurai's aneurysm does not extend to the three vessels.
Repair the three vessels with one anastomosis site?
I'd forgotten that option.
Bring more felt pledgets.
Got it.
Get more 4-0 thread.
Got it.
Syringe, please.
Here.
Proceeding to en bloc anastomosis.
4-0 thread.
Here.
They haven't given up.
They share the same goal: complete recovery for Dr. Sakurai.
That...
hasn't changed.
Temporary clipping of P1 and P2, complete.
Proceeding to anastomose graft to PCA.
Scalpel.
Here.
4-0 thread.
Here.
Graft.
Are you L&P guys watching this?
You'll never see an operation like this again.
If you have any pride as doctors,
watch these guys work with your eyes wide open.
Team Dragon and Okamura-san have amazing skills!
But what's really amazing...
aren't their skills.
It's their willpower—
they never give up on trying to make the best choice...
for the patient.
Another 4-0 thread.
Here.
Have the pump on standby.
Got it.
Felt pledget.
Here.
Increase suction.
Got it.
Proceeding to distal anastomosis of the ITA graft to the PCA.
Got it.
10-0 nylon.
Here.
Standby for rewarming.
Got it.
Asada.
4-0 thread.
Here.
Have the ventilator on standby.
Got it.
Syringe.
Here.
Tourniquet.
Here.
Felt pledget.
Here.
After anastomosis is complete,
release the P2 temporary clip.
Got it.
Resume dilator.
This is Team Dragon.
I want to become a doctor so that I can help people.
Never forget that.
I will create an ideal hospital suitable for the times to come.
I am sure you are up to the task.
4-0 thread.
Here.
Jacobson forceps.
Here.
Nerve hook.
Here.
Lavage.
Here.
Fibrin glue.
Here.
Rewarm.
Got it.
C'mon.
C'mon, c'mon, c'mon.
C'mon!
80 seconds remaining.
Felt pledget.
Here.
SEP's stable.
All right, applying pressure.
Metz.
Here.
Micro Metz.
Here.
En bloc anastomosis, complete.
ITA-PCA anastomosis, complete.
Reversing circulatory arrest.
Reversed.
Pump on.
Got it.
There's no bleeding.
We did in time.
We just have to restore normal bloodflow through the aortic arch now.
3-0 thread.
Here.
I'll be done after the STA-ITA anastomosis, as well.
Temporary clip.
Here.
Arterial cannula exchange, complete.
STA-ITA-PCA bypass, complete.
Spontaneous heartbeat, restored.
Let's check the SEPs.
All right,
SEPs look fine.
Basilar tip...
flow control surgery,
complete.
Aortic arch repair,
complete.
The simultaneous operation is a success.
The simultaneous operation is a success!
Yeah!
Thank god.
Great!
Wow!
Thank god.
We were able to...
save Dr. Sakurai because of you.
No,
it was the overall strength of the team.
But...
this is my last operation.
Japanese healthcare will collapse if it goes down its current path.
I...
want to use the power of business economics to save the lives
that fall through the current system's cracks.
We'll keep fighting on the front lines.
Asada Ryutaro.
I may...
need...
your help again someday.
Call me anytime.
You are...
one of us now.
You did it, Ijyuin.
You're amazing.
I thought you would,
but you actually did it.
He's my disciple, okay?
I see,
Okamura-kun helped.
Yes.
The surgery was a success.
We'll be waiting.
It's not just me.
Everyone around here...
is waiting for your recovery.
You all...
saved my...
life.
I'll...
do my best to safeguard...
the health and well-being...
of people here.
You're not taking Asada's team with you?
I'm just...
taking Ijyuin.
It's what he wants.
I'll also take young doctors from L&P who've shown similar ambition.
What's the meaning of this, Ms. Kito?
Your wish used to be to take the entire team with you into the world—
I changed my mind after seeing their operation.
Team Dragon is a complete team.
Even if I take all of them along,
I'd just be their manager.
Don't be ridiculous.
You'd be responsible for the best team in the world.
I want to lead the way
as a doctor, myself, and be on the front lines.
I want to save patients around the world
with my own two hands.
And I want to build a new team.
One that surpasses Team Dragon.
The India expansion cannot fail.
I believe I told you that we need a superstar like Asada.
I'd forgotten
that I'm also a superstar.
I guess we'll have to see what you're capable of.
So you're going to India.
Yes.
I want to go out into the world and hone my skills,
and teach the doctors there what I learned in Team Dragon.
I'll stay here as the hospital director
and build a hospital centered around anesthesiologists.
I'll get the pediatric artificial heart out to market.
As for me...
I'll go back to Sakurai Hospital.
We've done this sort of thing before.
Yeah.
What?
We're not going to do it?
Man, you don't let up.
We'll go our separate ways again,
but we'll always be a team, right?
We will each work
to make our vision of healthcare a reality,
and we'll...
come together again someday.
Sakurai Shuzo.
You've always been...
a man who never gave in to anything.
Even now, forty-six years later,
you refused to give in to...
your difficult medical condition.
Noguchi.
I'll look forward to seeing
the ideal hospital you'll build.
I think we should...
go with valve replacement this time.
No.
Don't be afraid to try something different.
Oh, right.
Hey.
Yes?
You should wait five more years before you grow a beard.
Why? It suits me just fine.
You like fiddling with your beard, too.
Right?
That's built on my 60 years of experience.
Well...
An "anesthesiology bank"?
Yeah.
We'll deploy anesthesiologists who were trained here
to areas that lack anesthesiologists.
That's wonderful.
I'll follow you for the rest of my life.
What?
Huh?
W-Wait.
I'm going to follow you for the rest of my life.
The pediatric artificial heart will go on the market in another year and a half.
If my R&D goes in tandem with your R&D on the cardiac cell sheets,
we can save even more children who can't receive transplants.
Yeah.
Patients are waiting for our research to reach fruition.
Congratulations.
I hear you're now the official director of Sakurai Hospital.
Yeah.
Five years.
After India,
I'll establish a global medical alliance...
in five years
and become its first president.
Power is beautiful.
I'll take Japanese healthcare to the pinnacle of the world.
I'll...
stay and save the lives of people here.
Local healthcare and global healthcare...
Are we headed toward the same ocean?
See you again.
I'm going to build Shanghai Fuping Hospital in China two years from now.
I'm still looking for a superstar to lead that hospital.
I think we have a long road ahead, you and I.
Ryu-chan.
It's been a long time,
Miki.
I'm back.
We'll now perform
a transapical aortic valve implantation...
for aortic stenosis.
Scalpel.
Here.
This Is a work of fiction