What's this about, Takashina?
There should be an article about the SNIPE decorating this cover,
but there isn't a single mention of the SNIPE in here.
You've only had two cases at Tojo so far,
and it would be hard to say I'm satisfied with the results of either one.
Teika University Research Lab 1
My apologies.
The chair selection for the Surgeons' Society is almost here.
What I want is a high impact factor,
impact factor!
If you don't get results next time,
the SNIPE will be taken away from you.
If you want to remain in this world,
please produce some results.
After two failures with the SNIPE, Dr Takashina was cornered,
with no way out.
But no more SNIPE operations had been planned,
so he had no way to recover.
I hear you haven't performed any SNIPE operations since then.
There's someone I'd like to introduce to you.
Meanwhile, the demand for surgery by Dr Saeki was even higher than before.
The Saeki method was used in surgery every day.
That included two new patients under my responsibility.
The first was suffering from mitral valve stenosis
and scheduled for surgery by the Saeki method: Kusunoki Hideo.
Until the surgery, Tokai here will be looking after you.
Thank you very much.
And the other patient
was introduced by Kinoshita, the clinical trial coordinator:
Tamura Hayato, a music student.
He has mitral insufficiency.
He was preparing for an upcoming piano contest in America,
and hoped to receive SNIPE surgery in order to recover quickly.
The important thing was his father,
Well, well! Mr Tamura!
Tamura Kouji, expected to be the next Vice-Minister of the Ministry of Health.
If the examination finds no problems, you'll be able to have surgery soon.
You can be discharged about a week after the surgery.
Thank you.
This SNIPE is impressive.
Scheduling this SNIPE surgery saved Dr Takashina from his hopeless situation.
The preoperative inspection was started right away.
Sera, bring me a towel. - Yes, sir.
What are you doing? Pay attention!
I'm sorry. Excuse me.
Dr Takashina is so harsh these days.
Maybe it's because he hasn't done a SNIPE operation in a while?
Excuse me.
Here are the results of Hayato's blood test and cardiac ultrasound.
The MRI results will be ready tomorrow.
Here you go. - Thank you.
I'm sorry for snapping earlier.
No, it was my mistake.
You aren't leaving yet?
Because of what went wrong last time,
I have to rewrite most of this paper.
Did you need anything else? - Oh, no.
It's just that Dr Tokai never writes any papers,
so it's sort of refreshing.
Just writing papers is meaningless, though.
The important thing is where your paper is published.
The impact factor, right?
Impact factor A number showing the influence of papers published in scientific journals, by which the paper and the doctor are evaluated
The journal with the most influence in Japan,
the Japan Surgical Journal, has an impact factor of 7.
When Dr Saeki first introduced the Saeki method to the world 10 years ago,
his paper was published here.
That meant the Saeki method
instantly became well-known throughout the world.
Together with the papers Dr Saeki has published since then,
his total impact factor is 77.
In contrast, Dr Nishizaki has published on a wide range of subjects
but his impact factor is only 71.
So the impact factor of papers about a single surgical method, the Saeki method,
is beating Dr Nishizaki, who is focused on research.
Tojo University was unknown,
but suddenly became an authority on heart surgery,
and now patients from all over the world come here, to Sakuranomiya city,
gathering at this single regional hospital.
The impact factors of papers
really changed the world.
But if I can complete this paper on the SNIPE,
we can beat Dr Saeki's impact factor by a wide margin.
I'll do anything I can to make that happen.
But we don't have enough cases to finish the paper yet.
I have to make this operation succeed, whatever it takes,
and get more patients as soon as possible.
If we use the SNIPE, we can save more people's lives.
Would you let me help you?
Like you said, if the SNIPE can be used in standard practice,
a lot of people from all over the world will be saved. I think that's wonderful.
Oh, excuse me. I know it's none of my business.
Excuse me.
Sera.
Yes?
The data needs cleaning up.
Can I leave that to you?
Yes, of course!
But the next day,
Tamura Hayato's test results revealed a big problem.
What is this?
Looking at Hayato's heart, he has hypertrophic cardiomyopathy
and unlike a normal heart, the inside of the ventricle is like a jungle,
Normal heart
Hayato's heart
Mitral valve
Hypertrophy
with a complex structure.
This means that moving in time with his heartbeat
and reaching the mitral valve will be a major challenge.
Even grazing the cardiac muscle could cause fatal arrhythmia
leading to death.
This is a very rare case requiring extremely delicate work.
Performing a SNIPE operation on this patient would be...
Impossible for you, right?
Well?
It's impossible.
But Dr Takashina, this is your chance to use the SNIPE!
Impossible is impossible.
Then let's have someone else as the lead surgeon.
Come in.
Dr Tokai...
Tokai, will you do the SNIPE operation this time?
If those are your orders, sir.
Unbelievably, Dr Tokai will take on the SNIPE operation this time.
What on earth will happen?
Please wait.
I'll acknowledge that Dr Tokai is skilled,
but letting him perform the SNIPE operation...
This surgery will need to be as precise as threading a needle.
I can't think of anyone other than Tokai who could do it.
If you're too worried, the only other choice is to give up on this operation.
What would Dr Nishizaki say if he heard about that?
Please support Tokai as his assistant.
Isn't this the first time Dr Tokai will be operating surgeon from the beginning?
Right! Usually he's officially just the assistant.
I wonder how the surgery will go this time. - Right?
Here is the SNIPE manual.
I just stick it into the mitral valve and push the switch, don't I?
The route will be complicated this time, not like the previous patients.
You need to do lots of simulations.
That guy did lots of simulations and still failed in the end,
so isn't it just a waste of time?
In the end, Dr Tokai didn't touch the SNIPE even once
before the day of the operation.
Let's start the SNIPE-based mitral valve replacement surgery.
Scalpel.
What's wrong?
I'm not sure...
What is it, Dr Tokai?
I'm stopping. - Huh?
Stopping?
Dr Tokai?
What's going on? - I'm not sure... Kurosaki!
Yes, I'll go and check right away.
What do you mean, you're stopping?
It's my decision as the operating surgeon. That's all.
Explain yourself!
We and Hayato have been preparing for this.
You weren't prepared.
Did you even look at the apical muscle?
The apical muscle...
Well, it can't be helped.
That was the operating surgeon's decision.
But... - The operating surgeon is Tokai.
Try examining the cardiac muscle.
There's not much difference, is there? - No.
After that, the results of the detailed examination revealed a shocking truth.
The apical muscle is a lot weaker than usual.
We can't insert a SNIPE through it.
If he'd inserted the SNIPE then,
the apex would have torn
and caused severe bleeding.
He could tell that much
just from the small movements of the heart...
What do you mean? You can't cancel it.
Just make that Tokai guy do the operation.
If he succeeds, it will be an important test case for the SNIPE.
It will make this paper better, too.
And if he fails...
In that case,
Tojo University will be responsible.
Oh, right.
This font is a bit too small.
Bold would be good, too.
Dr Takashina.
Will it really be possible to perform SNIPE surgery on Hayato?
Of course. But for that to happen,
we need to find a new route to the mitral valve that won't damage the ventricle.
Will you help me?
Yes, sir.
We'll use the 3D printer to make a perfect copy of Hayato's heart.
Wow!
Amazing.
It's just like the real thing. - Yes.
Let's try moving the SNIPE insertion point away from the apex, a little at a time.
Yes, sir.
I'm surprised you introduced vice-minister Tamura...
You must like Dr Nishizaki and Takashina a lot.
Like them?
Am I wrong?
I just like first-class things.
In that sense, I like both Dr Saeki and Dr Nishizaki.
Maybe I shouldn't ask,
but why did you persuade Mr Tamura to agree?
You even named Dr Tokai as operating surgeon.
It's almost as if you're the one who likes the SNIPE, Dr Saeki.
It's all for the patient's sake.
That didn't work either.
Next, let's try 11 mm
with an insertion angle of 75 degrees. - Yes, sir.
We kept running tests to find a new SNIPE route.
We moved the insertion point a few millimetres from the apex,
and calculated the insertion angle based on the pulse,
testing it over and over.
Are those guys still at it?
Sera shouldn't be helping with Teika University's research, anyway.
And finally...
We found the route at last. - Yes.
That means we can use my SNIPE.
But the only thing we can't predict about the next operation is
the surgeon.
What do you need?
The day of the contest is getting closer.
We'd like the surgery to be done tomorrow.
When can the surgery be performed?
As soon as possible. Right, Dr Tokai?
Before that, do you really understand what this SNIPE operation means?
What? - Of course,
I have explained it to them.
It has been performed twice at this hospital.
The first time, the patient's splenic artery ruptured
and she almost died.
The second time, the surgeon made a mistake and the patient almost bled to death.
Bled to death?
That's the kind of operation we'll be performing on you.
Well, they say "third time lucky",
so it might succeed,
but they also say "bad luck comes in threes".
Please think about it carefully.
There were problems both times...? - What is this?
I'll explain it again afterwards.
Dr Tokai, what are you trying to do?
I'm just telling the truth. - No,
that was a threat.
What if the patient refuses to have the SNIPE surgery?
Then it's cancelled.
Didn't I say this before? Either I leave here or you do.
If no one has a SNIPE operation,
I'll be forced to leave.
Is that what you want?
I'll say it clearly: I don't like that you're the operating surgeon.
But since the team has been decided, we have to work together.
Let's stop holding each other back.
This is the new SNIPE route we've decided on for Hayato's surgery.
It's worth publishing this finding, too.
Please follow this route for the SNIPE in the next operation.
Hey! Dr Tokai!
What did you just do?
I deleted it.
Don't mess around! Do you know what you've done?
Dr Takashina, please stop. Please.
Please.
I don't need that.
I've already picked my own route.
Insert the SNIPE 28 mm to the left of the apex
at an angle of 83 degrees. With that approach,
it can reach the valve without damaging the hypertrophic ventricle.
In fact, that's the only possible route.
Any problems with that?
If you could save lives by writing papers, there'd be nothing to worry about.
If there are any problems,
it's a problem with my own pride.
Since you don't write papers,
you don't know how much effort we put into it, do you?
If you'd ever been involved with research,
you wouldn't be able to do that. Papers are everything for a doctor!
I'll acknowledge that you have skill.
But if you can't understand those feelings,
I can't call you a doctor.
You're just a surgical craftsman.
If you keep praising me so much,
I'll get embarrassed.
I don't need that. I've already picked my own route.
Insert the SNIPE 28 mm to the left of the apex
at an angle of 83 degrees. With that approach,
it can reach the valve without damaging the hypertrophic ventricle.
In fact, that's the only possible route.
The SNIPE route that Dr Takashina discovered after running dozens of tests
was easily found by Dr Tokai.
What's going on, Dr Nishizaki?
You said he'd recover quickly, but if he could die from this,
I'd rather have the Saeki method.
This Tokai guy
seems to have caused a misunderstanding.
There are no problems whatsoever.
I trust Takashina,
so I'll let him explain it now.
After Dr Takashina's earnest explanation,
Mr Tamura finally agreed to the SNIPE operation.
First, please look at these documents.
Mr Tamura would like Hayato's next operation
to be done this Sunday.
Dr Saeki will be away on business that day.
This was requested by the future vice-minister Tamura himself.
It's fine by me.
Me too, of course.
So it's decided.
Thank you very much.
Takashina.
This is a big responsibility for you too.
What do you mean?
Dr Nishizaki only thinks of the SNIPE as a tool for winning the Society chair position.
Isn't he hounding you to get results and publish papers?
Takashina,
won't you join us officially?
You should test the SNIPE here at Tojo until it's accepted as Tojo University's research.
But this is Dr Nishizaki's research.
No, it's yours.
I want to support your research.
You still need a skilled doctor to use the SNIPE.
It works because you're using it here at Tojo.
Are you trying to poach me to get hold of the SNIPE?
The name printed at the end of your paper
is the person with final responsibility for the research.
That should be my name.
You mean... delete Dr Nishizaki's name?
We can change the rules if we need to.
Wasn't that your motto?
We aren't enemies. We're allies.
Meanwhile, Mr Kusunoki's preparation for next week's surgery with Dr Saeki was going well.
Okay, that's fine.
To be treated by Dr Saeki himself is a real honour.
I'll be staying in Tokyo on business tomorrow night,
so I wanted to check your condition before I go.
Thank you.
Just in case,
we'll do a coronary angiography on Monday. - Okay.
Order it for me. - Yes, sir.
Takashina, won't you join us officially?
That should be my name.
And so, the fateful day arrived.
Doctor, about Mr Kusunoki,
I booked a coronary angiography for him.
On Dr Saeki's orders? - Yes.
He wants it done as soon as possible, so it'll be tomorrow, on Monday.
Do it after this. - After this?
Yes. Set it up.
No, wait a minute. Even if you suddenly tell me that...
After you. - Ah, it's packed.
As expected, editor Ikenaga is amazing.
No, no. It wasn't me.
The previous editor had a lot of influence,
and he hired all of the Japan Surgical Journal's current editing staff.
Japan Surgical Journal's editing staff They choose which submitted articles will be published in the journal
He should be making an appearance today.
You can greet him later.
This way.
At last, Tamura Hayato's second SNIPE operation was about to start.
Now, let's perform this SNIPE-based mitral valve replacement surgery.
Scalpel. - Here.
Electrocautery knife. - Here.
Cut the pleura, then move the lung.
Dressing forceps. - Oh, yes.
Here we go.
Dr Nishizaki says not to worry.
Please watch calmly.
Tourniquet tube. - Here.
Pean.
You can insert the SNIPE now. - I know that.
Mitral valve
Hypertrophic portion
SNIPE inserted. - Don't shout.
28 mm to the left of the apex,
insertion angle 83 degrees.
Mitral valve
Hypertrophic portion
He did it so easily... as expected of Dr Tokai.
The Saeki method.
Although it's embarrassing, this surgical technique is named after me,
and is performed with the heart still beating...
Excuse me.
So far... - What is it?
Mr Kusunoki in room 304 is in shock. What are Dr Saeki's orders?
He's in cardiac tamponade.
Cardiac tamponade A condition where blood builds up around the heart and prevents it from beating normally. Fatal if not treated quickly.
He's speaking now, he can't give any orders.
That's Dr Saeki's patient. You can't let him die.
What should we do?
No problems so far. It's about to enter the hypertrophic part.
Mitral valve
Hypertrophic portion
Okay, here we go.
Mitral valve
Hypertrophic portion
Amazing. The route is so narrow,
but he's reading the heart's movements perfectly.
Sera. - Yes, sir.
Yes? - Kusunoki in 304 is in shock.
It's cardiac tamponade.
Someone... can someone come and help?
Um, Mr Kusunoki is in cardiac tamponade.
So his coronary artery ruptured, then.
How do you know? - Dr Saeki ordered angiography, didn't he?
We'll do a coronary angiography.
Ah...
Tsk, tsk, tsk.
It had to happen now.
Give me that. He needs emergency surgery.
Sekikawa can't do it. Dr Saeki isn't here.
He won't last 30 minutes like this. - Then what should we do?
Dr Tokai.
He can't. If he stops now,
we won't be able to insert the SNIPE again.
This is the only possible route. - Then what about Mr Kusunoki?
Dr Tokai.
Neko-chan.
From the left. - Yes, sir.
Mr Kusunoki, can you hear me? - Dear...
It's no good. He'll die like this. - Doctor!
Someone, come quickly!
What are they doing? Continue the operation!
Dr Tokai.
I only have one body, so I can only save one life.
So which one should I save?
What? - No, wait.
Which one should I kill?
I only have one body, so I can only save one life.
So which one should I save?
What? - No, wait.
Which one should I kill?
I can't decide that.
Since it's me,
I'll save them both.
Both?
How? - Tell them to bring the patient to the next room.
What? - Tell them!
Yes, sir. Please bring him to operating room 2.
Okay. Dr Sekikawa--
Nekota?
Operating room 2 is ready.
Quickly. - Yes.
Are you going over there? What about this patient?
Take my place.
You can continue.
Continue?
Then what? Are you planning to stand here the whole time
until I'm finished over there?
But...
The only route is the one you found.
All you need to do is keep moving forward with the right timing.
Keep moving forward? You know it's not that simple.
Are there no doctors in here?
Well?
Are there no doctors in here?
Okay.
Dr Takashina...
What are they doing? Tokai, get back in there!
You're going to continue?
Those were the operating surgeon's orders. - But...
The only chance is the instant when the pulse opens the route.
I know.
There's no other choice.
Operating Room 2
Why are we starting from the left? It should be the middle!
Move.
Left thoracotomy...
Let's start with the ruptured coronal aneurysm. Scalpel. - Here.
Why did he use a left thoracotomy?
Usually you'd use a midline incision
and cut open the middle of the chest,
Standard midline incision
Tokai's left incision
so why did he deliberately choose the more difficult left side?
Hey. - Yes, sir.
Excuse me. - That's in the way. You do it.
Yes, sir.
Video. - Yes, sir.
Ready.
Rib retractor. - Here.
Operating Room 1
The monitor is ready.
Good. You're taking longer than Dr Tokai,
but we should be able to keep going like this.
That's PSVT.
Mitral valve
Hypertrophic portion
Operating room 1 has PSVT.
PSVT… did he hit the cardiac muscle?
No, he didn't. It's just normal arrhythmia. Give him verapamil.
Yes, sir. Dr Tokai says it's normal arrhythmia and to give him verapamil.
They say it's normal arrhythmia, so administer verapamil.
Doing two operations at once... What a guy.
Here's the verapamil. - Quickly.
Anaesthetist, hurry up. - Yes, sir.
Damn it...
Dr Takashina...
Scissors. - Here.
Suturing of the coronal aneurysm, complete.
What? Already? - Electrocautery knife.
Raise his chest. Chair. - Yes, sir.
Next, he'll need a bypass to restore circulation to the blocked coronal artery.
This is a difficult operation, too.
How's it going over there?
His pulse is going crazy from the arrhythmia.
If he misses by even 1 mm...
If he hits the cardiac muscle, the patient will die.
Dr Takashina.
Scissors.
Bypass complete. - You're too fast. I can't believe it.
The bypass is finished here. - Thank goodness.
Blood pressure 72. - What?
Why won't his blood pressure recover?
It's because of his mitral stenosis.
To save him...
The Saeki method. Dr Tokai can do it.
Heart-lung machine. - Yes, sir.
Operating room 2, bypass complete.
We're starting the Saeki method now.
Blood pressure is 70/40, heart rate 110.
Hurry up. - Yes, sir.
Wait.
His blood pressure is still in the 70s.
Dr Takashina.
If I keep going any further,
I will definitely kill the patient.
So you're just going to let him die?
I can't do what I can't do.
I'm the one who knows my own limits the best.
Gown. - Dr Tokai.
Why...? What about the other operation?
Switch with me.
I'll do this one, so you do the other one.
I can't do the Saeki method... - Who thought you could?
Dr Tokai, here it is.
Use the SNIPE.
The SNIPE...?
I opened up the other patient from the left,
so just insert the SNIPE through the apex.
Did you plan this from the start?
What's going on?
He was planning to use the SNIPE later from the start.
Standard midline incision
Tokai's left incision
With a midline incision from the front,
the apex isn't accessible
and it's not possible to insert the SNIPE.
So to make this easier, he...
He's so skilled.
But we haven't tested--
Do it.
Surgeon's orders.
Understood.
Dr Takashina...
Dr Takashina?
Let's perform SNIPE-based mitral replacement surgery.
Thanks for your support. - Thank you.
First, purse-string sutures in the apex. - Yes, sir.
Mitral valve
Hypertrophic portion
SNIPE. - Here.
I'm inserting the SNIPE.
They're both using the SNIPE.
Mitral valve
Hypertrophic portion
It's through.
Here are his blood gas results.
I'm almost at the mitral valve.
It's at the mitral valve.
We're at the mitral valve.
Mitral valve
Hypertrophic portion
Done.
They did it! It's a success!
Thank you.
Can I leave the suturing to you? - Yes, sir.
That was unbelievable. Two SNIPE operations at once.
He's really as skilled as a demon.
I see. Tokai ordered that?
It seems they were both operated on with the SNIPE.
The SNIPE? - Yes.
I see.
Thank you, Dr Saeki.
Not at all. - The former editor
is in poor health, so he had to miss today's event.
I'm sure he'll recover soon.
Thanks to the SNIPE, my son was saved.
I'm friends with board members who can vote in the Society chair selection,
so please count on their votes.
That's wonderful to hear. Give them my thanks.
Goodbye.
Good job, Takashina.
The real battle starts here.
I'll make sure to finish that paper off soon.
For you, Dr Nishizaki.
Not long now.
Excuse me.
Dr Tokai, Mr Kusunoki is being discharged.
Please come with me.
Dr Saeki, thank you so much.
I'm glad you're feeling better.
I will definitely repay your kindness.
Thank you all so much.
Please take care.
Thank you. Excuse us.
Why did he leave from the back entrance?
Kusunoki Hideo is the former editor of the Japan Surgical Journal.
The editing staff of that journal are all personally indebted to him.
He also has a lot of influence over the Surgical Society.
If people find out that he came to me for his heart surgery instead of Dr Nishizaki,
the Society chair selection wouldn't be fair.
So back then...
Since it's me, I'll save them both.
The reason Dr Tokai saved them both was...
No matter how good your paper is,
the editors will decide whether to publish it based on whose name is written at the end.
Dr Nishizaki's
or mine.
Now that I think about it, Dr Tokai didn't make any demands this time.
What? - Well,
usually he won't save people without asking for money.
Dr Tokai.
Good work the other day.
Since you performed two SNIPE operations this time...
Will you cooperate with me again after this?
Is he such a bad person?
I mean, two lives were saved thanks to Dr Tokai this time.
No, no. He's a demon.
Excuse me, Dr Tokai.
I came to get Mr Igarashi's medical certificate...
Excuse me.
A pean?
Is this...?