SCIENCE AND PROFESSION

In all probability, surgery has been practiced as long as humans have had cutting tools. Ample reports of battlefield amputations exist almost from the beginning of reported time. Historians tell of rough field surgery, the hacking off of wounded limbs and the sealing of the wounds by searing the lacerated flesh. There are even suggestions that ancient civilizations, such as that of the Egyptians, practiced trepanning, cutting into the skull to operate on the brain.

Until the latter half of the nineteenth century, surgery was a brutal, dirty, and dangerous practice. About this time, the relationship between microorganisms and diseases was first enunciated, a relationship which explained why so many surgery patients sickened and died. It was also at this time that anesthetics were developed, which for the first time allowed the surgeon to deaden the patient’s pain.

Surgery today is one of the most respected medical specialties, requiring full training in the disciplines of medicine, as well as years of extensive work in surgical procedures. After becoming physicians, candidates for surgery spend years working under established surgeons learning the techniques that they will use in practice. They are subjected to intensive examination and receive certification only when their peers are convinced that they can perform their duties capably.

The tools and techniques of surgery that the surgical candidate must master present multiple challenges. In their training phase, surgeons learn to become skilled in the manipulation of all the basic instruments used in surgery, such as the various designs of scalpels, scissors, retractors, forceps, and sutures. The training surgeon learns a wide variety of stitching techniques and the materials used in suturing. Most challenging perhaps is mastery of the many new techniques and instruments that modern surgeons use.

After training and certification, some surgeons elect to practice general surgery. As the term implies, this field covers such diverse areas of the body as the stomach, gallbladder, liver, intestines, appendix, breasts, thyroid gland, salivary glands, main arteries and veins, lumps under the skin, hernias, and hemorrhoids. Other surgeons choose to specialize in disciplines that require still more training, such as heart surgery, bone (or orthopedic) surgery, and eye (or ophthalmic) surgery, to name some of the more prevalent specialties.

A typical operating room.

©EBSCO

Modern surgery is a far-ranging practice involving all body structures and systems. It is also a practice that sees constant advancements and improvements in operating techniques, in instrumentation and tools, and in high-tech equipment. Microsurgery, in which the surgeon uses a microscope to view the operating field and manipulates tiny instruments to repair or excise tissue, was virtually unheard of at the middle of the twentieth century. It is now common practice in virtually every surgical facility in the United States. At one time, a severed limb could never be reconnected, largely because it was impossible to repair severed nerves. Now, because of microsurgery, arms, legs, hands, digits, and other severed body parts can be stitched back on to the body, often with much of their mobility restored.

Much minor surgery takes place in the physician’s office or clinic. These procedures are generally simple, involving the excision of skin growths such as warts or cancers, hemorrhoids, and other surface conditions. Emergency surgery in the office, clinic, or emergency room may be necessary to open an airway for a patient whose breathing is impaired or to remove obstructions.

Major surgery usually requires a hospital stay, and its main characteristics are anesthesia and aseptic technique. Anesthesia may be local, regional, or general. For local anesthesia, anesthetic is injected into the site of the operation. The patient is usually fully awake during the surgery but feels no pain in the affected area. In regional anesthesia, a whole part of the body is anesthetized, such as a leg or an arm. As with local anesthesia, the patient is awake during the procedure but may be sedated for comfort. In general anesthesia, the patient is put to sleep and immobilized, usually by injections, and inhaled anesthetics are administered throughout the course of the operation.

To create an aseptic, germ-free environment, the operating room and everything in it are subjected to rigorous sterilization. Surgeons and all operating room staff scrub with antiseptic soaps. They don complete uniforms of sterilized cloth or paper: caps, masks, gowns, gloves, and foot coverings. Avoiding transmission of disease in the operating room can be said to be as important as the operation itself. It is vital that the patient be made safe from infection by the staff and from pathogenic organisms in the ambient atmosphere of the hospital.

It is equally important that staff be protected from infection by the patient. Operating room personnel are particularly vulnerable to blood-borne infections, such as hepatitis B and human immunodeficiency virus (HIV). Surgery can be a bloody procedure. In some operations, copious blood spurts are common, and the likelihood of staff being spattered is high, as is the possibility of disease transmission. It is possible that there will be a cut or tear in the staff ’s protective clothing and that the patient’s blood or other body fluids can make contact with an abrasion on the body or even land on mucous membranes of the mouth, nose, and throat, where they can infect the caregiver. This has happened so often that the U.S. government has issued rigorous guidelines to high-risk health care personnel-particularly operating room staff-detailing specific procedures to follow to avoid disease transmission.

DIAGNOSTIC AND TREATMENT TECHNIQUES

The surgeon is rarely the first physician whom the patient sees. Usually, a primary care physician makes a diagnosis and may confer with or send the patient to a specialist for confirmation of the diagnosis. When surgery is recommended, the surgeon confers with the primary care physician and/or the consulting specialist and is fully apprised of the patient’s condition. He or she reviews the patient’s history and inspects all relevant documents and diagnostic reports, such as X rays, computed tomography (CT) scans, and other information that he or she needs to plan and perform the procedure.

For the most part, surgeons deal with their patients only in the immediate context of the operation. They meet before the operation, and surgeons look in on patients afterward to check their progress and recovery. In some cases, follow-up visits to the surgeon are required.

In the operating room, the surgeon assembles the staff needed for the particular procedure. There will be an anesthesiologist, perhaps other specialized surgeons, and various general and specialized operating room nurses. The surgeon or the staff will also order everything needed for the procedure. There is an enormous range of specialized equipment that surgeons can use in their procedures. Cardiac surgeons use heart-lung machines, which take over the task of circulating the patient’s blood and allow the surgeon to open and enter the heart itself. The neurosurgeon may operate through specialized microscopic instruments.

A catalog of specialized endoscopes is now available to surgeons, many of which allow them to operate through a tiny hole in the patient’s skin, rather than having to make massive cuts with a scalpel. Pulmonary surgeons use a bronchoscope to look down into the patient’s bronchial tubes, where they can perform such surgical operations as removing obstructions and excising cancerous tissue. Gastrointestinal surgeons use a gastroscope both to investigate conditions in the stomach and to take small tissue samples for biopsy. Colon and rectal surgeons use a colonoscope to remove polyps from the colon and rectum, a major step in the prevention and treatment of colon cancer. Major surgery, however, still involves cutting the patient open to repair what has gone wrong inside the body. Fortunately, this procedure is now safer and more specialized than it has ever been before.

Management of disease in the United States has reached the point where there are surgical specialties to cover virtually all parts of the body individually. Some surgeons specialize in individual organs, such as the heart, lungs, brain, eyes, and ears. Some surgeons specialize in body systems such as bones or circulation. Furthermore, many surgeons hone their skills in certain specialized surgical techniques and become so adept that they are recognized as experts in highly complex and critical procedures, such as repairing detached retinas, performing heart transplants, correcting slipped disks, or sealing brain aneurysms.

Surgeons are major inventors and designers. Much of the instrumentation and many of the surgical tools that are used in the operating room were invented by surgeons. They often direct the fabrication of specialized tools and instruments to help them in their work. Most of the metal and plastic prostheses implanted to replace damaged internal structures were designed by surgeons. Orthopedic surgeons design prosthetic hips, knees, and other implants. Ophthalmic surgeons design corneal implants. The specialized surgeon knows his or her area of the body better than anyone else does and can visualize what sort of equipment or device is needed to improve the patient’s condition.

Surgeons are also at the forefront of major technical innovations that reach across the entire surgical field. They are adept at recognizing potential applications for new technology and adapting it to surgery. For example, fiber-optic science has been applied in surgical endoscopes. Cryosurgery, a technique of freezing tissue, is used in a wide range of procedures, from the removal of hemorrhoids to the reattachment of retinas.

Laser technology is employed in hundreds of surgical procedures. The laser is used for making incisions, for repairing tissue, and for excising diseased tissue, among other applications. One of the major areas that can benefit from the unique advantages of laser use is eye surgery. Ophthalmic surgeons use lasers to relieve diabetic retinopathy, glaucoma, macular degeneration, cataracts, and certain tumors, as well as to reattach torn retinas.

One of the critical qualities of the competent surgeon is judgment. No matter how thoroughly a surgeon may prepare for a procedure, there may be some surprises on the operating table. The surgeon learns the patient’s history and status and also reviews all the appropriate diagnostic documents, X rays, and other visualizations, but unforeseen complications may arise during the operation. The surgeon must have the experience and competence to deal with the unexpected.

PERSPECTIVE AND PROSPECTS

Up to the mid-nineteenth century, surgical procedures were probably responsible for as many deaths as cures. Today, surgery extends the lives of millions: heart disease victims, cancer patients, and victims of infection and accidents. Surgery helps improve the quality of life for patients with arthritis and rheumatism, gastrointestinal problems, lung disorders, and circulation problems.

Furthermore, surgery is entering new areas of medicine. For example, operations can now be performed in the uterus to correct anomalies in unborn fetuses. Many more such procedures are predicted for the future.

New areas of surgical expertise are opening constantly; new techniques, instrumentation, and equipment are making many old procedures obsolete. Practicing surgeons face a constant challenge in keeping abreast of what is happening all over the world and deciding what avenues to explore for the benefit of their patients.

See also Abscess drainage; Adrenalectomy; Amputation; Anesthesia; Anesthesiology; Aneurysmectomy; Appendectomy; Biopsy; Bladder removal; Bone marrow transplantation; Breast biopsy; Breast surgery; Bunions; Bypass surgery; Cardiac surgery; Cataract surgery; Catheterization; Cervical procedures; Cesarean section; Cholecystectomy; Cleft lip and palate repair; Colorectal polyp removal; Colorectal surgery; Corneal transplantation; Craniotomy; Cryosurgery; Cyst removal; Disk removal; Ear surgery; Electrocauterization; Endarterectomy; Endometrial biopsy; Eye surgery; Face lift and blepharoplasty; Facial transplantation; Fistula repair; Ganglion removal; Gender reassignment surgery; Gastrectomy; Grafts and grafting; Hair transplantation; Hammertoe correction; Heart transplantation; Heart valve replacement; Heel spur removal; Hemorrhoid banding and removal; Hernia repair; Hypospadias repair and urethroplasty; Hysterectomy; Kidney transplantation; Kneecap removal; Laceration repair; Laminectomy and spinal fusion; Laparoscopy; Laryngectomy; Laser use in surgery; Liposuction; Liver transplantation; Lung surgery; Mastectomy and lumpectomy; Myomectomy; Nail removal; Nasal polyp removal; Nephrectomy; Neurosurgery; Ophthalmology; Oral and maxillofacial surgery; Orthopedic surgery; Parathyroidectomy; Penile implant surgery; Periodontal surgery; Phlebitis; Plastic surgery; Prostate gland removal; Refractive eye surgery; Rhinoplasty and submucous resection; Shunts; Skin lesion removal; Sphincterectomy; Splenectomy; Sterilization; Stone removal; Surgery, pediatric; Surgical procedures; Surgical technologists; Sympathectomy; Tattoo removal; Tendon repair; Testicular surgery; Thoracic surgery; Thyroidectomy; Tonsillectomy and adenoid removal; Tracheostomy; Transfusion; Transplantation; Tumor removal; Ulcer surgery; Vagotomy; Varicose vein removal; Vasectomy.