Surgery - information and types

Surgery is the specialty within the practice of medicine in which its practitioners use instruments, devices, and techniques to repair or remove organs and structures affected by congenital defect, injury, or disease processes. Surgical operations are invasive—that is, they enter or open the body in some way.

Two health-care disciplines merge within the arena of surgical operations: ANESTHESIA and surgery. Physicians who administer anesthesia are anesthesiologists (MDs or DOs). Registered nurses who have advanced practice education and certification in anesthesiology are certified registered nurse anesthetists (CRNAs). Anesthesiologists may also choose to further specialize in PAIN management care.

Physicians who perform surgical operations are surgeons, with further designation according to the surgeon’s subspecialization. For example, a surgeon who operates exclusively on structures of the chest except the HEART is a thoracic surgeon; a surgeon who operates exclusively on the heart is a cardiac surgeon. A surgeon who operates exclusively on bones and joints is an orthopedic surgeon.

This section, “Surgery,” presents an overview discussion of the concepts and practices of surgery and general entries about surgical operations and their role in diagnosis and treatment of diseases, congenital anomalies, and injuries. Entries about specific operations are in the sections that discuss the relevant body system—for example, the entry for HYSTERECTOMY (an OPERATION to remove the UTERUS) is in the section “The Reproductive System” and the entry for CHOLECYSTECTOMY (an operation to remove the GALLBLADDER) is in the section “The Gastrointestinal System.”

Surgery Comes of Age

Early documents from diverse cultures provide evidence that surgery—entering the body for therapeutic purposes—has long been among the treatment options of physicians. Ancient Ayurvedic physicians extracted cataracts, amputated limbs, delivered babies by CESAREAN SECTION, drained pus from infected wounds, removed bladder stones, and even performed what plastic surgeons today call pedicle flap tissue grafts to repair damaged noses. Greek physicians operated on soldiers to repair battle wounds. In Babylonia and Egypt surgeons were distinct from physicians, with clearly defined duties and responsibilities.

Toward the end of the 19th century vastly improved understanding of anatomy (the body’s structure) and physiology (the body’s functions) encouraged physicians to explore the intentional opening of the body to remove tumors and repair damage such as from injury or disease. Nearly all of the misconceptions perpetuated through centuries evaporated in the evidence researchers acquired through scientific study and dissection of human cadavers. Surgeons boldly ventured into new territory: the inner body. Unfortunately, though surgeons had the knowledge their patients were less than eager to allow its display. Few willingly submitted to the scalpel when the only escape from pain was a fortuitously well-placed upper right to the jaw that delivered UNCONSCIOUSNESS. As well, more people died of INFECTION after surgery than recovered from the operation.

But in the 20th century two advances in medicine converged to make surgery feasible: antisepsis and anesthesia. As a result of these two crucial developments, today surgery is the treatment of first choice for numerous health circumstances. Surgical operations can restore and improve function, improve appearance, repair the damage of traumatic injury, replace dysfunctional organs and structures, remove tumors and infected tissue, and correct potentially life-threatening congenital anomalies. Surgeons in the United States perform more than 25 million operations a year.

Anesthesia: Making Surgery Painless

Until the middle of the 19th century surgery was a treatment of last resort, chosen only when the only alternative was certain death. The most effective, albeit unpredictable, anesthesia was a surprise uppercut punch to the jaw that could render a person unconscious long enough for a fast surgeon to complete an operation such as extraction of a bullet or AMPUTATION of a limb. ALCOHOL and opium were the drugs of choice for postoperative pain relief.

The first effective anesthetic agent was ether, administered by having the person breathe fumes as they evaporated from a saturated cloth. Though chemists had compounded ether (sulfuric acid distilled in alcohol) since the 13th century and explored it as a solvent and a sedative for centuries, its properties as an anesthetic did not become known until chemistry students in the early 1800s began using it for entertainment at parties. Their instructors observed that the more ether a person inhaled, the more impervious he or she was to pain. But not until the middle of the century did surgeons begin to explore using ether to intentionally intoxicate an individual to create a state of unconsciousness. In 1842 American physician Crawford Long (1815–1878) used ether to anesthetize a friend, then surgically removed several cysts from the friend’s neck. The friend felt no pain and had no memory of the surgery.

Discoveries of similar properties for chloroform and nitrous oxide rapidly expanded anesthesia options. These substances were more effective and less noxious than ether and soon displaced it for operations and dental procedures. Over the latter decades of the 19th century surgeons refined the mechanisms for delivery of anesthetic agents to provide relatively predictable and safe anesthesia during surgery. In the 1880s surgeons experimenting with controlled delivery of anesthetic agents had developed valve-controlled inhalers and the precursor of the endotracheal tube, a tube inserted into the trachea with an air-filled cuff on the end to hold it in place and seal the trachea. By 1930 endotracheal intubation had become the standard method for administering inhalation anesthesia, as it remains today.

Modern anesthetic agents are faster acting, more specific in the effects they achieve, and much safer than their predecessors. Though unpleasant side effects remain possible, anesthesia for most people accomplishes precisely and only the intended purpose. Anesthesiologists and certified nurse anesthetists (physicians and registered nurses, respectively) who specialize in the delivery of anesthesia, carefully administer anesthesia tailored to each individual patient’s needs and health circumstances.

Antisepsis: Making Surgery Safe

Though surgeons knew all too well the high rate of death after surgery, it was an obstetrician rather than a surgeon who made the connection between antisepsis and death rates among patients. Hungarian physician Ignaz Philipp Semmelweis (1818–1865) noticed that the death rate in the maternity ward was much higher among women cared for by doctors than by midwives. His investigation led him to recognize that doctors often went directly from performing autopsies (procedures in which midwives had no role) to delivering babies. In 1846 Semmelweis implemented procedures for doctors to wash their hands with chlorinated lime before examining obstetrical patients, and maternal death rates from childbirth FEVER (puerperal fever) plummeted.

It was 20 years later that Louis Pasteur (1822–1895) and Joseph Lister (1827–1912) proved the connection between microscopic “germs” and illnesses such as infection, and by the 1870s antisepsis was the standard of practice not only for childbirth but also for surgery and other treatment modalities. Today surgeons and other members of the surgical team follow stringent HAND WASHING (scrubbing) procedures, and wear sterile gowns and gloves in the operating room. The widespread use of ANTIBIOTIC MEDICATIONS has further reduced the risk for postoperative infection.

The Surgery Team

A typical surgery team today includes the

• primary surgeon
• assisting surgeon or physician assistant; may be several depending on the type of operation
• scrub nurse or surgery technician (also called surgical technologist)
• circulating nurse
• anesthesiologist or certified nurse anesthetist
• perfusionist for certain surgeries

Breakthrough Research and Surgical Advances

The last half of the 20th century saw surgery surge to the forefront of treatment options for numerous health conditions, revolutionizing care as well as survival for heart disease, cancer, CONGENITAL ANOMALY, and major trauma. OPEN HEART SURGERY and ORGAN TRANSPLANTATION are now conventional treatment options. Among the most exciting advances in surgery in recent years has been the evolution of MINIMALLY INVASIVE SURGERY, operations that use tiny video cameras to display the operative site on a monitor similar to a television screen. The surgeon operates using the display for visual guidance, much like a sophisticated video game. Through small incisions, called ports, the surgeon inserts tiny instruments. Minimally invasive surgery reduces the need for large, open incisions, decreasing patient discomfort and recovery time. Operations that were once major ordeals have become fairly minor procedures. Surgeons look forward to a future in which minimally invasive surgery becomes the standard for nearly all kinds of operations.