Surgery

Summary

Surgery involves penetration of the body with specialized instruments to examine, repair, remove, or replace internal structures. General practitioners and specialists in a variety of fields perform surgical procedures ranging from simple to complex. For example, a dermatologist may excise a small growth on the skin and a cardiothoracic surgeon may perform a heart transplant. Some specialties (such as general surgery and neurosurgery) focus primarily on surgical procedures and preoperative and postoperative care; others (such as ophthalmology and gynecology) include surgery as part of a treatment plan. Surgery can be performed directly through incision into a body area or indirectly through instruments known as endoscopes.

Definition and Basic Principles

Surgical procedures are usually classified by the type of procedure (such as laparotomy or laparoscopy), the urgency (for example, emergency or elective), the body area involved, any special instrumentation used (such as microsurgery or laser surgery), and degree of invasiveness. Superficial surgery takes place near the surface of the skin (such as removal of a wart) and minimally invasive surgery is accomplished through small skin incisions; in invasive surgery, the physician makes incisions and works with instruments or devices inside the body. A common type of minimally invasive surgery is laparoscopy, originally used by gynecologists to view pelvic structures and perform simple procedures such as cauterizing the Fallopian tubes for sterilization. Later, gynecologists used laparoscopy for more complex procedures such as hysterectomies, and the procedures began to be used by physicians in other specialties. For example, the laparoscope is used by urologists to perform nephrectomies (kidney removals) and by general surgeons to perform cholecystectomies (gallbladder removals).

The basic principles of surgery are the use of aseptic technique, exposure, hemostasis, and closure. Aseptic techniques maintain sterility. For example, surgeons scrub their hands and don sterile gloves for surgery. The operative field is cleansed with a strong antiseptic, and great care is taken to prevent any contamination of the area. Exposure involves making an incision in the skin and manipulating internal structures with retractors and other instruments to view the area needing attention. Hemostasis, or controlling bleeding, is accomplished with sutures and electric coagulation (cauterizing) of bleeding areas. Closure involves removing any instruments used during surgery and closing the tissue layers. All surgery requires some form of anesthesia. Minor procedures on the skin can be accomplished with a local anesthetic. More involved procedures require a general or regional anesthetic. General anesthesia involves rendering a patient unconscious by administering an anesthetic drug. Regional anesthesia involves administering an anesthetic agent to nerves supplying a body area, so that the patient does not feel pain in that area. Examples of regional anesthesia are spinal and epidural anesthetics.

Background and History

Surgery has been performed since prehistoric times. Human skulls from the Neolithic era show evidence of trepanation, a procedure that involved drilling or scraping a hole in the skull. The purpose of trepanation is unknown; however, evidence exists that many of the individuals survived the procedure. Written evidence of surgery has been found on a 3,500-year-old papyrus in ancient Egypt. Surgery was performed by priests who specialized in medical treatment. Other ancient civilizations that had surgical knowledge were China, India, and Greece. In ancient Greece, citizens could obtain medical advice and treatment at temples dedicated to Asclepius, the god of medicine and healing. In the first century, the Greek physician Galen performed a number of complex surgical procedures including brain and eye surgery. In China, Hua Tuo, a Chinese physician during the Tan Dynasty (221 to 206 b.c.e.) performed surgery with a rudimentary form of anesthesia. After the fall of the Roman Empire, surgery declined in the West; however, it continued to survive and develop in the Middle East.

In medieval Europe (fifth through fifteenth centuries), surgery was often performed by barbers. These individuals cut hair, pulled teeth, and performed simple operations such as setting bones and amputations. In the twelfth and thirteenth centuries, surgical techniques were revived in the West. Surgical training was offered at universities at Montpellier, Padua, and Bologna. In the late nineteenth century, London universities began offering a bachelor of surgery degree (ChB).

How It Works

Most surgeons have had specialty training in a surgical field; however, some family practitioners perform minor surgical procedures or assist surgeons in a hospital operating room. A general surgeon performs a wide range of procedures, primarily in the abdominal cavity (such as hernia repair and appendectomy). General surgeons also commonly operate on the breast. Some specialists, including plastic surgeons, begin their training in general surgery before being trained in procedures specific to their specialty. Cardiothoracic surgeons perform surgery involving the chest cavity (heart and lungs), while neurosurgeons specialize in brain and spinal surgery. Urologists specialize in surgeries of the bladder, kidney, and ureters (tubes connecting the kidneys to the bladder), and orthopedic surgeons perform surgery that involves the bones, joints, and muscles. Some surgeons further specialize within their field. For example, orthopedic surgeons might limit their practice to a specific body area such as the hand or hip. Some surgeons specialize in oncology, usually concentrating on specific types of cancer. For example, a gynecologic oncologist will operate on cancerous tumors of the female reproductive system.

Most surgeons have patients referred to them from other physicians. These physicians are often internists, family practitioners, or emergency room physicians; however, they can be other specialists. Surgeons may see patients in their offices, the emergency department, or the hospital bedside. Surgeons, especially specialists, are sometimes called to operating rooms when something requiring their expertise is encountered. When a patient visits a surgeon's office, the surgeon takes a medical history, performs a physical examination, and orders any necessary laboratory tests and X-rays or other imaging studies. If surgery is determined to be the best option, the surgeon performs the procedure and provides postoperative care. Once the patient has recovered sufficiently, generally the patient's primary care provider provides followup care. In some cases, the followup care can last for months or years and may require further visits to the surgeon and additional surgery. Obstetricians/gynecologists perform surgery such as cesarean sections and hysterectomies and also provide long-term care to their patients. Most surgeons are in group practice with other surgeons or a multispecialty group.

If at all possible, a patient must be apprised of the risks and benefits of a surgical procedure and give written consent. Consent may also be given by a parent in the case of a minor child or by a family member if the patient is unable to give consent (as with an unconscious or comatose person). If time permits, the patient has the option of obtaining a second opinion from another surgeon.

Not all surgery is performed in a hospital operating room. Some is performed in outpatient surgery centers, and simple procedures can be carried out in the surgeon's office. Many inpatient surgeries require an assistant surgeon. This individual is often a surgeon with comparable training or training in another specialty. For example, a gynecologist and a urologist might join forces for a complex bladder repair procedure in which expertise in both specialties is necessary.

An inpatient procedure requires a surgical team made up of the surgeon, assistant surgeon, anesthesiologist, scrub nurse, and circulating nurse. The anesthesiologist administers the anesthetic and monitors the patient's vital signs. The surgeon, assistant surgeon, and anesthesiologist communicate with one another during the procedure. The scrub nurse is positioned at the operating table with the two surgeons and hands off instruments, sutures, swabs, and other material during the procedure. They may be asked to participate directly in the procedure (for example, to hold a retractor). The circulating nurse brings requested material (such as a particular instrument, a unit of blood, or medication) to the operating table. Other personnel may be present for more complicated procedures. For example, a heart procedure requiring a heart-lung machine will require technicians to run and monitor the equipment.

Applications and Products

Since the mid-twentieth century, technology in the surgical arena has developed markedly. Technological advances in endoscopy—laparoscopy (abdomen), cystoscopy (bladder), hysteroscopy (uterus), and arthroscopy (joints)—have resulted in dramatic changes in patient care. Endoscopy has replaced traditional methods in many procedures. Many medical products have been designed for endoscopy and other surgical procedures. In addition, robotics have been developed to assist in endoscopic surgical procedures.

Laparoscopy. In laparoscopy, a needle is inserted into the abdominal cavity and the abdominal cavity is insufflated (filled) with carbon dioxide gas. This makes it possible to see abdominal organs with a small viewing instrument (laparoscope). One or more additional incisions are made to insert specialized instruments for grasping, cutting, and suturing internal organs. Gynecologists use laparoscopy to accomplish complex tasks such as removing fibroid tumors from the uterus and performing complete hysterectomies. General surgeons perform appendectomies with the laparoscope. The advantage of laparoscopic surgery is that the recovery time can be much less because the small incisions are much less painful. However, if complications arise, they are more difficult to control via the laparoscope and can result in serious consequences, even death. For example, if a hemorrhage occurs, visualization is lost and an immediate incision must be made to control it. Surgeons had to use eyepieces to view their work with the early laparoscopes, but video cameras were incorporated into the laparoscopes, and surgeons and all members of the surgical team can see the surgical area on a monitor. This not only increased the surgeons' comfort but also allowed the entire surgical team to watch and monitor the procedure.

Cystoscopy. Urologists and urogynecologists (gynecologists who specialize in the female urinary tract) perform cystoscopy, which involves passing an instrument (cystoscope) into the bladder to view its inner surface. The procedure also can visualize the opening of the ureters. If necessary, a urethroscope can be passed into the ureters and up into the kidney. This procedure can be used to remove bladder tumors or resect (reduce the size of) the prostate gland.

Hysteroscopy. In hysteroscopy, a hysteroscope is passed through the cervix into the uterus for viewing the endometrial cavity (uterine interior) and taking a biopsy of the uterine lining. The procedure can be used to remove fibroid tumors, polyps, and uterine abnormalities such as a septum (wall) in order to correct infertility problems. A small flexible video lens can be passed into the Fallopian tubes for viewing problems inside them and removing scar tissue.

Arthroscopy. Orthopedic surgeons use the arthroscope to view the interior of joints. As with other endoscopic procedures, abnormalities can be visualized and sometimes repaired. For example, a torn ligament can be rejoined using arthroscopy. Almost every joint in the human body can be examined with the arthroscope. The most common joints visualized are the knee, hip, ankle, foot, and shoulder.

Robotics. Robotic surgery is increasingly being used with endoscopes for a variety of surgeries, including cardiothoracic surgery, gastrointestinal surgery, gynecologic surgery, neurosurgery, pediatric surgery, and urologic surgery. Robotic surgery allows for superior visualization, precise manipulation, and improved dexterity. A commonly used robotic system is the da Vinci System. It consists of a console and a patient side cart with four arms controlled from the console. Three of the robotic arms hold and manipulate surgical instruments. The fourth arm is an endoscopic camera, which can visualize the surgical area in three dimensions. The surgeon sits comfortably at the console and manipulates the three arms with hand and foot pedals. The system allows the surgeon to make small, precise movements, which are beyond the capabilities and range of motion of the human arm and wrist.

Invasive Radiology. A rapidly evolving medical field is invasive radiology, which has replaced many complicated and difficult surgical procedures. Traditionally, the radiologist reviewed X-ray images to diagnose medical conditions. The invasive radiologist uses X-ray images or ultrasound to thread catheters inside the body to perform many surgical procedures. The procedures can be divided into three groups: neuroradiology procedures, vascular radiology procedures other than those that involve the brain and spinal cord, and nonvascular radiology procedures. Invasive neuroradiology procedures involve the brain and spinal cord. For example, to treat a brain aneurysm (weakened, dilated blood vessel that can rupture), special plugs are passed through blood vessels entering the brain and placed to seal off the weakened blood vessel. Invasive vascular radiology of other body areas involves either opening or closing a blood vessel. For example, a stent (tube) can be passed into a coronary artery to unblock it. Invasive nonvascular radiology involves passage of an instrument into the body cavity to obtain a biopsy. For example, an instrument may be passed through the chest wall into the lung to obtain a tissue sample.

Cutting Tissue. A surgeon in the mid-twentieth century almost exclusively used the scalpel for surgical procedure. Scalpels are small, sharp knife blades, which are fashioned in a variety of shapes. Since that time, a variety of devices have been developed for cutting tissue. These include electric current devices, which cut and cauterize tissue simultaneously; laser devices, which cut through a focused light beam; and the harmonic scalpel, in which ultrasound produces a vibration that can cut tissue.

Careers and Course Work

Students interested in pursuing careers as surgeons must first graduate from a four-year college. Students usually major in one of the sciences, such as biology, but whatever the choice of major, they must fulfill the course requirements for medical school. The next requirement is a medical degree from a four-year medical school, followed by an internship and residency program for specialty training. Surgeons complete a general surgery training program, and some continue training in a surgical specialty. Most surgeons take written and oral examinations to become certified in their specialty.

A variety of career opportunities await the surgeon. The surgeon can enter private practice, which usually entails joining the practice of an established physician or group of physicians. These physician groups may consist solely of surgeons or contain specialists in a variety of fields. Physicians in larger groups can benefit from the sharing of equipment and other resources, and they can assist one another with weekend and night calls. Larger groups often employ physician assistants and nurse practitioners to handle less complex problems. Surgeons can also enter a career in academia, where they engage in medical research and train medical students and resident physicians. A career as a surgeon is very demanding profession, but it also carries significant financial rewards. Salaries vary widely depending on the type of surgery and expertise of the surgeon, but, according to the US Bureau of Labor Statistics, the median salary for a surgeon or physician in 2020 averaged more than $208,000 a year. The Bureau of Labor Statistics reported that more than 727,000 people were employed as a physician or surgeon in 2020, although it did not break the data into specific categories.

Social Context and Future Prospects

Surgery continues to play a major role in medical treatment. Surgical techniques and equipment continue to undergo research and development. Surgical research involves finding better techniques to repair injuries or remove diseased tissues, discovering devices that enable these body parts to regain or maintain function, and developing means to replace body parts that cannot be repaired. Surgeons will be involved in both the research behind and the implementation of new developments. Areas that are the focus of research include endoscopy (laparoscopy, hysteroscopy, arthroscopy, and cystoscopy) and its associated robotics, invasive radiology, implants, artificial organs, and organ transplantation.

Techniques for minimally invasive surgery have shortened recovery time and will continue to be refined and improved. To deal with failing body parts, researchers have developed devices such as artificial heart valves and heart assistance devices (pacemakers), although not an artificial heart. Organ transplant research involves not only surgical techniques but also pharmaceuticals and other ways to reduce rejection of the transplanted organ. Considerable research has been conducted in stem cells, which many scientists believe may someday enable a person to grow a new heart or kidney to replace a defective one. In the meantime, research has developed equipment that can take on the function of the lungs, heart, and kidneys, if for a limited period of time, and these devices will continue to evolve.

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