HISTORY OF SURGERY
There have been evidences that the art and craft of surgery was developed even during prehistoric cultures.
- The human remains of Neolithic times and cave paintings show holes drilled into the skull exposing the dura mater to treat intracranial diseases.
- Early Harappan periods of Indus Valley Civilization (modern day Pakistan) show evidence of teeth being drilled during 3300 BC.
- In ancient Egypt, a mandible shows two perforations just below the root of first molar indicating drainage of tooth abscess during 2650 BC.
- Sushruta was well-known Indian physician who taught and practiced surgery on the banks of Ganges during 600 BC. He wrote volumes of surgical textbooks (Susrutha Samhita) and is known as Father of Surgery. His books described method of examination, diagnosis, treatment and prognosis of various illnesses. He also described detailed operative techniques of plastic and cosmetic surgery.
- In ancient Greece, Hippocrates was the Greek physician who innovated the famous Hippocratic Oath.
- In ancient China, Hua Huo was a famous Chinese physician who was the first to perform surgery with the help of anesthesia.
- In middle ages, surgery was developed in the Islamic world. Abulcasis was a great medieval surgeon who wrote comprehensive textbooks and is often regarded as Father of Surgery.
- In Europe, the surgery became a formal subject and got split away from medicine in 15th century. Rogerius Salernitanus composed the modern surgical manual (Chirurgia) that continued up to modern times. In 19th century, degree of bachelor of surgery (ChB) began to be awarded with bachelor of medicine (MB) that later became MBBS. The master degree became the higher degree and was awarded as master of surgery (MS).
- During World Wars, the battlefield doctors became surgeons by pioneering the treatment of gunshot wounds. Naval surgeons were often barbers doing surgery as an additional job.
The modern surgery progressed at a rapid pace based on three developments:
- Control of bleeding: Before modern surgery developed, there was a real threat of patient bleeding to death during operation. Wound cautery with extreme heat was tried as an effort to control bleeding. But it was destructive, painful and had poor outcome. Concept of ligating the bleeding vessels was given by Abulcasis in 10th century that was much better than cautery. But it was also very dangerous because of high rate of infection caused by ligatures. Later the results of ligatures improved once the concept of infection control came in. In early 20th century, concept of blood grouping allowed effective blood transfusion.
- Control of infection: The concept of infection control was unknown till early modern times. In 1847, Hungarian doctor Ignaz Semmelweis noticed that medical students coming from dissection hall were causing excessive maternal death compared to midwives. He introduced compulsory handwashing for everyone entering the maternal wards leading to significant decrease in maternal and fetal death. However, his advice was dismissed by Royal Society in UK.Later, Joseph Lister, a British surgeon, started using phenol during surgery to prevent infection that quickly reduced the infection rate. He also introduced techniques of instrument sterilization, rigorous handwashing and rubber gloves for surgical procedures. He published his work in The Lancet in 1867 and he was named Father of Antiseptic Surgery.
- Control of pain: In earlier times, surgery was traumatic and very painful procedure. Control of pain or anesthesia was first discovered by two American Dental Surgeons, Horace Wells (1815–1848) and William Morton. With discovery of anesthetic chemicals (ether and chloroform), surgical practice changed dramatically. Later, discovery of muscle relaxants (curare) allowed prolonged and complex surgeries to be performed effectively.
Consequently, other developments that led to the progress of modern day surgery are:
- Development of imaging techniques, like ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan.
- Ultrasound: These are high-frequency waves that are transmitted in beams and are used to scan the body tissues. Different tissues alter the waves in different ways, some reflect while others scatter them. The reflected waves return back to the transducer as echoes and are converted to electrical signals that are displayed on a video monitor. Its advantages are that it is a painless, noninvasive, relatively inexpensive outdoor procedure that does not use any radiations.
- Computed tomography scan: An X-ray tube rotates around the patient who is placed in the center of the scanner. It gives three-dimensional image of the body and delineates various body structures from each other and demonstrates their relationship.
- Magnetic resonance imaging: The patient is placed in a powerful magnetic field with which the protons within the body become aligned. Radiowaves in the form of a radiofrequency pulse transmitted into the patient cause the alignment of the protons to change (e.g. by 90°). When this radiofrequency pulse in turned off, the protons in the patient's body return to their neutral position, emitting their own weak radiosignals which are detected by receiver coils and used to produce an image using powerful computers. The contrast resolution of MRI is 100 times better than CT scan and it does not use any radiations.
- Positron emission tomography scan: PET is a functional imaging modality that detects the disease process in its early phase as metabolic abnormalities that generally precede anatomical changes. It allows imaging of whole body and is valuable in detection of metastatic cancer. F-18 fluoro-2-deoxy-D-glucose is commonly used positron emitting radiopharmaceutical used for PET imaging. Aim is to assess metabolic functions such as oxygen and glucose consumption and blood flow.
- Microvascular and reconstructive surgery: It is aimed at reattachment of severed limbs, digits, or other body parts by plastic surgeons. Modern techniques such as the use of a bone grinder to assist in grafting bone back into place are becoming more common.
- Transplant surgery: In case some vital organ is damaged by disease process (kidney, liver), it is removed and replaced by the same organ retrieved from the human donor (live or cadaver). It involves complex microvascular procedures. Since transplanted organ is a foreign element to the body, it is likely to be rejected by autoimmune response. Its rejection is prevented by use of immunosuppressive drugs. Once the transplant is taken up, the patient is able to lead near normal life.
- Development of minimal access surgery: It is a technique that helps in performing surgical procedures with less invasion, less disfigurement, less postoperative pain and early recovery of the patient. With increasing experience, surgeons are becoming experts in performing major surgical procedures with minimal access surgery.
Various minimal access techniques are:
- Laparoscopic surgery: The peritoneal cavity is inflated with carbon dioxide to produce pneumoperitoneum. A telescope is then introduced to visualize the inside of peritoneal cavity by projecting the image on a television screen (video-assisted surgery). Various instruments are then introduced into peritoneal cavity through various ports in abdominal wall to perform the surgical procedures, e.g. laparoscopic cholecystectomy, hernia repair.
- Thoracoscopic surgery: The thoracic cavity is entered in the same way (as laparoscopy) to perform various procedures in the thoracic cavity.
- Endoscopy: Flexible tubes are introduced into hollow organs (esophagus, colon, urinary bladder) through natural orifices for visualization of internal pathologies and their management. ENT surgeons perform minimal access surgery on ear and paranasal sinuses using small flexible endoscopes.
- Arthroscopy: Visualization of inside of joint spaces, e.g. knee joint.
- Endoscopic brain surgery: Flexible endoscope and fine instruments are introduced into cranial cavity through small holes in the skull to perform surgery on intracranial lesions.
- Endoscopic thyroidectomy: Small incisions are made on the chest wall, and thyroidectomy is done using laparoscopic instruments. Its advantage is that it avoids neck scar and is cosmetically better in young females.
- Natural orifice transluminal endoscopic surgery: In this new concept meant for avoiding skin incision for surgery, a flexible endoscope is introduced through natural orifices (oral cavity, anal canal, vagina, etc.). Then an abdominal viscus (stomach, rectum, etc.) is transgressed to enter into peritoneal cavity. With the help of video-assisted surgery, operation is performed, e.g. appendicectomy or cholecystectomy and the specimen is removed through the viscus (e.g. stomach).
- Robotic surgery: In place of surgeon's hands, robot is used for performing a surgical procedure. The surgeon sits on a computer console and gives command to the robot for performing various surgical steps. Its advantages are:
- The movements are precise and free from tremors giving high accuracy in sensitive areas.
- Dexterity of movements, i.e. unlike human hands, the robot can move the instruments up to 360.
It helps in performing surgical procedures in great depth even when space for the movements is restricted.
- Telemedicine: With use of Internet in medical sciences, it has further improved surgical teaching and training. The surgical procedure performed at one place can be telecast live at any other place through video conferencing while operating surgeon interacts with the audience. This technique is becoming very popular and is being widely used in live operative workshops meant for training young surgeons.
- Newer energy sources: Apart from use of high-quality electrocautery (monopolar or bipolar), newer energy sources have been devised for precise tissue cutting as well as coagulation, e.g. lasers, high-frequency ultrasonic waves, harmonic scalpel, etc. (see Chapter 20). These energy sources have made the minimal access endoscopic surgery very safe and simple.
DEALING WITH A SURGICAL PATIENT
Out of all medical disciplines, surgery is a unique specialty where surgeon, who is primarily a doctor, treats the disease using surgical instruments.
The stages through which a surgical patient passes are described as surgical crescendo. These are:
- History taking
- Clinical examination
- Making clinical diagnosis and keeping possibilities of various differential diagnoses
- Making final diagnosis
- Sometimes diagnosis is still not made even after exploration. In such situation, either nature cures the disease and diagnosis is never made or the patient dies and postmortem reveals the exact pathology.
A surgical patient coming to the hospital can be:
- Elective case
- Emergency case.
Elective case reports in the surgical outdoor during routine hours where diagnosis of disease is made. Then he is admitted in indoor and operation is performed (Flowchart 1).
Emergency case reports in the casualty at any time and is managed in a different way. After quick history and examination, resuscitation is started.
Performing investigations and reaching the final diagnosis is considered only after the patient is stabilized. If patient remains unstable despite resuscitation, then emergency surgery is planned (Flowchart 2).
It is very important to do repeated clinical examination in emergency because it helps in delineating the ongoing changes and reaching the diagnosis.
Thus, it is apparent that actual operation is only a part of total surgical care. Equally important are making diagnosis, preoperative build up and postoperative management. If diagnosis is incorrect, it may lead to improper surgery and patient may not have any benefit from it.
Inadequate preoperative build up can lead to intraoperative and postoperative complications and mortality. Similarly, lack of postoperative care can lead to serious postoperative complications like hypostatic pneumonia, deep vein thrombosis, wound sepsis, etc.
History taken in outdoor or emergency relates to the specific complaints of patient so as to reach the diagnosis.
On the other hand, history taken in the indoor for admitted patient has two objectives:
- To reach the clinical diagnosis
- To look for fitness of patient for surgery.
“Symptoms” are the complaints told by the patient while “signs” are the features seen by the clinician on clinical examination.
Before asking “symptoms”, background of the patient is recorded that includes:
- Marital status
Then symptoms are asked and recorded preferably in patients own words and in “chronological order” of their appearance.
History of Present Illness
Duration of illness: It is very important to ask “When were you perfectly well before the present illness”? The patient is likely to tell about mild episodes of similar illness in the past which otherwise he may ignore to mention. However, in reality, it may be of great importance in making the diagnosis.
Mode of onset: How the illness started, e.g. a swelling appearing on scalp after trauma is likely to be a hematoma.
Progress: Whether illness is improving or worsening, e.g. an inflammatory pathology is likely to improve with analgesics and anti-inflammatory drugs.
Aggravating and relieving factors: For example, an inflammatory pathology is likely to be aggravated with movement of the part and relieved with rest and analgesics.
Constitutional symptoms: These are those which occur secondary to the illness, e.g. pain, fever, cough, nausea, vomiting, weight loss, anorexia.
Past history: Any illness suffered in the past is recorded in chronological order. It may or may not be related to present illness. Past dental history is asked that includes history of dental extraction, scaling, root canal treatment, any implants or prosthetic appliances.
Personal history: Smoking, dietary habits, alcoholism are enquired. Marital status of the patient is asked and if married, number of children and their health is recorded. If some child has died, age and cause of death is noted.
Menstrual history: It is asked in female patients. Age at menarche, any menstrual irregularity, vaginal discharge, age at menopause, postmenopausal bleeding, etc. are recorded.
Family history: Whether any family member has suffered from similar illness. It can help in finding out genetic disorders (hemophilia) and communicable diseases (tuberculosis).
Treatment history: Any treatment taken and its effect on illness may help in reaching the diagnosis, e.g. a neck swelling improved with tablet eltroxin will suggest goiter. Any history of drug allergy and previous operations is also recorded.
General Physical Examination
Make the patient sit or lie in the bed comfortably.
Examine the patient with warm hands.
- General appearance, viz.
- Level of consciousness (decreased in head injury).
- Patient cooperative or uncooperative.
- Build (assessed by skeletal framework). Skeletal deformities may be seen on exposure (Fig. 1).
- Nourishment (assessed by triceps skin fold thickness, subcutaneous fat, skin texture, muscle mass).
- Pulse rate (normal 72/min), regularity, volume.
- Blood pressure (normal 120/80 mm Hg).
- Temperature (normal 37°C).
- Respiratory rate (normal 12–16/min), regularity, type (abdominal or thoracic).Look for various clinical signs from head to toe:
- Anemia in palpebral conjunctiva, nail beds, tongue (areas rich in capillaries).
- Cyanosis: Bluish discoloration of tongue (central cyanosis), bluish discoloration of tip of nose, fingers (peripheral cyanosis).
- Clubbing: Drumstick appearance of fingers and toes (Fig. 4).
- Platonychia: Flat nails seen in iron deficiency anemia (Fig. 5).
- Edema feet: Apply pressure with thumb for 10–15 seconds on the shin or ankle. Sign is positive if pit is produced at the site of pressure and remains for more than 30 seconds (Fig. 6). Edema gives rise to soft pitting while if pus is present, induration is always felt.
- Side of the lesion (right or left) should always be recorded carefully.
- A few simple instruments are necessary as “armamentarium” during patient examination. There are:
- Pocket torch
- Black paper
- Tongue depressor
- Metal scale
- Measuring tape
- Disposable gloves
- Skin marking pen
- While examining a lesion, be particular in noting its site, external appearance, possible anatomical organ of origin and its effects on surrounding structures.
- The lesion may present as swelling, ulcer, sinus or fistula. Their details of examination are described in the relevant sections.
- Always examine the lymph nodes draining the site of lesion.
Local Examination for Orodental Diseases
- Facial symmetry
- Symmetry of soft tissue movement: It is used for assessment of motor functions of cranial nerves, e.g.
- Movement of facial muscles: Facial nerve.
- Ocular muscle movement: 3rd, 4th and 6th cranial nerves.
- Symmetry of hard tissue movement: It is assessed by opening and closing of mouth.
- Facial profile and facial proportions
- Skull forms
- Skin and soft tissues: Eyes, ears, nose, lips.
- Temporomandibular joint examination
- Lymph node examination
- Salivary gland examination.
- Jaw movement and mouth opening
- Teeth (number, size, color, caries, missing teeth, occlusion)
- Gingiva (size, shape, color, ulceration, growth)
- Alveolar mucosa
- Labial mucosa
- Bucccal mucosa
- Palate (soft and hard palate) and fauces (tonsils)
- Uvula, posterior pharyngeal wall
- Floor of mouth.
The aim is to know the patient as a whole. During this, some other pathology related or unrelated to presenting disease may be discovered.
Various systems examined are:
- Cardiovascular system
- Central nervous system
- Respiratory system (chest)
- Gastrointestinal tract (abdomen)
On the basis of history and examination, a clinical diagnosis is made. Aim is to localize the organ of origin, type of pathological process and its extent.
Pathological diseases are broadly classified as:
- Inflammatory (acute or chronic)
- Neoplastic (benign or malignant)
Other rare ones are:
- Degenerative diseases
- Metabolic diseases
- Hormonal diseases.
In case, the diagnosis is doubtful, other possibilities are kept as differential diagnosis, starting with most probable diagnosis as first. Based on “law of probability”, commonly seen disease should be kept as first possibility.
Aims of doing investigations are:
- To reach final diagnosis
- To look for fitness for anesthesia and surgery
- In case of malignancy, staging of disease so as to plan treatment and assess prognosis.
Various investigations are decided according to the site and nature of pathology. These are:
- Hematological investigations
- Hemoglobin—for anemia
- Bleeding time, clotting time—for bleeding disorders
- Total and differential leukocyte count—raised in infections
- Erythrocyte sedimentation rate—raised in chronic infections
- Blood sugar—raised in diabetes
- Blood urea and serum creatinine—raised in renal failure
- Thyroid function tests—in case of thyroid pathology
- Liver function tests—deranged in liver dysfunction.
- Urine examination: For albumin, sugar and microscopy.
- Stool examination: For ova, cyst, pus cells, occult blood.
- X-ray—for bony changes and fractures
- Ultrasound—differentiates solid and cystic lesions
- Doppler imaging—for blood flow
- CT scan with contrast enhancement—for solid organs
- MRI—for joints and spine.
- Fine-needle aspiration cytology
- Tissue biopsy
- USG/CT-guided biopsy—helpful in localizing the site of lesion especially if it is deep seated.
MANAGEMENT OF UNFIT PATIENT
- The patient should be hospitalized and built up for surgery.
- In case of severe anemia, fresh blood transfusions are given to improve hemoglobin. The patient should have hemoglobin level of 10 g% at the time of surgery.
- In case of severe hypoproteinemia (serum albumin less than 2 g%), parenteral nutrition should be given.
- In uncontrolled diabetes, insulin injections are given.
- In patients with chronic lung disease, preoperative preparation helps in preventing postoperative respiratory complications. Measures taken are:
- Smoking cessation
- Chest physiotherapy
- Antibiotics (for purulent sputum)
- Uncontrolled hypertension is treated with antihypertensive drugs.
RISK ASSESSMENT OF THE SURGERY
Before subjecting the patient to surgery, always put following questions to yourself:
- What is the risk of surgery?
- Whether patient will benefit from the operation?
Based on risk-benefit ratio, the patient should be counseled and written consent should be obtained from him before performing the operation.