Surgery



Editor-In-Chief: Niral Shah, M.D. [mailto:nashah@bidmc.harvard.edu]

Overview
In medicine, surgery (from the Greek χειρουργική and latin chirurgiae meaning "hand work") is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, or sometimes for some other reason. An act of performing surgery may be called a surgical procedure, operation, or simply surgery. In this context, the verb operating means performing surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments or surgical nurse. The patient or subject that the surgery is being performed on can be a person or an animal. A surgeon is a person who performs surgery on patients. Persons described as surgeons are commonly medical practitioners, but the term is also applied to dentists and veterinarians. Surgery can last from minutes to hours, but is typically not an ongoing or periodic type of treatment.

The term surgery can also refer to the place where surgery is performed, or simply the office of a physician, dentist, or veterinarian.

Overview of modern surgery
Although it is sometimes difficult to determine when a medical procedure is considered surgery, a medical treatment that involves a cutting of a patient's live tissue (e.g., hair and nails are dead tissue) is usually considered surgery of some sort. A medical procedure involving a drilling of live tissue in a body would often be considered surgery, but mere piercing of a body is not necessarily surgery since piercing is often done for taking samples or draining fluids from or injecting materials into the body, or setting up intravenous drip, and usually does not require suturing to close the pierced opening. Even if a medical procedure or treatment does not include cutting or drilling of live tissue in a body, it may be considered surgery, if it involves common surgical procedure or a setting, such as use of an operating room or table in a hospital, anesthesia, antiseptic conditions, typical surgical instruments, and suturing or stapling. Surgery is considered an invasive procedure. Examples of surgery without cutting the body may include debridement or closing (suturing or stapling) an open wound or applying skin grafts if done under typical surgical conditions. Many types of more complicated or involved surgery are obviously considered surgery, since they involve common surgical procedure or setting as mentioned above. A medical procedure may be surgery even if not all of the typical surgical conditions or procedures mentioned above are used.

A few general types of surgery
Surgery can be categorized in many ways, a few of which are mentioned as follows. Some surgery may be required to save the life of a patient. Elective surgery is surgery not needed to save the life of the patient, but is expected to provide some other benefit. Emergency surgery is surgery which must be done quickly to save life, limb, or other capacity such as eyesight. Exploratory surgery is for investigating a patient's medical condition or making a diagnosis. Therapeutic surgery is for treating a patient. Surgery may start out as exploratory and become therapeutic. Amputation involves cutting off a body part; for example, a limb or digit. Replantation, an often difficult type of surgery more recently developed, involves reattaching a severed body part. Reconstructive surgery involves reconstruction of an injured, mutilated, or deformed part of the body. Reconstructive surgery is for reshaping of certain bodily tissues including bone, cartilage, muscle, fat, and skin that have been previously damanged by trauma or are congenitally abnormal. Cosmetic surgery, a common type of elective surgery that is done to improve the appearance of the patient. Excision is the cutting out of an organ or other body part from the patient. Transplant surgery is the replacement of an organ or body part by insertion of another from different human (or animal) into the patient. Removing an organ or body part from a live human or animal for use in transplant is also a type of surgery. Minimally invasive surgery involves smaller outer incision(s) to insert some sort of endoscope, which is tube-like equipment, to perform surgery. There are also many types of more specific surgeries. Laser surgery involves use of a laser for cutting tissue instead of a scalpel or similar surgical instruments. Microsurgery is fine surgery with the aid of a microscope for the surgeon to see better. Bariatric surgery is a class of surgery for treating obesity, a common example of which is gastric bypass surgery. Surgery is also used for sterilization to prevent reproduction, although it is a rather simple procedure for males.

Suffixes used for some surgical procedures:


 * Excision surgery names often start with a name for the organ to be excised (cut out) and end in -ectomy.
 * Procedures involving cutting into an organ or tissue end in -otomy. A surgical procedure cutting through the abdominal wall to gain access to the abdominal cavity is a laparotomy.
 * Minimally invasive procedures involving small incisions through which an endoscope is inserted end in -oscopy. For example, such surgery in the abdominal cavity is called laparoscopy.
 * Procedures for formation of a permanent or semi-permanent opening called a stoma in the body end in -ostomy.
 * Reconstruction or Cosmetic surgery of a body part starts with a name for the body part to be reconstructed and ends in -oplasty. Rhino is used as a prefix for "nose", so rhinoplasty is basically reconstructive or cosmetic surgery for the nose.

For specific examples, see List of surgical procedures.

Description of surgical procedure
At a hospital, modern surgery is often done in an operating room using surgical instruments, an operating table for the patient, and other equipment. Any surgical instrument which go into the body must be pre-sterilized to avoid infection by micro-organisms. Also to maintain sanitation and sterility, surgeons clean (scrub) their hands. The surgical team wears sterile gloves during surgery. Surgical masks and gowns are also worn.

Modern surgery usually proceeds as follows:

Prior to surgery, particularly if it's non-emergency, the patient is given a medical examination, certain pre-operative tests, an ASA score, and (if satisfactory) a surgical clearance to be operated on. An autologous blood donation may be made a couple weeks prior to surgery to readd in case of blood loss during surgery. If the surgery involves the digestive system, evacuation of the digestive tract with subsequent fasting is done by the patient.

Other preparations for surgery are often done. When the patient enters the operating room, intravenous injection and various instruments to monitor the patient's vital signs are attached. The skin surface to be operated on is cleaned and prepared by shaving hair in area of incision and applying an antiseptic such as betadine to avoid a possibility of infection.

Anesthesia is administered to prevent pain from incision, other tissue cutting and suturing, etc. Although in theory it may sometimes be possible to operate without anesthesia, in most surgeries the pain would be unbearable and a patient would not hold sufficiently still for a surgeon to precisely operate. The anesthesia could be local or general anesthesia. With local anesthesia, the body area operated on is anesthetized, but the patient can remain conscious. With general anesthesia, the patient is rendered unconscious during surgery by an anesthesiologist. The anesthesia is often administered in the form of a drug. For certain serious types of surgery when a muscle relaxant is used, the patient undergoes intubation and is placed on mechanical ventilation using a mechanical ventilator. Intubation is inserting an endotracheal tube into the mouth, through the throat, and into the trachea to provide oxygen to the lungs. Open heart surgery often involves placement of a patient on a heart-lung machine and lowering body temperature so the heart stops beating. When finished, body temperature is raised and, if necessary, an electrical impulse administered to restart the heart.

Then, an incision is made to access the inside of the body area to be worked on. Blood vessels may be clamped to prevent bleeding. Other surgical tools (instruments) may be used to keep the incision open. It is commonly desired to keep the incision as small as possible. Various internal membranes may be cut also for further access inside. In certain cases, bone may be cut to further access the interior of the body; for example, cutting the skull for brain surgery or cutting the sternum for thoracic (chest) surgery to open up the rib cage.

Work to correct the problem in body then proceeds. This work may involve:
 * excision - cutting out an organ, tumor, or other body part.
 * resection - partial removal of an organ or other bodily structure.
 * reconnection of organs, tissues, etc., particularly if severed. Resection of organs such as intestines involves reconnection.  Internal suturing or stapling may be used.  Surgical connection between blood vessels or other tubular or hollow structures such as loops of intestine is called anastomosis.
 * ligation - tying off blood vessels, ducts, or "tubes".
 * grafts - may be severed pieces of tissue cut from the same (or different) body or flaps of tissue still partly connected to the body but resewn for rearranging or restructuring of the area of the body in question. Although grafting is often used in cosmetic surgery, it is also used in other surgery.  Grafts may be taken from one area of the patient's body and inserted to another area of the body.  An example is bypass surgery, where clogged blood vessels are bypassed with a graft from another part of the body.  Alternatively, grafts may be from other persons, cadavers, or animals.
 * insertion of prosthetic parts when needed. Pins or screws to set and hold bones may be used.  Sections of bone may be replaced with prosthetic rods or other parts.  Sometime a plate is inserted to replace a damaged area of skull.  Artificial hip replacement has become more common.  Heart pacemakers or valves may be inserted.  Many other types of prostheses are used.
 * creation of a stoma, a permanent or semi-permanent opening in the body
 * injury wound repair including cleaning and suturing injury wounds, setting broken bones, removal of foreign objects such as bullets, broken blades, etc.
 * in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the recipient's body and reconnected to the recipient in all necessary ways (blood vessels, ducts, etc.).
 * arthrodesis - surgical connection of adjacent bones so the bones can grow together into one. Spinal fusion is an example of adjacent vertebrae connected allowing them to grow together into one piece.
 * modifying the digestive tract in bariatric surgery for weight loss.
 * repair of a fistula, hernia, or prolapse
 * other problem corrections may include:
 * clearing clogged ducts, blood or other vessels
 * removal of calculi (stones)
 * draining of accumulated fluids
 * debridement- removal of dead, damaged, or diseased tissue


 * Surgery may also involve reattachment of severed limbs, digits, or other body parts. Often a lot of microsurgery is involved in replantation.  Muscles, blood vessels, and nerves often need to be reattached.
 * Surgery has also been conducted to separate conjoined twins.
 * Sex change operations are also a form of surgery.

Blood transfusions to the patient may be made to compensate for blood lost during surgery. Towards the end of surgery, sutures or staples are used to close the incision. Such closure allows the incision(s) to heal naturally. An incision scar typically remains. At the end of surgery when the patient is able to breath on one's own, the patient is taken off of mechanical ventilation and any endotracheal tube used is removed.

After completion of surgery, the patient is brought to a recovery room for a while and closely monitored. After some major operations, the patient may be in an intensive care unit (ICU) for a while. Afterwards a patient often continues recuperation in a regular hospital room or if surgery was relatively minor, discharged to recuperate at home. A patient having undergone surgery on the digestive system may be put on a liquid diet for a while. Often after surgery, the incision closure is checked periodically for signs of infection. External stitches are removed after perhaps 10 days or so (See Suture), after healing of the incision is well under way.

Adjuvant treatment such as chemotherapy, radiation therapy, or administration of medication such as anti-rejection medicine for transplants may be done. Other follow-up checks or rehabilitation may be done for a recovery period. As a result of some serious surgery, it is possible for a patient to suffer perioperative mortality, i.e. die during or after the surgery.

History
At least two prehistoric cultures had developed forms of surgery. The oldest for which we have evidence is trepannation, in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order to treat health problems related to intracranial pressure and other diseases. Evidence has been found in prehistoric human remains from Neolithic times, in cave paintings, and the procedure continued in use well into recorded history. Surprisingly, many prehistoric and premodern patients had signs of their skull structure healing; suggesting that many survived the operation. In modern-day Pakistan, remains from the early Harappan periods of the Indus Valley Civilization (c. 3300 BC) show evidence of teeth having been drilled dating back 9,000 years. A final candidate for prehistoric surgical techniques is ancient Egypt, where a mandible dated to approximately 2650 BC shows two perforations just below the root of the first molar, indicating the draining of an abscessed tooth. Recent excavations of the construction workers of the Egyptian pyramids also led to possible evidence of brain surgery.

The oldest known surgical texts date back to Indian physician Sushruta, the "Father of Surgery", who taught and practiced surgery on the banks of the Ganges around 600 BC. Much of what is known about Sushruta is contained in a series of volumes he authored, which are collectively known as the Susrutha Samhita. It is the oldest known surgical text and it describes in great detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of plastic surgery, such as cosmetic surgery and rhinoplasty. His technique for the latter, used to reconstruct noses that were amputated as a punishment for crimes, is practiced almost unchanged in technique to this day.

Other ancient cultures to have surgical knowledge include ancient Greece - the Hippocratic Oath was an innovation of the Greek physician Hippocrates - and ancient China. However ancient Greek culture traditionally considered the practice of opening the body to be repulsive and thus left known surgical practices such as lithotomy to such persons as practice [it]. In China, Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms era. He was the first person to perform surgery with the aid of anesthesia, some 1600 years before the practice was adopted by Europeans.

In the Middle Ages, surgery was developed to a high degree in the Islamic world, with renowned practitioners such as Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi), an Andalusian-Arab physician and scientist who practised in the Zahra suburb of Córdoba. A great medieval surgeon, whose comprehensive medical texts shaped European surgical procedures up until the Renaissance. He is also often regarded as a Father Of Surgery.

In Europe, the demand grew for surgeons to formally study for many years before practicing; universities such as Montpellier, Padua  and Bologna Universities were particularly renowned. By the fifteenth century at the latest, surgery had split away from physics as its own subject, of a lesser status than pure medicine, and initially took the form of a craft tradition until Rogerius Salernitanus composed his Chirurgia, laying the foundation for modern Western surgical manuals up to the modern time. Late in the nineteenth century, Bachelor of Surgery degrees (usually Ch.B.) began to be awarded with the (M.B.), and the mastership became a higher degree, usually abbreviated Ch.M. or M.S. in London, where the first degree was M.B.,B.S.

Modern surgery
Modern surgery developed rapidly with the scientific era. Ambroise Paré (sometimes spelled "Ambrose" ) pioneered the treatment of gunshot wounds, and the first modern surgeons were battlefield doctors in the Napoleonic Wars. Naval surgeons were often barber surgeons, who combined surgery with their main jobs as barbers. Three main developments permitted the transition to modern surgical approaches - control of bleeding, control of infection and control of pain (anaesthesia).


 * Bleeding: Before modern surgical developments, there was a very real threat that a patient would bleed to death before treatment, or during the operation. Cauterization (fusing a wound closed with extreme heat) was successful but limited - it was destructive, painful and in the long term had very poor outcomes. Ligatures, or material used to tie off severed blood vessels, are believed to have originated with Abulcasis in the 10th century and improved by Ambroise Paré in the 16th century. Though this method was a significant improvement over the method of cauterization, it was still dangerous until infection risk was brought under control - at the time of its discovery, the concept of infection was not fully understood. Finally, early 20th century research into blood groups allowed the first effective blood transfusions.
 * Infection: The concept of infection was unknown until relatively modern times. The first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths, however the Royal Society in the UK still dismissed his advice. Significant progress came following the work of Pasteur, when the British surgeon Joseph Lister began experimenting with using phenol during surgery to prevent infections. Lister was able to quickly reduce infection rates, a reduction that was further helped by his subsequent introduction of techniques to sterilize equipment, have rigorous hand washing and a later implementation of rubber gloves. Lister published his work as a series of articles in The Lancet (March 1867) under the title Antiseptic Principle of the Practice of Surgery. The work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern aseptic operating theatres widely used within 50 years (Lister himself went on to make further strides in antisepsis and asepsis throughout his lifetime).
 * Pain: Modern pain control (anesthesia) was discovered by two American Dental Surgeons, Horace Wells (1815-1848) and William Morton. Before the advent of anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimize patient suffering. This also meant that operations were largely restricted to amputations and external growth removals. Beginning in the 1840s, surgery began to change dramatically in character with the discovery of effective and practical anaesthetic chemicals such as ether and chloroform, later pioneered in Britain by John Snow. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body.  In addition, the discovery of muscle relaxants such as curare allowed for safer applications.

Conditions treated by surgery
Surgery is used to both as a treatment, and as an aspect of treatment, for many conditions, including:


 * Physical trauma, e.g. wounds
 * Anatomical Abnormalities
 * Disorders of function
 * Inflammation
 * Ischaemia and infarction
 * Metabolic disorders
 * Neoplasia
 * Other abnormalities of tissue growth, e.g. cysts, hyperplasia or Organ hypertrophy, as well as some cancers, if caught early enough
 * Deformity and heavy scarring.
 * Brain damage and nerve damage

Common procedures
Five of the most common surgical procedures in the United States are male circumcision, obstetric: episiotomy, repair of obstetric laceration, cesarean section, and artificial rupture of the amniotic membrane

The most common non-obstetric surgical procedures include amputation, appendectomy, cataract surgery, circumcision, dental extraction and herniorraphy.

According to 1996 data from the US National Center for Health Statistics, 40.3 million inpatient surgical procedures were performed in the United States in 1996, followed closely by 31.5 million outpatient operations.