Surgery (from the
cheirourgikē, via ,
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 on which the surgery is performed can be a person or an
animal. A
surgeon is a person who performs
operations on patients. Persons described as surgeons are commonly
medical practitioners, but the
term is also applied to
physicians,
podiatric physicians,
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.
Definitions of surgery
Surgery is a medical technology consisting of a physical
intervention on tissues.
As a general rule, a procedure is considered surgical when it
involves cutting of a patient's tissues or closure of a previously
sustained wound. Other procedures that do not necessarily fall
under this rubric, such as
angioplasty
or
endoscopy, may be considered surgery if
they involve "common" surgical procedure or settings, such as use
of a sterile environment,
anesthesia,
antiseptic conditions, typical
surgical instruments, and
suturing or
stapling. All forms of surgery are
considered invasive procedures; so-called "noninvasive surgery"
usually refers to an excision that does not penetrate the structure
being excised (e.g. laser ablation of the cornea) or to a
radiosurgical procedure (e.g. irradiation of a tumor).
Types of surgery
Surgical procedures are commonly categorized by urgency, type of
procedure, body system involved, degree of invasiveness, and
special instrumentation.
Elective surgery is done to correct
a non-life-threatening condition, and is carried out at the
patient's request, subject to the surgeon's and the surgical
facility's availability.
Emergency
surgery is surgery which must be done quickly to save life,
limb, or functional capacity.
Exploratory surgery is performed to aid
or confirm a diagnosis. Therapeutic surgery treats a previously
diagnosed condition.
Amputation involves cutting off a body
part, usually a limb or digit.
Replantation involves reattaching a severed
body part.
Reconstructive
surgery involves reconstruction of an injured, mutilated, or
deformed part of the body.
Cosmetic surgery is done
to improve the appearance of an otherwise normal structure.
Excision is the cutting out of an organ,
tissue, 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.
When
surgery is performed on one organ
system or structure, it may be classed by the organ, organ system
or tissue involved. Examples include cardiac surgery (performed on
the heart), gastrointestinal surgery (performed within the
digestive tract and its accessory organs), and orthopedic surgery
(performed on bones and/or muscles).
Minimally invasive
surgery involves smaller outer incision(s) to insert
miniaturized instruments within a body cavity or structure, as in
laparoscopic surgery or
angioplasty. By contrast, an open
surgical procedure requires a large incision to access the area of
interest.
Laser surgery involves use
of a
laser for cutting tissue instead of a
scalpel or similar surgical instruments.
Microsurgery involves the use of an
operating
microscope for the surgeon to
see small structures.
Robotic
surgery makes use of a surgical robot, such as the
Da Vinci or the Zeus surgical
systems, to control the instrumentation under the direction of the
surgeon.
Terminology
- 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, plastic 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.
- Reparation of damaged or congenital abnormal structure ends in
-rraphy. Herniorraphy
is the reparation of a hernia, while perineorraphy is the
reparation of perineum.
Description of surgical procedure
At a
hospital, modern surgery is often done
in an
operating theater using
surgical instruments, an
operating table for the patient, and other equipment. The
environment and procedures used in surgery are governed by the
principles of
aseptic technique:
the strict separation of "sterile" (free of microorganisms) things
from "unsterile" or "contaminated" things. All surgical instruments
must be
sterilized, and
an instrument must be replaced or re-sterilized if it becomes
contaminated (i.e. handled in an unsterile manner, or allowed to
touch an unsterile surface). Operating room staff must wear sterile
attire (
scrubs, a scrub cap, a
sterile surgical gown, sterile latex or non-latex polymer gloves
and a surgical mask), and they must scrub hands and arms with an
approved disinfectant agent before each procedure.
Prior to surgery, the patient is given a
medical examination, certain
pre-operative tests, and its
physical
status is rated according to the
ASA physical status
classification system. If these results are satisfactory, the
patient signs a consent form and is given a surgical clearance. If
the procedure is expected to result in significant blood loss, an
autologous blood donation may be made some weeks prior
to surgery. If the surgery involves the
digestive system, the patient may be
instructed to perform a
bowel
prep by drinking a solution of polyethylene glycol the night
before the procedure. Patients are also instructed to abstain from
food or drink (an
NPO order after
midnight on the night before the procedure, to minimize the effect
of stomach contents on pre-operative medications and reduce the
risk of aspiration if the patient vomits during or after the
procedure.
In the pre-operative holding area, the patient changes out of his
or her street clothes and is asked to confirm the details of his or
her surgery. A set of vital signs are recorded, a peripheral
IV line is placed, and
pre-operative medications (antibiotics, sedatives, etc) are given.
When the patient enters the operating room, the skin surface to be
operated on is cleaned and prepared by applying an
antiseptic such as
chlorhexidine gluconate or
povidone-iodine to reduce the possibility of
infection. If hair is present at the surgical site, it is clipped
off prior to prep application. Sterile drapes are used to cover all
of the patient's body except for the surgical site and the
patient's head; the drapes are clipped to a pair of poles near the
head of the bed to form an "ether screen", which separates the
anesthetist/
anesthesiologist's working area (unsterile)
from the surgical site (sterile).
Anesthesia is administered to prevent
pain from incision, tissue manipulation and
suturing. Based on the procedure, anesthesia may be provided
locally or as
general anesthesia.
Spinal anesthesia may be used when the
surgical site is too large or deep for a local block, but general
anesthesia may not be desirable. With local and spinal anesthesia,
the surgical site is anesthetized, but the patient can remain
conscious or minimally sedated. In contrast, general anesthesia
renders the patient unconscious and paralyzed during surgery. The
patient is
intubated and is placed on a
mechanical ventilator, and
anesthesia is produced by a combination of injected and inhaled
agents.
An incision is made to access the surgical site.
Blood vessels may be clamped to prevent
bleeding, and retractors may be used to expose the site or keep the
incision open. The approach to the surgical site may involve
several layers of incision and dissection, as in abdominal surgery,
where the incision must traverse skin, subcutaneous tissue, three
layers of muscle and then peritoneum. 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
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 tissue.
- 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
- 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 procedures, including:
- *clearing clogged ducts, blood or other
- *removal of calculi (stones)
- *draining of accumulated fluids
- *debridement- removal of dead,
damaged, or diseased tissue
Blood or blood expanders may be
administered to compensate for blood lost during surgery. Once the
procedure is complete,
suture or
staples are used to close the
incision. Once the incision is closed, the anesthetic agents are
stopped and/or reversed, and the patient is taken off ventilation
and extubated (if general anesthesia was administered).
After completion of surgery, the patient is transferred to the
post anesthesia care unit
and closely monitored. When the patient is judged to have recovered
from the anesthesia, he/she is either transferred to a surgical
ward elsewhere in the hospital or discharged home. During the
post-operative period, the patient's general function is assessed,
the outcome of the procedure is assessed, and the surgical site is
checked for signs of infection. If removable skin closures are
used, they are removed after 7 to 10 days post-operatively, or
after healing of the incision is well under way.
Post-operative therapy may include adjuvant treatment such as
chemotherapy,
radiation therapy, or administration of
medication such as anti-rejection
medication for transplants. Other follow-up studies or
rehabilitation may be prescribed during and after the recovery
period.
History
At least two prehistoric cultures had developed forms of surgery.
The oldest for which there is evidence is
trepanation, 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
ancient
India, 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.
The oldest known surgical texts date back to ancient India about
3500 years ago and many evidences found around the Indus valley
civilization show that even dentistry is practised then.Sushruta
(also spelled Susruta or Sushrutha) is called as the father of
surgery and the first known surgeon in the world and even wrote a
book and his practices reached the middle east and later to the
west .In his book, he described over 120 surgical instruments, 300
surgical procedures and classifies human surgery into 8 categories.
Sushruta is also known as the father of plastic surgery and
cosmetic surgery. He was a surgeon from the
dhanvantari school of
Ayurveda.In
Ancient
Egypt surgeries were performed by priests, specialized in
medical treatments similar to today. The procedures were documented
on papyrus and describe patient case files; the
Edwin Smith Papyrus (held in the
New York Academy of
Medicine) documents surgical procedures based on anatomy and
physiology, while the
Ebers Papyrus
describes healing based on
magic.
Their medical expertise was later documented by Herodotus: "The
practice of medicine is very specialized among them. Each physician
treats just one disease. The country is full of physicians, some
treat the eye, some the teeth, some of what belongs to the abdomen,
and others internal diseases."
Other
ancient cultures to have surgical knowledge include Egypt
, China and Greece. The
Hippocratic Oath was an innovation of the
Greek physician
Hippocrates. 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, albeit a
rudimentary and unsophisticated form.
In the
Middle Ages, surgery was
developed to a high degree in the
Islamic world.
Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas
Al-Zahrawi), an Andalusian-Arab
physician and scientist who practised in the
Zahra suburb of Córdoba
, wrote medical texts that 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
were particularly renowned. By the fifteenth
century at the latest, surgery had split away from
physic 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 ChB) began to be
awarded with the
, and the mastership
became a higher degree, usually abbreviated
ChM or MS in London, where the first
degree was
MB, BS.
Barber-surgeons generally had a bad
reputation that was not to improve until the development of
academic surgery as a specialty of medicine, rather than an
accessory field. Basic surgical principles for asepsis etc are
known as
Halsteads
principles
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 Abu
al-Qasim al-Zahrawi (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.
- Pain:
Modern pain control through 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.
- Infection: Unfortunately, the introduction of anesthetics
encouraged more surgery, which inadvertently caused more dangerous
patient post-operative infections. 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).
Surgical specialties and sub-specialties
- *Cardiothoracic
surgery
- *Colorectal surgery
- *Paediatric surgery
- *Plastic surgery
- *Vascular surgery
- *Trauma surgery
- *Breast surgery
- *Surgical Oncology
Some other specialties involve some forms of surgical intervention,
especially
gynaecology. Also, some
people consider invasive methods of treatment/diagnosis, such as,
cardiac catheterization, endoscopy, and placing of chest tubes or
central lines "surgery". In most parts of the medical field, this
view is not shared.
See also
Governing bodies
Qualifications in the UK and Ireland
References
- Wagman LD. "Principles of Surgical Oncology" in Pazdur R,
Wagman LD, Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach. 11
ed. 2008.
- BBC NEWS | Science/Nature | Stone age man used
dentist drill
- Herodotus, Histories 2,84
- biography from Famousmuslims.com accessed
16 April 2007.
- Rabie E. Abdel-Halim, Ali S. Altwaijiri, Salah R. Elfaqih,
Ahmad H. Mitwall (2003), "Extraction of urinary bladder
described by Abul-Qasim Khalaf Alzahrawi (Albucasis) (325-404
H, 930-1013 AD)", Saudi Medical Journal 24 (12): 1283-1291
[1289].
External links
Top topics
Wikis
Quiz
Map
Misc
Search