Essence of surgery

A brief journey through surgical history

"So the Lord God caused a deep sleep to fall upon the man, and while he slept he took one of his ribs, and closed up its place with flesh". (Revised Standard Version)

For those who believe in the Old Testament, this is the first documented account of a surgical operation.

The first hard evidence of early surgical procedures came with the finding of trephined skulls some 10,000 years old. The indications for trephining (or trepanning) are unclear, but most authorities hold that it was done to release evil spirits, and as a treatment for epilepsy and migraine.

Although there is little evidence that the Ancient Egyptian practice of mummification led to detailed knowledge of human anatomy, the Edwin Smith papyrus from the 17th BC provides one of the earliest written record of surgical procedures.¹

Some of you may possess souvenir papyri showing the surgical instruments engraved in the wall of the Temple of Sobek and Horus at Kom-Ombo.²

In the early centuries of the Christian era, the Greek surgeon Claudius Galen was an important influence, going to Rome and reviving the Hippocratic method. He stressed the importance of anatomy, and although limited to the study of pigs and apes (it is only rumoured he dissected humans, as this was illegal at the time), he was the founder of experimental physiology. Galen contended that blood was continually produced and used up, a concept which persisted for 1400 years. He is credited with the first prescribed use of the medicine ball, and is considered the father of sports medicine.³

At the beginning of the Middle Ages, surgeons of the great Muslim empire were blazing the way for developments in the fields of orthopaedics, ophthalmic and cancer surgery. Although often described as the period of Arabian medicine, physicians were drawn from all cultures, and all parts of the empire which extended from Spain to Arabia along the entire coast of North Africa, including Christians and Jews. The textbooks they wrote were translated into Latin and used by European doctors. The texts written by Abu al Qasim al-Zahrawi was most well-known in this respect. The monks who translated the works and copied the diagrams did so inaccurately, and this led to calls for dissection (formerly banned on religious grounds) to be permitted.

In 1628 William Harvey published ‘An Anatomical Exercise Concerning the Motion of the Heart and Blood in Animals’, detailing his experiments using ligatures.⁴ He proved that there was a fixed amount of blood, which was pumped round the body in one direction only. The use of ligatures themselves was not new. Ambroise Paré outlined their employment as a method of stopping bleeding on the battlefield in his ‘Works of Surgery’ published in 1575.⁵ Because he was only a barber-surgeon the Paris College of Physicians tried to stop the publication of his texts.

In 1799, Humphry Davey discovered nitrous oxide, but its benefits were not widely publicised. Surgeons such as Robert Liston had to operate without the benefit of anaesthetic in the quickest possible time.⁶ His use of ether as an anaesthetic in 1800 was to revolutionise surgery. Chloroform, a less irritant preparation, was discovered by James Simpson in 1847 and was used until 1900, when reports of liver toxicity led to its decline.⁷

The next significant development was the concept of ‘antisepsis’, promulgated by Joseph Lister.⁸ He recognised the similarity between the smells in sewers and in operating rooms. Sewer smells were treated with carbolic acid, so in 1867 Lister developed a weak carbolic solution to be sprayed on wounds.

Whilst this considerably reduced the post-operative infection rate, it was not until 1878 that Robert Koch propounded the link between bacteria in the blood and septicaemia.⁹ This laid the foundation for aseptic surgical techniques, and his discovery that hot steam killed more bacteria than carbolic acid led to the routine sterilisation of instruments, sutures and dressings.

In 1900, Karl Landsteiner discovered that blood was divided into four main groups and that certain blood types could not be mixed.¹⁰ This paved the way for blood transfusions. The First World War saw the advent of blood storage, plastic surgery and skin grafts, portable X-ray machines and developments in the field of surgical prosthesis.

The 20th century was dominated by the development of transplant surgery. The first corneal transplant was carried out in 1905, and the first kidney transplant in 1954. A liver was transplanted in 1963, a heart in 1967, lung in 1982 and brain tissue in 1987. Since the 1980s, one of the most well-known transplants has been bone marrow for leukaemia sufferers.

The late 20th and early 21st century has focused on the increasing use of laser surgery and the application of robotic technology. This is likely to lead to increasingly precise and complex procedures being carried out through ever-smaller incisions. The future is likely to see an explosion of new surgical techniques as micromechanical techniques merge with technological advances inspired by biology to create new instruments that are more instinctive to use than the rigid tools of yore.¹¹

The language of surgery

Some common surgical incisions

• Kocher's incision (cholecystectomy)

• Right paramedian (any laparotomy)

• Grid iron (or Lanz) (appendicectomy)

• Loin (renal surgery)

• Midline (laparotomy)

• Left paramedian (any laparotomy)

• Pfannenstiel incision (pelvic surgery)

Definitions

• A fistula is an abnormal communication between two epithelial surfaces (or endothelial in arterio-venous fistulae), eg gastrocolic fistula (stomach/colon). Fistulae often close spontaneously unless prevented from doing so by foreign bodies, malignancy, chronic inflammation, distal obstruction, or epithelialisation of the track. External intestinal fistulae are managed by barrier methods to protect the skin, fluid and electrolyte replacement and parenteral nutrition. Surgery is used as a last resort.

• A sinus is a blind-ending track. Typically this is lined by epithelial or granulation tissue which opens on to an epithelial surface.

• An ulcer is an abnormal area of discontinuity in an epithelial surface.

• An abscess is a cavity filled with pus. Surgeons love quoting the aphorism: if there is pus about, let it out.

Common suffixes and their meanings

• -ostomy This is an artificial opening usually made to create a new connection either between two conduits or between a conduit and the outside world - eg colostomy: the colon is made to open onto the skin. Stoma means a mouth.

• -plasty This is the refashioning of something to make it work, eg pyloroplasty relieves pyloric obstruction.

• -ectomy This means cutting something out - eg appendicectomy.

• -otomy This means cutting something open - eg laparotomy (the opening of the abdomen).

• -oscope This refers to an instrument for looking into the body - eg cystoscope (a device for looking into the bladder).

• -lith- This relates to a stone eg nephrolithotomy (cutting the kidney open to get to a stone).

• -chole- This relates to gall or bile.

• -cyst- This means a fluid-filled sac.

• -gram This is applied to a radiological image, often using a radio-opaque contrast medium.

• -docho- This means relating to ducts.

• -angio- This means relating to tubes or blood vessels.

• Per- This means going through a structure (invasive).

• Trans- This means going across a structure.

Some eponyms

Billroth, Christian Albert Theodor (1829-1984) German-Austrian surgeon, born in Bergen, on the island of Rügen, Prussia.¹² After failing as a general practitioner in Berlin, he joined the Vienna School of Surgery. He is considered to be a founder-figure of modern abdominal surgery. His operating techniques on the stomach and biliary tract, or modifications of these, are still in use.

Douglas, James (1675-1742) Scottish physician and anatomist.¹³ A life physician to the Queen of England, he obtained his medical doctorate at Reims and in 1700 returned to London. Apart from the famous pouch, he also gives his name to a fold (the fold of peritoneum forming the lateral border of the pouch) and a line (the arcuate line of the sheath of the rectus abdominalis muscle).

Kocher, Emil Theodor (1841-1917) A Swiss surgeon, gave his name not only to the incision but also to tweezers, a method for reducing dislocations of the shoulder, and a syndrome (splenomegaly with or without lymphocytosis and lymphadenopathy in thyrotoxicosis).¹⁴ A man of many parts, he won the 1909 Nobel Prize in Physiology or Medicine for his work on the physiology, pathology and surgery of the thyroid gland. He has also given his name to the Kocher Institut in Bern.

Meckel, Johann Friedrich (1781-1833) German anatomist, was born into a family of eminent physicians.¹⁵ After studying anatomy under the direction of his father (which he hated) he transferred in 1801 to the University of Göttingen. Among his most lasting and impressive contributions was the study of the abnormalities occurring during embryological development.

Murphy, John Benjamin (1857-1916) was born in Appleton, Wisconsin and received his doctorate from Rush Medical College in 1879.¹⁶ In 1889 Murphy established a pattern of early symptoms for appendicitis and strongly urged immediate removal of the appendix when this pattern appeared. Although Murphy’s programme first met with incredulity and derision from his colleagues, his more than 200 successful appendectomies over the next several years provided ample evidence to make the operation common medical practice. He did much pioneering work on intestinal anastomosis, and was the first person to successfully unite a femoral artery severed by a gunshot wound.

Pfannenstiel, Hermann Johannes (1862-1909) studied medicine in his native city of Berlin and graduated in that city in 1885.¹⁷ Pfannenstiel was equally recognised as physician, gynaecological surgeon, and teacher. He left a comprehensive written work, concerning the pathology of the ovaries, tumours of the uterus, the formation of carcinomas after ovariotomy and the encapsuling of the egg in the uterus. As well as the incision he was at one time also known for the disease, a description of morbus haemolyticus neonatorum which has since fallen out of use.