Surgery M.D. Wenbing Ai Surgical Department of Renhe Hospital of The Three Gorges University.

Surgery

M.D. Wenbing Ai

Surgical Department of Renhe Hospital of The Three Gorges University

What is the Surgery ?

Surgery: A branch of medicine concerned with the diagnosis and treatment of injuries and the excision and repair of pathological condition by means of operative procedures

surgery

Ancient surgery : trauma and some diseases in the surface of the body

Modern surgery: include much more internal diseases

Some ancient surgical instruments

Some modern surgical instruments

The category of modern surgery

• Injury. For example, bowels broken, fractures, burns, and so on. • Infection. For example, abscess, appendicitis, cholecystitis, and

so on.• Tumor. Include benign tumor and malignant tumor.• Malformation. Include congenital malformation and acquired

malformation.• Other diseases. Intestinal obstruction, obstruction of urinary

pathway, varicosity of lower limbs, portal hypertension, cholelithiasis ， urinary lithiasis ， hyperthyroidism ， and so on.

The Development of Modern Surgery

The modern surgery began to develop rapidly since 1840s with the resolution of some problems one by one.

What factors accelerated the development of modern surgery or how did the modern surgery develop?

3 Main Problems With Surgery

• Pain

• Infection

• Bleeding

Lesson Objectives

• To introduce the development of modern surgery focusing on anaesthesia, antiseptics and aseptic, hemostasis and blood transfusion.

Development of Anaesthetics

• By the 1800s there were no decent anaesthetics. • People relied on alcohol, opium and hypnosis.• In 1799 Humphrey Davey discovered that

nitrous oxide (laughing gas) relieved pain.• His discovery was ignored by the medical

profession who believed it unimportant.• In 1845 Horace Wells saw people inhaling the

gas at a fair. He observed that they failed to feel the effects of pain.

Development of Anaesthetics

• He set up a demonstration but it failed miserably!• In 1846 William Morton removed a tumor from a

patients neck using ether as an anaesthetic.• In December of the same year Robert Liston

removed a patients leg in 26 seconds! The medical profession began to sit up and take notice.

• In 1847 James Simpson experimented with chloroform. He administered it to over 50 women and the results were impressive.

Opposition

There were various reasons why people were opposed to the development.

• It was difficult to judge the correct amount. Accidents happened.

• People opposed on religious grounds e.g. childbirth.

• Some people didn’t trust surgeons.• Others felt that men that relied on

anaesthetics were soft.

Breakthrough!

• Opposition melted away when Queen Victoria used chloroform to give birth to her 8th child.

• By the end of the 19th century the anaesthetist had become a specialist in his own right.

Danger! Infection!

• Surgeons got a little carried away.• Operations could now be carried out

with the patients feeling little pain or serious discomfort.

• The big danger was now infection.• Surgeons wore normal clothes.

Instruments were not sterilized, sometimes not even cleaned!

Antiseptics• Louis Pasteur established the fact that

microbes are responsible for infection and disease.

• In 1847 a Hungarian doctor called Semmelweiss ordered doctors in his hospital to wash hands after handling dead bodies.They did. Rates of puerperal fever amongst new mothers fell.

Lister rhymes with Blister

• Joseph Lister was responsible for the big breakthrough in fighting infection. He had studied Pasteur’s findings.

• In the 1860s Joseph Lister introduced the use of carbolic acid as a cleansing and disinfecting agent,

• He ensured that instruments, the patient, the surgeons hands and even the air were drenched with a carbolic acid spray.

• His results in reducing infection were dramatic.

• By 1912 up to 10 times more operations were taking place than 40 years before with less infection.

• It was now safe to be operated on.

Aseptic Surgery

• The problem with carbolic acid is that it could act as an irritant.

• In Germany aseptic surgery began to be developed. This is the process of killing germs without the need for chemicals. (superheated steam).

• In America a surgeon called William Halstead introduced surgical masks and gloves and cut rates of infection even further.

• Operating theatres were now pristine places.

Two Very Clean Doctors

Antibiotics and surgery

• Penicillin was discovered in 1929 by Alexander Fleming

• In Germany, Sulfanilamide was proposed to be used in 1935.

• In the 1940s, a second clinically important antibiotic, streptomycin, was discovered by A. Schatz and S. Waksman.

Antibiotics and surgery

• More and more antibiotics were discovered and used to prevent and treat infections.

• The use of antibiotics in surgery reduced the rate of infection greatly.

• Antibiotics made the development of modern surgery enter a new phase.

Bleeding is an inevitable problem during the process of an operation, which must be overcome.

Hemostasis

• In 1872, American doctors introduced to use hemostatic In 1872, American doctors introduced to use hemostatic forceps.forceps.

• In 1873, German doctors proposed to use toumiquet when In 1873, German doctors proposed to use toumiquet when amputation.amputation.

• Electrically powered surgical instruments are invaluable for Electrically powered surgical instruments are invaluable for cautery, which is very useful to hemostasis.cautery, which is very useful to hemostasis.

The development of blood transfusion

• In 1900, American doctors discovered blood group typing direct blood transfusion （ can not be controlled easily)

• In 1915, German doctors understood of blood clotting and the use of anticoagulants

indirect blood transfusion (it is more feasible)

The development of modern surgery in the second half of 20th century

• Surgical instruments have developed along with modern technology and are now sophisticated, meticulously designed devices.

• New medical glues, surgical tapes, and even zippers now enable surgeons to close some wounds effectively without stitches.

• With the development of X-ray techniques and fluoroscopy and, later, CT scans and magnetic resonance imaging (MRI), surgery gained valuable diagnostic instruments.

• Ultrasound techniques, using very-high-frequency sound waves, are used to break up kidney stones and are employed in brain and inner-ear operations, which require great precision and control.

• Medical lasers, which produce amplified monochromatic light waves in a very narrowly focused beam, have become useful tools in various forms of surgery.

• The heart-lung machine made open-heart surgery possible by taking over the blood-pumping and breathing functions of these organs during operations.

• Hypothermia, or cold surgery, by which the body is cooled to lower the rate of metabolism, thus reducing the need for oxygen, has made long operations, especially those involving transplantation ,possible.

• Other recent transplantation advances include procedures involving the liver, lungs, pancreas, bone marrow, and the kidney

• New techniques in orthopedic surgery have also been introduced, including the use of cementing substances to unite bones destroyed by tumor and the replacement of joints with metal or plastic devices.

• Plastic surgery and reconstructive surgery have made enormous strides, and microsurgery is making severed or injured limbs usable.

• A trend toward less invasive surgery and shorter hospital stays began in the 1980s.

• Endoscopic surgery, using small incisions and tiny instruments attached to fiber-optic viewing devices , has been used in place of more traditional procedures for gall-bladder surgery, and it has been used on the fetus in the womb to correct life-threatening birth defects before birth.

• Angioplasty is frequently used to circumvent or postpone the need for coronary artery bypass.

Surgical ethics

Ethics and surgical intervention must go hand in hand

Patients consent to surgery because they trust their surgeons. Yet what should such consent entail in practice and what should surgeons do when patients need help but are unable or unwilling to agree to it? When patients do consent to treatment, surgeons wield enormous power over them ,the power not just to cure but to maim, disable and kill. How should such power be regulated to reinforce the trust of patients and to ensure that surgeons practice to an acceptable professional standard?

Are there circumstances where it is acceptable to sacrifice the trust of individual patients in the public interest through revealing information that was communicated in what patients believed to be conditions of strict privacy?

These questions about what constitutes good professional practice concern ethics rather than surgical technique.

Respect for autonomy

• When we talk of the particular type of respect which it is appropriate to show to humans, the focus should primarily be on our autonomy rather than our particular physical characteristics.

• Respect for human dignity is respect for human autonomy.

• Patients have a right to make choices about proposed surgical treatment. They should be allowed to refuse treatments that they do not want, even when surgeons think that they are wrong.

Informed consent

• their condition and the reasons why it warrants surgery;• what type of surgery is proposed and how it might correct their

condition;• what the proposed surgery entails in practice;• the anticipated prognosis of the proposed surgery;• the expected side effects of the proposed surgery;• the unexpected hazards of the proposed surgery;• any alternative and potentially successful treatments for their

condition other than the proposed surgery, along with similar information about these;

• the consequences of no treatment at all.

For agreement to surgical treatment, patients need to be given appropriate and accurate information about:

Attention must be paid to:

• whether or not the patient has understood what has been stated;

• not using overly technical language in descriptions and explanations;

• the provision of translators for patients for whom English is not their first language;

• asking patients if they have further questions.

It is not good enough just to go through the motions of providing patients with information required for considered choice.

• be able to understand, remember, deliberate about and believe whatever information is provided to them about treatment choices;

• not be coerced into decisions which reflect the preferences of others rather than themselves;

• be given sufficient information for these choices to be based on an accurate understanding of reasons for and against proceeding with specific treatments.

For consent to be valid, patients must:

Practical difficulties

• First, surgical care will grind to a halt if it is always necessary to obtain explicit informed consent every time a patient is touched in the context of their care.

• Second, some patients will not be able to give consent because of temporary unconsciousness.

• Third, informed consent may be made impossible by incompetence of other kinds.

• Where competence is severely compromised by psychiatric illness or mental handicap, other moral and legal provisions hold.

• Matters of life and death

• Confidentiality

• Maintaining standards of excellence

• Research

Conclusions

• The two general duties of surgical care are to protect life and health and to respect autonomy.

• The specific duties of surgeons were shown to follow from these: acceptable practice concerning informed consent, confidentiality, decisions not to provide or to omit life-sustaining care, surgical research and the maintenance of good professional standards.

• The final duty of surgical care is to exercise all of these general and specific responsibilities with fairness and justice, and without arbitrary prejudice.

Surgical audit

• The conduct of ethical surgery illustrates good citizenship: protecting the vulnerable and respecting human dignity and equality.

• To the extent that the practice of individual surgeons is a reflection of such sustained conduct, they deserve the civil respect which they often receive.

• To the extent that it is not, they should not practise the honourable profession of surgery.

Thank you