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The discovery and advancements in the practice of surgery in medicine

The Egyptians, the Sushrutas, and the Greeks developed scientific principles on surgical technique, trauma care, and anatomy. In fact, clinicians often perform a broad spectrum of procedures, including gastrointestinal, endocrine, breast, vascular, and thoracic, in a variety of patients, from the fetal to the frail.

Interestingly, general surgeons performed cardiac procedures until the 1970s. Clinical expertise, experience, and technical skills had previously allowed general surgeons to maintain a broad scope of practice. Technological advances in medicine during the 20th century led to exponential growth in new surgical procedures.

By the end of the century, laparoscopic surgery was being widely performed, and a wealth of newfound information and knowledge led to subspecialization. Concurrently, the electronic revolution and socioeconomic factors have added to the complexity of health care practice and delivery.

How do these challenges affect the profession, art, and practice of surgery? When new techniques are introduced, though, new complications or indications for procedures also arise. Laparoscopic cholecystectomy is reported to be the most commonly performed procedure on the digestive tract.

However, the most worrisome complication, bile duct injury, increased to a 0. At this time, proctoring was encouraged but not mandatory.

Although most general surgery residents now graduate with proficiency in basic laparoscopic procedures, more advanced procedures require additional training, obtained either through fellowships or postgraduate courses. Many industry- and association-sponsored programs provide postgraduate training to surgeons in practice, including lecture-based and hands-on formats.

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Most of these committees have proctoring requirements for surgeons prior to providing full credentials for a procedure, but this standard varies by institution. As surgeons continue to push the boundaries of which operations can be performed with minimally invasive techniques, complications will continue to arise.

With the addition of single-incision laparoscopic procedures, morbidity due to bile duct injury and hernia rates may, in fact, rise. Gizmos, gadgets, and toys Given the rapid growth of surgical technology, many clinical practices are in the market for young surgeons trained in minimally invasive surgery.

Surgeons trained in the early 1980s learned laparoscopy as the technology evolved to remain compliant with the modern standard of surgical care. Advancements in medical technology have brought many new and exciting techniques and options, but with them, some standard and cherished procedures are slowly being relegated to the senior surgeons who have amassed expertise in these operations.

The trend away from open procedures has forced more senior staff to learn how to perform new operations. Each of us can relate to becoming comfortable with a procedure, as well as the anxiety that accompanies doing something new.

Even in residency, when trainees are exposed to new procedures on an almost daily or weekly basis, one anticipates that the learning curve will plateau after graduation. The following scenarios highlight how senior surgeons may rely on junior surgeons for their expertise and vice-versa.

In this example, the senior pediatric surgeon in a busy group practice sought assistance from the junior faculty, and together they completed a laparoscopic Nissen fundoplication.

The junior surgeon led the senior surgeon through the procedure, encouraging him to continue at points when it became frustrating. The infant was unable to tolerate thoracoscopy, so the procedure required an open technique. The junior faculty had less experience with this procedure in such a small infant, so he the discovery and advancements in the practice of surgery in medicine with the senior surgeon to successfully treat the patient.

Other senior surgeons have built their careers on the practice of specific procedures that most trainees and young surgeons have rarely seen or even read about in surgical textbooks. These situations are not specific to one discipline in surgery, but rather, are seen in a variety of contexts. Peptic ulcer was traditionally treated as a surgical disease. The long list of post-gastrectomy syndromes and complications also required an equal expertise in identification and management. In 1982, Barry Marshall, AC, DSc, and Robin Warren, AC, discovered Helicobacter pylori, which now is recognized as the cause of 90 percent of duodenal ulcers and 80 percent of gastric ulcers; they received the Nobel Prize in Physiology or Medicine in 2005 for this discovery.

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Medical advancements are particularly evident in the field of vascular and endovascular surgery. The discovery and advancements in the practice of surgery in medicine devices and technologies have changed the way many vascular conditions are surgically treated, allowing for a more minimally invasive and intraluminal approach.

In North America, most infrarenal abdominal aortic aneurysms, ruptured or elective, are repaired with endovascular aneurysm repair EVAR. Since the approval of endograft devices, the number of EVARs performed annually has increased by approximately 600 percent. Most surgical procedures are unlikely to become truly obsolete, but already younger trainees are becoming less familiar with certain open procedures due to significant advances in pharmacology and technology, yielding stronger medications, advanced devices for minimally invasive surgery such as laparoscopy, and endoluminal and endovascular methods for the treatment of common vascular diseases.

Procedural specialists Since 1933, the American Board of Medical Specialties ABMS has overseen the board-certification process for physicians by assisting the now 24 medical specialty boards with developing and implementing educational and professional standards to evaluate physicians. Indeed, the gold standard treatment for achalasia has shifted over time from pneumatic dilatation to laparoscopic Heller myotomy and now, possibly, to other modes.

Medical or surgical treatment? Although temporary relief can be achieved with traditional endoscopic methods, and myotomy remains the gold standard in medically fit patients, the clinical practice varies with demographics and geography. Unless a practitioner has all the treatment modalities in his or her armamentarium, bias in practice pattern is introduced. Pancreatitis with concomitant pancreatic pseudocysts and necrosis have long been exclusively managed with surgery.

Now, however, pancreatic sphincterotomy, stenting, dilatation, and stone extraction of the pancreatic duct, sometimes with extra-corporeal shock wave lithotripsy, are being performed. In other words, viable alternatives to open or laparoscopic surgical cyst-gastrostomy or cyst-duodenostomy or pancreatic necrosectomy are now being performed. The patients often prefer minimally invasive options despite unknown or possibly lower efficacy, similar to the trend with laparoscopic cholecystectomy in the early adoption phase.

Another discipline that is being heavily affected by new technology is cardiac surgery, where percutaneous coronary interventions with or without the use of stents have challenged the use of coronary-artery bypass graft CABG. One-third fewer CABGs were performed in 2008 than one decade earlier.

  • Take, for example, an obese patient who presents to the surgery clinic with a diagnosis of hyperparathyroidism;
  • Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection;
  • Experiments through time that led to the discovery of blood circulation Doctors also conducted experiments;
  • John Simon, who had replaced Chadwick to become chief medical officer to the General Board of Health, turned this work into action;
  • Surgeons did not go to university to study, but were apprenticed to practising surgeons to learn through observation;
  • A review and a word of caution.

In fact, three out of four revascularization patients had angioplasties instead of CABG in 2008, compared with two out of three 10 years ago. The annual rate of CABG surgeries is decreasing steadily due to the introduction of more advanced percutaneous devices, as well as a drop in patient demand and satisfaction. The first robotic cholecystectomy was performed nearly 20 years ago, and since then, robotic surgery has been increasingly widespread. Published data from the Nationwide Inpatient Sample show an increase from 2008 to 2009 in the proportion of prostatectomies, nephrectomies, hysterectomies, coronary artery bypasses, and gastrectomies performed robotically.

Hysterectomy was the second most common 18 percent of total robotic procedure performed in U. A more recent study estimates that 90 percent of prostatectomies and 20 percent of hysterectomies in the U. Data from the Nationwide Inpatient Sample in 2009 and 2010 reveal that less than 3 percent of all colorectal procedures in the U.

Robotic surgery has a significantly higher perioperative cost, but long-term costs are still being evaluated.

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Several recent, large population studies have not revealed improvements in complication rates following robotic hysterectomy, colectomy, or prostatectomy. With proper patient selection and cost containment, it may represent a valuable tool for treating different diseases and specific patient populations.

A large database analysis of robotic hysterectomy for benign disease suggests shorter hospital length of stay than laparoscopy. In addition, research has suggested that robotic colon surgery is associated with lower conversion to open surgery than is laparoscopy, as well as possibly decreased length of hospital stay and postoperative ileus after left-sided resections. Considering the challenges and issues raised in this article and elsewhere in the literature, the benefit of a formal robotic training curriculum is clear.

Interestingly, the learning curve for robotic surgery is not well-established. For example, the minimum number of cases required for competency in robotic prostatectomy—the most commonly performed robotic operation—has been increasing as experience with the procedure has changed over time. Experience has been emphasized as a way to obtain technical abilities. However, experience comes from practice, which should occur only after proper education. Clearly, education is the key, and a previously published Bulletin article on the topic of the future of robotics underscores this point.

To bring fellowship training to a broader range of procedures, various industry leaders are planning to fund the development of clinical robotic fellowships for general surgery starting with the academic year 2016. Today, many patients first turn to the Google search engine before seeking medical attention.

As a the discovery and advancements in the practice of surgery in medicine, patients often obtain fragmented information about their condition, complications, concerns, and hospital stays—which, in turn, sometimes leads to unrealistic expectations.

Take, for example, an obese patient who presents to the surgery clinic with a diagnosis of hyperparathyroidism. However, the surgeon believes that this operation may not be the best option for her and that the traditional approach may allow for the fastest recovery, less operative time, and less discomfort.

Dissatisfied with the conflicting recommendation, her experience is negative. Although she goes ahead with a traditional operation with excellent outcomes, the patient feels frustrated because she did not receive the newest, fanciest operation. After their hospitalizations, patients are given a 32-question survey that addresses the following topics: They may be unable to differentiate primary provider from consultant. Interestingly, the study showed that higher patient satisfaction was associated with less emergency department use, but greater inpatient use, higher overall health care and prescription drug expenditures, and higher mortality.

Now, with the fear of retribution through lack of reimbursement, how will our system change? And as practicing surgeons, we must continue to maintain safety and quality while learning new techniques in a technology-wealthy environment. Edwin Smith Surgical Papyrus: The oldest known surgical treatise. The discovery of the body: Human dissection and its cultural context in ancient Greece.

Yale J Biol Med. Shushruta of ancient India. From barber-surgeon to modern doctor. Two hundred years of surgery.

New Eng J Med. Bile duct injury during laparoscopic cholecystectomy: Results of a national survey. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Windsor JA, Pong J. More than a learning curve problem. A contemporary analysis of 42,474 patients. An analysis of the problem of biliary injury during laparoscopic cholecystectomy.

J Am Coll Surg. Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: A review and a word of caution. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: