Surgery: Under the Operating Light

Surgery: Under the Operating Light

Rihab FELLAH

Medicine has known in these last 200 years great leaps and many cutting-edge revolutions that the contrast of these advancement with the ways of the past leaves us in awe. Of the many medical fields that have changed drastically during this period, surgery is in the lead. And so, on surgery the spotlight must fall today!

It is general knowledge that the history and future of surgery faced a turning point in 1846 when ether anesthesia was introduced (1). Indeed pain has always been a great obstacle in the face of surgical advancement (1, 2). Not only does it worsen patient’s comfort, it is also deeply related to the outcome  of the intervention. Pathophysiologically speaking, pain increases heart rate, systemic vascular resistances and circulating catecholamines resulting thus in an elevated risk of myocardial infarction, stroke and bleeding among other complications. It may alter neural sensitization in both the peripheral and central nervous system which could lead to chronic pain syndromes (2, 11).

Surgeons thus were given a tool that could help them in the operating theatre by extending their operating time. It also lessened for the patient the horror of being operated on in giving him the gift of unconsciousness. It was the birth of anesthesia and anesthesiology.

In 1867, sepsis was also being dealt with. A series of publications in the Lancet by Joseph Lister
(after whom Listeria monocytogenes was named by the way) demonstrated the efficiency of using carbolic acid as an antiseptic to prevent post-operative infection (1). A few decades later, the wear of latex gloves was introduced by Halstead (1).

After these two major discoveries, diseases that have always been an issue and to which medical treatment gave mediocre results have found in surgery the salvation of patient’s endeavors. Among those, there is the common case of Gallbladder disease: cholelithiasis or gallstones (stone in the gallbladder) and cholecystitis (inflammation of the gallbladder).

It is a disease that predominates in the feminine population and increases with age. It concerns a
small pouch annexed to the liver called the Gallbladder which stores bile and excretes it in the Duodenum. This disease manifests often in a typical abdominal pain localized in the upper right quadrant with radiation to the right Scapula area. Such pain is called a hepatic colic. Fever and jaundice maybe associated to it and are signs of complications. These symptoms aren’t constantly found and may even lack in some cases (3).

Gallbladder disease was thought to be caused by an accumulation of black bile. It was treated by many “medical remedies” such as taking ox bile, eating grass and administering ether or other organic solvents in order to dissolute the calculi. None of these remedies proved their efficiency. Even the injections of such solvents endoscopically through the sphincter of Oddi or the use of shock wave therapy (lithotripsy) in association with gallstone solubilizing agents (cheno- and/or ursodeoxycholic acid) proved futile because of the numerous recurrences and multiple complications (3).


Cholecystectomy: from open to closed by keyholes!

Therefore, cholecystectomy became the gold-standard in treating Gallbladder disease. It is one of the most performed surgeries worldwide (1,3,6).

If by chance we took a surgery textbook such as Maingot’s abdominal operation, and compared the chapter on cholelithiasis and cholecystectomy between two editions: one prior to the 1980s and one after, the difference found would be staggering.

Before the 1980s, open cholecystectomy was the standard procedure. Classically, “The operation required a large incision under the patient’s ribs on the right side, allowing the anatomy to be displayed and the gallbladder removed.” (7)

Maingot’s 7th edition described it as follow: “After the [cystic] artery is divided the fatty envelope around the cystic duct is dissected clear, and the duct is traced to its junction with the common hepatic duct and the common bile duct. When there three ducts have been freed and displayed, an aneurysm needle threaded with a strand of 0 (m.4) chromic catgut is passed underneath the cystic duct, and this duct is ligatured almost flush with the main ducts.” (7)

In 2013’s 12th edition, an overall view of the chapter permits us already the interception of words
such as pneumoperitoneum, trocar, electrocautery, laparoscope and entrapment sac. The technique is
described as follow: an “American” or a “French” way refers to the possible position the surgeon might take vis-à-vis the patient. In the former, the surgeon is left of the patient and the assistant is right. In the latter, the surgeon is between the two abducted legs of the operated-on (8).

A pneumoperitoneum is created by insufflating CO2 into the peritoneal cavity to allow future maneuvering. The use of CO2 is advantageous: not only is it a noncombustible gas which allows the use of electric devices, it is also absorbed quickly. The patient is then placed in a reverse Tredelenburg position with a 15° inclination to the left. Four incisions of small diameter are made, called ports: one on the anterior axillary line between the 12th rib and the iliac crest. The second is
right underneath the ribs on the mid-clavicular line. Both of these ports are on the right. Through them are introduced two grasping forceps manipulated by the assistant. Their main function is to elevate the liver (8). The third incision is in the periumbilical region and is for introducing the laparoscope. It has been used beforehand to insufflate the CO2. The last port is situated 5cm bellow the xyphoid process in epigastrium’s midline and is used for inserting dissecting forceps (8).

The actual procedure differs little from the open technique. After dissecting and ligating all the necessary anatomic structures and inspecting for hemostasis and bile leakage, the retrieving of the gallbladder at the end of the cholecystectomy is done with “claw” grasping forceps via an entrapment sac. Everything (sac, forceps and trocar) is then retracted through the umbilical incision and the remaining instruments are restored. Finally, the four ports are stitched up and the patient can go home in the six to twelve following hours (8). A few days later, he would have resumed his daily routine.
One can easily guess the benefits such innovation has over its predecessor. First, it has minimized patient’s hospitalization stay and rendered many an operation doable in outpatient settings. It has also permitted an earlier return to full activity therefore reducing the total costs of the operation. The smallness of the incisions made them more esthetically tolerable and less debilitating for the operated-on (1, 8).


Team work and work hours 

Notable is the trip which the field of surgery had gone through. In fact, of the remarkable changes that came with such an evolution, there is the shift of interest from the surgeon: once main actor of the operating theatre, main conveyer of orders and knowledge to trainees and soul decision-holder, the surgeon is now part of a team. Decisions are more and more made in a multidisciplinary fashion. The patient has also a word to say in the matter and medical care is now said to be patient-centered (6).

In the US and UK, surgical trainees no longer work on call at all time since the 2003 modifications on shift-hours. The regulation has limited work time between 90 and 120 hours for most specialties, with a 24-hours-limit to consecutive hours (non-stop) and an additional 6 hours for education and transfer of care (5).

Evidently, such program did enhance the quality of a resident’s life. Nonetheless, it remains obvious that the discontinuity in medical care through hand-offs and changing teams is subject to controversy. It is also argued that the quality of training has been altered by this disruption. The supporting evidence is however lacking (5).


Clinical trials in surgery

Another challenge faced in this domain is the difficulty of applying evidence-based methods in surgical trials. Indeed, applying placebo-controlling and blinding in order to bypass biases was often thought impossible in surgical interventions. But even this seemingly impossible task was challenged: 66 surgical placebo-controlled trials were reported in the first 15-years of the 21st century versus 19 in all of the 20th century (4).

But what is placebo-controlling? It is having two groups of patients randomly assigned to each. One would receive the tested operation/drug while the other would receive a sham (fake) procedure or a placebo drug (Placebo: Latin for “I will please”, is a pharmaceutical preparation lacking any active ingredient).

Why do we “control” such experiments? We do it to insure their efficacy and superiority to the placebo treatments, verifying thus that the outcome is in fact due to the experimented intervention while eliminating a placebo effect, i.e. the psychological improvement reported after receiving a treatment regardless of its actual efficacy (12).

Why is it done “randomly”? Randomization guaranties no other factor has influenced the outcome between the two groups other than the difference in the experimented intervention. For example, let’s say a treatment called T for a disease is about to be tested and controlled with a placebo P in a non-randomized trial. One might put very sick people in the group receiving treatment T and mildly sick people in the group receiving Placebo P. When assessing the outcome, the result was little improvement observed in the T group compared to the P group. Was it due to the treatment itself?Was it not because the individuals in T group were clinically worse than those in P group? We couldn’t possibly know as we wouldn’t if the situation was vice versa. A simple solution would be to randomly allocate people to each group, ensuring there’s no systematic differences between intervention groups in other factors (13).

How would a sham surgery be done? Many examples exist, one of which is seen in faking an orthopedic operation such as a menisectomy. Surgeons are required to use a mechanized shaver to which the blade has been removed. Applying it against the patella mimics the actual operation. Some had to prolong the duration of the sham operation in the control group so as to match that of a real one (4).

As to blinding, it is the case when the patient doesn’t know what group he belongs to. The operation would be called double-blinded when both the attending physician and patient are in the dark. Thus, eliminating any biases that might be encountered while assessing outcomes (12).

Some of the biases observed in patients that blinding surpasses: if a patient knows he is in the control group, he might not comply with the prescribed medication or protocol (non-compliance). He might also drop out from the trial (attrition bias). Some might seek other treatments elsewhere “contaminating” the experiment (Co-intervention).

In outcome assessors, not knowing which group is which prevents observer bias which is the tendency to assess patients with experimented intervention more favorably (12).
Blinding has been rendered more and more feasible in the field of surgery due to the fact that there’s an increasing use of implants and energy-emitting tools. The surgeon would simply introduce the catheter in and leave the subsequent procedure for a technician to follow it through, never knowing therefore whether the operation was completed or not (4).

It is regarded by some as unethical to fool a group of patients into thinking they have been operated on when they were simply incised and stitched back up. Others would speculate on the high costs of such procedures. It is, however, necessary to back up surgical results observed in the field with valid data and prevent useless interventions from being utilized at high costs.


Other challenges? 

Surgeons today still face many challenges. Though history may show them to have conquered many obstacles, we must bring to attention the fact that post-operative pain and sepsis remain major health problems and account for high mortality-rates and care-costs in hospitals throughout the world. Nevertheless, this burden is nowadays shared by both surgeons and other specialists, showing the importance of team work in handling these delicate issues (9, 11).

Furthermore, the frequent use of state-of-the-art techniques as is the case with laparoscopic cholecystectomy may have amputated surgical trainees from learning the open cholecystectomy as once taught before the 1990s. Keeping in mind that if a minimally invasive procedure goes wrong, the conversion to open laparotomy is a must. Acute cholecystitis is one of such cases where the risk of conversion is high10 which emphasizes the importance of an experimented hand in managing such situations. A solution may come in the form of simulation based re-enactment or SBR7. SBR offers surgical residents and medical students the chance to revisit the operating theatre and re-enact the classic open cholecystectomy under the supervision of a senior surgeon on a mannequin with animal organs. Not only does it help residents with technicalities it also imprints them with all tacit behaviors that no textbook nor teacher bothers talking about anymore because they seem too obvious to be explained (7).

In conclusion, some might entertain the preposterous idea that the future holds no place for surgery1, arguing that in an era where nanotechnologies are taking over every field, the minimally invasive might be replaced by the molecularly invasive. I personally think that surgery could never be lost. How so? When it keeps rising up to all and every challenge put up to it? But this particular bias of mine can only be effectively proven (right or wrong) by time.


References

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8- Auyang E, Soper N. Cholecystitis and cholelithiasis. In: Zinner M, Ashley S, ed. by. Maingot’s ABDOMINAL OPERATION. 12th ed. 2013.
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10- Coccolini F, Catena F, Pisano M, Gheza F, Fagiuoli S, Di Saverio S et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. International Journal of Surgery. 2015;18:196-204.
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