1. Conflicts (2) Violence (3) War

• Surgery is the practice of treating diseases, injuries and deformities by operative, manual or instrumental methods

• 1840 - Anaesthesia - Wells, Morton, Simpson (no anaesthesia = hurried surgery; ether = formerly used; still use in 3rd World countries)
• 1860 - Antisepsis - Lister
• 1880 - Germ Theory; Asepsis - Koch, Bergmann
• 1900 - Blood transfusion - Landsteiner (allows magnitude of operation to increase)
• 1920 - Parenteral fluids - Gamble (esp. when intestines cannot absorb fluids)
• 1930 - ABX - Fleming, Chain, Florey (ABX available for 1st time during WWII; ABX resistance)
• 1950 - Open heart surgery; Vascular prosthesis
• 1960 - Kidney transplantation (ice - decrease metabolism and metabolic by-products do not freeze because crystals damage cells; once transplanted, colour returns and it immediately produces urine)
• 1970 - Microsurgery
• 1980 - Liver/ heart transplantation (once transplanted, liver immediately produces bile); Artificial tissues + organs; Lithotripsy
• 1990 - Minimally invasive surgery (keyhole surgery; less trauma; shorter hosp stay) - eg. Gallstones, arthroscopy (note: 5 x 1" key-holes is better than 1 x 5" incision)
• 2000 - Twd zero operative mortality; Stem cells (note: for oeso ca resection, hospital mortality and 30-days mortality is going to zero; this translates into longer survival; medial survival has doubled, 5-yr survival has increased by 20-30%)

• Operation = procedure (1) Open, eg. Thoracotomy (2) MIS, eg. Laparoscopic cholecystectomy (3) Non-invasive, eg. Reduce # (4) Conservative, eg. Close observation, meds
• Surgery = discipline

All operations carry risk of complications or death

1. Emergency vs. elective: emergency - don't have time to prepare Pt properly
2. Major vs. minor
3. Solid organ vs. hollow organs - solid organ harder to handle
4. Cancer vs. non-malignant: ca operations more difficult
5. Elderly vs. young
6. Long vs. short illness
7. Prolong vs. expeditious operation
8. Surgeons vs. residents

Operative risk depends on

1. Condition of the disease (eg. Ca staging; duration disease has been present)
2. Condition of the patient: age, smoking, DM (most factors cannot change; may be able to reverse some physiological disturbances - eg. Intestinal obstruction: can correct electrolyte disturbances)
3. Condition of the surgeon (surgeons' technical skill matters in saving lives)

• A 20-year old man with short history of acute appendicitis ® Supervised intern (1st year resident; 2 years out of medical school)
• A 50-year old diabetic lady with an obstructing cancer of ascending colon, presenting with a 2-day history ® Need major laparotomy, chief resident/ senior medical officer (independently)
• A 75-year old man, a heavy smoker, with a cancer of the middle third of the oesophagus and dysphagia for 2 months ® Major operation, chest compromised, need good team (+ professor, consultant)

1. Localisation: where is the problem
2. How fit is the Pt? What has this done to the Pt? How much of it is reversible?

• The patient as a whole
• Localisation of lesion
• Physiological consequences

• Operative procedures are usually carried out on diseases of one anatomical site. Therefore an operation is often restricted to one part of the body, eg. abdomen, chest, brain
• Because diseases in one organ can involve adjacent structure/ system, exact localisation is desirable/essential prior to operation (1) Abdomen, intestine vs. liver (2) Chest; lung vs. mediastinum (3) Neurosurgery, head and neck
• No investigation can give 100% accuracy consistently.
• Precision is more important in some situations, e.g. cancers invading vital structures.
• "Exploratory" laparotomy is still necessary in some patients, but has decreased because of US, CT, MRI, laparoscopy.

• Anatomy
• Distortion from disease
• Flexibility
• Repertoire
• Safety is priority

1. Localised solid organ lesions: usually cancers, or benign tumours
2. Blockage of hollow structures: tumour, stones, foreign body
3. Bleeding, e.g. GI tract, solid organ
4. Trauma: WW, MVA, triads, construction injuries
5. Organ transplantation
6. Localisable inflammatory/infective conditions
7. Congenital anomalies
8. Acquired conditions, eg. hernia, haemorrhoids, varicose veins, cystic diseases

• Resection: to remove - usually a mass
• ectomy: to remove
• otomy: a temporary opening in a hollow organ
• ostomy: a permanent opening in a hollow organ
• Anastomoses: a permanent connection between two hollow organs

A 50-year old patient with an obstructing ascending colon cancer:

1. Exploratory laparotomy (wondering whether infiltrated ab, metastases, LN enlarged, liver secondaries?)
2. Caecotomy to decompress the obstruction (air comes out)
3. Right colon and terminal ileum is mobilised
4. The right colon and terminal ileum is resected - or right hemicolectomy (after blood supply secured)
5. An ileo-colic anastomosis is made - or an ileo-colostomy is made; with a covering protective ileostomy (protects anastomosis by directing faecal stream outside anastomosis)
6. Note: Anastomosis: Joining of two hollow organs (intestine, ducts, blood vessels, urinary system, trachea/bronchi)

Operation site

• Bleeding: immediate to 1-2 days
• Anastomotic leakage: within 1-2 weeks
• Infection: within 1-2 weeks

• Ileus/obstruction
• Urinary problems

• Pain
• Pulmonary
• Cardiac
• Metabolic
• Organ dysfunction

• All postoperative complications are related to operation until proven otherwise (eg. If Pt has hypotension post-op, not because Pt had MI, because Pt bled)
• Deal with complications as early as possible; preferably prophylactically (eg. Pulse increases before BP decreases - therefore if Pt has tachycardia, do not assume Pt has fever, assume he is bleeding)
• Be paranoid about everything. Anything that can go wrong will go wrong
• Change management only in the mornings on week days (when everyone is around)

• Surgeons' mistakes are directly attributable
• Surgeons are more liable to legal action
• Surgeons' success is more personalised
• Surgical decisions are made upon incomplete information (esp. in emergencies)
• Surgeons love operating

Operations are jt decisions

1. Surgeons, other specialists
2. Patients, close relatives
3. Others, in special situations

Palliative medicine (esp. ca Pt's)