General Surgery: An introduction

Dr. F van der Schyff

Transplant Surgeon

Wits Donald Gordon Medical Center

Surgery defined

• Surgery is a procedure that involves cutting a patient’s tissue or closing a previously sustained wound
• Surgery is defined as the treatment of injuries or disorders of the body by incision or manipulation
• In any other setting, surgery would = assault!
• Obtaining full consent and establishing a trust relationship between the surgeon and the patient is vital

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Why do we need to perform surgery?

According to Ambroise Pare, 16th century French military surgeon:

1. Eliminate that which is superfluous
2. Restore that which has been dislocated
3. Separate that which has been united
4. Join that which has been divided
5. Repair the defects of nature

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3 Serious barriers to the development of surgery

1. Pain (Modern anaesthesia, mechanical ventilation)

2. Bleeding (Blood products and transfusions)

3. Infection (Antimicrobials, sterile technique)

• Advances in these fields have transformed surgery from a risky "art" into a scientific discipline capable of treating many diseases and conditions
• Longmire considered the liver to be a hostile organ: “because it welcomes malignant cells and sepsis so warmly, bleeds so copiously, and is often the 1st organ to be injured in blunt abdominal trauma”

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What is general surgery: American College of Surgeons

• A discipline of surgery having a central core of knowledge about:
• Anatomy
• Physiology and metabolism
• Immunology
• Nutrition
• Pathology
• Wound healing
• Shock and resuscitation
• Intensive care
• Neoplasia
• A GENERAL SURGEON is one who has specialized knowledge and experience related to the diagnosis, preoperative, operative, and postoperative management, including the management of complications.

Scope of general surgery

• Abdominal surgery (Liver, pancreas, diaphragm, small bowel, large bowel, kidney)
• Breast, skin, and soft tissue
• Head and neck (incl. trauma, vascular, endocrine, congenital and oncologic disorders)
• Vascular system (excl. the intracranial vessels and heart)
• Endocrine system (incl. thyroid, parathyroid, adrenal, and endocrine pancreas)
• Surgical oncology
• Comprehensive management of trauma
• Complete care of critically ill patients with underlying surgical conditions (Emergency room, intensive care unit, and trauma/burn units)

Classification of general surgery procedures

• Urgency
• Elective: pre-planned to suit patient and facility, no ill effects of delay in procedure
• Urgent: must be performed in a relatively short time frame to avoid poor outcomes (appendicectomy, amputation)
• Emergency: must be performed immediately to save the patients life (arrest of hemorrhage, removal of necrotic tissue, relief of bowel obstruction)
• Risk
• Major surgery: Requires hospitalization and specialized care, carries higher degree of risk, involves major body organs or life-threatening situations
• Minor surgery: Short day cases with low risk for complications. Mostly elective.
• Purpose

General surgery procedure classification based on purpose

• Diagnostic (e.g. Biopsy, bronchoscopy, endoscopy)
• Ablative (removal of a diseased body part: amputation, mastectomy)
• Reconstructive ( Restores function or improves self concept: Tissue flaps, breast reconstruction, cosmetic)
• Constructive (Repair of congenital defects: Cleft lip repair, cardiac defect surgery)
• Transplantation (Replaces solid organs or tissues which are diseased)
• Palliative (non-curative procedure to reduce intensity of illness: nerve ablation, bowel diversion)

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Prerequisites for a successful operation

Correct patient:

Fit for the procedure intended

Consented fully

Assent in children

Correct indication

Correct timing:

Optimized patient

Optimized theater and staff (level of training, equipment)

Correct surgeon:

Adequately trained

Help at hand

Able to handle own complications

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If in doubt, cut it out! But…�When not to operate?

• Absolute contra-indications:
• Moribund state
• Prohibitive cardio-respiratory compromise
• Severe metabolic or hemostatic imbalance
• Lack of informed consent (expect in life-threatening cases)

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• Relative contra-indications:
• Age
• Pregnancy (depending on trimester)
• Co-morbidities
• End-stage incurable disease
• Better alternative therapies
• Technical issues

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The surgeon’s job: far beyond manual abilities

• Theoretical knowledge
• All possible treatment options, esp. non-surgical ones
• Assessment of risk vs. benefit
• Practical knowledge
• Experience: beyond the learning curve
• Honour your limits
• Audition your results
• M and M
• Publish your units outcomes
• We will all hurt patients. But not learning from it is the ultimate disservice.

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• Knowledge of the patient
• History, examination, special investigations
• Never operate on a patient you have not reviewed and examined yourself!

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What is general surgery not?

Surgical specialties

The road to becoming a general surgeon

• MBChB: 5-6 years
• Internship and community service: 3 years
• Medical officer post 1-3 years
• Training registrar post (affiliated with a university with a training number): 4-5 years. 3 Sets of exams and research dissertation and logbook filled
• Subspecialty: 2-3 years
• Followed by a lifetime of learning, preferably under a mentor

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Career pathways for a general surgeon

• General Surgeon in State practice
• General Surgeon in Private practice
• Subspecialist in state or private practice
• Subspecialist in an academic firm or partnership, affiliated with the university

What does a student and intern need to know

• General conduct
• Emergency room conduct
• Theater conduct
• Ward conduct

General conduct

• Every patient presenting to you is in a vulnerable, frightening situation
• Establishing a trust relationship with the family and patient, based on competent management and good communication is key
• That patient is your responsibility until discharge, and often thereafter
• Things that should not need mentioning:
• Your dress and personal hygiene should reflect the respect you have for the patient
• Watch your language around overhearing patients
• Check and recheck on your patient throughout your treatment plan
• The patient who irritates you most, is in most danger of having something missed (drunk, belligerent, difficult patients)

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The general surgery patient in the emergency unit

• Recognize the shocked patient
• Start resuscitation in parallel to other activities
• Always cover the basics: Airway, Breathing, Circulation, Neurological status etc…
• Always wear protective gear against blood, secretions and radiation
• Take a thorough history
• Focus on previous surgical complaints, surgeries, co-morbidities which elevates risk (DM, HPT, Cardiac)

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• Examine each patient
• Each patient offers you the privilege to learn from his/her illness, harness every opportunity to hone your clinical skills
• Verify your findings with a senior
• Make good notes
• Legal document
• If it is not recorded, it was not done.
• Record all specialties consulted with dates and times.

What happens in theater

• Theater prep:
• Previously used instrument sets and anesthetic disposables removed, including light handles
• Bed, all trolley surfaces cleaned, floor mopped
• New anesthetic drugs pulled up, correct surgical sets fetched from CSSD, clean linen placed on bed
• Introduce yourself to the scrub nurse, floor nurses, anesthetist , anesthetic nurse, perfusionist, lab technicians and radiographers: The surgeon is in charge of the theater and a successful operation depends on the team work of each member
• Confirm that blood products are available, all required surgical instruments are available and working
• Run through the procedure with the anesthetist: cross clamping planned, anticipated blood loss, need for single lung ventilation
• Call for the patient/ fetch patient from ICU with the anesthetist

Once the patient arrives in theater..

• Confirm consent forms are correctly filled in
• Do first surgical pause: patient identified, doctors identified, procedure planned, allergies, antibiotics to be given
• Patient transferred to bed: protect the patients dignity, roll the patient if weak or in pain
• Anesthesia administered (help where you can, e.g. invasive lines, catheterize, pre-wash the area)
• Set theater lights in correct position
• Check instruments and laparoscopic stacks
• Do not touch any green sterile packs being opened: be mindful of where the scrub nurse is working
• Do not walk through the sterile trolleys and the right side of the theater bed: it is a sterile zone
• Empty your bladder and eat something before every case!

Scrubbing for a case

• Check hair is covered, face mask fitted, elbows exposed. Fit surgical loops securely, attach light source
• Open taps to supply warm water, not scalding
• Keep hands above elbows at all times
• Dispense soap into one hand, using opposite elbow to dispense. Wash from the elbow to the wrist. Leave soap on and repeat on the other side.
• Dispense soap and wash hands, at least once with a brush under the nails. Make sure to cover the wrists, in between fingers, finger -tips, web spaces, back of hands
• Rinse soap from finger -tips down to elbow
• Dry each arm and hand from the fingertips down in one motion
• Discard towel away from sterile trolley
• Unfold sterile gown away from you, insert arms without ever touching the outside of the gown
• Don each glove sterile, making sure it covers the cuff of the gown fully
• Sister will tie your gown at the back, hand the waist tie to her with the end having a detachable tag onto it
• Walk purposefully to the left side of the bed once the scrub sister has finished draping and rest your hands on the patient

Laparotomy surgical instruments

Morris retractor

Deaver retractor

Copper maleable

Mosquito clamp

Burkitt clamp

Crile clamp/Straight clamp

Forceps: toothed (Guillies),

non-toothed (tissue forcep/DeBakey)

Needle holder

Angled Lahey/ Go-rounder

Scissors: Tissue scissor/McIndoe,

stich scissor

During the operation

• Anesthetist will be at the head-end of the table with a screen between him/her and the operative field (aka. Blood-brain barrier). You should still be able to see the patient’s vitals.
• Lead surgeon will stand on the right side of the table
• Scrub nurse will stand on the left side of the table (some surgeons prefer them on the right), with the Mayo table set up
• First assistant will stand on the left side of the bed, second assistant at the discretion of the lead surgeon
• Do not touch your face, do not scratch your head. Do not touch the sterile light handles with your head.
• Sneeze into the mask, don’t turn you head away (the bugs will fly out the side).
• Do not fart: the surgeon may worry about a bowel injury.
• If you feel faint, tell the lead surgeon. Do not collapse into the wound.
• Do not sweat into the wound.
• Watch out for needles.
• Suction where you expect the surgeon would like to see without being asked.
• Do not take criticism personally, some cases are very stressful

After the operation

• Do not rush to un-scrub and disappear for coffee
• Help the scrub nurse confirm all swabs and instruments are accounted for before closing
• Help to undrape the patient
• Help to move the ward/ICU bed into theater
• Help the anesthetist to move the patient across from the operating table
• Make good notes on the operation performed (lead surgeon)

Ward conduct

• See your patient properly at least twice a day, and always before you leave for home
• Hand over any issues to the person on call on paper
• Listen to patients. They are as entitled to develop a new problem as any patient presenting in the emergency department.
• Listen to your nursing staff. They see much more of the patient than you and often spot deterioration best.
• Listen to the family, especially a mother in the paediatric ward. A parent knows the child best
• Update each family on the progress of the patient, especially the critically ill patient or patients who had been operated on that day
• Communication is key: the vast majority of medical litigation is not because of honest mistakes, but poor communication around the event and negligence in rescuing the situation

Interaction with other specialists

• There is a natural tendency for each specialist to think their field is superior to all others
• Know that each clinician has trained hard and sacrificed much to be where they are, and is very likely to know something you don’t
• You will need a friend in each field to ensure good outcomes for your patient
• Do not perpetuate the cycle of speaking ill of other disciplines when they are not there to defend themselves
• Stereotypes exist for a reason, but each doctor remains a human being with similar needs to your own (getting their patient through, getting home to their families, coping with sleep-deprivation, training and stress)
• If a colleague is a real problem, escalate the matter in private.

Core knowledge: Common conditions, emergencies and malignancies

• Resuscitation of the shocked patient
• Trauma: Abdomen, chest, head and neck, vascular, orthopedic
• Vascular: AAA, the threatened limb
• The acute abdomen:
• Perforated hollow viscus (peptic ulcer, diverticuli, malignancy, necrotic bowel)
• Ischemic bowel ( complicated bowel obstruction, volvulus, thrombosis of the inflow or outflow vessels)
• Appendicitis
• Hernias and their complications (including diaphragmatic, inguinal, femoral, incisional, internal)
• Cholecystitis and gallstone disease (choledocholithiasis, cholangitis)
• Pancreatitis
• Malignancy:
• Breast, Colon, Melanoma, Thyroid, Pancreatic, Oesophageal

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Common radiological problems

OESOPHAGEAL CANCER, ACHALASIA

• GASTRIC OUTLET OBSTRUCTION, HIATUS HERNIA

Common radiological problems

SMALL BOWEL OBSTRUCTION, PNEUMOPERITONEUM

• LARGE BOWEL OBSTRUCTION

Common radiological problems

DIVERTICULAR DISEASE

• BREAST CANCER

Transplantation

The future of general surgery

• Super-specialization
• The rise of the generalist
• Robotics and remote surgery
• Telemedicine
• Personalized medicine
• CRISPR and gene editing
• Xenotransplantation
• Machine perfusion and auto-transplantation

Personal considerations

• By far the biggest challenge of your life will be to balance the needs of you family with that of your patients
• Surgery will take its toll on even the strongest of partnerships
• Keep your partner and children involved and informed on what is going on in your life: they are part of the team!
• Never waste time at work, that is precious time away from your family

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Conclusion

• General surgery is a wide, challenging field
• To become a good surgeon will take up most of your adult life
• The road is riddled with hardship and set-backs and sacrifice
• It is one of the most direct ways of stalling death and relieving suffering
• Many patients are ungrateful, but most will bring more to your life than you to theirs
• Children are very forgiving, up to a point. Prioritize your family. They will grow old with you, not patients or colleagues.