Description
Asepsis, hemostasis, and gentleness to tissues are the bases o the surgeon’s art. Nevertheless, recent decades have shown a shi in emphasis rom the attainment o technical skill to the search or new procedures. T e advances in minimally invasive techniques have allowed the surgeon great exibility in the choice o operative techniques. Nearly all operations may be perormed by an open or a minimally invasive laparoscopic technique. T e surgeon must decide which approach is in the best interest o the individual patient. In addition, application o robotic surgery has added a new dimension to the surgical armamentarium. T roughout the evolution o surgery it has been recognized that aulty technique rather than the procedure itsel was the cause o ailure. Consequently it is essential or the the young, as well as the experienced surgeon, to appreciate the important relationship between the art o per orming an operation and its subsequent success. T e growing recognition o this relationship should reemphasize the value o precise technique.
T e technique described in this book emanates rom the school o surgery inspired by William Stewart Halsted. T is school, properly characterized as a “school or sa ety in surgery,” arose be ore surgeons in general recognized the great advantage o anesthesia. Be ore Halsted’s teaching, speed in operating was not only justi ed as necessary or the patient’s sa ety but also extolled as a mark o ability. Despite the act that anesthesia a orded an opportunity or the development o a precise surgical technique that would ensure a minimum o injury to the patient, spectacular surgeons continued to emphasize speedy procedures that disregarded the patient’s wel are. Halsted rst demonstrated that, with care ul hemostasis and gentleness to tissues, an operative procedure lasting as long as 4 or 5 hours le the patient in better condition than a similar procedure per ormed in 30 minutes with the loss o blood and injury to tissues attendant on speed. T e protection o each tissue with the exquisite care typical o Halsted is a dif cult lesson or the young surgeon to learn. T e preoperative preparation o the skin, the draping o the patient, the selection o instruments, and even the choice o suture material are not so essential as the manner in which details are executed. Gentleness is essential in the per ormance o any surgical procedure.
Young surgeons have dif culty in acquiring this point o view because they are usually taught anatomy, histology, and pathology by teachers using dead, chemically xed tissues. Hence, students regard tissues as inanimate material that may be handled without concern. T ey must learn that living cells may be injured by unnecessary handling or dehydration. A review o anatomy, pathology, and associated basic sciences is essential in the daily preparation o young surgeons be ore they assume the responsibility o perorming a major surgical procedure on a living person. T e young surgeon is o en impressed by the speed o the operator who is interested more in accomplishing a day’s work than in teaching the art o surgery. Under such conditions, there is little time or review o technique, discussion o wound healing, consideration o related basic scienti c aspects o the surgical procedure, or the criticism o results. Wound complications become a distinct problem associated with the operative procedure. I the wound heals, that is enough. A little redness and swelling in and about wounds are taken as a natural course and not as a criticism o what took place in the operating room 3 to 5 days previously. Should a wound disrupt, it is a calamity; but how o en is the suture material blamed, or the patient’s condition, and how seldom does the surgeon inquire into just where the operative technique went wrong?
T e ollowing detailed consideration o a common surgical procedure, appendectomy, will serve to illustrate the care necessary to ensure success ul results. Prior to the procedure, the veri ed site o the incision is marked with the surgeon’s initials by the operating surgeon. T en the patient is trans erred to the operating room and is anesthetized. T e operating table must be placed where there is maximum illumination and adjusted to present the abdomen and right groin. T e light must be ocused with due regard or the position o the surgeon and assistants as well as or the type and depth o the wound. T ese details must be planned and directed be ore the skin is disin ected. A prophylactic antibiotic is administered within 1 hour o the skin incision and, in uncomplicated cases, is discontinued within 24 hours o the procedure.
T e ever-present threat o sepsis requires constant vigilance on the part o the surgeon. Young surgeons must acquire an aseptic conscience and discipline themselves to carry out a meticulous hand-scrubbing technique. A knowledge o bacterial ora o the skin and o the proper method o preparing one’s hands be ore entering the operating room, along with a sustained adherence to a methodical scrub routine, are as much a part o the art o surgery as the many other acets that ensure proper wound healing. A cut, burn, or olliculitis on the surgeon’s hand is as hazardous as the in ected scratch on the operative site.
T e preoperative preparation o the skin is concerned chie y with mechanical cleansing. It is important that the hair on the patient’s skin is removed with clippers immediately be ore operation; pre erably in the operating suite a er anesthetization. T is eliminates discom ort to the patient, a ords relaxation o the operative site, and is a bacteriologically sound technique. T ere should be as short a time-lapse as possible between hair removal and incision, thus preventing contamination o the site by a regrowth o organisms or the possibility o a nick or scratch presenting a source o in ection. T e skin is held taut to present an even, smooth sur ace, as the hair is removed with power-driven disposable clippers. T e use o sharp razors to remove hair is discouraged.