SURGERY – THE WONDERS WE CREATED AND THE POTHOLES WE DUG

55 Years ago, as an intern, I slept in a hospital provided room and worked most days. Meals were free and I was paid $55 every 2 weeks. When rotating through surgery I rolled out of bed between 5 and 6 A.M. and accompanied the cowboys of the hospital, the general surgeons, as they made in-patient rounds. We ate breakfast and washed hands for 10 minutes by the clock. Mornings were spent tugging on a retractor, stretching open the edges of the wound while a gall bladder was being removed.

Long skin incisions were usually needed when the surgeon was operating on someone who presented to the emergency room with severe pain and rigid abdominal muscles, or when merely touching the belly made the patient withdraw. Sometimes we wondered if the appendix had ruptured? Was blood pouring into the abdomen of a person who had been shot or stabbed? Why did the X-Ray show air filling the abdomen? Did an ulcer perforate?

The lengthy slash through the skin and the fat layer was followed by a pause to buzz (electrically cauterize) or tie off the severed ends of bleeding arterioles. A series of additional gashes cut a path through layers of fat and muscle. A scissors sliced open the peritoneum, the membrane that surrounds the organs. The opening had to be large enough for the surgeons to see what they were doing and to get their tools and hands inside. Sliding a large light over the opening, an assistant would aim the beam down the long, dark tunnel. The smaller the gap, the more precise the ray had to be. Deep inside tissue was cut, clamped, and sewn by skilled people using long handled tools. Adhesions, fibrous tissue caused by prior operations, created matted intestines and made it hard to identify various organs, blood vessels, or nerves. By slipping a hand into the cavity and palpating the edges of the liver, pancreas and other organs— by feeling for masses or abnormalities, the surgeon “explored the abdomen”. Aware of “the possibility and consequences of failure,” the surgeons needed to be able to improvise when they had a complication or encountered something out of the ordinary. The people doing the cutting had spent many of their waking hours practicing basic techniques like sewing and tying knots, and they were adept. When I was a junior medical student one of my buddies bragged that the resident let him remove the patient’s appendix. It made no sense at the time, and it still doesn’t.¹⁷

Man has long known how to “suture lacerations, amputate limbs, and drain pus.” Prior to 1858 the people who cut and sawed learned their craft as apprentices. When gangrenous or damaged limbs had to be amputated, resections were quick, bloody, and accompanied by loud shrieks. The fastest knife in England was wielded by Scottish surgeon Robert Liston. “Operating with a knife gripped between his teeth,” he could amputate a leg in two minutes. On one occasion he inadvertently cut off the fingers of someone holding a person down. The stump end of the man’s fingers and the raw end of the hip got infected and both men died.

Elective surgery was uncommon. Perforations or obstructions of the intestine were not approached. In the U.S. and Europe, medical school learning was “wholly didactic: seven or eight hours of lectures a day, supplemented by textbook reading. Laboratory work was sparse, and there was no opportunity to work with patients.²⁸”

In the 1800s some surgical procedures were carried out in homes. Doctors at a few prestigious hospitals performed operations on a stage that was surrounded by a semicircle of tiered seats. Observers apparently came to watch and perhaps be “thrilled by spectacular public performances.²⁴”

In the mid 19^th century we learned about and started using anesthesia to prevent pain. Surgeons could now enter the abdomen or thorax, but they didn’t know what to do when they got there. Operating rooms became “quiet and to the observer seemed tedious.” A number of new operations were developed and there were risks, failures, and deaths. Apprentices learned the techniques of one practicing surgeon, then struck out on their own. There were no blood banks or antibiotics. It’s not clear how often the adage see one, do one, teach one was more than a tall story.^{25, 26}

In 1890, William Halsted, the son of a wealthy “tight-fisted, hard- nosed Presbyterian” started the nation’s first surgical residency program at Johns Hopkins University in Baltimore Maryland. “Self trained, as were all U.S. surgeons of the day, he spent 1 year as an intern at Bellevue, 1 year as a house physician at New York Hospital, and then 2 years abroad as an observer.” While in Germany, Austria, and Switzerland, he saw how other countries trained young surgeons, and he realized the U.S. system was ineffective. There was no mechanism for developing and passing knowledge on to other doctors. Halsted developed the nation’s first residency program at Johns Hopkins Medical School. ³⁰

For many years Halsted trained many of the nation’s future teachers and professors. The doctors on his service created and modified operations, and they taught one another. 11 of his 17 chief residents started training programs in hospitals in other parts of the country.

A “bold aggressive surgeon” when young, Halsted was addicted to morphine and heroin when he came to Hopkins. His operations were performed “almost excruciatingly slowly and meticulously.” On one occasion he must have been under the influence because he stopped operating and asked an assistant to scoot over. The man had been standing on his foot for the pervious half hour.” Outwardly shy, Halsted was adamant about cleanliness, bleeding control and carefully reconstructing tissue. He had quirks like shipping “dozens of his dress shirts to Paris or London every year for laundering. His wife was only allowed to burn white oak and hickory in his fireplace.” In his operating room surgeons and nurses wore rubber gloves not to prevent infections but because one of the scrub nurses developed a rash when she immersed her hands in mercuric chloride.

Dubbed the nation’s father of neurosurgery, Harvey Cushing, was born into status and privilege. His father, grandfather, and great grandfather were all prominent Cleveland surgeons. He was a descendent of the Puritans who landed in Boston 18 years after the Mayflower, and he was a descendent of the nation’s 4^th ever Supreme Court justice. At Yale he was a gymnast and would somersault backwards with a lighted cigarette in his mouth.” After medical school his money and influence allowed him tour Europe and meet and observe the world’s most prominent surgeons. In 1913, after spending 4 years as one of Halsted’s surgical residents he moved to Boston. When Harvard’s Peter Brent Brigham opened its doors in 1914 he was the hospital’s first chief of surgery and the founder of the country’s second surgical training program.

During the First World War Cushing performed surgery on soldiers with severe head wounds. Up to 8 times a day he removed a part of the bone from the skull and exposed the brain. Later at Harvard he learned and taught many others how to operate on brain tumors. A talented surgeon, Cushing had removed 2000 brain tumors by the time he retired. His mortality rate was half that of his colleagues.

Described as “a man of ambition, boundless, driving energy, and a fanatical work ethic,” he also had “a penchant for self-promotion and ruthlessness.” He insulted his residents and operating-room nurses for their errors and tended to blame others for his mistakes. Outside the hospital he paid little attention to his family and had no patience for women. When “his oldest son, 22 year old William was killed in a traffic accident Cushing received the news in a telephone call in the morning, informed his wife, and continued to the hospital to perform his scheduled surgery.¹⁸

Two decades later in St Louis Missouri, Evarts Graham removed a lung that contained cancer and his patient survived. Graham went on to become one of the giants of his era.

Deciding at a young age that he would follow his father’s path and become a doctor, Graham went to Princeton, then Chicago’s Rush Medical school. His father David, a professor of surgery at a women’s college and a hospital chief of staff, was well connected. David presumably learned how to operate as an apprentice and he was not (according to his son) “by any means a polished or trained surgeon.” I suspect he didn’t wear a mask when he operated because his son tells of how, prior to performing surgery, David Graham washed his hands then “washed his beard in antiseptic solution.”

Evarts, ever ambitious, became the president of his class, performed 50 autopsies while in school, and wrote a number of journal articles. In 1907 when most graduates “left school and became general practitioners,” he spent five months as a surgical intern. He assisted his father, “occasionally performed operations under his dad’s supervision,” and at the end of his internship believed he was qualified.

Joining a group of physicians in Mason City Iowa a town of 22,000, he was appalled when he learned that surgeons paid colleagues a portion of their fee for referring the patient. Surgeons, he believed, should not be chosen on the basis of how much they pay the referring doctor. Becoming embroiled in a campaign to end “fee splitting,” he was considered an upstart by some colleagues, and was the brunt of “personal attacks.” When the U.S. entered the First World War in 1917 he volunteered for the army and left town.

Unable to become a battlefront surgeon because his vision was “defective”, he became an assistant Surgeon General. Young and inexperienced, he was sent to Alabama and given orders to take charge of the local military hospital. When he presented his papers to the facility’s medical commander, the doctor refused to step down. He “didn’t give a damn about Graham’s orders” and called Graham a fly-by night major. Evarts fought back, tried to label the Colonel a German sympathizer, and got the Surgeon General involved. The hospital eventually became Graham’s, but the facility wasn’t sent to Europe until November 1918, the month the war ended. Graham was in charge during the 1917 and 1918 influenza pandemic. It devastated the world and killed more soldiers than the enemy fire had.

While in the military, Graham studied empyema, pus that developed in the space just outside the lungs but inside the thorax, in some people who had pneumonia. The smelly material had to be removed but “open drainage resulted in a high immediate mortality rate.”³²Graham was part of a group that figured out the safest time to draw off the fluid. In civilian life the infected liquid was usually a result of pneumococcal pneumonia. It typically appeared after the infection was improving, at a time when the lung was partially attached to the chest wall by scar tissue. Drainage was safe.

In people with battlefield wounds the pneumonia was often caused by streptococcus. The fluid appeared early, was massive and thin “like pea soup.” Adhesions would not form for a few weeks When a large amount of fluid was drained too early the mediastinum, the structure that encased the heart, often shifted dramatically and the good lung collapsed. Many died.³⁵

After the war ended, based on recommendations from doctors in Chicago, Graham was chosen to be the professor of surgery at Washington University in St. Louis, a school that was growing and reorganizing. In the early 1900s the university had been rated as “a little better than the worst”. After the world war it received funding from Rockefeller and Robert Brookings, a St Louis millionaire who grew rich selling wooden spoons and bowls. The school was hiring and paying full time professors. No longer needing a private practice on the side, doctors were salaried and could devote all their time to teaching and research. The concept was new, but Graham embraced it, his department developed surgical subspecialties, and the school flourished. After he successfully removed a cancerous lung Graham operated on two more cancer patients. Both died. Then 5 in a row survived.

An avid smoker Graham “openly scolded colleagues for suggesting that cigarettes caused lung cancer. “Yes, there is a parallel between the sale of cigarettes and the incidence of cancer of the lung, but there is also a parallel between the sale of nylon stockings and the incidence of lung cancer.” Shortly before he died of lung cancer in 1957 Graham publically conceded cigarettes were responsible for his malignancy. In 1965 his successor Thomas Burford, a heavy smoker who operated on countless smokers with lung cancer told a Senate committee that he did not believe cancer was caused by cigarettes. His death was in part due to emphysema caused by his heavy smoking²²

In the early 20^th century surgeons increasingly learned how to remove tonsils, appendices, gallbladders, and cancers. Other skills and techniques were acquired while caring for the wounded in First World War. As the century wore on operating rooms became cash cows for many hospitals.

In 1961, during my third year in medical school I spent a week with a physician in a small town an hour drive from St. Louis. The doctor was a friend of the family and had removed my tonsils when I was 6. Like most general practitioners of the day he cared for common injuries, delivered babies, and performed a few operations. People who needed complex interventions were sent to an experienced surgeon in St. Louis. For standard operations like hernias and diseased gall bladders a surgeon came from the big city once a week and operated in the local hospital. The visiting surgeon earned a bit of money and taught the local docs who assisted him. They scrubbed in and learned how and when to cut into an abdomen. They needed to know because some problems couldn’t wait. On occasion a patient’s condition was such that he or she might not survive if their operation was delayed for the few hours it took to travel to St. Louis and find an available surgical crew and operating room suite.

Prior to the 1950s, with a few documented exceptions, the inside of the heart and major blood vessels were off limits.

One of the “exceptions” occurred when bullets and shrapnel entered a soldier’s heart during battle. During the Second World War, Dwight Harken, a battlefield surgeon wrote his wife about a time he used a clamp to grasp a piece of metal deep in a heart’s ventricle. He felt the pressure force the fragment to jump out. It was sudden and like uncorking a bottle of champagne. “Blood poured out in a torrent.” Harken sewed the opening in the muscle closed and the patient survived. He later removed bullets and shrapnel from 56 wounds “in or in relation to the heart.”

Son of a physician who made house calls on horseback and a former prize fighter, Harken was harsh, energetic, and aggressive. He became a Harvard professor and at one point decided to fix “rusty” mitral valves. That’s the gate that opens and closes when blood flows from the atrium (the collecting chamber) to the ventricle (the muscular compartment that forces blood out.) The valve can become calcified and stiff. Harken thought he could pry the area open with a finger or cut it open with a blade that he inserted through an incision in the atrium. In 1948 he operated on 10 patients. In the process he sometimes loosened a blood clot, it traveled to the person’s brain, and they had a massive stroke. Six of his first ten patients died. Harken kept at it and 14 of the next 15 patients survived¹⁹.

The other notable “heart exception” took place in the major vessels just beyond the heart. The fetus receives oxygen rich blood from the placenta and shunts most of it around the lung. . A surgical resident named Richard Gross learned how to seal a detour between the upper aorta and the pulmonary artery that generally closes by the time a newborn is 6 weeks old. When the ductus (we still call it by its Latin name) remains “patent” it puts pressure on the right side of the heart and the baby has problems.

In 1938 Gross was a chief resident at Boston Children’s Hospital and he learned how to close the defect in dogs. He wanted to try his technique on a child, but his chief of service “forbade” human surgery. Gross waited till the chief was on vacation. Then he operated on a 7 year old girl. The anesthesia nurse who helped him “was scared to death.” The operation had been tried at another hospital and the child had died. Gross’ patient did well, but the chief of service was “furious.” “Some accounts say Gross was fired.” Years later when the chief retired Gross succeeded him.

The son of a German immigrant, Gross was blind in one eye. He had a congenital cataract. To compensate for his lack of depth perception his father encouraged him to take clocks apart and put them back together. The exercise helped him develop depth perception and motor skills and it “instilled a love for tinkering.” A cardiac innovator he once said “an academic surgeon has to pull a new rabbit out of a hat every few years.²⁰”

In 1950 president Harry Truman called heart disease “our most challenging medical problem” and federal funding started flowing. In 1947 the NIH was spending $4 million a year and by 1950 $46 million. A number of medical schools wanted some of that money and recruited and hired talented physicians who were ambitious and wanted to make a difference. Two of the major programs were located 90 miles apart in Minnesota.

The major defects that were tackled early were openings between the heart’s receiving chambers, the right and left atria or between the heart’s pumping chambers, the right and left ventricles. They couldn’t be sewn or patched shut because a surgeon couldn’t see what he or she was doing when the heart was beating and full of blood. When the “defects” stayed open blood was pushed from the left to right side with each heart beat. The left heart muscle is more powerful than the right. Over time the atria or ventricle on right side gets would get full, then stuffed and stretched.

By the time cardiac surgeons started tackling the problem started John Gibbon had spent 15 years trying to build a machine that could keep the body alive when the heart chambers were empty. To work, his pump had to be filled with a lot of blood. It was hard to sterilize and would periodically break down. In 1935 using his machine Gibbon kept a cat whose heart wasn’t beating alive for 20 minutes. That made the papers. In the 1950s he was introduced to Tom Watson, head of IBM, and Watson asked one of his engineers to help Gibbon. Three years later the Gibbon machine kept a young woman alive long enough for Gibbon, a surgeon, to sew shut a hole between the upper chambers of her heart. His efforts and limited success showed that much could be done if surgeons had a good heart lung machine.

The descendent of a long line of doctors Gibbon was the 6^th physician in the chain. As a sophomore he wanted to quit medicine and become a writer, but his father talked him out of it and convinced him to use his writing urge to promote medical research. Graduating from medical school in 1927, he was an intern when a young woman who broke her leg developed a blood clot that traveled to her lungs and killed her. He thought he could have saved her life if he had a machine that bypassed the lungs, a “heart lung machine.” In the 1930s as a Harvard research fellow, he tried to construct such an apparatus. Harvard gave him a small grant. The chief of surgery, who thought the project was nonsense, gave Gibbon lab space.

A surgeon by day, Gibbon spent his evenings “in the little room in the cellar of the Massachusetts General Hospital.” A nurse helped him. They were together every night, and they eventually married⁹” and moved to Philadelphia. The machine Gibbon developed was a conglomeration of a filter from here and a pump from Michael DeBakey, a future vascular surgeon. DeBakey’s device, designed when he was a medical student, was based on the irrigation pump developed by the Sicilian Archimedes in the 2^nd century B.C.

When the Second World War ended Gibbon became a medical school professor in Philadelphia. After he successfully sewed an interatrial septal defect closed in 1953, Gibbon operated on 5 kids with holes in their hearts. They all did and Gibbon “led a movement to have Congress ban or have a moratorium on heart lung surgery for an indefinite time. It didn’t succeed.

By the early 1950s surgeons at the Mayo Clinic and 90 miles away at the University of

Minnesota started operating on kids with congenital heart defects. Each group used a different heart lung machine and each center suffered through the tragic deaths of a number of children.

The University of Minnesota group was led by Walt Lillehei, a bright talented suburban kid whose father was a doctor. During the Second World War Lillehei accompanied the troops that landed on the Italian coast, 35 miles south west of Rome. The Germans allowed them to come ashore then mercilessly bombarded them for four months. Seven thousand Americans and Brits were killed and 80,000 were wounded, missing, or hospitalized. Lillehei “saw the horrors of modern warfare” and it may have had an effect on the way he emotionally dealt with death.

In 1945 he became one of the young surgeons at the University of Minnesota. Wangensteen, the chief of surgery at the time, was the son of an immigrant farmer. He had a photographic memory and was the best student in each class, but he didn’t want to be a doctor. Then his father exposed him to the harsh reality of farming. The summer before he was scheduled to enter medical school Wangensteen spent his days hauling manure. At the end of the summer he decided “anything would be better than this.” When fall rolled around and classes began Owen was a medical student and excelled.

The Mayo Clinic attempt to fix heart defects was led by a young surgeon named John Kirklin. He graduated from Harvard Medical School In 1942 and was stationed in Missouri during the Second World War. Before returning to Minnesota Kirklin visited Gibbon, and he brought a Gibbon heart lung machine and/or its specs with him to Minnesota. He then convinced a few engineers to help him improve it. In 1955, after 9 of 10 dogs survived the machine, Kirklin used the heart lung bypass and operated on 8 kids with congenital heart problems. 4 died and Kirklin learned what he was doing wrong. By the end of the year Kirklin had sewn closed holes between the upper chambers of the heart in 29 additional kids without another death.

Fixing the gap between the two ventricles proved to be risky. The wiring that stimulates the pumping chambers sits on the edge of the opening between the right and left pumping chambers. When the wiring is inadvertently tied off, the heart slows and sometimes stops beating.

The Lillehei heart lung machine didn’t always supply enough oxygen and early on surgeons got extra oxygen rich blood by connecting the arteries and veins of the patient with those of a parent. That put two individuals in harm’s way. Thomas Starzl was present during one of those operations and “witnessed a tragedy.” A parent veins were pumped full of air when a pressurized bottle ran out of fluid and no one noticed. Her heart stopped, she was resuscitated, and she had permanent brain injury. Ultimately she died.” After a few cases Lillehei stopped using cross circulation. 16 of the kids he operated on had ventricular septal defects and over half survived²³.

In the early 1950s the heart-lung pump wasn’t very good and Bill Bigelow, a Canadian Surgeon told the world about hypothermia. Bigelow began pondering the effect of cold on a body after he cut the fingers off a man who developed frost bite, then gangrene. He, of course, knew that some animals hibernate and survive “cold dark winters by turning down their metabolism.” One day he awoke with the thought that maybe hypothermia could be used to “decrease the body’s need for oxygen and thus allow surgeons to operate on a heart.” Working in a basement room in Toronto he learned how to control a dog’s shivering and lowered the animal’s body temperature to 68 degrees Fahrenheit. After waiting 15 minutes he warmed the animal. It was unharmed. He presented his findings at a medical meeting and John Lewis, a Minnesota cardiac surgeon was inspired.^33,34.

Working with dogs Lewis learned how to safely cool the animal and clamp the vessels that supplied blood to the heart. In 1952 he slowly lowered the temperature of a 5 year old girl who had a hole between the atria of her heart. When it fell below 86 degrees Fahrenheit Lewis blocked blood flow to and from the organ, opened the atria, and sewed the defect shut within 5 minutes. During the next 3 years he repeated the operation in 60 more people²¹.

In the spring of 1958 Dr. Albert Starr was running the only heart surgery team in Oregon, and was mainly performing surgery on kids with congenital defects. He was “up to his eyeballs” in clinical work when a 60 year old engineer with a “background in hydraulics” Miles Edwards, arranged a meeting. They talked about an artificial heart and decided to “start” improving the heart one valve at a time. It took two years before they were able to implant an artificial gate that opens to let blood through, then closes to prevent it from pouring back in the chamber that ejected it. The valve was handmade and acrylic. Later valves were made of stainless steel, and still later a non corrosive material¹⁰. By 2018, 182,000 metal and tissue heart valves were being replaced each year in the U.S.¹¹

Periodically a technique or technology shook things up and made surgery easier or better. Doctors slowly adjusted, and the new gradually became the norm.

In 1984 Eddie Joe Reddick, the doctor who made surgeons alter their approach, moved to Nashville. He came “in part because he loved the music.” The grandson of an Arkansas soy bean farmer, Reddick went to medical school, was drafted, and while in the army became a trained surgeon. As a military doc, he used a long hollow tube with a light on its end, a laparoscope, to help a colleague locate and biopsy a liver. He learned how to manipulate the instrument. After he was discharged, he moved to Music City and wrote country music. (His song, “I’m Listening to Hank” made it to number 70 on the country music billboard.)

As the new guy in Nashville he struggled financially for a while, and made a little money assisting gynecologists perform laparoscopic procedures. Early scopes that allowed us to see areas deep in the abdomen were rigid metal tubes with tiny bulbs on the end. Gynecologists could introduce a laparoscope, and insert grasping or sewing instruments through the scope or through adjacent tiny incisions. They would watch through a magnifying lens as they tied fallopian tubes shut, biopsied suspicious growths, checked out ovarian cysts, or tore through adhesions. In the early 1960s, older models were gradually replaced by instruments that used quartz light rods. A few decades later, video chips on their tips allowed surgeons and their assistants to see what was happening by studying TV monitors.

In 1988 Reddick met a Georgia surgeon named McKernan at a medical meeting, and he was intrigued by his fellow doctor’s plan to remove a gall bladder using the laparoscope. A few months later, McKernan found a willing patient and would have become the first American to remove a gall bladder through a tiny hole, but the stone in the “bile bag” was big, and McKernan had to make an incision to get it out. Two days later, this time in Nashville, Reddick used a laparoscope. Assisted by a scrub nurse he excised a diseased gall bladder and pulled it out through the tiny hole. He cut through tissue with a laser, and didn’t use a needle and thread to tie off the cystic duct and artery. He clamped them shut with a homemade clip. The patient recovered and went home in short order.

People obsessed with detail are quick to point out that the two southern doctors were not the first to remove a gall bladder laparoscopically. A surgeon in Germany named Muhe removed one in 1985. His patient died post–operatively and there was a subsequent legal hassle. Two Frenchmen removed gall bladders by this technique in 1988, but their colleagues apparently didn’t think it was a big deal, and they temporarily ended their venture.

Reddick’s patients by and large got well quickly, and his complication rate was low. He had the touch, the knack, the hidden quality that makes some surgeons really good. But he didn’t come from a big medical school, wasn’t a professor, and I suspect he was looked down on by the men who gave lectures and wrote books. Reddick published his results and wrote about the successes of McKernan and a doctor named Saye. At a medical meeting the following September, he gave a talk and played a three-minute video of a gall bladder being removed laparoscopically. In subsequent months, surgeons were invited to his O.R. to watch and assist. A few came. Some of the surgeons at his hospital were nervous and “urged that he not be allowed to perform the procedure,” but the hospital review board gave him the green light.

Someone alerted the media. The Wall Street Journal wrote an article about the medical maverick, and ABC World News ran a story that was seen by millions. At a subsequent surgical meeting, a few instrument companies ran tapes of his surgeries in their booths, and crowds of doctors gathered around. Then Reddick and Saye opened a training center in Nashville for doctors who had long since completed their formal training.¹

As skills grew and people recovered from their operations relatively quickly, surgeons increasingly removed stone–filled gall bladders that may or may not have been causing problems. Within a few years, twice, then four times as many of the muscular sacs were excised annually. Over the subsequent 20 years, surgeons learned to perform a slew of additional operations laparoscopically. Inflamed appendices were removed, hernias were plugged from the inside, and cancer containing portions of colon were resected. Renamed minimally invasive surgery, the approach was used to treat heartburn that was caused by the reflux of stomach juices and hadn’t responded to pills. It was long known that the problem could be controlled by wrapping the upper stomach around the esophagus, but a surgeon had to get his or her hand into the narrow space under the rib cage. Access was difficult, and the spleen (which was often in the way) was sometimes damaged. The laparoscope made the procedure safer. The minimally invasive approach was also used to turn many a large stomach into a receptacle the size of a shot glass, and to thus help obese people lose weight.

Chest surgeons increasingly used scopes inside the thoracic cavity to identify and biopsy abnormalities, to remove parts of a lung or pleura, and to perform a number of procedures on the esophagus, the swallowing tube that runs through the back of the chest. Problems that used to require a long incision and spreading of ribs could often be solved with VATS, –video–assisted thoracic surgery.

Using a similar rigid scope and a camera, orthopedists entered knee joints without damaging the surrounding muscles and ligaments. They repaired torn internal ligaments and injured cushions (menisci). Some used the approach to mend torn shoulder rotator cuffs and to patch tears in the cartilage that lines the rim of the shoulder joint—the labrum.

Back surgeons call surgery performed through a small incision using a scope with a camera on it–minimally invasive surgery. They are sometimes able to employ the technique to remove herniated discs and fuse vertebrae. A few years back I had sciatica. The pain was in the left leg and was caused by pressure on the nerve that traversed the space between my 4^th and fifth lumbar vertebrae. The MRI showed a cyst was causing the problem. A back surgeon inserted a scope, removed the cyst, the pain disappeared, and I went home.

Ear, nose, and throat surgeons who wanted to visualize and remove head and neck tumors had approached growths with incisions made in the chin or neck. Over time, they learned to put a thin video endoscope through the mouth and advance it until they saw the enemy. Jaws were only “cracked” when a tumor had invaded. Called “small field” surgery, the approach allowed experts to destroy tissue and control bleeding with cautery or the beam of a laser. After a growth was removed, the remaining tissue was biopsied and pathologists could tell if cancer cells were left behind. Less blood was lost, and vocal cord function was preserved.

Fiber optic and later video endoscopes and colonoscopies were used by gastroenterologists. They allowed ENT doctors to better evaluate vocal cord paralysis and other benign laryngeal problems. Plugged sinuses could be opened and debris sucked out.

Neurosurgeons used scopes to remove pituitary tumors. The gland they tackled is normally the size of a grape; it hangs below the brain in a “bony hollow in the base of the skull.” Some of the organ’s small tumors produce hormones that cause harm in dramatic and weird ways. Before a local neurosurgeon entered a patient’s skull, my ENT colleague would “shove” his scope through the nose and breech the wall between the adjacent sinus cavity and the brain. The abnormal pituitary growth usually looked like the top of an ice cream cone. A neurosurgeon would take over and remove all or part of the gland piecemeal.

A company called Di Vinci developed flexible small internal robotic hands whose actions could be monitored through a three–dimensional viewer. Surgeons maneuvered the appendages remotely, using external, space age, knob-dial–fingers. Those who mastered the approach claimed their resections were more precise. The technique required a person to visualize tissue a little differently, and there was a learning curve.

Medicine, like industry, has innovators who can mentally visualize the “possible” and find a way to make it happen. In 1964 Michael DeBakey a Houston doctor used a vein from a person’s leg to create a tube that bypassed a narrowing in one of the coronary arteries. The vein allowed blood from the aorta to circumvent the diseased vessel. He didn’t report it to the medical community until 1973, when he could prove the graft had remained patent.⁹“

“You learn on animals. We did hundreds of bypasses on dogs and were 50% successful. The first coronary bypass was an accident. The patient was scheduled for an endarterectomy, separating the plaque (the deposit of cholesterol and fiber) from the inner lining of a diseased vessel. We’d been doing the operation since 1964. The nature of the first patient’s coronary artery blockage was such that we couldn’t separate the plaque. His coronary arteries were so bad that we couldn’t get him off the table (and expect him to survive.) So we did what we had been doing in dogs. It was the first heart bypass. Fortunately it worked. You have to take risks. The first carotid endarterectomy was done on a man with recurrent episodes of temporary paralysis —TIA’s. The carotid artery supplies blood to the brain and his artery had plaques. He was a bus driver. Surgery stopped his TIA’S. He lived for 19 years and died of a heart attack. The first aneurysm of the aorta in the chest was causing pain. We knew how to fix aneurysms in the abdomen and the man was hurting so he took the risk and agreed to surgery.¹³”

DeBakey virtually created vascular surgery. The son of Lebanese immigrants and a combat surgeon during the Second World War, he “convinced the surgeon general to form what would become the mobile army surgical hospital MASH unit.” Later, as a Baylor University surgeon, he revolutionized our approach to narrowed blood vessels. “In 1953, he performed the first successful carotid endarterectomy;” (he cleaned out one of the arteries that supplied blood to the brain.)

As a youth he liked working with his hands. He and his brother took apart car engines and reassembled them. His mother taught him to knit and sew and “By the age of ten he could cut his own shirts from patterns and assemble them.¹⁴”

He later used his boyhood skills to create a vascular graft from Dacron. As he said in an interview: “When I went down to the department store … she said, ‘we are fresh out of nylon, but we do have a new material called Dacron.’ I felt it, and it looked good to me. So I bought a yard of it. … I took this yard of Dacron cloth, I cut two sheets the width I wanted, sewed the edges on each side, and made a tube out of it. .. . We put the graft on a stent, wrapped nylon thread around it, pushed it together, and baked it. … After about two or three years of laboratory work (and performing experiments in dogs), I decided that it was time to put the graft in a human being. I did not have a committee to approve it. … In 1954, I put the first one in during an abdominal aortic aneurysm. That first patient lived, I think, for 13 years and never had any trouble.²”

Years later as a medical student at Baylor, TV doc Gabe Mirkin recalled that Debakey liked to visit the patients he had recently operated on at 5 AM.^{16 “}He often was accompanied by an entourage of more than 50 people composed of medical students, surgeons-in-training and some of the most famous surgeons from all over the world. Mirkin “saw first-hand his incredible drive for perfection. As medical students, we would often study at the medical school through much of the night, and I saw the light at his office stay on as he wrote papers often beyond 3:00 in the morning.”²⁷

Three years after his first wife died, the 67 year old surgeon met and married an attractive 33 year old German woman “who dabbled in acting and painting.” When the pastor performing the ceremony asked if Debakey preferred to sit during the ceremony his bride said “he stands for hours for his operations. He’ll stand for this.” Debakey performed over 60,000 operations in his lifetime and became a surgeon to the stars. His patients included the Duke of Windsor and the Shah of Iran.

The transplantion of one person’s organs into the bodies of another is a story of surgery, immunosuppression, and delivery of care. It’s in the game changer chapter.

Many of the tasks of general surgeons are now performed by interventional radiologists. Over the last half–century our ability to see structures within the body increased dramatically. X-ray doctors who call themselves “Interventionalists” use the fluoroscope and drain pockets of fluid, biopsy shadows that look like tumors, pass catheters through blood vessels, and perform complicated procedures that halt or prevent blood loss.

Some interventionists perform TIPPS in people with cirrhosis and stretched out esophageal veins that bleed. The livers of these individuals are scarred; blood from the intestines can’t flow into or through them, and the vessels that carry blood around the organ enlarge and can leak or rupture. To decompress the situation, trained radiologists create a tunnel through the liver.

Cataracts, cloudy eye lenses, are now removed and replaced with artificial implants in 6 to 14 minutes—then people go home.

Knees are resurfaced; hips are replaced- and people with the new joints walk out of the hospital the same day.

Video scopes allow gastroenterologists to screen colons and stomachs, to biopsy or remove abnormalities, control gi bleeding, remove bile duct stones, remove foreign bodies—and much more.

Our approach to combat injuries has changed. In a recent war, surgical teams—surgeons, nurses, and medics, traveled in Humvees directly behind the troops. When a soldier was wounded they would “focus on damage control, stop bleeding from the liver with sterile packs, staple perforated bowels, and wash out dirty wounds.” Since blast injuries can cause bleeding from multiple locations, they would cut the abdomen open, pack areas at risk, and cover the area with saran wrap. When the surgeons had done their best–and always within two hours–the injured were flown by helicopter to a hospital less than an hour from the zone of combat.⁴

Worldwide “about 234 million operations performed annually.⁵

”44,000 and 98,000 patients die each year in the United States as a result of preventable medical errors. “Adverse events in surgery account for between one-half and two-thirds of all such events in hospitals and half are potentially preventable.”⁸

In 2007 Atul Gawande, a Harvard surgeon, wrote an article that promoted the use of checklists before during and after surgery. He pointed out that even surgeons who are super-specialists sometimes neglect small details. The idea of a directory of procedural steps had previously been developed by the aircraft industry, as a result of crashes that were caused by a minor oversight. ⁶

In 2008, the World Health Organization (WHO) published a 19-item checklist intended to be globally applicable, and hospital operating rooms became even more compulsive. Are antibiotics or blood available? Did we mark the breast or limb that we’re going to operate on?

Between 2007 and 2008 the WHO checklist was used in 3733 surgeries in 8 hospitals in Canada, New Zealand, the U.S., England, India, Jordan and the Phillipines. The death rate fell from 1.5% to 0.8%, and inpatient complications decreased from 11 to 7 percent.⁷ The checklists, however, did not make a detectable difference in hospitals in Ontario Canada. They are increasingly being required by governments in certain U.S. states and in various countries, and they were mandated by the U.K. National Patient Safety Agency in 2009.⁸

A medical educator interviewed by Atul Gawande asserted the innately exceptional surgeon, the doctor who, as a trainee, can figuratively “see one, do one, and teach one” is pretty rare. For the vast majority competence is not the result of a God given skill. It’s the result of diligence and by young doctors who keep practicing difficult tasks.

And (Gawande again) “while the best possible care is more important than teaching novices, everyone is harmed if no one is trained.” Not surprisingly in “teaching” hospitals, the poorest, the uninsured, and the demented” are disproportionally the responsibility of surgical trainees. That’s how it always was and still is.

REFERENCES:

“An Unsung Hero of the laparoscopic revolution” by Leon Morgenstern, M.D., https://journals.sagepub.com/doi/10.1177/1553350608325119 Surgical Innovations: Oct 22, 2008

A Time for All Things by Craig Miller. Oxford University Press. 2019 https://www.mdedge.com/vascularspecialistonline/article/83514/vascular-surgery-chronicles-michael-e-debakey

“The Puzzle People” by Thomas Starzl. University of Pittsburg Press. 1992

Casualties of War — Military Care for the Wounded from Iraq and Afghanistan by Atul Gawande, M.D. December 9, 2004 N Engl J Med 2004; 351:2471-2475 https://www.nejm.org/doi/full/10.1056/NEJMp048317

Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet2008;372:139-144

New YORKER DECEMBER 10, 2007 THE CHECKLIST By Atul Gawande https://www.newyorker.com/magazine/2007/12/10/the-checklist

https://www.nejm.org/doi/full/10.1056/NEJMsa0810119 Alex B. Haynes, M.D N Engl Med 2009; 360:491-499

A detailed review of their emergence, development, and relevance to neurosurgical practice. Douglas J. McConnell et al. Surg Neurol Int. 2012; 3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279961/

https://pubmed.ncbi.nlm.nih.gov/14667692/

https://www.youtube.com/watch?v=voTxtx72niU10. http://www.quotehd.com/quotes/dr-john-kirklin-quote-surgery-is-always-second-best-if-you-can-do-something-else