Surgery
Surgery is the term traditionally used for treatments that involve cutting or stitching tissue. However, advances in surgical techniques have made the definition more complicated: Sometimes lasers, rather than scalpels, are used to cut tissue, and wounds may be closed without stitches. In modern medical care, distinguishing between a surgical and medical procedure is not always easy; however, making that distinction is not important as long as the doctor performing the procedure is well trained and experienced.
Surgery is a broad area of care and involves many different techniques. In some surgical procedures, tissue is removed. In others, blockages are opened. In still others, arteries and veins are attached in new places to provide additional blood flow to areas that do not receive enough. Grafts, sometimes made of artificial materials, may be implanted to replace skin, and metal rods may be inserted into bone to replace broken parts.
Surgery is sometimes used to aid in the diagnosis of a problem. A biopsy, in which a piece of tissue is removed for examination under a microscope, is the most common type of diagnostic surgery. In some emergencies, in which there is no time for diagnostic tests, surgery is used for both diagnosis and treatment. For example, surgery may be needed to quickly identify and repair organs that are bleeding from a gunshot wound.
Three categories of surgery are often described--emergency, urgent, and elective. Emergency surgery, such as stopping rapid internal bleeding, is performed as soon as possible; minutes can make a difference. Urgent surgery, such as removal of an inflamed appendix, is best performed within hours. Elective surgery, such as replacement of a knee joint, can be delayed for some period of time, until everything has been done to optimize a person's chances of doing well during and after the surgical procedure.
 See the sidebar Cosmetic Surgery.
Anesthesia: Because surgery is generally painful, it is almost always proceeded by the administration of some type of anesthesia. Anesthesia blocks the perception of pain. Anesthesia may be local, regional, or general.
Local and regional anesthesia consist of injections of drugs, such as lidocaine or bupivacaine, that numb only specific parts of the body. In local anesthesia, the drug is injected under the skin of the site to be cut, numbing only that site. In regional anesthesia, which numbs a larger area of the body, the drug is injected into one or more nerves and numbs an area of the body supplied by those nerves. For example, injecting a drug into certain nerves can numb fingers, toes, or large parts of limbs. One type of regional anesthesia involves injecting a drug into a vein (intravenous regional anesthesia). A device such as a woven elastic bandage or blood pressure cuff compresses the area where the limb joins the body, trapping the drug within the veins of that limb. Intravenous regional anesthesia can numb an entire limb.
During local and regional anesthesia, the person remains awake. However, doctors sometimes give antianxiety drugs intravenously to calm and relax the person. Local and regional anesthesia are generally considered safer than general anesthesia because they usually do not affect the vital organs, such as the heart, lungs, brain, liver, and kidneys. Rarely, numbness, tingling, or pain can persist in the numbed area for days or even weeks.
Spinal and epidural anesthesia are specific types of regional anesthesia in which a drug is injected around the spinal cord in the lower back. Depending on the site of the injection and position of the body, a large area (such as from the waist to the toes) can be numbed. Spinal and epidural anesthesia are useful for operations of the lower body, such as hernia repairs and prostate, rectal, bladder, leg, and some gynecologic operations. Spinal and epidural anesthesia can also be useful for childbirth. Headaches occasionally develop in the days after spinal anesthesia but usually can be treated effectively.
In general anesthesia, a drug that circulates throughout the bloodstream is administered, rendering the person unconscious. The drug can be given intravenously or inhaled. Because a general anesthetic slows breathing, the anesthesiologist may insert a breathing tube in the windpipe. For short operations, however, such a tube may not be necessary; instead, the anesthesiologist can support breathing using a hand-held breathing mask. For longer operations, the breathing tube and a ventilator breathe for the person. General anesthetics affect vital organs, so the anesthesiologist closely monitors the heart rate, heart rhythm, breathing, body temperature, and blood pressure until the drugs wear off. Fortunately, serious side effects are very rare.
Major and Minor Surgery: A distinction is sometimes made between major and minor surgery, although many surgical procedures have characteristics of both.
Major surgery usually involves the use of general anesthesia. Major surgery often involves opening one of the major body cavities--the abdomen (laparotomy), the chest (thoracotomy), or the skull (craniotomy)--and can stress vital organs. The surgery is usually performed in an operating room by a team of doctors. A stay of at least one night in the hospital is usually needed after major surgery.
Minor surgery can involve the use of local, regional, or general anesthesia. Major body cavities are not opened. Minor surgery may be performed in an emergency department, an ambulatory surgical center, or a doctor's office. Vital organs usually are not stressed, and surgery can be performed by a single doctor, who may or may not be a surgeon. Usually, the person can return home on the same day that minor surgery is performed.
Second Opinion: The choice to undergo surgery is not always clear, and there may be several options for the kind of surgical procedure. Thus, a person may seek the opinion of more than one doctor. Some medical insurance plans require a second opinion for elective surgery.
Some experts advise establishing up front that the doctor giving the second opinion will not perform the operation, so that there is no conflict of interest. Others advise obtaining a second opinion from a doctor who is not a surgeon, to eliminate any bias toward surgery when nonsurgical treatment is an option. However, some experts recommend that another surgeon give the second opinion, believing that a surgeon knows more about the advantages and disadvantages of surgery than would a nonsurgeon.
See the sidebar Surgery Through a Keyhole.
Preparing for the Day of Surgery
Various preparations are made in the days and weeks before surgery. It is often recommended that physical conditioning and nutrition be improved as much as possible, because good general health helps a person recover from the stress of surgery.
Eliminating or minimizing tobacco and alcohol use before undergoing surgery that involves general anesthesia can increase safety. Recent tobacco use makes abnormal heart rhythms more likely to develop during general anesthesia and impairs lung function. Excessive alcohol consumption can damage the liver, causing heavy bleeding during surgery and unpredictably increasing or decreasing the effect of the drugs used for general anesthesia. Alcohol consumption should be decreased gradually, however, because a sudden decrease before undergoing general anesthesia can cause harmful effects, such as fever and abnormalities of blood pressure or heart rhythm.
The doctor performs a physical examination and takes a medical history, which includes the person's recent symptoms, past medical conditions, use of tobacco and alcohol, and allergies. The person is also asked to list all drugs currently being taken. Nonprescription as well as prescription drugs must be disclosed, or serious health problems could result. For example, the use of aspirin, which a person may consider too trivial to mention, can increase bleeding during surgery.
Tests performed before surgery (preoperative testing) may include blood and urine tests, an electrocardiogram, x-rays, and pulmonary function tests. These tests determine how well the vital organs are functioning. If organs are functioning poorly, the stress of surgery or anesthesia can cause problems. Preoperative tests may also reveal an inapparent temporary illness, such as an infection, which would require the postponement of surgery.
A person may wish to store his own blood in case a blood transfusion is needed during surgery. Use of one's own blood (autologous blood transfusion (see Section 14, Chapter 171)) eliminates the risk of infections and most transfusion reactions. A pint of blood can be withdrawn from the person--several times, if necessary--and preserved until surgery. The body replaces the missing blood during the weeks after the blood donation.
The anesthesiologist may meet the person before the day of surgery to review test results and identify any medical conditions that might affect the choice of anesthetic. The safest and most effective types of anesthesia may be discussed as well.
A durable power of attorney for health care and a living will (see Section 1, Chapter 9) should be prepared before surgery in case the person becomes unable to communicate or incapacitated after surgery.
Sometime before the surgery, the surgeon obtains the person's permission to perform the operation, a process called informed consent. The surgeon discusses risks and benefits of the operation and answers questions. The person reads and signs a form documenting consent. In cases of emergency surgery in which the person is unable to provide informed consent, doctors try to contact the family. Rarely, emergency surgery must proceed before the family is contacted.
Because some of the drugs given during surgery may cause vomiting, the person should generally not eat or drink anything for at least 8 hours beforehand. Specific guidelines should be given and vary depending on the kind of surgery. The person should ask the doctor which of his regularly prescribed drugs should be taken before surgery. People undergoing surgery involving the intestines are given laxatives for a day or two before the operation.
Because the device that monitors the level of oxygen in the blood is attached to a finger, nail polish and artificial nails should be removed before going to the hospital. Then, this device can perform more accurately. Also, valuables should be left at home.
The Day of Surgery
Before most operations, a person removes all clothing, jewelry, hearing aids, false teeth, and contact lenses or eyeglasses and puts on a hospital gown. The person is taken to a specially designated room (the holding area) or to the operating room itself for final preparations before surgery. The skin that will be cut (operative site) is scrubbed with an antiseptic, which removes bacteria, helping to prevent infection. A health care practitioner may shave the operative site. A plastic tube (catheter) is inserted in one of the veins of the hand or arm, through which fluids and drugs are given. A drug may be given intravenously for sedation.
 See the figure In the Operating Room.
If the final preparations are done in the holding area, the person is then taken to the operating room. At this point, the person may still be awake, although groggy, or may already be asleep. The person is moved to the operating table, over which are specially designed surgical lights. Doctors, nurses, and other personnel who will be near or touching the operative site thoroughly scrub their hands with antiseptic soap, which minimizes the number of bacteria and viruses in the operating room. For surgery, they also wear scrub suits, caps, masks, shoe covers, sterile gowns, and sterile gloves.
Anesthesia--local, regional, or general--is given.
After Surgery
After the operation is completed and anesthesia begins to wear off, the person is taken to a recovery room to be closely watched for about 1 or 2 hours. Most people feel groggy when awakening, particularly after major surgery. Some people are nauseated for a short while. Some may feel cold.
Depending on the nature of the surgery and the type of anesthesia, a person may go home directly from the recovery room or be admitted to the hospital, sometimes in an intensive care unit (ICU). A person being sent home must be thinking clearly, breathing normally, able to drink fluids, able to urinate, able to walk, and be free of severe pain. The operative site should be free of bleeding and unexpected swelling.
A person who is admitted to the hospital may awaken to find many tubes and devices in and on him. For example, there may be a breathing tube in the throat, adhesive pads on the chest to monitor the heartbeat, a tube in the bladder, a device attached to a finger to measure the level of oxygen in the blood, a dressing on the operative site, a tube in the nose or mouth, and one or more tubes in the veins.
Pain is expected after most operations and can almost always be relieved. Drugs that relieve pain (analgesics) can be given intravenously, by mouth, by injection into the muscle, or applied to the skin as a patch. If epidural anesthesia was administered, the anesthesiologist may leave a plastic tube in the person's back through which opioid analgesics, such as morphine, can be injected. A person staying in the hospital may be given a device with which he can control the amount of analgesia he receives (patient-controlled analgesia). If pain persists, additional treatment can be requested (see Section 6, Chapter 78). Repeated use of opioid analgesics often causes constipation. To prevent constipation, a stimulant laxative or stool softener may be given.
Complications such as fever, blood clots, and infection can develop during the days after surgery. Common causes of fever include collapse of small parts of the lungs (atelectasis), urinary tract infections, and infections at the operative site. Atelectasis often can be prevented by periodically breathing forcefully in and out of a hand-held device (incentive spirometry).
Lying immobile during and after surgery sometimes causes clots to develop in the legs (deep vein thrombosis). The clots can dislodge from the legs and travel through the bloodstream to the lungs, where they can block blood from circulating through the lungs (pulmonary embolism). As a result, the oxygen supply to the rest of the body may be decreased, and sometimes blood pressure may fall. For certain operations after which blood clots are particularly likely, and for those people who are likely to have to lie still without much movement, doctors give preventive anticoagulants, such as low-molecular-weight heparin, or put elastic stockings on the person's legs to improve blood circulation.
If surgery makes eating impossible for more than several days, an alternative source of nutrition can speed recovery and prevent problems. People who had surgery of the digestive tract may be given nutrients through one of the body's large veins (parenteral nutrition). People whose digestive tracts are functioning but who are otherwise unable to eat may be given nutrients through a tube placed into the stomach. Such a tube may be passed through the nose, mouth, or abdominal wall.
To decrease the risk of infection, the surgical incision is dressed after surgery. The dressing includes a sterile bandage and usually includes an antibiotic ointment. The bandage absorbs fluids that ooze from the incision. Because prolonged exposure to these fluids can infect the incision, the dressing is changed often, usually daily.
Occasionally, the edges of the operative site that were stitched together begin to separate (dehiscence). The operative site can also become infected. An infected site can become increasingly painful 1 or more days after surgery and become red and warm or drain pus or fluid. Fever can develop. If symptoms of dehiscence or infection develop, the doctor should be seen as soon as possible.
Before being discharged home, a person should schedule a follow-up visit with the doctor, should know what drugs to take, and should know what activities to avoid or limit. Examples of activities that may need to be avoided temporarily include climbing stairs, driving a car, lifting heavy objects, and having sexual intercourse. A person should know what symptoms necessitate contacting the doctor before the scheduled follow-up visit.
During recovery from surgery, the person gradually resumes normal activity. Some people need rehabilitation, which involves special exercises and activities, to improve strength and flexibility (see Section 1, Chapter 7). For example, rehabilitation after hip replacement surgery can involve learning ways to walk, stretch, and exercise.
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