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A FOCUSED HISTORY OF SURGERY
Seymour I. Schwartz
1
e word surgery derives from the French term “chirurgien,”
which came from the Latin and in turn from the Greek words
“cheir,” meaning “hand” and “ergon,” meaning work. Surgery
has a long history beginning with what is said to be the earliest scienti c document known, e Edwin Smith Surgical
Papyrus , dating from the 17th century before Christ, actually a copy of an Egyptian manuscript originally written circa
3000–2500 . e document deals with a variety of wounds
and cauterization for breast cancer. No intraperitoneal operation is mentioned.
Although Maingot’s Abdominal Operations had its genesis in
England, elective abdominal operations had their beginning
in Danville, Kentucky, a town of 1000 at the time, with the
removal of a 22½-lb ovarian tumor by Ephraim McDowell on
December 25, 1809. roughout the 19th century, surgeons
from Great Britain and the United States, the two countries
that would eventually play major roles in the development of
the multiple editions of Maingot’s Abdominal Operations , con-
tributed signi cantly to the evolution of abdominal operations.
In 1804, Sir Astley Cooper published a Treatise on Hernia. In
1833, William Beaumont, an American military surgeon, published Experiments and Observations on the Gastric Juice and the
Physiology of Digestion. e experiments conducted through a
permanent gastric stula constituted the rst controlled clinical study on a human being and de ned the process of intragastric digestion. On October 16, 1846, at the Massachusetts
General Hospital, the birth of ether anesthesia took place and
ushered in a new generation of possibilities for all of surgery.
In 1867, John Stough Bobbs of Indianapolis reported the rst
successful elective operation on the gallbladder, a cholecystostomy with removal of stones and closure of the organ. e
patient remained relatively asymptomatic for over 40 years.
e 1886 landmark paper by the Boston pathologist Reginald
H. Fitz established the entity of appendicitis and championed
early operation. As the 19th century came to a close, the German schools of surgery became increasingly dominant, in large
part related to eodor Billroth and the surgeons he trained.
Billroth is often referred to as “the father of abdominal surgery”
based on his rst resection of cancer of the pylorus in 1881 and
also the numerous intestinal resections and enterorrhaphies
that he performed.
As the rst decade of the 21st century has come to an end,
it is appropriate to focus on the developments that took place
during the preceding 20th century, by dividing this period
into two time spans: one before 1940, the year that the rst
edition of Maingot’s Abdominal Operations was published, and
the other considering the progress that has taken place in the
ensuing 60 years.
In discussing the history of surgical advances pertaining
to the gastrointestinal tract per se, it is reasonable to proceed
aborally from esophagus to rectum. In regard to the esophagus, the rst signi cant operation was reported in 1913 by
Franz Torek of New York City, who removed the entire thoracic esophagus and connected the cervical esophagus with
the stomach by means of an external tube. Although in 1935
Winkelstein rst de ned the clinical picture of esophageal
re ux and indicted the erosive action of gastric juice as the
culprit, the issue of a functioning gastroesophageal sphincter
was not appreciated. Consequently, no corrective operation
was devised prior to the publication of Maingot’s rst edition.
e surgical treatment of re ux esophagitis was rst popularized by Allison, who de ned a repair in 1951, mainly
consisting of correction of the hiatal herniation. e high
recurrence rate associated with that operation led to a consideration of fundoplication procedures, which were introduced
in 1966 by Nissen and subsequently modi ed by Belsey, Hill,
and Toupet. Since the advent of minimally invasive surgery
in 1989, the majority of these fundoplications have been performed laparoscopically.
During the rst four decades of the 20th century, there
was considerable interest in the surgical treatment of peptic
ulcer disease. Gastric resection was often the most commonly
performed indexed operative procedure in a residency program. e operations were outgrowths of the procedures that
were initially applied by Billroth and his associates for gastric
cancer. In the early decades of the 20th century, excision of a
gastric ulcer was widely practiced. When the excision, as was
frequently the case, was extensive, there were problems with
gastric emptying, prompting William Mayo in 1911 to add
a complemental gastrojejunostomy. en as now, the indications for surgical intervention in patients with peptic ulcer
were obstruction, bleeding, perforation, and intractability.
3
4 Part I Introduction
Pyloroplasty and gastrojejunostomy were the most frequently
performed procedures for obstruction, and as early as 1925
Lewisohn reported a 34% incidence of neostomal ulcer after
gastrojejunostomy. Before 1940, the surgeons at the Mayo
Clinic continued to champion the procedure for duodenal
ulcer. In 1937, R.R. Graham introduced his patch procedure
for perforation. Gradually partial gastrectomy became the
preferred surgical treatment for the complications of peptic
ulcer disease.
e modern era of vagotomy in the management of peptic
ulcer began in January 1943, when Dragstedt performed a
subdiaphragmatic resection of the vagal trunks in a patient
with an active duodenal ulcer. Dragstedt’s earlier approach
was transthoracic. Later, when he appreciated that a signicant percentage of his patients developed gastric stasis, Dragstedt added a drainage procedure, either gastroenterostomy
or pyloroplasty, as an accompaniment to the truncal vagotomy. Farmer and Smithwick recommended a two-pronged
attack against the ulcer diathesis, combining truncal vagotomy with hemigastrectomy. In 1960, Grith introduced the
concept of selective gastric vagotomy, preserving the nerve of
Laterjet and thereby obviating the need for a gastric drainage
procedure.
1
e applicability of vagotomy and partial gastric resection
has been greatly reduced over the past two decades by the
introduction of acid suppressive pharmaceuticals, including
the histamine receptor antagonists and proton pump inhibitors. e use of these preparations has also generally obviated
partial gastrectomy for ulcer diathesis and total gastrectomy
for the intractable ulcers associated with the Zollinger–
Ellison syndrome. Perhaps the most signicant factor causing
a marked reduction in the need for surgical management
of peptic ulcer disease was the discovery by Warren and
Marshall in 1983 of an association between Helicobacter
pylori and peptic ulcer that is readily treatable with the hopes
of totally eradicating peptic ulcer disease. is transition of
gastric surgery from the 19th-century understanding of anatomy, to the 20th-century understanding of physiology and
pathophysiology, to the 21st-century understanding of pharmacology mirrors the growth, development, and progress of
the understanding of surgical diseases.
2
e greatest increase in gastric surgery since 1940 is the
application of gastric reduction for obesity. e initial surgical
approach to the management of extreme obesity, jejunoileal
bypass, was introduced by Kremen, Linner, and Nelson in
1954. e procedure was popularized by Payne and DeWind
in 1969, but had many hazardous consequences and has been
essentially discarded. Gastric bypass, introduced by Mason in
1966, has been the preferred method of surgical management
for the past four decades and has become increasingly popular
with the advent of minimally invasive surgery.
e principles of intestinal anastomosis are in large part
based on Halsted’s late-19th century studies on the importance of the submucosa as the layer providing strength for the
suture line. Most of the early-20th century procedures on the
small intestine were related to the treatment of obstruction.
In 1932, Crohn, Ginzburg, and Oppenheimer introduced a
newly recognized pathologic entity they called regional ileitis,
which has come to be known as Crohn’s disease or regional
enteritis.
e major operative changes in small intestinal surgery that
have taken place over the past two decades have been brought
about by the introduction of stapling techniques. ese were
preceded by John B. Murphy’s button, when it was described
in 1892. Mechanical suture instruments using staples began
with Humer Hültl of Budapest, who in 1908 described an
instrument for use in distal gastrectomy. It was modied
by von Petz in 1924 and enjoyed a period of popularity in
many centers. e next major step in stapling was the result
of the dedicated eorts of the Scientic Research Institute
for Experimental Surgical Apparatus and Instruments in
Moscow. e investigators developed magazine-loaded
instruments for vascular anastomosis, side-to-side intestinal
anastomosis, and end-to-end intestinal anastomosis. ese
were imported to the United States and modied, beginning in 1958, largely due to the leadership of Ravitch and
3
Steichen.
e introduction and widespread application of
stapling devices helped revolutionize the technical aspectsof
surgery that have allowed minimally invasive procedures to
be developed.
In the realm of colorectal surgery, although in 1883
Czerny introduced a technique for combined abdominalperitoneal excision of rectal tumors, Miles’ method, reported
in 1907, popularized the procedure. e advent of stapling
techniques during the past two decades has allowed for more
anal preservation operations. e ileal pouch procedure represents a signicant advance in the management of ulcerative
colitis and familial polyposis. In 1947, Ravitch and Sabiston
performed total colectomy, proximal proctectomy, mucosal
distal proctectomy, and ileal anal anastomosis, but the results
were generally not satisfactory with regard to frequency of
defecation. e introduction in 1978 of a valveless ileal reservoir anastomosed to the anus addressed the problem and has
become the standard.
4
Over the past two decades, there have also been changes
in the pathologic denitions of tumors of the gastrointestinal (GI) tract and there has been an increased recognition of
gastrointestinal stromal tumors (GIST) in all regions of the
GI tract.
e rst successful elective hepatic resection for tumor was
performed by Langenbuch in 1888. e rst collective review
of hepatic resections for tumor was reported by Keen in 1899
and included only 20 cases. In 1911, Wendell reported the
rst case of near total right lobectomy for a primary hepatic
tumor, but the modern age of hepatic resection is generally
dated to the 1952 report of Lortat-Jacob and Robert that
detailed a right lobectomy using a technique designed to
control hemorrhage with ligation of the blood vessels and
bile ducts to the right lobe in the hepatoduodenal ligament
followed by extrahepatic ligation of the right hepatic vein
prior to transection of the hepatic parenchyma. In 1967,
using corrosion casts, Couinaud demonstrated that the liver
is made up of eight distinct segments, thereby opening the
door for segmental hepatic resections. e recent applications
Chapter 1 A Focused History of Surgery 5
of new instruments such as the harmonic scalpel and LigaSure vessel sealing system have expedited the performance of
major hepatic resections without a need for transfusion.
5
e year 1945 marked the beginning of the modern era of
surgical intervention for portal hypertension with the report by
Whipple and associates of the performance of end-to-side portacaval anastomoses and end-to-end splenorenal anastomoses.
In 1953 Marion and in 1955 Clatworthy and colleagues independently described a shunt between the proximal transected
end of the inferior vena cava and the side of the superior mesenteric vein. In 1967, Gleidman performed the rst Dacron
interposition mesocaval shunt, and the same year, Warren and
colleagues introduced the selective (distal) splenorenal shunt
as a method of preserving ow to the liver. e shunt procedures are now performed infrequently, and are generally
reserved for patients with massively bleeding esophagogastric
varices and normal hepatocellular function. By contrast, in
patients with uncontrollable bleeding varices and signicant
hepatocellular dysfunction, a TIPS (transjugular intrahepatic
portosystemic shunt) procedure is generally used as a bridge
to orthotopic liver transplantation. In 1959, Kasai and Suzuki
introduced hepatic portoenterostomy for the management of
biliary atresia. More recently, orthotopic liver transplantation
has been employed for these patients because of uncorrectable
hepatocellular dysfunction.
Fifteen years elapsed between Bobbs’ cholecystotomy and
the rst successful cholecystectomy, which was performed
by Carl Langenbuch in 1882. By 1919, William J. Mayo
was able to report on 2147 cholecystectomies. In 1923,
Graham and Cole introduced cholecystography, leading to
a marked increase in biliary surgery. Operations for injuries
and strictures of the common duct have undergone many
renements over the past century. An obstructed common
bile duct was rst successfully drained by a lateral anastomosis to the duodenum by Sprengel in 1891. A variety of plastic
procedures and intestinal ap advancements were applied to
bridge a gap between the common duct and the duodenum
with minimal success. Beginning in 1941, Vitallium tubes
were inserted into bile ducts as conduits, but all the tubes
eventually became obstructed with sludge. e groups at
the Mayo Clinic and Lahey Clinic, who both had extensive
experience with these procedures, expressed a preference for
choledochoduodenostomy, while most surgeons now employ
a mucosal-to-mucosal anastomosis between the proximal
duct and a Roux limb of jejunum.
Operations on the pancreas directed at the management
of pancreatitis and neoplasms generally evolved subsequent
to the publication of the rst edition of Maingot’s textbook.
In 1958, Puestow introduced the popular lateral pancreaticojejunostomy. In 1965, Fry and Child reported their results
with a 95% distal pancreatectomy. In 1985, Beger proposed
resection of the head of the pancreas with duodenal preservation for pathology that was most marked in the head of
the pancreas. In regard to the neuroendocrine tumors ofthe
pancreas, Roscoe Graham performed the rst successful
resection of an insulinoma in 1929. In 1955, Zollinger and
Ellison reported that nonbeta islet cell tumors produced an
“ulcerogenic humoral factor.” e pathophysiology often
mandated total gastrectomy to control the massive gastric
hypersecretion, but the therapy has been markedly altered
with the advent of proton pump inhibitors.
6,7
Although in 1912 Kausch successfully performed a partial
pancreatectomy in two stages, the name of Allen O. Whipple
has achieved eponymic status as far as resection of pancreatic
neoplasms is concerned. In 1935, Whipple initially carried
out a two-stage operation for carcinoma of the ampulla consisting of an initial cholecystojejunostomy followed by total
duodenectomy. By 1945, he advocated a one-stage pancreatoduodenectomy as the treatment of choice.
Splenectomy is performed for trauma or hematologic
disorders. e rst recorded successful splenectomy for trauma
is credited to a British naval surgeon, E. O’Brien, in 1816,
who tied o the pedicle and removed a protruding spleen
while stationed in San Francisco. In 1892, Reigner performed
the rst successful intraperitoneal splenectomy for trauma. In
1867, Péan successfully removed a spleen containing a large
cyst. In 1911, Micheli reported the rst splenectomy for a
hematologic disorder in a patient with hemolytic anemia.
Five years later, at the suggestion of Kaznelson, a Czech
medical student, Schloer, performed the rst splenectomy
for idiopathic thrombocytopenic purpura, the most common
hematologic indication. e most recent changes in splenic
surgery relate to an increased willingness to observe patients,
particularly children, with blunt trauma to the spleen, and the
fact that elective splenectomies are generally being performed
laparoscopically, as championed by Phillips and Carroll, Cuschieri and associates, and ibault and coworkers.
8
Intra-abdominal vascular surgery traces its modern origin
to Dubost and colleagues’ 1951 resection of an abdominal
aortic aneurysm with reestablishment of continuity. e
introduction of a prosthetic material to create a conduit is
credited to Voorhees, Jaretzki, and Blakemore, who used Vinyon “N” cloth in 1969. e same year, Wylie and associates
described autogenous tissue revascularization techniques for
correction of renovascular hypertension.
e major advances in abdominal surgery that took place
in the second half of the 20th century relate to the elds of
organ transplantation and minimally invasive procedures.
On December 23, 1954, Murray, Merrill, and Harrison
performed the rst renal transplant in identical twins. Eight
years later, the rst successful cadaveric kidney transplant
was performed by Murray in an immunosuppressed patient.
e liver was the second visceral organ to be transplanted. In
1963, Starzl performed the rst human liver transplant in a
patient with biliary atresia. e patient died as did four other
patients operated on by Starzl and one by Moore that year. In
1968, Starzl achieved the rst success. e eld recently has
been extended by the use of live donors who provide a lobe
for the recipient.
e rst successful clinical pancreas transplant was
performed by Kelly and Lillehei in 1966. In 1973, Gliedman
and associates suggested using the ureter for exocrine
pancreatic drainage. In 1982, the group at the University of
Wisconsin developed the technique of direct drainage of the
6 Part I Introduction
pancreas into the urinary bladder. Now, most whole organ
pancreas transplants use the intestine for drainage. Recently
improved results have been reported with islet cell transplants.
e small intestine was the last of the abdominal organs
to be transplanted successfully. In 1987, Starzl and associates performed a multivisceral organ transplant, including the
small intestine. e following year, the same group performed
a successful combined liver and small intestine transplant,
and Grant reported a successful isolated intestinal transplant
from a live donor. In 1989, the Pittsburgh group performed
the rst successful cadaveric small intestinal transplant.
Doubtless, the most dramatic development in abdominal
surgery is the introduction and expansion of laparoscopic
procedures. Kelling was the rst to examine the peritoneal
cavity with an endoscope. In 1901, using a Nitze cystoscope,
he entered and visualized the peritoneal cavity of a dog and
referred to the procedure as “Koelioskopie.” e rst major
series of laparoscopies in humans is attributed to Jacobaeus,
who in 1911 reported examining both the abdominal and
thoracic cavities with a “Lapaothorakoscopie.” In 1937,
Ruddock published a paper on “Peritoneoscopy” in which he
detailed his experience with 500 cases including 39 in which
biopsies were performed.
Laparoscopy essentially remained a procedure performed
by gynecologists for many years. In fact, it was a gynecologist, Mouret, who in 1987 performed the rst laparoscopic
cholecystectomy, using four trocars. But credit is generally
assigned to Dubois, who described the procedure in 1988,
for initiating interest in the procedure. In the 25 years that
have ensued, there has been an explosive increase in the use
of laparoscopic techniques for abdominal operations. Basic
laparoscopic procedures include cholecystectomy, appendectomy, and hernia repair. Advanced procedures include
fundoplication, Heller myotomy, gastrectomy, bariatric surgery, esophagectomy, enteral access, bile duct exploration,
partial hepatectomy, partial pancreatectomy, colectomy,
splenectomy, adrenalectomy, and nephrectomy in addition
to the standard gynecologic applications.
9
e most recent renement has been the addition of robotics, or more currently, computer-assisted remote mechanical
devices. e appropriateness of the application of robotics to
cholecystectomy has not been demonstrated. An advantage,
however, has been ascribed to robotics for adrenalectomy.
10
Paralleling the expansion of laparoscopic surgery, there has
been an increased application of endovascular techniques for
the repair of aneurysm of the abdominal aorta. Endovascular abdominal aortic repair was introduced independently by
Parodi and associates and Volodos and coworkers in 1991.
Over a dozen endovascular grafts have been developed, and in
2002, there were more abdominal aortic aneurysms repaired
in the state of New York by endovascular procedures than
open operations.
11
e expansion in surgery that has occurred during the 20th
and early 21st centuries has been a consequence of contributions by surgeons, unrelated to technical improvements. e
critical maintenance of blood volume was instated by James
Blundell in London over 150 years ago. In 1883, Halsted
reported the rst successful autoreinfusion of blood. In 1908,
George W. Crile published a book detailing his laboratory
and clinical experiences with transfusion. In 1915, Richard
Lewisohn, a New York surgeon, introduced the sodium citrate
method of blood preservation. e use of frozen blood was
rst reported in 1965 by Charles Huggins of Massachusetts
General Hospital.
In reference to the use of intraoperative and postoperative uid therapy, early contributions were made by John H.
Gibbons in 1907, and Wilder Peneld and David Teplitsky
in 1923. A year later, Rudolph Matas prescribed the intravenous administration of 4000–5000 mL of 5% glucose solution over 24 hours. After a period in which saline was avoided,
the importance of saline and potassium was demonstrated by
Francis D. Moore, Henry T. Randall, and G.Tom Shires. In
1959, Moore’s Metabolic Care of the Surgical Patient brought
into focus the importance of body composition, homeostasis, and endocrinology of the traumatized and surgical
patient. e problem of nutritional support was resolved
by Dudrick and associates in 1968 when they demonstrated
that nutritional requirements could be satised totally by
administration of high caloric uid by a catheter position in
the superior vena cava.
Over seven decades have elapsed since the rst edition
of Maingot’s Abdominal Operations was published. As is true
for all of the sciences, growth recently has been geometric.
During the time from the initial publication to the present,
there have been more new and rened operations introduced
than throughout the preceding years. e accelerated rate of
change can only ensure the viability of future editions.
REFERENCES
1. Nyhus LM, Wastell C (eds). Surgery of the Stomach and Duodenum.
Boston, MA: Little Brown and Co; 1986.
2. Modlin IM. e Evolution of erapy in Gastroenterology. Montreal, Canada:
Axcan Pharma; 2002.
3. Steichen FM, Ravitch MM. Stapling in Surgery. Chicago, IL: Year Book
Medical; 1971.
4. Goligher J. Surgery of the Anus Rectum and Colon. 5th ed. London,
England: Baillière Tindall; 1984.
5. McDermott WV. Surgery of the Liver. Cambridge, England: Blackwell
Scientic; 1988.
6. Schwartz SI, et al. Principles of Surgery. 7th ed. New York, NY: McGraw-
Hill; 1989.
7. Schwartz SI. Gifted Hands. Amherst, New York: Prometheus Books;
2009.
8. Hiatt JR, Phillips EH, Morgenstern L. Surgical Diseases of the Spleen.
New York, NY: Springer; 1997.
9. Laparoscopy for the general surgeon. Surg Clin North Am. 1992;72:
997–1186.
10. Jacob BP, Gagner M. Robotics and general surgery. Surg Clin North Am.
2003;83:1405–1419.
11. Krupinski WC, Rutherford RB. Update on open repair of abdominal
aortic aneurysms: the challenges for endovascular repair. J Am Coll Surg.
2004;199:946–960.
PREOPERATIVE AND POSTOPERATIVE MANAGEMENT
Zara Cooper • Edward Kelly
2
Modern advances in patient care have enabled surgeons to
treat more challenging and complicated surgical problems.
In addition, surgical treatment can be o ered to more fragile
patients, with successful outcomes. In order to achieve these
good results, it is vital to master the scienti c fundamentals of
perioperative management. e organ system–based approach
allows the surgeon to address the patient’s pre- and postoperative needs, and ensures that these needs are part of the surgical
plan.
MANAGEMENT OF
PAIN AND DELIRIUM
e most common neuropsychiatric complications following
abdominal surgery are pain and delirium. Moreover, uncontrolled pain and delirium prevent the patient from contributing to vital aspects of his or her care such as walking and
coughing, and promote an unsafe environment that may lead
to the unwanted dislodgment of drains and other supportive
devices, with potentially life-threatening consequences. Pain
and delirium frequently coexist, and each can contribute to
the development of the other. Despite high reported rates of
overall patient satisfaction, pain control is frequently inadequate in the perioperative setting
plications such as drowsiness and unacceptable levels of pain.
erefore, it is mandatory that the surgical plan for every
patient include control of postoperative pain and delirium
and regular monitoring of the e cacy of pain control.
Pain management, like all surgical planning, begins in the
preoperative assessment. In the modern era, a large proportion of surgical patients will require special attention with
respect to pain control. Patients with preexisting pain syndromes, such as sciatica or interspinal disc disease, or patients
with a history of opioid use may have a high tolerance for
opioid analgesics. Every patient’s history should include a
thorough investigation for chronic pain syndrome, addiction (active or in recovery), and adverse reactions to opioid,
nonsteroidal, or epidural analgesia. e pain control strategy
1
with high rates of com-
may include consultation with a pain control anesthesiology
specialist, but it is the responsibility of the operating surgeon
to identify complicated patients and construct an e ective
pain control plan.
Opioid Analgesia
Postoperative pain control using opioid medication has been
in use for thousands of years. Hippocrates advocated the use
of opium for pain control. e bene ts of postoperative pain
control are salutary, and include improved mobility and respiratory function, and earlier return to normal activities. e
most e ective strategy for pain control using opioid analgesia
is patient-controlled analgesia (PCA), wherein the patient is
instructed in the use of a preprogrammed intravenous pump
that delivers measured doses of opioid (usually morphine or
meperidine). In randomized trials, PCA has been shown to
provide superior pain control and patient satisfaction compared to interval dosing,
improve rates of pulmonary and cardiac complications
length of hospital stay,
contribute to postoperative ileus.
unsuitable for patients with a history of substance abuse, high
opioid tolerance, or those with atypical reactions to opioids.
2
but PCA has not been shown to
4
and there is evidence that PCA may
5
In addition, PCA may be
3
or
Epidural Analgesia
Due to the limitations of PCA, pain control clinicians have
turned to epidural analgesia as an e ective strategy for the
management of postoperative pain. Postoperative epidural
analgesia involves the insertion of a catheter into the epidural
space of the lumbar or thoracic spine, enabling the delivery
of local anesthetics or opioids directly to the nerve roots. e
insertion procedure is generally safe, with complication rates
of motor block and numbness between 0.5% and 7%,
an epidural abscess rate of 0.5 per thousand.
tages of epidural analgesia include elimination of systemic
7
Potential advan-
6
and
7
8 Part I Introduction
opioids, and thus less respiratory depression, and improvement in pulmonary complications and perioperative ileus.
8–10
ere have been several large trials,
11
a systematic review
comparing PCA with epidural analgesia
a meta-analysis, 6 and
in the setting of abdominal surgery. ese studies indicate
that epidural analgesia provides more complete analgesia than
PCA throughout the postoperative course. Furthermore, in
randomized prospective series of abdominal procedures,
epidural analgesia has been associated with decreased rates
of pulmonary complications
12,
13 and postoperative ileus.
14,
15
Epidural analgesia requires a skilled anesthesia clinician to
insert and monitor the catheter and adjust the dosage of
neuraxial medication. Some clinicians may prefer correction
of coagulopathy before inserting or removing the catheter,
although the American Society of Anesthesiologists (ASA)
has not issued o cial guidelines on this issue.
Analgesia With Nonsteroidal
Anti-In ammatory Drugs
Oral nonsteroidal anti-in ammatory drugs (NSAIDs) have
long been used for postoperative analgesia in the outpatient
setting, and with the development of parenteral preparations,
have come into use in the inpatient population. is class of
medication has no respiratory side e ects and is not associated with addiction potential, altered mental status, or ileus.
In addition, these medications provide e ective pain relief
in the surgical population. However, use of NSAIDs has not
been universally adopted in abdominal surgery due to concerns regarding the platelet dysfunction and erosive gastritis associated with heavy NSAID use. In prospective trials,
NSAIDs were found to provide e ective pain control without
bleeding or gastritis symptoms following laparoscopic chole-
16
cystectomy,
repair.
abdominal hysterectomy, 17 and inguinal hernia
18,
19 NSAIDs have also been shown to improve pain
control and decrease morphine dosage when used in combi-
20
nation following appendectomy.
e sensation of pain is very subjective and personal.
Accordingly, the surgeon must individualize the pain control plan to t the needs of each patient. e pain control
modalities discussed above can be used in any combination,
and the surgeon should not hesitate to use all resources at his
or her command to provide adequate relief of postoperative
pain.
Postoperative Delirium
Delirium, de ned as acute cognitive dysfunction marked
by uctuating disorientation, sensory disturbance, and
decreased attention, is an all too common complication of
surgical procedures, with reported rates of 11–25%, with
the highest rates reported in the elderly population.
postoperative phase of abdominal surgery exposes patients,
some of whom may be quite vulnerable to delirium, to a
21,
22 e
TABLE 2-1: CAUSES OF PERIOPERATIVE
DELIRIUM
Pain
Narcotic analgesics
Sleep deprivation
Hypoxemia
Hyperglycemia
Acidosis
Withdrawal (alcohol, narcotics, benzodiazepines)
Anemia
Dehydration
Electrolyte imbalance (sodium, potassium, magnesium, calcium,
phosphate)
Fever
Hypotension
Infection (pneumonia, incision site infection, urinary tract
infection)
Medication (antiemetics, antihistamines, sedatives, anesthetics)
Postoperative myocardial infarction (MI)
large number of factors that may precipitate or exacerbate
delirium ( Table 2-1 ). ese factors can augment each other:
postoperative pain can lead to decreased mobility, causing
respiratory compromise, atelectasis, and hypoxemia. Escalating doses of narcotics to treat pain can cause respiratory
depression and respiratory acidosis. Hypoxemia and delirium can cause agitation, prompting treatment with benzodiazepines, further worsening respiratory function and
delirium. is vicious cycle can play out right before the
physician’s eyes, and if not interrupted, can result in serious
complications or death. Preoperative recognition of highrisk patients and meticulous monitoring of every patient’s
mental status are the most e ective ways to prevent postoperative delirium; treatment can be remarkably di cult once
the vicious cycle has begun.
Patient factors that are associated with high risk of perioperative delirium include age greater than 70 years, preexisting
cognitive impairment or prior episode of delirium, history of
21,
alcohol or narcotic abuse, and malnutrition.
23 Procedural
factors associated with high delirium risk include operative
time greater than 2 hours, prolonged use of restraints, presence of a urinary catheter, addition of more than three new
22
medications, and reoperation.
Once the patient’s risk for postoperative delirium is
identi ed, perioperative care should be planned carefully
to decrease other controllable factors. Epidural analgesia has been associated with less delirium than PCA after
24
abdominal surgery.
Sedation or “sleepers” should be used
judiciously, if at all, with high-risk patients. If the patient
requires sedation, neuroleptics such as haloperidol and the
atypical neuroleptics such as olanzapine are tolerated much
25
better than benzodiazepines.
e patient’s mental status,
including orientation and attention, should be assessed
Chapter 2 Preoperative and Postoperative Management 9
with every visit, and care should be taken to avoid anemia,
electrolyte imbalances, dehydration, and other contributing
factors.
Once the diagnosis of postoperative delirium is established, it is important to recognize that some of the causes
of delirium are potentially life-threatening, and immediate
action is necessary. Evaluation begins with a thorough history and physical examination at the bedside by the surgeon.
e history should focus on precipitating events such as falls
(possible traumatic brain injury), recent procedures, use of
opioids and sedatives, changes in existing medications (eg,
withholding of thyroid replacement or antidepressants),
and consideration of alcohol withdrawal. e vital signs
and uid balance may suggest sepsis, hypovolemia, anemia,
or dehydration. e examination should include brief but
complete sensory and motor neurological examinations to
di erentiate delirium from stroke. Pay attention to common sites of infection such as the surgical wound, the lungs,
and intravenous catheters. Urinary retention may be present
as a result of medication or infection. Deep venous thrombosis may be clinically evident as limb swelling. Postoperative myocardial infarction (MI) may often present as acute
cardiogenic shock.
e history and physical examination should then direct
the use of laboratory tests. Most useful are the electrolytes,
blood glucose, and complete blood cell count. Pulse oximetry
and arterial blood gases may disclose hypercapnia or hypoxemia. Chest x-ray may disclose atelectasis, pneumonia, acute
pulmonary edema, or pneumothorax. Cultures may be indicated in the setting of fever or leukocytosis, but will not help
immediately. Electrocardiogram (ECG) and cardiac troponin
may be used to diagnose postoperative MI.
Resuscitative measures may be required if life- threatening
causes of delirium are suspected. Airway control, supplemental oxygen, and uid volume expansion should be
considered in patients with unstable vital signs. e patient
should not be sent out of the monitored environment for
further tests, such as head computed tomography (CT),
until the vital signs are stable and the agitation is controlled.
Treatment of postoperative delirium depends on treatment
of the underlying causes. Once the underlying cause has
been treated, delirium may persist, especially in elderly or
critically ill patients, who regain orientation and sleep cycles
slowly. In these patients, it is important to provide orienting
communication and mental stimulation during the day, and
to promote sleep during the night. e simplest ways are the
most e ective: contact with family members and friends, use
of hearing aids, engagement in activities of daily living, and
regular mealtimes. Sleep can be promoted by keeping the
room dark and quiet throughout the evening, and preventing
unnecessary interruptions. If nighttime sedation is required,
atypical neuroleptics or low-dose serotonin reuptake inhibitors such as trazodone are better tolerated than benzodiazepines. If agitation persists, escalating doses of neuroleptics
(or benzodiazepines in the setting of alcohol withdrawal) can
be used to control behavior, but hidden causes of delirium
must be considered.
CARDIAC EVALUATION
Risk Assessment
It has been estimated that 1 million patients have a perioperative MI each year, and the contribution to medical costs is $20
billion annually.
and major orthopedic procedures are associated with increased
cardiac risk. Diabetes, prior MI, unstable angina, and decompensated congestive heart failure (CHF) are most predictive
of perioperative cardiac morbidity and mortality, and patients
with these conditions undergoing major surgery warrant further
evaluation
risk include mild angina and chronic renal insu ciency with
baseline creatinine ≥2 mg/dL.
were underrepresented in the studies on which the American
College of Cardiology and the American Heart Association
(ACC/AHA) guidelines are based.
gynecological patients found that hypertension and previous
MI were major predictors of postoperative cardiac events, as
opposed to the ACC/AHA guidelines, which indicate that they
are minor and intermediate criteria, respectively.
vascular surgical patients are at highest risk because of the prevalence of underlying coronary disease in this population.
Other high-risk procedural factors include emergency surgery,
long operative time, and high uid replacement volume; these
are associated with a more than 5% risk of perioperative cardiac
TABLE 2-2: CLINICAL PREDICTORS OF
INCREASED RISK FOR PERIOPERATIVE
CARDIAC COMPLICATIONS
Major
Recent MI (within 30 days)
Unstable or severe angina
Decompensated CHF
Signi cant arrhythmias (high-grade atrioventricular block,
symptomatic ventricular arrhythmias with underlying heart
disease, supraventricular arrhythmias with uncontrolled rate)
Severe valvular disease
Intermediate
Mild angina
Any prior MI by history or ECG
Compensated or prior CHF
Diabetes mellitus
Renal insu ciency
Minor
Advanced age
Abnormal ECG
Rhythm other than sinus (eg, atrial brillation)
Poor functional capacity
History of stroke
Uncontrolled hypertension (eg, diastolic blood pressure
>10 mm Hg)
26
oracic, upper abdominal, neurological,
27
( Table 2-2 ). Patient factors conferring intermediate
28
It is worth noting that women
29
A retrospective study in
30
erefore,
27,
31
10 Part I Introduction
morbidity and mortality. Intraperitoneal procedures, carotid
endarterectomy, thoracic surgery, head and neck procedures,
and orthopedic procedures carry an intermediate risk, and are
28
associated with a 1–5% risk of a perioperative cardiac event.
Perioperative evaluation to identify patients at risk for cardiac
complications is essential in minimizing morbidity and mortality. Workup should start with history, physical examination, and
ECG to determine the existence of cardiac pathology. Screening with chest radiographs and ECG is required for men over
40 and women over 55. According to the ACC/AHA guidelines, indications for preoperative cardiac testing should mirror
32
those in the nonoperative setting.
e preoperative evaluation
should include the surgeon, anesthesiologist, primary care physician, and possibly a cardiologist. Cardiology consultations are
recommended for patients with major clinical predictors, those
with intermediate clinical predictors and poor functional status
undergoing intermediate-risk procedures, or those undergoing
high-risk procedures with poor functional status or intermediate
clinical predictors ( Table 2-3 ). Overall functional ability is the
best measure of cardiac health. Patients who can exercise without
limitations can generally tolerate the stress of major surgery.
33
Limited exercise capacity may indicate poor cardiopulmonary
reserve and the inability to withstand the stress of surgery. Poor
functional status is the inability to perform activities such as driving, cooking, or walking less than 5 km/h.
Intraoperative risk factors include operative site,
inappropriate use of vasopressors, and unintended hypotension. Intra-abdominal pressure exceeding 20 mm Hg during
laparoscopy can decrease venous return from the lower extrem-
34
ities and thus contribute to decreased cardiac output,
and
Trendelenburg positioning can result in increased pressure
on the diaphragm from the abdominal viscera, subsequently
reducing vital capacity. Intraoperative hypertension has not
been isolated as a risk factor for cardiac morbidity, but it is
often associated with wide uctuations in pressure, and has
been more closely associated with cardiac morbidity than intraoperative hypotension. Preoperative anxiety can contribute to
hypertension even in normotensive patients. ose patients
with a history of hypertension, even medically controlled
hypertension, are more likely to be hypertensive preoperatively.
ose with poorly controlled hypertension are at greater risk
of developing intraoperative ischemia, arrhythmias, and blood
TABLE 2-3: FACTORS THAT INCREASE
THE RISK OF PERIOPERATIVE CARDIAC
COMPLICATIONS
Risk Variable
Poor functional status 1.8 (0.9–3.5)
Ischemic heart disease 2.4 (1.3–4.2)
Heart failure 1.9 (1.1–3.5)
Diabetes 3.0 (1.3–7.1)
Renal insu ciency 3.0 (1.4–6.8)
High-risk surgery 2.8 (1.6–4.9)
Odds Ratio (95%
Con dence Interval)
pressure derangements, particularly at induction and intubation. Twenty- ve percent of patients will exhibit hypertension
during laryngoscopy. Patients with chronic hypertension may
not necessarily bene t from lower blood pressure during the
preoperative period because they may depend on higher pressures for cerebral perfusion. ose receiving antihypertensive
medications should continue them up until the time of surgery. Patients taking beta-blockers are at risk of withdrawal
and rebound ischemia. Key ndings on physical examination
include retinal vascular changes and an S
gallop consistent
4
with left ventricular (LV) hypertrophy. Chest radiography may
show an enlarged heart, also suggesting LV hypertrophy.
Noninvasive cardiac testing is used to de ne risk in patients
known to be at high or intermediate risk, and detect those
with CHF or dyspnea. It is most useful in intermediate-risk
patients. No special laboratory tests are necessary unless there
is evidence of active ischemia. A baseline ECG is necessary
to identify any new ECG ndings, to rule out active ischemia, and as a baseline for comparison during the postoperative period. e baseline ECG will be normal in 25–50% of
patients with coronary disease, but no history of MI. A 12-lead
ECG should be obtained in patients with chest pain, diabetes,
prior revascularization, prior hospitalization for cardiac causes,
all men age 45 or older, and all women aged 55 with two or
more risk factors. High- or intermediate-risk patients should
also have a screening ECG. A lower-than-normal ejection
fraction demonstrated on echocardiography is associated with
the greatest perioperative cardiac risk, and should be obtained
in all patients with symptoms suggesting heart failure or valvular disease. Tricuspid regurgitation indicates pulmonary
hypertension and is often associated with sleep apnea. e
chest x-ray is used to screen for cardiomegaly and pulmonary
congestion, which may signify ventricular impairment.
Exercise testing demonstrates a propensity for ischemia
and arrhythmias under conditions that increase myocardial
oxygen consumption. Numerous studies have shown that
performance during exercise testing is predictive of perioperative mortality in noncardiac surgery. ST-segment changes
during exercise including horizontal depression greater than
2 mm, changes with low workload, and persistent changes
after 5 minutes of exercise are seen in severe multivessel
disease. Other ndings include dysrhythmias at a low heart
rate, an inability to raise the heart rate to 70% of predicted,
and sustained decrease in systolic pressure during exercise.
Unfortunately, many patients are unable to achieve adequate
workload in standard exercise testing because of osteoarthritis,
low back pain, and pulmonary disease. In this case, pharmacological testing is indicated with a dobutamine echocardiogram.
Dobutamine is a beta-agonist that increases myocardial oxygen
demand and reveals impaired oxygen delivery in those with
coronary disease. Echocardiography concurrently visualizes
wall motion abnormalities due to ischemia. Transesophageal
echocardiography may be preferable to transthoracic echocardiography in obese patients because of their body habitus, and
has been shown to have high negative predictive value in this
35
group.
Nuclear perfusion imaging with vasodilators such as
adenosine or dipyridamole can identify coronary artery disease
Chapter 2 Preoperative and Postoperative Management 11
and demand ischemia. Heterogeneous perfusion after vasodilator administration demonstrates an inadequate response to
stress. Wall motion abnormalities indicate ischemia and an
ejection fraction lower than 50% increases the risk of perioperative mortality. Angiography should only be performed if the
patient may be a candidate for revascularization.
Coronary Disease
Most perioperative MIs are caused by plaque rupture in
lesions that do not produce ischemia during preoperative
36
testing.
is presents an obvious challenge for detecting
Step 1 Is emergency noncardiac
surgery needed?
No
Step 2 Has coronary revascularization been
done in the past 5 years?
No
Step 3 Has coronary angiography or stress
testing been done in the past 2 years?
No
Step 4 Evaluate clinical predictors.
patients at risk. Stress testing has a low positive predictive value in patients with no cardiac risk factors, and has
been associated with an unacceptably high rate of falsepositives.
37
Preoperative optimization may include medical management, percutaneous coronary interventions (PCI),
38
or coronary artery bypass grafting (CABG).
e ACC/
AHA guidelines (Fig. 2-1) recommend coronary revascularization prior to noncardiac surgery in the following
situations:
1. e combined risk of the two procedures does not exceed
the risk of the surgical procedure alone.
Ye s
Ye s
Ye s
Ye s
Operating room
No
Recurrent symptoms
Favorable results?
No
Ye s
Major clinical predictors
Unstable angina
Recent MI
Decompensated CHF
Significant arrhythmias
Severe valvular disease
Consider delay
or cancel
noncardiac
surgery
Initiate therapy for
risk-factor modification
Reevaluate cardiac
angiography
status
Consider
coronary
Intermediate clinical predictors
Mild angina
Prior MI
Compensated or prior CHF
Diabetes
Renal insufficiency
Poor functional
capacity (<4 METs)
or high-risk
procedure
Noninvasive
testing
Consider coronary
angiography
Subsequent care
dictated by
angiography
Moderate or excellent
functional capacity
(≥4 METs) or low-
or intermediate-risk
procedure
Operating
room
Favorable
Reevaluate
cardiac
status
Minor clinical predictors
Advanced age
Abnormal ECG
Rhythm other than sinus
Poor functional capacity
History of stroke
Uncontrolled hypertension
Poor functional
capacity (<4 METs)
or high-risk
procedure
Noninvasive
testing
Consider coronary
angiography
Subsequent care
dictated by
angiography
Moderate or excellent
functional capacity
(≥4 METs) or low-
or intermediate-risk
procedure
Operating
room
Favorable
Reevaluate
cardiac
status
FIGURE 2-1 Preoperative cardiac risk assessment algorithm suggested by the ACC/AHA. (Adapted with permission from Eagle KA, Brundage
BH, Chaitman BR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/ American
Heart Association Task Force on Practice Guidelines [Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery]. J Am Coll Cardiol.
1996;27:921.) MI, myocardial infarction; CHF, congestive heart failure; ECG, electrocardiography; METs, metabolic equivalents.