Surgery
Surgery[a] is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (i.e., malabsorption created by bariatric surgery such as gastric bypass), to reconstruct or improve aesthetics and appearance (cosmetic surgery), or to remove unwanted tissues (body fat, glands, scars or skin tags) or foreign bodies. The subject receiving the surgery is typically a person (i.e. a patient), but can also be a non-human animal (i.e. veterinary surgery).
This article is about the medical specialty. For other uses, see Surgery (disambiguation).
The act of performing surgery may be called a surgical procedure or surgical operation, or simply "surgery" or "operation". In this context, the verb "operate" means to perform surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments, surgical facility or surgical nurse. Most surgical procedures are performed by a pair of operators: a surgeon who is the main operator performing the surgery, and a surgical assistant who provides in-procedure manual assistance during surgery. Modern surgical operations typically require a surgical team that typically consists of the surgeon, the surgical assistant, an anaesthetist (often also complemented by an anaesthetic nurse), a scrub nurse (who handles sterile equipment), a circulating nurse and a surgical technologist, while procedures that mandate cardiopulmonary bypass will also have a perfusionist. All surgical procedures are considered invasive and often require a period of postoperative care (sometimes intensive care) for the patient to recover from the iatrogenic trauma inflicted by the procedure. The duration of surgery can span from several minutes to tens of hours depending on the specialty, the nature of the condition, the target body parts involved and the circumstance of each procedure, but most surgeries are designed to be one-off interventions that are typically not intended as an ongoing or repeated type of treatment.
In British colloquialism, the term "surgery" can also refer to the facility where surgery is performed, or simply the office/clinic of a physician,[1] dentist or veterinarian.
Description of surgical procedure[edit]
Setting[edit]
Inpatient surgery is performed in a hospital, and the person undergoing surgery stays at least one night in the hospital after the surgery. Outpatient surgery occurs in a hospital outpatient department or freestanding ambulatory surgery center, and the person who had surgery is discharged the same working day.[6] Office-based surgery occurs in a physician's office, and the person is discharged the same day.[7]
At a hospital, modern surgery is often performed in an operating theater using surgical instruments, an operating table, and other equipment. Among United States hospitalizations for non-maternal and non-neonatal conditions in 2012, more than one-fourth of stays and half of hospital costs involved stays that included operating room (OR) procedures.[8] The environment and procedures used in surgery are governed by the principles of aseptic technique: the strict separation of "sterile" (free of microorganisms) things from "unsterile" or "contaminated" things. All surgical instruments must be sterilized, and an instrument must be replaced or re-sterilized if it becomes contaminated (i.e. handled in an unsterile manner, or allowed to touch an unsterile surface). Operating room staff must wear sterile attire (scrubs, a scrub cap, a sterile surgical gown, sterile latex or non-latex polymer gloves and a surgical mask), and they must scrub hands and arms with an approved disinfectant agent before each procedure.
Epidemiology[edit]
United States[edit]
In 2011, of the 38.6 million hospital stays in U.S. hospitals, 29% included at least one operating room procedure. These stays accounted for 48% of the total $387 billion in hospital costs.[38]
The overall number of procedures remained stable from 2001 to 2011. In 2011, over 15 million operating room procedures were performed in U.S. hospitals.[39]
Data from 2003 to 2011 showed that U.S. hospital costs were highest for the surgical service line; the surgical service line costs were $17,600 in 2003 and projected to be $22,500 in 2013.[40] For hospital stays in 2012 in the United States, private insurance had the highest percentage of surgical expenditure.[41] in 2012, mean hospital costs in the United States were highest for surgical stays.[41]
Special populations[edit]
Elderly people[edit]
Older adults have widely varying physical health. Frail elderly people are at significant risk of post-surgical complications and the need for extended care. Assessment of older people before elective surgery can accurately predict the person's recovery trajectories.[42] One frailty scale uses five items: unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking speed. A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes.[42] People who are frail and elderly (score of 4 or 5) have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.
Children[edit]
Surgery on children requires considerations that are not common in adult surgery. Children and adolescents are still developing physically and mentally making it difficult for them to make informed decisions and give consent for surgical treatments. Bariatric surgery in youth is among the controversial topics related to surgery in children.
Global surgery[edit]
Global surgery has been defined as 'the multidisciplinary enterprise of providing improved and equitable surgical care to the world's population, with its core belief as the issues of need, access and quality".[43] Halfdan T. Mahler, the 3rd Director-General of the World Health Organization (WHO), first brought attention to the disparities in surgery and surgical care in 1980 when he stated in his address to the World Congress of the International College of Surgeons, "'the vast majority of the world's population has no access whatsoever to skilled surgical care and little is being done to find a solution.As such, surgical care globally has been described as the 'neglected stepchild of global health,' a term coined by Paul Farmer to highlight the urgent need for further work in this area.[44] Furthermore, Jim Young Kim, the former President of the World Bank, proclaimed in 2014 that "surgery is an indivisible, indispensable part of health care and of progress towards universal health coverage."[45]
In 2015, the Lancet Commission on Global Surgery (LCoGS) published the landmark report titled "Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development", describing the large, pre-existing burden of surgical diseases in low- and middle-income countries (LMICs) and future directions for increasing universal access to safe surgery by the year 2030.[46] The Commission highlighted that about 5 billion people lack access to safe and affordable surgical and anesthesia care and 143 million additional procedures were needed every year to prevent further morbidity and mortality from treatable surgical conditions as well as a $12.3 trillion loss in economic productivity by the year 2030.[46] This was especially true in the poorest countries, which account for over one-third of the population but only 3.5% of all surgeries that occur worldwide.[47] It emphasized the need to significantly improve the capacity for Bellwether procedures – laparotomy, caesarean section, open fracture care – which are considered a minimum level of care that first-level hospitals should be able to provide in order to capture the most basic emergency surgical care.[46][48] In terms of the financial impact on the patients, the lack of adequate surgical and anesthesia care has resulted in 33 million individuals every year facing catastrophic health expenditure – the out-of-pocket healthcare cost exceeding 40% of a given household's income.[46][49]
In alignment with the LCoGS call for action, the World Health Assembly adopted the resolution WHA68.15 in 2015 that stated, "Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage."[50] This not only mandated the WHO to prioritize strengthening the surgical and anesthesia care globally, but also led to governments of the member states recognizing the urgent need for increasing capacity in surgery and anesthesia. Additionally, the third edition of Disease Control Priorities (DCP3), published in 2015 by the World Bank, declared surgery as essential and featured an entire volume dedicated to building surgical capacity.[51]
Data from WHO and the World Bank indicate that scaling up infrastructure to enable access to surgical care in regions where it is currently limited or is non-existent is a low-cost measure relative to the significant morbidity and mortality caused by lack of surgical treatment.[52] In fact, a systematic review found that the cost-effectiveness ratio – dollars spent per DALYs averted – for surgical interventions is on par or exceeds those of major public health interventions such as oral rehydration therapy, breastfeeding promotion, and even HIV/AIDS antiretroviral therapy.[53] This finding challenged the common misconception that surgical care is financially prohibitive endeavor not worth pursuing in LMICs.
A key policy framework that arose from this renewed global commitment towards surgical care worldwide is the National Surgical Obstetric and Anesthesia Plan (NSOAP).[54] NSOAP focuses on policy-to-action capacity building for surgical care with tangible steps as follows: (1) analysis of baseline indicators, (2) partnership with local champions, (3) broad stakeholder engagement, (4) consensus building and synthesis of ideas, (5) language refinement, (6) costing, (7) dissemination, and (8) implementation. This approach has been widely adopted and has served as guiding principles between international collaborators and local institutions and governments. Successful implementations have allowed for sustainability in terms of longterm monitoring, quality improvement, and continued political and financial support.[54]
Human rights[edit]
Access to surgical care is increasingly recognized as an integral aspect of healthcare, and therefore is evolving into a normative derivation of human right to health.[55] The ICESCR Article 12.1 and 12.2 define the human right to health as "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health"[56] In the August 2000, the UN Committee on Economic, Social and Cultural Rights (CESCR) interpreted this to mean "right to the enjoyment of a variety of facilities, goods, services, and conditions necessary for the realization of the highest attainable health".[57] Surgical care can be thereby viewed as a positive right – an entitlement to protective healthcare.[57]
Woven through the International Human and Health Rights literature is the right to be free from surgical disease. The 1966 ICESCR Article 12.2a described the need for "provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child"[58] which was subsequently interpreted to mean "requiring measures to improve… emergency obstetric services".[57] Article 12.2d of the ICESCR stipulates the need for "the creation of conditions which would assure to all medical service and medical attention in the event of sickness",[59] and is interpreted in the 2000 comment to include timely access to "basic preventative, curative services… for appropriate treatment of injury and disability.".[60] Obstetric care shares close ties with reproductive rights, which includes access to reproductive health.[60]
Surgeons and public health advocates, such as Kelly McQueen, have described surgery as "Integral to the right to health".[61] This is reflected in the establishment of the WHO Global Initiative for Emergency and Essential Surgical Care in 2005,[62] the 2013 formation of the Lancet Commission for Global Surgery,[63] the 2015 World Bank Publication of Volume 1 of its Disease Control Priorities Project "Essential Surgery",[9] and the 2015 World Health Assembly 68.15 passing of the Resolution for Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.[50] The Lancet Commission for Global Surgery outlined the need for access to "available, affordable, timely and safe" surgical and anesthesia care;[63] dimensions paralleled in ICESCR General Comment No. 14, which similarly outlines need for available, accessible, affordable and timely healthcare.[57]
John Syng Dorsey wrote the first American textbook on surgery
