Surgical management of renal tumors: a historical perspective

The modern era of renal surgery began on August 2, 1869 when the first planned nephrectomy on a living human being was performed. Eighteen years later in 1887, the first partial nephrectomy to remove a renal tumor was performed. Both total and partial nephrectomy have become the hallmark surgical procedures used today to treat renal tumors, and their conception and evolution represent two of the most important advances in medicine and surgery. Surgery for kidney cancer continues to evolve. This article traces the history of surgical management for renal tumors.     

Surgical treatment of portal hypertension: A historical perspective

Portal hypertension has been treated surgically by diversion of blood from the portal system, by interruption of the flow of blood to esophageal varices, or by direct obliteration of the varices. At the beginning of the twentieth century, portal diversion was achieved by omentopexy and, in a few patients, by the creation of a portacaval shunt. The latter operation was abandoned because of high mortality and morbidity rates, including shunt encephalopathy. In the 1940's, interest was renewed in the portacaval shunt. Improved understanding of hepatic physiology and the establishment of precise criteria for selection of cases for surgery resulted in a low operative mortality rate. The operation was highly successful in the control of hemorrhage from esophageal varices but was associated with an undesirable incidence of impairment of hepatic function. Currently, selective decompression of varices by the distal splenorenal shunt is under evaluation as a method of preventing variceal hemorrhage, while preserving hepatic function. Elimination of the threat of hemorrhage from varices by arterial ligation, sclerotherapy, or direct suture has been practiced for almost a century. The result remains one of temporary control with recurrent hemorrhage in the majority of cases.Ascites was formerly considered the dominant manifestation of portal hypertension. Currently, it is usually well controlled by diuretics. Surgery is reserved for the rare case of intractable ascites, often with hepatorenal syndrome. In such cases, a shunt is established between the peritoneal cavity and the systemic venous system, a procedure first performed early in this century.

---

Resumen La hipertensión portal ha sido tratada quirúrgicamente mediante la desviación de la sangre del sistema portal al sistema venoso sistémico, la interrupción del flujo de sangre hacia las várices esofágicas o la obliteración directas de las várices. En los comienzos del siglo XX, la desviación portal era realizada mediante la omentopexia y, en unos pocos pacientes, mediante la creación de un shunt portacava. Esta última operación fué abandonada debido a la alta mortalidad y morbilidad, incluyendo la encefalopatía. En la década de 1940 se produjo un renovado interés en el shunt portacava. Un mejor conocimiento de la fisiología hepática y la definición de criterios precisos para la selección de los pacientes a ser sometidos a cirugía dió como resultado una baja mortalidad operatoria. La operación demonstró ser muy exitosa en cuanto al control de la hemorragia de las várices esofágicas pero se halló asociada con una indeseable ocurrencia de alteración en la función hepática. En la actualidad la descompresión selectiva de las várices por medio del shunt esplenorrenal distal está siendo evaluado como un método de prevenir la hemorragia al tiempo que preserva la función hepática. La eliminación de la amenaza de hemorragia varicosa por medio de la ligadura arterial, la escleroterapia o la sutura directa de las várices ha sido practicada en el curso de casi un siglo. El resultado todavía es el de un control temporal con hemorragia recurrente en la mayoría de los casos.La ascitis fué considerada como la manifestación dominante de la hipertensión portal en el pasado. En la actualidad es usualmente bien controlada con diuréticos. Se reserva la cirugía para el caso raro de ascitis refractaria al tratamiento médico, generalmente con síndrome hepatorrenal. En tales circumstancias se coloca un shunt entre la cavidad peritoneal y el sistema venoso sistémico, un procedimiento que fué realizado por primera vez a comienzos del siglo XX.La conditión patológica que produce la hipertensión portal casi siempre es una enfermedad irreversible del hígado. Por consiguiente, la cirugía es, por definición, de tipo paliativo y el beneficio que se obtiene es limitado.

---

Résumé L'hypertension portale a été traitée chirurgicalement par la dérivation du sang veineux portal, par l'interruption du flux sanguin nourrisant les varices oesophagiennes ou par l'oblitération directe des varices. Au début du vingtième siècle, la dérivation portale était réalisée par l'omentopexie et plus rarement par la constitution d'une dérivation portocave, opération qui fut abandonnée en raison de sa haute mortalité et de sa haute morbidité, cette dernière étant le fait surtout de l'encephalopathie. Des 1940, la dérivation portocave revint à l'honneur.Une meilleure connaissance de la physiologie hépatique et la détermination de critères précis pour sélectionner les cas relevant de la chirurgie se manifesta par une réduction de la mortalité. L'intervention permit de contrôler efficacement l'hémorragie par rupture des varices oesophagiennes, mais au prix d'un taux élevé d'altération des fonctions hépatiques. A l'heure actuelle la décompression sélective des varices à l'aide d'une dérivation spléno-rénale distale est en cours d'étude car elle est susceptible de prévenir le risque hémorragique et de préserver les fonctions du foie. L'élimination de la menace hémorragique grâce à la ligature des artères, à leur sclérose ou à la suture directe des varices a été pratiquée depuis un siècle mais les résultats montrent que ces méthodes n'évitent pas la récidive de l'hémorragie dans la majorité des cas.L'ascite dans le passé fut considérée comme la manifestation essentielle de l'hypertension portale. Actuellement, elle est traitée souvent avec succès par les diurétiques le recours à la chirurgie n'étant envisagé qu'en présence d'une ascite récidivante souvent associée à un syndrome hépatorénal. Dans ces cas, une dérivation est établie entre la cavité péritonéale et la circulation veineuse générale et cela depuis le début du siècle. En fait le processus pathologique à l'origine de l'hypertension portale est presque toujours irréversible. La chirurgie de ce fait n'est qu'une méthode thérapeutique palliative.

     

Surgical robotics: a review and neurosurgical prototype development

PURPOSE: The purpose of this article is to update the neurosurgical community on the expanding field of surgical robotics and to present the design of a novel neurosurgical prototype. It is intended to mimic standard technique and deploy conventional microsurgical tools. The intention is to ease its integration into the "nervous system" of both the traditional operating room and surgeon. CONCEPT: To permit benefit from updated intraoperative imaging, magnetic resonance imaging-compatible materials were incorporated into the design. Advanced haptics, optics, and auditory communication with the surgical site recreate the sight, sound, and feel of neurosurgery. RATIONALE: Magnification and advanced imaging have pushed surgeons to the limit of their dexterity and stamina. Robots, in contrast, are indefatigable and have superior spatial resolution and geometric accuracy. The use of tremor filters and motion scalers permits procedures requiring superior dexterity. DISCUSSION: Breadboard testing of the prototype components has shown spatial resolution of 30 microm, greatly exceeding our expectations. Neurosurgeons will not only be able to perform current procedures with a higher margin of safety but also must speculate on techniques that have hitherto not even been contemplated. This includes coupling the robot to intelligent tools that interrogate tissue before its manipulation and the potential of molecular imaging to transform neurosurgical research into surgical exploration of the cell, not the organ.     

Psychiatric neurosurgery: a historical perspective

Psychosurgery. Psychiatric neurosurgery. Neurosurgery for psychiatric disorders. Whatever the name, each of these refers to the surgical treatment of mental disease. Indeed, as many have pointed out, the most common term, "psychosurgery," is itself a misnomer, because the target of these procedures is not the "mind" or "psyche" but the neural substrates of higher cognitive function.     

Aortic surgery: a historical perspective

Aortic aneurysms have been recognized since at least the 2nd century. However, little progress in their treatment was made until the early 1800s, when surgical ligation of these lesions sometimes proved successful. Until the mid 20th century, the most widespread approach was indirect treatment to provide palliation and prevent rupture. Such treatment involved introducing foreign materials into the aneurysm to promote blood coagulation or wrapping the aneurysm with plastic film to stimulate periarterial fibrosis. In 1888, Rudolph Matas introduced endoaneurysmorrhaphy, in which the diseased portion of the aorta was removed and a tunnel was constructed through the remaining healthy portion. This approach was widely used until the 1950s, when the advent of synthetic grafts allowed modern, direct repair. Emphasis began to be placed on excising aortic aneurysms and restoring pulsatile distal flow. In the 1980s, however, most surgeons reverted to the endoaneurysmorrhaphy technique-this time relining rather than removing the diseased portion of the aorta-thus bringing the history of aortic aneurysm surgery full circle. Today, an increasing number of aortic repairs are being achieved with endovascular methods, which offer new hope to patients at high risk for traditional aortic surgery.     

Zollinger-Ellison syndrome: a personal perspective

The odyssey of Zollinger-Ellison Syndrome is one of the most interesting in surgery. From the initial recognition of two patients with severe peptic ulcer disease in 1955 sprung an international dialogue on this unique disease culminating in discovery that gastrin was the hormone secreted by these pancreatic and duodenal tumors. The impact was the birth of a new area of science, "gastrointestinal endocrinology." Initially, surgeons were challenged by the complexity of the patients and the need to perform total gastrectomy to prevent death from complications of the severe ulcer disease. Later, after the discovery of proton pump inhibitors, total gastrectomy was no longer needed and the surgeon could focus treatment on tumor removal added by radioimmunoassay for gastrin and new imaging modalities. Today, we recognize that all gastrinomas have malignant potential; early surgical removal can reduce the incidence of metastases and improve survival, independent of biochemical cure, in both sporadic and familial forms of the disease.     

Total ankle arthroplasty: a historical perspective

The ideal total ankle prosthesis has yet to be determined, but much has been learned from early experiences in ankle arthroplasty. Modern implants are typically more respectful of anatomic concerns, have found a happy medium of constraint, and have found novel approaches to decrease interface stress. Biologic fixation has improved on cemented results. Surgical techniques and understanding of wound healing and ligamentous deficiency have advanced. Current series still have varied results, and longer-term follow-up is needed. Despite this, some modern ankle replacements represent significant progress, with improved results and survival challenging those of arthrodesis. Further, benefits of preserved motion and avoidance of foot arthritis outstrip this traditional "gold standard." Today, tempered enthusiasm for the future of total ankle arthroplasty is again apparent. A diverse, international effort is underway to create a lasting joint implant. Building on the lessons of the past, different investigators in different countries, using markedly different prostheses, continue to work toward this goal.     

Innovation in surgery: a historical perspective

OBJECTIVE: To describe the field of surgical innovation from a historical perspective, applying new findings from research in technology innovation. BACKGROUND: While surgical innovation has a rich tradition, as a field of study it is embryonic. Only a handful of academic centers of surgical innovation exist, all of which have arisen within the last 5 years. To this point, the field has not been well defined, nor have future options to promote surgical innovation been thoroughly explored. It is clear that surgical innovation is fundamental to surgical progress and has significant health policy implications. A process of systematically evaluating and promoting innovation in surgery may be critical in the evolving practice of medicine. METHODS: A review of the academic literature in technology innovation was undertaken. Articles and books were identified through technical, medical, and business sources. Luminaries in surgical innovation were interviewed to develop further relevance to surgical history. The concepts in technology innovation were then applied to innovation in surgery, using the historical example of surgical endoscopy as a representative area, which encompasses millennia of learning and spans multiple specialties of care. RESULTS: The history of surgery is comprised largely of individual, widely respected surgeon innovators. While respecting individual accomplishments, surgeons as a group have at times hindered critical innovation to the detriment of our profession and patients. As a clinical discipline, surgery relies on a tradition of research and attracting the brightest young minds. Innovation in surgery to date has been impressive, but inconsistently supported. CONCLUSION: A body of knowledge on technology innovation has been developed over the last decade but has largely not been applied to surgery. New surgical innovation centers are working to define the field and identify critical aspects of surgical innovation promotion. It is our responsibility as a profession to work to understand innovation in surgery, discover, translate, and commercialize advances to address major clinical problems, and to support the future of our profession consistently and rationally.     

Infections within the peritoneal cavity: a historical perspective

Physicians in antiquity dreaded abdominal infections. Despite the fact that peritonitis was extremely common, reports of successful surgical interventions were only anecdotal before the past century. Medicine's comprehension of the pathophysiology of the peritoneal cavity is still evolving. The history of our understanding of the process could be considered to be as recent as the current literature. Despite this, the mortality rates for patients with secondary peritonitis have fallen in the last century from almost 100 per cent to less than 10 per cent.     

Leg lengthening: the historical perspective

An overview of lengthening is presented from the scarlet cloth through skeletal traction, screw distraction, and patient mobility. Unquestionably, significant advances have been made in the technology and techniques of lengthening legs, but more are yet to be made.