The value of surgical history

It remains a rhetorical question whether or not an understanding of surgical history is important to the maturation and continued education of a surgeon. Conversely, it is hardly necessary to dwell on the heuristic value that an appreciation of history provides in developing adjunctive humanistic, literary, and philosophic tastes. Unfortunately, modern medical historians usually hold nonmedical degrees and basically restrict themselves to research concerning medical or public health aspects of social history. Clinical surgical history is increasingly avoided because the professional medical historian has no clinical background. However, practicing surgeons, who can serve as amateur medical historians, have knowledge and experience that place them in a unique position to assess historic facts and direct surgical historic inquiry. It is my belief that if medicine were taught with a greater emphasis on the historic approach, our country's physicians would be better prepared to cope with the health care problems of the future. By increasing the number of surgeons, who as an avocation, research and write about surgical history, our ability to provide better surgical care in our nation's coming years will be enhanced.     

The history of surgical management of hernias

At the dawn of the third millennium, the aim of this brief historical review was to trace the evolution of the surgical management of hernias during the recent past centuries after the advent of true anatomical knowledge. Because it is a frequent and ubiquitous surgery, many surgeons have devised new techniques in order to perform more and more efficient procedures, suitable to the patients' demands, the health care economy and quality care control.     

Atypical surgical infections

The management of infections requiring surgical drainage or debridement is a significant component of surgical education and practice. Standard Gram's stain and culture techniques usually allow ready identification and adjunctive therapy of the offending organism; however, the surgical patient population is changing. More patients who require surgery are elderly, critically ill, have been exposed to broad-spectrum antibiotics, or are otherwise immunosuppressed. We identified 33 infections in this group of 32 patients. The majority of the etiologic agents were not identified using traditional microbiologic techniques, often leading to a delay in diagnosis. In this high-risk group of patients, we recommend histologic study of tissue with special stains such as methenamine silver. When the patient's condition warrants, frozen sections can be used. Optimal outcome requires early recognition of the specific etiologic agent.     

The third generation cephems for surgical infections

The third generation cephems, Cefotaxime, Ceftizoxime, Cefmenoxime and Latamoxef, have been developed to aim opportunistic Gram negative pathogens and applied for surgical infections since 1980. Although they have excellent antibacterial activities in vitro against Enterobacter spp., indole positive Proteus spp., Pseudomonas spp. and Bacteroides spp., they show lower activities against Gram positive bacteria. Their pharmacokinetic characteristics are longer serum half-life, lower urinary excretion and higher biliary transmission without any metabolic inactivation in human body. Clinical trials of the third generation cephems to surgical infections in Japan revealed the average efficacy rate of 84% which might be better than that of the second generation cephems. It may be a discrepancy between their antibacterial spectrum and clinical results that responses in cases caused by Gram negatives did not exceed those by Gram positives. Clinical application of the third generation cephems should be limited to the surgical infections caused by Gram negatives in immunocompromised host to avoid the emergence of resistant strains.     

The history of thoracic surgical instruments and instrumentation

Thoracic surgical practice has evolved from the innovations of its pioneers. Beginning with the stethoscope discovered by La?nnec with his system of auscultation, to the tools we use in the dissection and control of the hilum of the lung for resection, our practice of thoracic surgery has been entwined with the development of instruments and instrumentation. The development of strategies to prevent death from the open pneumothorax began with manual control of the mediastinum and progressed through differential pressure to, finally, the technique of intubation and the methods of positive-pressure and insufflation anesthesia. The instruments we place in our hands are not enough to define our art. Entry into the chest would not be possible without the use of rib retractors, rib shears, and even periosteal elevators. Finally, to the present day of minimally invasive techniques and the application of thoracoscopy for therapeutic purposes, we find the efforts of our predecessors well developed. For the progression from the fear of the open pneumothorax to the present-day state of the ease of thoracotomy for lung resection we are indebted to those who gave so much of their time and, for some, their lives to death from tuberculosis, to allow the advancement of our practice of surgery. These great people should be remembered not only for their acceptance of novel ideas but also, more importantly, for their lack of fear of testing them.     

The history and evolution of bariatric surgical procedures

The search for the ideal weight loss operation began more than 50 years ago. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Variations, alterations, and modifications of these original procedures, combined with intense efforts to follow and document outcomes, have led to the evolution of modern bariatric surgery. More recent research has focused on the hormonal and metabolic effects of these procedures. These discoveries at the cellular level will help develop possible mechanisms of weight loss and comorbidity reduction beyond the traditional explanation of reduced food consumption and malabsorption.     

The surgical management of atypical mycobacterial soft-tissue infections

Group IV atypical mycobacterial infections, especially Mycobacterium fortuitum and M. chelonei, are being reported with increased frequency. We report our experience with five cases of soft-tissue infection with these acid-fast bacilli. Often these infections are chronic, with formation of abscesses and multiple fistulas. Optimal surgical treatment often requires wide excision of all diseased tissue followed by delayed closure. Presentation, optimal surgical management, and antibiotic therapy are discussed.     

The importance of beta-lactamase resistance in surgical infections

Substantial costs are associated with the treatment of nosocomial infections, 2 million cases of which occur annually in the United States. Hospital-acquired, gram-negative infection has become an increasing problem, particularly in the intensive care unit where up to 40% of the most frequently isolated strains of Enterobacteriaceae are resistant to standard beta-lactam antibiotics. Among several mechanisms of acquisition of resistance, beta-lactamase production accounts for a high percentage of treatment failures and relapses. By the end of the 1980s, some 10-30% of all nosocomial infections were caused by type-1 beta-lactamase-producing gram-negative isolates, and Enterobacter species had emerged as a major resistant pathogen. The beta-lactam/beta-lactamase inhibitor combinations, such as ampicillin/sulbactam, represent an innovative approach to the problem of beta-lactamase-mediated resistance. Clinical use of these agents has been associated with low rates of resistance and new data suggest they may have a specific role in controlling the emergence and spread of nosocomial infections.     

Culture-negative surgical site infections

BACKGROUND: The appearance of postoperative surgical site infection (SSI) in the absence of culturable bacterial pathogens is a common dilemma for the surgeon. METHODS: The literature was searched through references to primary articles, as well as a MEDLINE review, for reports of culture-negative SSIs. RESULTS: Potential causes of culture-negative SSIs include prior antimicrobial therapy; the presence of fastidious or slow-growing microorganisms such as mycobacteria, Mycoplasma spp., and Legionella spp.; infection caused by mundane bacteria that may be dismissed as "contaminants"; factitious infection; and others. CONCLUSIONS: We review the recognized causes of "culture negative" SSIs and discuss the laboratory capabilities that may enhance recognition of many of these pathogens and management options.     

Prevention of surgical site infections

Surgical site infections (SSI) are a major healthcare burden throughout the world and prevention is paramount in reducing the impact of this common category of healthcare associated infection. SSI may be classified as superficial incisional, deep incisional or organ/space and are caused by both patient and procedural factors. UK guidelines on prevention were published in 2008 and the World Health Organization has recently published guidelines in 2016 which are summarized here.