Breast reconstruction with pedicled TRAM flap (a retrospective study of 115 consecutive cases)

Purpose of the study

The purpose of this study is to analyse the advantages, disadvantages and results of the unipediculed TRAM flap.

Patients and method

This retrospective study concerns 115 consecutive unipediculed TRAM flaps realised by two surgeons between 1994 and January 2007. These reconstructions were all realised for oncologic pathology and were either immediate or delayed surgery. Concerning the immediate reconstruction, a skin sparing mastectomy has been realised as often as possible for intraductal carcinomas and small invasive carcinomas. For the immediate reconstruction the study takes into account complications and oncologic recurrences with an average backward of 45 months.

Results

The unipediculed TRAM flap offers a good reliability and the esthetics results are stable at long-term for immediate breast reconstruction and delayed breast reconstruction. The major complications are flap necrosis (12,2%) and parietal complications (6%). The recurrence rate after mastectomy and unipediculed TRAM flap is equivalent of the recurrence rate expected for mastectomy alone. There were never late diagnostic for recurrence after unipediculed TRAM flap. The esthetic improvement by surgery concerns the opposite breast for 31,3%, it was a mastopexy or reduction. The esthetic improvement of the TRAM flap concerns 14 patients (12,1%). The improvement of inframammary crease was the most frequent improvement (9/115–8%).

Conclusion

The TRAM flap unipediculed allows a delayed, immediate breast reconstruction or bilateral synchronised breast reconstruction. The long-term disadvantages are the abdominal complications and the impossibility to realise the same technique for a later controlateral reconstruction.     

A survey of volunteer reconstructive surgery performed outside of Canada by Canadian plastic surgeons

BACKGROUND:

Members of the Canadian Society of Plastic Surgeons have been offering humanitarian services to countries outside of Canada since the 1960s.

OBJECTIVE:

To document the extent of voluntary reconstructive services performed by members of the Canadian Society of Plastic Surgeons.

METHOD:

A survey was sent to all members of the Canadian Society of Plastic Surgeons asking them to list the extent of their voluntary services.

RESULTS:

Over 80 Canadian Society of Plastic Surgeons members have performed voluntary reconstructive services with more than 40 organizations in over 60 countries.

CONCLUSION:

These voluntary services provide a significant benefit to patients around the world and are rewarding for the surgeons who perform them.     

Practice profiles in breast reduction: A survey among Canadian plastic surgeons

BACKGROUND:

Breast reduction is an increasingly common procedure performed by Canadian plastic surgeons. Recent studies in the United States show that use of the inferior/central pedicle inverted T scar method is predominant. However, it is unknown what the practice preferences are among Canadian plastic surgeons.

OBJECTIVE:

The goal of the present study was to assess trends in breast reduction surgery among Canadian surgeons, including patient selection criteria, surgical techniques and outcomes.

METHOD:

Surveys were distributed to plastic surgeons at the Canadian Society for Plastic Surgery meetings in 2005 and 2006. Completed surveys were obtained from 140 respondents, and results were analyzed with Excel and SAS software.

RESULTS:

There was a 40% response rate. The majority of surgeons (66%) used more than one technique for breast reduction. Most commonly, surgeons use the inverted T scar technique (66%) followed by vertical scar techniques (26%). The most popular vertical scar techniques included the Hall-Findlay (14%) and Lejour (13%) methods. Most surgeons (55%) reported complication rates of less than 5% and the most common complication reported was wound dehiscence. There was no difference in overall complication rates between inverted T scar and vertical scar surgeries. The majority of surgeons (98%) carried out breast reduction either exclusively as day surgery or in combination with same-day admission. Breast reduction performed as day surgery resulted in cost savings of $873 per patient.

CONCLUSIONS:

Canadian plastic surgeons are performing more vertical scar breast reductions than American surgeons. However, both groups rely predominantly on inverted T scar techniques.     

Survey of terminology used for the intraoperative direction of C-arm fluoroscopy

Background

Orthopedic surgeons depend on the intraoperative use of fluoroscopy to facilitate procedures across all subspecialties. The versatility of the C-arm fluoroscope allows acquisition of nearly any radiographic view. This versatility, however, creates the opportunity for difficulty in communication between surgeon and radiation technologist. Poor communication leads to delays, frustration and increased exposure to ionizing radiation. There is currently no standard terminology employed by surgeons and technologists with regards to direction of the fluoroscope.

Methods

The investigation consisted of a web-based survey in 2 parts. Part 1 was administered to the membership of the Canadian Orthopedic Association, part 2 to the membership of the Canadian Association of Medical Radiation Technologists. The survey consisted of open-ended or multiple-choice questions examining experience with the C-arm fluoroscope and the terminology preferred by both orthopedic surgeons and radiation technologists.

Results

The survey revealed tremendous inconsistency in language used by orthopedic surgeons and radiation technologists. It also revealed that many radiation technologists were inexperienced in operating the fluoroscope.

Conclusion

Adoption of a common language has been demonstrated to increase efficiency in performing defined tasks with the fluoroscope. We offer a potential system to facilitate communication based on current terminology used among Canadian orthopedic surgeons and radiation technologists.     

Posterior Reconstruction Before Anastomosis Improves the Anastomosis Time During Robot-Assisted Radical Prostatectomy

Background and Objectives:

Our goal was to evaluate posterior reconstruction of the rhabdosphincter during robot-assisted radical prostatectomy and determine whether this technique decreased anastomotic time of a surgeon in training to perform vesicourethral reconstruction.

Methods:

We reviewed the first 25 robot-assisted prostatectomies performed by 2 urology surgeons in training (surgeon 1 and surgeon 2). The patient populations were matched for age, Gleason score, clinical stage, and PSA. Whereas surgeon 1 performed the vesicourethral anastomosis without posterior reconstruction, surgeon 2 reapproximated Denonvilliers'' fascia of the posterior bladder to the rhabdosphincter. Time for each surgeon to complete the anastomosis and clinical factors was compared.

Results:

Surgeon 1 had a median anastomosis time of 25 minutes (range, 17 to 48), whereas surgeon 2 had a median anastomosis time of 15 minutes (range, 10 to 30) (P<0.001). Biopsy Gleason score, pathological tumor stage, perineural invasion, median age at the time of surgery, PSA, prostate weight, and estimated blood loss were not significantly different between surgeons (P>0.05). Pathological Gleason score (P=0.045) and total console time (surgeon 1=216 minutes, surgeon 2=176 minutes; P=0.002) were significantly different between surgeons.

Conclusion:

Posterior reconstruction prior to anastomosis decreases anastomosis time for robotic surgeons in training.     

Groupe pour L��Avancement de la Microchirurgie Canada (GAM): Abstracts presented at the 28th Annual Meeting / 28e R��union annuelle May 29, 2007, Banff, Alberta

PURPOSE:

Previous reports on DIEP or TRAM flap breast reconstruction and post-reconstructive radiation therapy (RT) lead to recommendations that reconstructive surgery should be delayed until RT is complete. This recommendation leads to many patients being offered delayed reconstruction. We reviewed our series of DIEP breast reconstructions that subsequently received RT.

METHODS:

Retrospective review was performed using the University of Manitoba’s Database. Patients who underwent DIEP breast reconstruction and postoperative RT were included.

RESULTS:

455 patients underwent a DIEP flap reconstruction over a two-year period. 14 patients met our criteria. Average age was 45 (30–65). Cancer types were invasive ductal (n=12), inflammatory and infiltrating papillary (n=1). Average BMI was 24.3 (20–34). Average follow up time post radiation therapy was 12 months (3–24 months). Eight women had RT to the right breast and six had RT to the left. Two women had bilateral reconstruction. There was no documentation of fat necrosis by the two surgeons. One patient had mild volume loss. One patient had revision surgery post RT. Two women who had SLN biopsy scars revisions had minor infections, requiring dressing changes and oral antibiotics. One patient had repeat nipple reconstruction due to loss of projection.

CONCLUSIONS:

Women undergoing immediate breast reconstruction with a free DIEP showed no evidence of significant fat necrosis due to RT. We suggest that the degree of fat necrosis is determined by the initial perfusion characteristics of the flap and postoperative RT is not an independent variable for determining significant fat necrosis rates. The potential for post-operative RT should not relegate the patient to a delayed reconstruction.

LEARNING OBJECTIVES:

To learn about effects of RT on DIEP flaps, and show its viability as a treatment option.

• Can J Plast Surg. 2007 Summer; 15(2): 121–125.
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• 02 Partial breast reconstruction with free autologous tissue transfers

Can J Plast Surg. 2007 Summer; 15(2): 121.

02 Partial breast reconstruction with free autologous tissue transfers

E Buchel and T HayakawaAuthor information Copyright and License information DisclaimerUniversity of Manitoba, Winnipeg, MBCopyright © 2007, Pulsus Group Inc. All rights reserved     

Canadian human resource needs in vascular surgery

Objective

To outline the distribution of vascular surgeons in Canada and to determine the present and future human resource needs in vascular surgery practice in Canada.

Design

Voluntary questionnaires sent to all members of the Canadian Society for Vascular Surgery (CSVS), the administrators of hospitals in Canada with more than 100 beds, and interrogation of the membership database of the CSVS.

Main outcome measures

The perceived present and future needs for fulltime and part-time vascular surgeons, determined by a variety of methods.

Participants

One hundred and forty active members of the CSVS and administrators of 120 hospitals.

Main results

From the CSVS members 62 responses were received from those residing in Canada, revealing 47 fulltime vascular (more than 75% of the practice) surgeons working with 0 to 5 colleagues (mean 1.8 [SD 1.3]). Fifteen responding surgeons combined the practice of vascular surgery with another specialty. Perceived immediate needs were 24 surgeons, with 42 required in 4.8 (1.8) years. Of 120 hospitals offering vascular surgery services, 90 stated that they met the needs of their community; however, additional immediate manpower requirements totalled 27 surgeons. Hospital administrators predicted a need of 55 additional vascular surgeons in a mean of 5.5 (4.6) years. Over 85% of hospitals stated that they had the resources to support the currently practising surgeons and their immediately required additions.

Conclusions

Prediction of the need for additional vascular surgeons should be based on an estimated retirement age of 65 years, with an adjustment for the increasing percentage of the Canadian population reaching the age of 60 years. All methodologies used in this study predict the need for additional human resources in vascular surgery. The need for continued training of new vascular surgeons is apparent, but the optimal number of trainees per year is less clear.     

Surgical management of ulcerative colitis: a comparison of Canadian and American colorectal surgeons

Background

Ileal pouch anal anastomosis (IPAA) to surgically manage ulcerative colitis may involve multiple separate surgical procedures, impacting treatment costs, length of stay in hospital, complication rates and patient outcomes, and there is currently no accepted standard of care regarding the number of stages that should be performed. The purpose of this study was to compare the practice patterns of Canadian and American colorectal surgeons regarding the surgical management of ulcerative colitis.

Methods

A questionnaire was mailed to all practisng fellows of the American Society of Colon and Rectal Surgeons (ASCRS) in Canada and the United States. Surgeons were asked to describe their typical practices for 3 clinical scenarios.

Results

Questionnaires were mailed to 40 Canadian and 873 American ASCRS fellows with response rates of 86% and 62%, respectively. In the case of a patient who has had a prior colectomy, who is not taking steroids and in whom a tension-free IPAA is possible, 44% of Canadian surgeons would perform IPAA alone and 56% would perform IPAA with a loop ileostomy. In contrast, only 26% of American surgeons would perform IPAA alone and 74% would perform IPAA with a loop ileostomy (p = 0.002). In the case of a patient who has not had previous surgery, who is taking 10 mg/day of prednisone and in whom a tension-free IPAA is possible, the majority of both Canadian and American surgeons would perform an IPAA with a loop ileostomy (93% and 89%, respectively, p = 0.06). In the case of a patient who has not had previous surgery, who is taking 40 mg/day of prednisone and in whom a tension-free IPAA is possible, 45% of Canadian surgeons would perform a subtotal colectomy with an end ileostomy compared with 14% of American surgeons (p < 0.001).

Conclusion

There are significant differences in the surgical management of ulcerative colitis between Canadian and American colorectal surgeons.     

Reconstructive or cosmetic plastic surgery? Factors influencing the type of practice established by Canadian plastic surgeons

BACKGROUND:

Some argue that the specialty of plastic surgery is facing a changing identity. Challenged by factors such as increasing competition in the cosmetic marketplace and decreasing reimbursement for reconstructive procedures, many American plastic surgeons have increasingly adopted cosmetic-focused practices. The present study investigated the currently unknown practice profiles of Canadian plastic surgeons to determine the reconstructive-cosmetic mix, as well as factors that influence practice type to determine whether a similar pattern exists in Canada.

METHODS:

An anonymous online survey regarding practice profiles was distributed to all 352 Canadian plastic surgeons with e-mail accounts registered with the Canadian Society of Plastic Surgeons and/or the Canadian Society for Aesthetic Plastic Surgery.

RESULTS:

The survey response rate was 34% (120 responses), of which 75% of respondents currently had a reconstructive practice and 25% had a cosmetic practice. Reconstructive surgeons had more educational debt following their training, spent more time on emergency call, academics and teaching and, when deciding which type of practice to establish, were more influenced by academic opportunities and less influenced by financial and nonfinancial metrics. Similarities between the groups included hours worked per week and academic achievements.

CONCLUSIONS:

The field of reconstructive plastic surgery appears to be thriving in Canada. While a transition from reconstructive to cosmetic practice is common, compared with their American colleagues, a greater proportion of Canadian plastic surgeons maintain reconstructive practices. Differences between reconstructive and cosmetic plastic surgeons are discussed.     

Are complication rates for elective primary total hip arthroplasty in Ontario related to surgeon and hospital volumes? A preliminary investigation

Objective

To test the hypothesis that complication rates for elective total hip replacement operations are related to surgeon and hospital volumes.

Design

Retrospective population cohort study.

Study cohort

Patients who had undergone elective total hip replacement in Ontario during 1992 as captured in the Canadian Institute for Health Information database.

Main outcome measures

In-hospital complications, 1- and 3-year revision rates, 1- and 3-year infection rates, length of hospital stay, and 3-month and 1-year death rates.

Results

Surgeons with patient volumes above the 80th percentile (more than 27 hip replacements annually) discharged patients approximately 2.4 days earlier (p < 0.05) than surgeons with volumes below the 40th percentile (less than 9 hip replacements annually) even after adjusting for discharge disposition, hospital volume, patient age, sex, comorbidity and diagnosis. Complication rates requiring hospital readmission and death rates did not differ by surgeon or hospital volume (p > 0.05).

Conclusions

There is no evidence to support regionalization of elective hip replacement surgery in Ontario based on adverse clinical outcomes. Surgeons who perform a large number of total hip replacements are discharging patients earlier than less experienced surgeons, without any demonstrable increase in complications leading to hospital readmission. The explanation for this observation remains unknown and will require further study.     

The effect of timing of postmastectomy radiation on implant-based breast reconstruction: a retrospective comparison of complication outcomes

Background

The optimal timing of postmastectomy radiation for women undergoing delayed permanent implant exchange continues to remain controversial. The objective of our study is to compare complication rates when tissue expanders are exchanged for permanent implants pre- vs postradiation.

Methods

A retrospective review of 54 consecutive patients who underwent implant-based breast reconstruction and received postmastectomy radiation was conducted. Complications including infection, implant loss, and capsular contracture (measured in Baker score) were compared between the 2 groups.

Results

Of the patients studied, 32 patients had radiation before placement of permanent implants, whereas 22 patients received radiation after implant placement. There was no difference in individual complication rates between the 2 groups.

Conclusions

In our study of 54 patients, the timing of radiation did not affect individual complication rates for patients who underwent implant-based breast reconstruction after immediate tissue expander placement.     

A sample of Canadian orthopedic surgeons expressed willingness to participate in osteoporosis management for fragility fracture patients

Objective

The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients.

Methods

A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association.

Results

Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients.

Conclusion

Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients.     

Delayed two-stage breast reconstruction with implants: The authors�� recent experience

BACKGROUND:

Presently, breast cancer detection is delayed in Poland and, thus, the only other option for patients is amputation and breast reconstruction (immediate or delayed). Reconstructive methods are based on using the patient’s own tissue (pedicled or free myocutaneous flaps) or implants (a tissue expander, which is later exchanged for a prosthesis or an expandable implant).

OBJECTIVE:

To evaluate the aesthetic results of a delayed two-stage breast reconstruction with the use of implants (expander and prosthesis) in patients who have previously undergone cancer-related mastectomy.

METHODS:

From 2006 to 2009, 54 patients (34 to 65 years of age) underwent reconstruction at least one year after their mastectomy and adjuvant chemotherapy; three women also received x-ray therapy. All women underwent a two-stage treatment with a tissue expander, which was later exchanged for a prosthesis.

RESULTS:

Outcomes of the surgery (evaluated by the physician and the patient at least six months after all stages of reconstruction) were found to be very good in 42 patients and good in 12 patients. After amputation and x-ray therapy in two cases, a fistula developed, which necessitated implant removal.

CONCLUSIONS:

After amputation, breast reconstruction with implants (expander and prosthesis) provides good aesthetic results. The method is mildly burdening to the patient and does not cause severe scarring. Symmetrization of the second breast is often recommended; however, the cost is not covered by the national health system. In principle, earlier x-ray therapy disqualifies the application of implants. Dividing reconstruction into two stages (expander and prosthesis) allows for possible correction of prosthesis placement.     

Spine surgeons’ requirements for imaging at the time of referral: a survey of Canadian spine surgeons

Background

Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons’ requirements with respect to imaging studies accompanying spine-related referrals.

Methods

We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints.

Results

Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints.

Conclusion

Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.     

Factors influencing prioritization for carpal tunnel syndrome consultation

BACKGROUND:

In a socialized medicine model, prioritization of referrals for specialist consultation is highly important in the distribution of heath care. For high-burden diseases, such as carpal tunnel syndrome (CTS), the factors that influence prioritization are not well understood.

OBJECTIVE:

To determine the factors that influence the prioritization of referrals for CTS consultation by plastic surgeons in Canada.

METHODS:

All members of the Canadian Society of Plastic Surgery with e-mail addresses were invited to participate in an online survey regarding the method by which they prioritize referrals for CTS.

RESULTS:

Forty per cent of invited members completed the survey (150 surgeons). Of these, 118 (79%) stated that they performed CTS surgery. The majority of respondents who performed CTS surgery prioritized their consultation list chronologically (77%). Factors that would alter the chronological order or prioritization included subsequent contact by the referring physician (24%); personal relationship with the patient (16%); and specific information in the referral letter (15%), which usually involved symptom severity or electromyography findings. Sixty-six per cent of plastic surgeons stated that there was no conscious decision on how they came to choose the method of prioritization they used for referrals regarding CTS.

DISCUSSION:

The majority of plastic surgeons in Canada prioritize referrals for consultation on CTS chronologically. A minority of respondents reported reassigning priority based on clinical severity. The rationale for the methods by which Canadian Society of Plastic Surgery members prioritize these referrals is poorly understood. Further study on developing evidence-based prioritization methods may be useful in assisting surgeons and their patients in outcome-based decisions.     

The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction

INTRODUCTION

The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis.

METHODS

A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis.

RESULTS

Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis.

CONCLUSION

The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.     

Evolution in the management of Hirschsprung��s disease in the UK and Ireland: a national survey of practice revisited

INTRODUCTION

The management of Hirschsprung’s disease continues to evolve. This questionnaire survey aimed to determine current surgical management strategies for Hirschsprung’s disease in Britain.

SUBJECTS AND METHODS

The survey was sent electronically to all British paediatric surgeons. Initial questions explored individual experience and regional service provision. Additional questions, reserved for surgeons who perform definitive Hirschsprung’s disease surgery, addressed specific clinical scenarios.

RESULTS

Surveys were sent to 142 surgeons yielding 85 responses. After exclusions, 64 surveys from 21 centres were analysed. Forty-seven respondents worked in centres with designated ‘Hirschsprung’s disease surgeons’. Forty respondents perform definitive Hirschsprung’s disease surgery. In a well neonate with left-sided Hirschsprung’s disease, 34 of 40 surgeons favour primary pull-through following bowel decompression with rectal washouts; 35 of 40 surgeons aim to perform definitive surgery at less than 3 months of age, with 17 favouring laparoscopic-assisted Soave–Boley and 15 favouring an open Duhamel pull-through. Of the 40 surgeons, 36 use a staged approach to right-sided/total colonic Hirschsprung’s disease with 23 favouring a Duhamel or Long Duhamel pull-through.

CONCLUSIONS

The primary pull-through, using an open Duhamel or laparoscopic-assisted Soave–Boley technique, during the first 3 months of life, has become the operative strategy of choice in rectosigmoid Hirschsprung’s disease in Britain. Marked variation in practice remains for right-sided Hirschsprung’s disease.     

Origins of the Canadian school of surgery

Background

Since its inception 50 years ago, the Canadian Journal of Surgery has published articles under the banner “History of Canadian Surgery.” Because no comprehensive history of surgery in this country has yet been written, these articles may provide its basis.

Method

The Canadian Journal of Surgery was searched from October 1957 to August 2007 for articles on the practice of surgery in Canada before 1957. Articles regarding the development of surgery in provinces, universities, hospitals and surgical specialty societies were included, as well as biographies and obituaries of surgeons.

Results

Thirty-six articles dealing with the lives of 57 Canadian surgeons were located. Three periods of Canadian surgery were covered: the French regime (1535–1759), the transition period (1759–1870) and the early modern period (1870–1945). The review shows that persistent efforts were made in Canada to develop surgical education and to regulate the practice of surgery. Isolation forced a spirit of adaptability that led to innovation and progress.

Conclusion

The practice of surgery in Canada today can be traced back to contributions made by pioneering surgeons over the entire history of modern Canada. An archive of materials related to the history of surgery in Canada is being created at www.historyofsurgery.ca to facilitate further research.