Nikolay Ivanovich Pirogov: a surgeon's contribution to military and civilian anaesthesia

A key figure in the development of anaesthesia in Russia was the surgeon Nikolay Ivanovich Pirogov (1810–1881). He experimented with ether and chloroform and organised the general introduction of anaesthesia in Russia for patients undergoing surgery. He was the first to perform systematic research into anaesthesia‐related morbidity and mortality. More specifically, he was one of the first to administer ether anaesthesia on the battlefield, where the principles of military medicine that he established remained virtually unchanged until the outbreak of the Second World War.     

Extremity vascular injuries on the battlefield: tips for surgeons deploying to war

BACKGROUND: Recent events have refocused attention on certain principles regarding the surgical management of casualties on the battlefield. Extremity vascular injuries predominate, representing 50 to 70% of all injuries treated during Operation Iraqi Freedom, and exsanguination from extremity wounds is the leading cause of preventable death on the modern battlefield. Recent advances in military medicine have translated into a greater percentage of wounded soldiers surviving during Operations Enduring and Iraqi Freedom than in any other previous American conflict. The combat-experienced military surgeon, a fraction of those in uniform until recently, rarely has had the opportunity to convey lessons learned to the newly indoctrinated war surgeon. The purpose of this review is to do exactly that. METHODS: We collectively reviewed the experience and opinions of five U.S. Army surgeons with regard to management of extremity vascular injuries in a combat zone RESULTS: The modern battlefield has a staunch reputation of being unclean, noisy, and lacking of valuable resources. High-kinetic energy injuries such as those resulting from high explosives, munitions, and high-velocity missiles often cause soft-tissue destruction that is not routinely seen in civilian settings. Military-specific considerations in the management of these injuries are reviewed. CONCLUSIONS: The management of extremity vascular injuries on the modern battlefield presents many unique and demanding challenges to even the most seasoned of surgeons. Preparation goes a long way in overcoming some of the obstacles to seamless patient care.     

The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study

We quantified the accuracy of trained nurses to correctly assess the pre‐operative health status of surgical patients as compared to anaesthetists. The study included 4540 adult surgical patients. Patients' health status was first assessed by the nurse and subsequently by the anaesthetist. Both needed to answer the question: ‘is this patient ready for surgery without additional work‐up, Yes/No?’ (primary outcome). The secondary outcome was the time required to complete the assessment. Anaesthetists and nurses were blinded for each other's results. The anaesthetists' result was the reference standard. In 87% of the patients, the classifications by nurses and anaesthetists were similar. The sensitivity of the nurses' assessment was 83% (95% CI: 79–87%) and the specificity 87% (95% CI: 86–88%). In 1.3% (95% CI: 1.0–1.6%) of patients, nurses classified patients as ‘ready’ whereas anaesthetists did not. Nurses required 1.85 (95% CI: 1.80–1.90) times longer than anaesthetists. By allowing nurses to serve as a diagnostic filter to identify the subgroup of patients who may safely undergo surgery without further diagnostic workup or optimisation, anaesthetists can focus on patients who require additional attention before surgery.     

“To Afford the Wounded Speedy Assistance”: Dominique Jean Larrey and Napoleon

Dominique Jean Larrey (1766–1842) has been described as the father of modern military surgery and is considered even today as the model military surgeon. He developed a plan of rapid evacuation of wounded soldiers from the battlefield during combat, using flexible medical units which he named ambulances volantes (“flying ambulances”). He won the admiration of Napoleon Bonaparte (1769–1821), who was amazed by the results of Larrey’s sanitary system. Larrey spent almost 18 years with Napoleon, accompanying him in 25 campaigns, 60 battles, and more than 400 engagements. Napoleon’s enormous military success was due not only to his strategy and skill but also to the medical services provided by Larrey. The surgeon became a master of wound management and limb amputation. In his vivid battlefield journals, Larrey documented the course of tetanus, the pathophysiology of cold injury, the effective control of hemorrhage, the drainage of empyema and hemothorax, the aspiration of pericardial effusion or hemopericardium, and the packing of sucking chest wounds. Larrey established a categorical rule for the triage of war casualties, treating the wounded according to the observed gravity of their injuries and the urgency for medical care, regardless of their rank or nationality.     

From Leonardo to da Vinci: the history of robot-assisted surgery in urology

What's known on the subject? and What does the study add? Numerous urological procedures can now be performed with robotic assistance. Though not definitely proven to be superior to conventional laparoscopy or traditional open surgery in the setting of a randomised trial, in experienced centres robot‐assisted surgery allows for excellent surgical outcomes and is a valuable tool to augment modern surgical practice. Our review highlights the depth of history that underpins the robotic surgical platform we utilise today, whilst also detailing the current place of robot‐assisted surgery in urology in 2011. The evolution of robots in general and as platforms to augment surgical practice is an intriguing story that spans cultures, continents and centuries. A timeline from Yan Shi (1023–957 bc ), Archytas of Tarentum (400 bc ), Aristotle (322 bc ), Heron of Alexandria (10–70 ad ), Leonardo da Vinci (1495), the Industrial Revolution (1790), ‘telepresence’ (1950) and to the da Vinci® Surgical System (1999), shows the incredible depth of history and development that underpins the modern surgical robot we use to treat our patients. Robot‐assisted surgery is now well‐established in Urology and although not currently regarded as a ‘gold standard’ approach for any urological procedure, it is being increasingly used for index operations of the prostate, kidney and bladder. We perceive that robotic evolution will continue infinitely, securing the place of robots in the history of Urological surgery. Herein, we detail the history of robots in general, in surgery and in Urology, highlighting the current place of robot‐assisted surgery in radical prostatectomy, partial nephrectomy, pyeloplasty and radical cystectomy.     

Examining Occupational Stress,Sources of Stress and Stress Management Strategies through the Eyes of Management Consultants: A Multiple Correspondence Analysis for Latent Constructs

To date, little research has yet focused in broad assessment for management consultancy professionals. This investigation aims to analyse management consultants' self‐perceptions of occupational stress (SPoOS), sources of stress (SoS) and stress management strategies (SMS) and to find latent constructs that can work as major determinants in consultants' conceptualization of SPoOS, SoS and SMS. Measures were completed, including demographics and interviews. Complete data were available for 39 management consultants, 53.8% male and aged between 23 and 56 years (M = 38.0; SD = 9.2). The data were subjected to content analysis. Representation of the associations and latent constructs were analysed by a multiple correspondence analysis. Results indicated that ‘intellectual disturber’ (31.4%) was the most referred SPoOS, ‘high workload’ (15.1%) was identified as the most prevalent perceived SoS and ‘coaching’ (19.0%) was the most mentioned SMS. No significant differences between the two gender groups were found regarding the three total scores. SPoOS was explained by a two‐factor model: ‘organization‐oriented’ and ‘person‐oriented’. A three‐dimension model formed by ‘job concerns’, ‘organizational constraints’ and ‘career expectations’ was indicated as a best‐fit solution for SoS, and SMS was best explained in a three‐dimension model by ‘group dynamics strategies’, ‘organizational culture strategies’ and ‘individual support strategies’. This research makes a unique contribution for a better understanding of what defines SPoOS, SoS and SMS for management consultants. Copyright © 2013 John Wiley & Sons, Ltd.     

Reviewing the technological challenges associated with the development of a laparoscopic palpation device

Minimally invasive surgery (MIS) has heralded a revolution in surgical practice, with numerous advantages over open surgery. Nevertheless, it prevents the surgeon from directly touching and manipulating tissue and therefore severely restricts the use of valuable techniques such as palpation. Accordingly a key challenge in MIS is to restore haptic feedback to the surgeon. This paper reviews the state‐of‐the‐art in laparoscopic palpation devices (LPDs) with particular focus on device mechanisms, sensors and data analysis. It concludes by examining the challenges that must be overcome to create effective LPD systems that measure and display haptic information to the surgeon for improved intraoperative assessment. Copyright © 2012 John Wiley & Sons, Ltd.     

The impact of didactic read‐aloud action cards on the performance of cannula cricothyroidotomy in a simulated ‘can't intubate can't oxygenate’ scenario

Significant benefits have been demonstrated with the use of peri‐operative checklists. We assessed whether a read‐aloud didactic action card would improve performance of cannula cricothyroidotomy in a simulated ‘can't intubate, can't oxygenate’ scenario. A 17‐step action card was devised by an expert panel. Participants in their first 4 years of anaesthetic training were randomly assigned into ‘no‐card’ or ‘card’ groups. Scenarios were video‐recorded for analysis. Fifty‐three participants (27 no‐card and 26 card) completed the scenario. The number of steps omitted was mean (SD) 6.7 (2.0) in the no‐card group vs. 0.3 (0.5); p < 0.001 in the card group, but the no‐card group was faster to oxygenation by mean (95% CI) 35.4 (6.6–64.2) s. The Kappa statistic was 0.84 (0.73–0.95). Our study demonstrated that action cards are beneficial in achieving successful front‐of‐neck access using a cannula cricothyroidotomy technique. Further investigation is required to determine this tool's effectiveness in other front‐of‐neck access situations, and its role in teaching or clinical management.     

Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Studies in other surgical populations have found that scarring is a relatively unimportant preoperative patient consideration when compared with surgical cure and safety, but that younger age was a significant factor influencing preference for ‘scarless’ surgery. The present study corroborates the findings of previous series, among patients who were contemplating kidney surgery.

OBJECTIVE

• ? To evaluate patient attitudes towards cosmesis relative to other considerations, before and after undergoing laparoendoscopic single‐site surgery (LESS) vs laparoscopic/robot‐assisted vs open kidney surgery.

METHODS

• ? Participants were provided with a survey querying demographic information, surgical history and importance of scarring relative to other surgical outcomes and considerations.
• ? The relative importance of each outcome was recorded on a nine‐level ranking scale, ranging from 1 (most important) to 9 (least important).
• ? The median scores for each outcome were compared before and after surgery using the Wilcoxon signed‐rank test, and by surgical approach using the Kruskal–Wallis test.
• ? The importance of scarring was further analysed according to age (≤50 vs >50 years), surgical indication (oncological vs non‐oncological), gender, and proportion of patients who had undergone previous abdominal surgery.

RESULTS

• ? A total of 90 patients completed surveys before surgery, of whom 65 (72.2%) also completed surveys after surgery.
• ? ‘Surgeon reputation’ and ‘no complications’ were the most important considerations before surgery (median scores 2 and 3, respectively) and after surgery (median scores of 2 for both).
• ? ‘Size/number of scars’ was the least important consideration before surgery (median score 8) and the second least important consideration after surgery (median score 7).
• ? The median score for ‘size/number of scars’ was significantly higher for the LESS cohort before surgery (laparoscopic/robot‐assisted vs LESS vs open surgery: 8.5 vs 6 vs 9; P = 0.003), but was nonsignificant after surgery (laparoscopic/robotic vs LESS vs open surgery: 7 vs 6.5 vs 7.5; P = 0.83).
• ? The median score for ‘size/number of scars’ before surgery was significantly higher for younger patients (P = 0.05) and those with non‐oncological surgical indications (P < 0.001), but there was no significant difference in this outcome for these sub‐groups after surgery.

CONCLUSIONS

• ? For most patients contemplating urological surgery, cosmesis is of less concern than surgeon reputation and avoidance of surgical complications.
• ? Cosmesis may be a more important preoperative consideration for younger patients and those with benign conditions, which warrants further investigation.

     

Colorectal surgeons should be open to modern surgical technologies for challenging cases

Today, colorectal surgeons globally are practicing in an exciting era where surgical technologies are constantly emerging. Most of these cutting‐edge technologies are readily available in Australia and New Zealand at present. Thus the ‘modern surgeon’ should always be defined by this open‐minded attitude towards these new and emerging surgical technologies. This review article highlights current modalities that we have been using in our north‐Brisbane public and private hospitals for cases predicted to be technically challenging using minimally invasive approaches for most of them. We examined the current evidence regarding the following modalities and critiqued their use in clinical practice: lighted ureteric stents, minimally invasive surgery approaches of laparoscopy and robotic surgery, pressure barrier insufflation devices, 3D camera systems, hand‐assist device ports and indocyanine green dye fluorescence angiography. The objective of this review paper is to alert colorectal surgeons to new surgical technologies available to them, to encourage colorectal surgeons' familiarization with these many technologies, and to support evidence‐based consideration for the clinical use of such. These technologies should be supplemental aides to the safe, oncologically adequate and efficient operation that they already routinely perform.     

History and Evolution of Surgical Ethics: John Gregory to the Twenty-first Century

As surgery grew to become a respected medical profession in the eighteenth century, medical ethics emerged as a response to the growing need to protect patients and maintain the public’s trust in physicians. The early influences of John Gregory and Thomas Percival were instrumental in the formulation of patient-centered medical ethics. In the late nineteenth century, the modern surgical advances of anesthesia and antisepsis created the need for a discipline of ethics specific to surgery in order to confront new and evolving ethical issues. One of the founding initiatives of the American College of Surgeons in 1913 was to eliminate unethical practices such as fee-splitting and itinerant surgery. As surgery continued to advance in the era of solid organ transplantation and minimally invasive surgery in the latter half of the twentieth century, surgical innovation and conflict of interest have emerged as important ethical issues moving forward into the twenty-first century. Surgical ethics has evolved into a distinct branch of medical ethics, and the core of surgical ethics is the surgeon–patient relationship and the surgeon’s responsibility to advance and protect the well-being of the patient.     

Implementing guidelines about colorectal cancer: a national survey of target groups

Background : An Australia‐wide postal survey was undertaken to determine surgeons’ attitudes towards guidelines and their preferred strategies for dissemination and implementation of guidelines for the management of colorectal cancer, developed by the Australian Cancer Network (ACN) and the Clinical Oncological Society of Australia (COSA). This survey was conducted as a baseline before the release of the definitive guidelines. Methods : All members of the Royal Australasian College of Surgeons (RACS) with a self‐nominated special interest in colorectal surgery and members of the Colorectal Surgical Society of Australia (CSSA) were surveyed. Results : A total of 195 of the 219 surgeons eligible for the study returned questionnaires (89% response rate). Most (86%) were aware that these guidelines were being developed. More than one‐half had read at least one draft version. Almost half (44.6%; 95%CI: 37.6–51.9%) agreed that guidelines represented ‘cookbook medicine’ and one‐third (33.3%; 95%CI: 26.9–40.5%) agreed that guidelines might increase the number of malpractice suits. Local adaptation of guidelines and ‘academic detailing’ were most favourably ranked to assure implementation. Further, 54.9% (95%CI: 47.6–61.9%) of respondents believed that a successful legal defence of a surgeon whose practice had been within the guidelines would encourage uptake. Surgeons operating outside teaching hospitals were more likely to endorse this view than others. Conclusions : These results demonstrate that an important target group for colorectal cancer guidelines, namely surgeons, appears receptive to clinical practice guidelines. These results could also permit interventions that target attitudinal barriers to implementing guidelines and subgroups of surgeons who have particular concerns. Expensive strategies for implementation ought to be subject to rigorous evaluation for their impact in modifying clinical practice.     

Dietary patterns and surgically treated benign prostatic hyperplasia: a case control study in Western Australia

OBJECTIVES

To investigate dietary patterns and food intake as risk factors for surgically treated benign prostatic hyperplasia (BPH), as few risk factors have been established for BPH and recently there has been some interest in a role for diet in the development of BPH.

PATIENTS, SUBJECTS AND METHODS

A case‐control study was conducted in Western Australia (WA) during 2001 and 2002. BPH cases were men with a diagnosis of BPH hospitalized for their first prostatectomy. Controls were frequency matched for age and sex from the WA electoral roll. A previously evaluated food‐frequency questionnaire (FFQ) collected information on usual dietary intake 10 years earlier. Factor analysis identified dietary patterns in the FFQ data. Effects of dietary patterns and food intakes on the risk of BPH were examined using unconditional logistic regression, adjusting for various confounders.

RESULTS

In all, 406 cases and 462 controls (aged 40–75 years) provided data. Three dietary patterns were identified, i.e. ‘Vegetable’, ‘Western’ and ‘Health Conscious’. BPH risk was not associated with the ‘Health Conscious’ or ‘Western’ patterns, but there was a lower risk with an increasing score for the ‘Vegetable’ pattern (odds ratio 0.78, 95% confidence interval 0.63–0.98). BPH risk was significantly and inversely related to the intake of total vegetables, dark yellow vegetables, other vegetables, tofu and red meat. There was a higher risk of BPH with increasing intake of high‐fat dairy products.

CONCLUSIONS

These results indicate that vegetables, soy products, red meat and high‐fat dairy foods might be important in the development of BPH.     

Implementing a pre‐operative checklist to increase patient safety: a 1‐year follow‐up of personnel attitudes

Background: The operating room is a complex work environment with a high potential for adverse events. Protocols for perioperative verification processes have increasingly been recommended by professional organizations during the last few years. We assessed personnel attitudes to a pre‐operative checklist (‘time out’) immediately before start of the operative procedure. Methods: ‘Time out’ was implemented in December 2007 as an additional safety barrier in two Swedish hospitals. One year later, in order to assess how the checklist was perceived, a questionnaire was sent by e‐mail to 704 persons in the operating departments, including surgeons, anesthesiologists, operation and anesthetic nurses and nurse assistants. In order to identify differences in response between professions, each alternative in the questionnaire was assigned a numerical value. Results: The questionnaire was answered by 331 (47%) persons and 93% responded that ‘time out’ contributes to increased patient safety. Eighty‐six percent thought that ‘time out’ gave an opportunity to identify and solve problems. Confirmation of patient identity, correct procedure, correct side and checking of allergies or contagious diseases were considered ‘very important’ by 78–84% of the responders. Attitudes to checking of patient positioning, allergies and review of potential critical moments were positive but differed significantly between the professions. Attitudes to a similar checklist at the end of surgery were positive and 72–99% agreed to the different elements. Conclusion: Staff attitudes toward a surgical checklist were mostly positive 1 year after their introduction in two large hospitals in central Sweden.     

UPDATE: ANATOMICAL ABSTRACTS

The following synopses, which have been prepared in conjunction with members of the Editorial Board, are presented to promote the link between anatomy and operative surgery. Older surgeons may remember a slender but dense text called ‘Anatomical Abstracts’ that was produced by the late Professor Howard H. Eddey. Younger surgeons may remember seeing his portrait on the wall of the Gordon Craig Library in the College. This section, which will be published from time to time, honours his memory. John Hall
(Editor‐in‐Chief)
School of Surgery & Pathology (Royal Perth Hospital)
University of Western Australia     

Vascular surgery on the modern battlefield

Management of traumatic vascular injury can offer special challenges even to experienced surgeons who are functioning in resource-limited situations. Lessons learned from past conflicts have advanced the practice of vascular trauma surgery on the battlefield and in urban trauma centers. Current conflicts provide a fresh opportunity to examine those recent advancements that have improved surgical capability and as a result have changed the practice of vascular surgery on the modern battlefield. This article provides an overview of the contemporary management of vascular injuries in combat casualties during recent United States military operations.     

Work stress and performance among financial traders

This study investigated factors associated with work stress and performance among professional decision‐makers in financial markets. Three hundred and twenty‐six financial traders completed questionnaires while supervisors provided performance ratings. Of these 32 per cent of traders reported ‘very high’ or ‘extremely high’ stress levels. Overall, traders ranked ‘profit goal’ as the highest stressor followed by ‘long working hours’. Traders' experience of occupational stress was based on four main factors: Profit Pressure, Social Pressure, Work Load, and Decision‐Processing. These factors varied systematically across different trading roles. Proprietary traders with higher performance ratings experienced less stress. Similar stress ‘profiles’ of North American and European traders indicate universal responses to job demands. Trader work stress is possibly mitigated through self‐selection and substantial latitude over trading style. Copyright © 2005 John Wiley & Sons, Ltd.     

Quantitative and qualitative analysis of the recovery of potency after radical prostatectomy: effect of unilateral vs bilateral nerve sparing

OBJECTIVES

To analyse the impact of a ≈50% reduction of cavernous nervous tissue on the qualitative and quantitative recovery of sexual function after unilateral (UNS) and bilateral (BNS) nerve‐sparing robotic radical prostatectomy (RALP), by evaluating these differences in two groups treated with cautery and a cautery‐free technique (CFT).

PATIENTS AND METHODS

UNS was defined as wide‐excision of one neurovascular bundle (NVB). Only men aged ≤65 years with preoperative International Index of Erectile Function (IIEF‐5) scores of ≥22 were included. The cautery group comprised 42 men (of case numbers 1–125) undergoing RALP with cautery, and the CFT group (62 men of cases 151–350) had a cautery‐free technique along the NVB. Data were collected prospectively using validated self‐administered questionnaires. Potency was defined as two affirmative answers to: do you have erections ‘adequate for vaginal penetration?’ and ‘Are they satisfactory?’. Patient‐reported IIEF‐5 scores and quality of erections (i.e. an estimate of erection as 0%, 25%, 50%, 75% or 100% of preoperative fullness) were obtained after surgery.

RESULTS

In the cautery group, doubling the nerve volume increased potency by 1.36 times (UNS 50% vs BNS 68%). The results were similar in the CFT group as doubling nerve tissue increased potency by 1.15 times (UNS 80% and BNS 93%). At 24 months, comparing IIEF‐5 scores, there was no difference between UNS and BNS for the cautery group, at 19.6 (95% confidence interval 15.7–23.5) vs 18.9 (16.6–21.0), or the CFT group, at 22.0 (20.2–23.8) vs 21.0 (19.8–22.1).

CONCLUSIONS

Doubling the nerve volume only increased potency by 1.15–1.36 times for both the CFT and cautery groups. Furthermore, the quality of erections and IIEF‐5 scores did not vary appreciably with doubling of nerve tissue.     

Influence of Body Size on Clinical Outcome in Patients Undergoing Coronary Surgery with or Without Cardiopulmonary Bypass

Aim: Saphenous vein (SV) is the most commonly used conduit in bypass procedures but has a one‐year occlusion rate of 15‐30%. A new ‘no‐touch’ technique where the SV is harvested with a cushion of surrounding tissue with no distension has led to improved early patency rates of 5% at 18‐months. Nitric oxide (NO), synthesised by nitric oxide synthase (NOS) has properties beneficial to graft patency. Our aim was to study the distribution of NOS in SV harvested by this technique and the effect of distension and removal of perivascular tissue on NOS content of SV. Methods: Following ethical committee approval and patients' informed consent, SVs were harvested from ten patients undergoing coronary artery bypass grafting. A segment of vein was harvested by the conventional technique (surrounding tissue stripped and vein distended with saline); another part was stripped but not distended (‘control’) and the remaining parts harvested by the ‘no‐touch’ technique. Samples of each segment were taken and transverse sections prepared for NOS identification using ³[H]L‐N^G nitroarginine (NO Arg) autoradiography and NADPH‐diaphorase histochemistry. NOS isoforms were studied using standard immunohistochemistry. Endothelial cells and nerves were also identified using immunohistochemistry with CD31 and NF200 respecitvely, to confirm sources of NOS. Morphometric analysis of NADPH‐diaphorase staining was carried out to study tissue NOS content. Results: NO Arg binding representing NOS was preserved on the lumen of ‘no‐touch’ vessels whilst that on conventional and control vessels was reduced. NOS was also localised to the medial smooth muscle cells of all vein segments and to the intact adventitia of ‘no‐touch’ segments. This was confirmed by NADPH‐diaphorase staining, which revealed a mean reduction of NOS by 19.5% (p < 0.05, ANOVA) in control segments due to stripping of surrounding tissue alone and a reduction of 35.5% (p < 0.01, AVNOVA) in conventional segments due to stripping and distension, compared to ‘no‐touch’ segments. Adventitial NOS sources in ‘no‐touch’ vessels corresponded to vasa vasorum and paravascular nerves. All three NOS isoforms contributed to the preserved NOS in ‘no‐touch’ vessels. Conclusions: Apart from preserved lumenal NOS, NOS sources are also located in the media and adventitia of SV grafts. These are reduced by both adventitial damage and vein distension during conventional vein harvesting. The ‘no‐touch’ technique avoids these procedures, preserving NOS sources. This may result in improved NO availability in SV harvested by this technique, contributing to the improved patency rates reported.