Inoperability

INOPERABILITY (from Lat. inoperabilis), a term applied to denote a state in which, for some reason, operative intervention cannot be performed. At the present level of knowledge and surgical technique, inoperability is a relative, conditional concept. In each individual case much depends on the knowledge of the question, the surgeon's technique, and the individual properties of the surgeon. And since with the accumulation of experience knowledge expands and surgical technique is perfected, the boundaries of inoperability gradually diminish. If in 1896 Oppenheim considered 14% of brain tumors to be operable, and Bruns even from 2% to 9%, then in 1921 the Eiselsberg clinic reported 135 removed tumors out of 318. For the same reasons the mortality rate fell from 60% to 12% (Cushing). With the introduction of the coagulation method (Cushing) in tumors with infiltrating growth, the percentage of inoperability has fallen even further. Thus, what in recent past was considered inaccessible to surgical intervention is now operated upon. Esophageal cancers, which were considered inoperable, are now sometimes operated upon with good results; in stomach cancer, even with invasion of neighboring organs, radical operations are performed (Hesse); tumors and purulent processes in the lungs are cured by surgical intervention (Sauerbruch). Only recently it was considered that operations could not be performed with 30% Hb in the blood; now, with the introduction of blood transfusion, even with 10% the most complex operations are performed. Thus, it is extremely difficult to establish exact boundaries of inoperability, and what today can be considered inoperable may be in the near future accessible to operative influence. Absolutely inoperable can be considered only cases where the tumor or pathological process occupies an organ (liver, lung, vessels, etc.) or a part of it, the removal of which may lead to the death of the patient on physiological grounds, or where there are metastases in nearby or distant organs and the removal of the primary focus will not prevent further development in other places. In the latter case absolute inoperability is also constant. In absolute inoperability no operative intervention can be performed, while constant inoperability does not exclude the possibility of performing another operation that does not eliminate the basic disease but temporarily alleviates the severe condition of the patient (palliative decompressions in non-localized or inoperable brain tumors, gastrostomy in esophageal cancer, etc.). Absolute inoperability is at the same time true inoperability. In contrast to the latter, inoperability can be apparent, when careful observation of the patient and all examinations exclude the possibility of performing an operation, and a trial operation (trial laparotomy in inoperable stomach cancers) reveals the possibility of a radical operation. All this is explained by the imperfection of research methods and the insufficiency of our knowledge. Often inoperability is temporary and sometimes depends on causes having no relation to the basic disease, for example the presence of another, completely independent disease (infectious disease), or causes that are a consequence of the basic disease (exhaustion, weakening of cardiac activity, etc.). In other cases the basic process is in such a stage of development that surgical intervention may not improve the patient's condition but only harm him. In such cases waiting and appropriate treatment eliminate inoperability. Inoperability acquires extremely important significance under conditions of military situation, when with a large concentration of wounded one has to decide who to operate upon first. It would seem that the most severely wounded have the advantage, as is the case in conditions of rear work. Here, however, one has to reckon with other circumstances — whether a good outcome can be hoped for; operative aid should be rendered first to the one who has more chances of a favorable outcome. An example can be the almost dying wounded in the abdomen and a second, bleeding profusely due to injury of a limb vessel; first of all, operative aid must be rendered to the second, since besides the fact that he may survive, his limb may also be saved. The first one's operation may not save him, and the time for saving the second will be lost.