Operations

OPERATIONS, any mechanical interventions on tissues and organs undertaken with the aim of alleviating or curing a disease. A distinction is made between non-bloody and bloody operations, otherwise known as operations without incision and with incision of tissues. The former include the reduction of dislocations, the setting (coaptatio) of bones in fractures, forced bending (brisement forcé), lithotripsy, etc. With a broad interpretation, massage and various kinds of mechanotherapeutic procedures can also be included here. Bloody operations include all operations performed with cutting instruments. Injections performed for the extraction of fluid or the administration of medicinal substances constitute the middle ground between the two. Surgical techniques cannot be contrasted with medicinal treatment: in the majority of cases, they complement each other. Thus, after an operation for a gastric ulcer, subsequent dietary and medicinal treatment is usually necessary; for Basedow's disease, subsequent medicinal and sanatorium treatment, etc., and the act of the operation itself often requires medicinal preparation and subsequent, sometimes complex, therapy. Every surgical intervention is associated with a greater or lesser risk. The more dangerous the intervention itself, the more carefully one must weigh the indications and contraindications for the operation. Even such manipulations as massage, which can only be classified as surgical techniques with a stretch, can threaten major complications if the indications are incorrect: the harm of massaging tuberculous foci is known, as is the danger of massage in thrombophlebitis, and the danger of a trial puncture of the peritoneal cavity, etc. Indications for bloody operations should be established even more carefully. A distinction is made between absolute indications, if the operation is necessary to save a life (indicatio vitalis), and relative indications, if the operation is to be performed for a disease that does not directly threaten life. The former include: tracheotomy, the arrest of arterial bleeding, operations for strangulated hernia, acute intestinal obstruction, perforation of hollow organs of the abdominal cavity, heart wounds, etc.; the latter include operations for reducible hernias, gastric ulcers, chronic cholecystitis, chronic appendicitis, etc. The middle ground between these two groups consists of indications for diseases that threaten the loss of an important organ: operations for glaucoma, vascular suture for wounds of large limb vessels, etc. To what has been said, it should be added that the indications for an operation are ultimately determined by the operating surgeon. Therefore, even in so-called "borderline" cases, when a patient is referred to a surgeon for an operation by an internist, neuropathologist, or even a psychiatrist, the surgeon must personally arrive at the conviction of the expediency of the operation or reject it. In the event that the performed operation turns out to be unnecessary or harmful, the error in indications lies with the surgeon no less than with the specialist who referred the patient to the surgeon for the operation. To save a life, it is sometimes necessary to sacrifice part of an organ or an entire organ, i.e., to perform more or less mutilating operations. Thus, the mammary gland or bladder is removed if they are affected by cancer, or a lower or upper limb is removed in cases of unresectable malignant tumors along their length or in cases of gangrene, etc. In contrast to such mutilating operations, a distinction is made for sparing or conservative operations; these include, for example: gastrointestinal anastomosis for gastric ulcers, arterial suture, removal of stones from the bile ducts, etc. Finally, operations can restore a lost organ. These include all kinds of plastic operations and transplantations of organs and tissues. Before deciding to operate, contraindications to the operation are taken into consideration. Contraindications may be related to the general condition of the organism or to individual organs. Thus, more serious operations are contraindicated in hemophilia, senile frailty, deep cancerous cachexia, in the final stage of sepsis, in certain forms of psychoses, etc. Among diseases of individual organs, we mention the state of decompensation in myocardiopathy, severe nephrosis, and in general all types of renal tissue insufficiency, liver insufficiency, etc. Contraindications, just like indications, can be absolute and relative. The assessment of indications and contraindications clarifies the expediency or necessity of the operation. Furthermore, one must weigh the risk of the disease and the risk of the operation. Thus, in the absence of contraindications, a surgeon easily decides on an appendectomy in the quiescent period or at the beginning of an acute one, since the operation itself is less dangerous than the disease. Conversely, a surgeon will refrain, for example, from a nephrectomy or nephrolithotomy if the other kidney is in poor condition, since under such conditions the operation may prove riskier than the disease itself. Having weighed all the "pros" and "cons" and having decided (for himself) the question of the operation in the affirmative, the surgeon must obtain the patient's consent for the operation. If the patient is a child, the consent of the parents or those taking their place is necessary. However, even to a child, if they have passed early childhood, it is better to tell them about the upcoming operation and convince the little patient of its necessity. Consent for the performance of an operation on patients in an unconscious state and on the mentally ill is requested from relatives, guardians, etc. In life, one often has to deviate from these rules. Thus, sometimes small operations, such as the incision of a superficial abscess or the removal of a loose tooth, are possible without warning the patient. One should also try to provide surgical assistance, if possible, even without the patient's consent in cases directly threatening life: for example, to stop arterial bleeding, to perform a tracheotomy in case of narrowing of the glottis, etc. (see Physician). The question of the patient's consent to an operation is closely connected with another question: should the risk of the operation be explained to the patient upon their request? There can be no uniform solution here. In cases with relative indications, especially in so-called cosmetic operations, it is better to inform the patient of the risk of the operation, of course without going into great detail about this risk. In cases of vital indications, one should speak as little as possible about the risk. These general considerations have many exceptions depending on the general condition of the patient, their psychological balance, their development, etc. The main thing to remember is to ensure that the patient desires the operation and does not fear it. It is a different matter with the patient's close relatives. If they ask about the chances of the operation, they must be clearly informed about the risk of the disease and the risk of the operation, clarifying, as much as necessary, the dangers of the operation and the immediate postoperative period. The performance of an operation is preceded by the preparation of the patient. First of all, it is important to surround the patient with an atmosphere of attention and care; this is especially important in relation to nervous, impressionable people. From this follow the requirements for the organizational side of the matter in surgical departments, the appropriate placement of patients, the discipline of the attending staff, etc. At the same time, the patient's trust in the surgeon is necessary. A calm attitude toward the upcoming operation is an extremely important circumstance, and sometimes absolutely necessary for the successful conduct of the operation. Should patients be informed in advance about the day and hour of the operation? This question cannot be decided in a stereotyped way for all cases. Some patients, especially in acute cases with severe pain, "crave" the operation, others calmly await the day and hour of the operation, while others are so anxious that they do not sleep at night and feel palpitations. Therefore, some can be informed exactly about the day and hour, while to others it is better to speak indefinitely about the possibility of the operation tomorrow, the day after tomorrow, etc., and only on the day of the operation to speak more definitely. American surgeons, in the case of very nervous patients (women with Basedow's disease), schedule an operation and postpone it with the aim of "accustoming" the patients to the expectation of the operation. It is unlikely that such a tactic is applicable to the majority of cases. Usually, postponing an operation affects patients very heavily. Sometimes it is necessary to tonify the heart, in others to improve general nutrition, and in cases of anemia from bleeding, to transfuse blood, etc. Thus, preparation for an operation must be based on a full and comprehensive preliminary examination of the patient. Recently, views on the preparation of the gastrointestinal tract have changed. Until recently, many surgeons considered it necessary to force patients to fast on the eve of the operation and to cleanse the intestine with laxatives; at present, fearing acidosis (see), food intake is restricted only in cases of general anesthesia; the intestine, if necessary, is cleansed mainly by enemas. The preparation of the patient's skin, especially in the area of the operation, is of no small importance. Inflammatory processes of the skin must be eliminated in advance, especially in "clean" operations. The preparation of healthy skin before the Grossich method (see Grossich method) was a complex and long process. At present, skin preparation is reduced to observing ordinary cleanliness (a bath), shaving the hair, and applying either iodine tincture or alcohol-tannin to the skin. In recent years, other agents have been proposed for the same purpose; among them, solutions of brilliant green (Dr. Bakkal from the clinic of V. L. Pokotilo) have begun to enjoy the greatest success. Upon obtaining consent, the surgeon finally plans the operation, decides the question of narcosis or anesthesia, and the distribution of the roles of assistants. The place where the operation is to be performed must be an operating room (see Operating Room). In well-equipped surgical departments, there should be at least two: for clean and purulent operations.

Simple operations are performed on an outpatient basis, after which it is difficult to expect hemorrhages and other complications. Usually, they are performed under local anesthesia. Such operations include, for example, the removal of tumors of the skin and subcutaneous tissue, removal of an ingrown nail, tenotomy, removal of superficially lying bone sequestra, incision of superficial abscesses, etc. In exceptional cases, an operation may be performed in the patient's apartment. According to current legislation, only urgent and simplest operations may be performed at home (see Physician). It is not always easy to resolve the question of anesthesia. Without going into details (see General Anesthesia), it can be pointed out that until now, the subjective views of the surgeon play a large role in the choice of narcosis or method of anesthesia. The reasons for this are: 1) the numerous conditions on the part of the organism that influence the choice of the method of anesthesia (general condition, state of internal organs, the patient's attitude toward the operation, etc.), 2) the negative aspects from which all types of narcosis and anesthesia are not free. The question of the number of assistants and the distribution of their duties during an operation is resolved differently depending on the type of operation, the type of anesthesia, the working conditions of the institution, the number of physicians, paramedical personnel, etc. In any case, it is desirable that, in addition to the operating surgeon, one of the assistants be a physician working in the surgical department. If the operation is performed under local anesthesia, then besides the directly assisting physician, no other assistants are required at the operating table. Narcosis is administered either by a physician or by an experienced person from the paramedical staff. There is a special operating nurse for ligature material, needles, gauze, gloves, etc. In addition, there are two members of the junior staff for bringing in the patient, removing them from the table, and tidying up the operating room in the interval between operations. Thus, the desirable minimum for an operation with local anesthesia is as follows: one operating physician, one assistant physician, one operating nurse, two members of the junior staff. In the case of narcosis, another physician or an experienced nurse is added. Only in an extreme case can one agree to replace the assisting physician with a nurse. One must always remember the possibility of the sudden illness of the operator. The assistant physician can then take his place, while the operating nurse will assist during the operation. The minimum number of participants in an operation given here should also be considered the optimum. An extra assistant for retracting the wound during some abdominal operations can be conveniently replaced by a special instrument—a retractor. An increase in the number of assistants increases the chances of infection and makes the environment of the operation more complex. However, some operations require a larger number of participants. Thus, during an amputation, an assistant (nurse, attendant) is necessary to hold the limb being removed. Sometimes an assistant is necessary to compress an artery. In other cases, a special person is necessary at the apparatus used during the operation: an electric motor, an apparatus for increased pressure, etc. The entire operating room staff must be strictly disciplined and must precisely execute all orders of the operator. Discipline must be based on the awareness of the importance of the task in which every operating room worker participates, and on a full understanding of their role and its necessity. In view of this, the operating room staff should not be transient. It is necessary to conduct training sessions with the junior staff explaining their work, and especially discussions on asepsis and antisepsis. Before an operation, the persons participating in it (physicians, operating nurse) must prepare their hands, put on masks, a cap on their head, don sterile gowns, and, if at all possible, put on rubber gloves. The work of the surgeon and his assistants proceeds the more correctly, the more they have "worked together" and become accustomed to each other. The assistant should not make unnecessary movements or fuss; he must know his role well. The surgeon himself must maintain composure during the operation, talk as little as possible, limiting himself only to necessary brief commands. The surgeon must not get irritated, shout, throw instruments, etc.: such actions cause panic, confusion among the staff, and undermine the significance of the surgeon's orders and even his authority. Ultimately, the entire order in the operating room is in the hands of the surgeon, who must inspire respect for himself and trust in his staff. This proves especially important during accidental complications during an operation, for example, during significant hemorrhages, respiratory arrest, a drop in cardiac activity, etc. In such cases, there must by no means be any confusion; the staff must be confident that all the surgeon's actions and orders during such complications are correct. After an operation, a "negative phase" usually occurs—a deterioration of the general condition under the influence of surgical trauma or narcosis, if it took place (see Postoperative period). Then, in the vast majority of operative cases, improvement or recovery occurs. However, an operation does not lead to recovery or even improvement in all cases. Firstly, it may end in death on the operating table or in the hours or days immediately following the operation; it may worsen the situation; it may prove ineffective; and finally, it may result in incomplete or unstable recovery. Death on the operating table can occur 1) from causes unforeseen by the surgeon, residing in the patient's organism, 2) from narcosis or anesthesia, 3) from a technical error by the anesthetist or the surgeon. The most frequent causes of the first kind include: status thymico-lymphaticus, surgical shock. Among the accidents sometimes leading to death, we note: large hemorrhages from individual large vessels or parenchymal organs (brain, thyroid gland, liver, spleen, kidney), entry of air into veins, rapid entry of a large amount of air into the pleura, etc. General narcosis, especially chloroform, can lead to death on the operating table, causing cardiac arrest (see General Anesthesia). Death has been observed with actually all types of narcosis, however, it cannot always be attributed specifically to the narcosis. Local (regional, infiltration) anesthesia is devoid of the risk of general narcosis. The situation is different with spinal anesthesia, which Shaak considers even more dangerous than general narcosis (see Local Anesthesia). Sometimes the very anticipation, the fear of an operation, can lead to death. The amount of blood lost during an operation is, in the vast majority of cases, extremely insignificant. The amount of blood that the person being operated on can lose without bad consequences cannot be determined with any precision. An anemic, emaciated patient is less resilient than a strong subject with normal blood pressure. Women generally tolerate blood loss better than men. Blood loss, all other conditions being equal, affects children and the elderly worse than people of intermediate age. Rapid blood loss is tolerated worse than slower loss. In the postoperative period, death can occur as a result of various complications. The most frequent of these are the following: 1) secondary hemorrhage. It arises from the slipping of a ligature; a stopped parenchymal hemorrhage may resume (e.g., from the kidney after nephrotomy); reduced blood coagulability (hemophilia, obstructive jaundice) also contributes to the appearance of dangerous postoperative hemorrhage. The best remedy for hemorrhage, besides local measures, is blood transfusion. 2) Thrombosis, embolism. Pulmonary artery embolism quickly leads to death. Only in isolated cases could an operation to open the pulmonary artery and extract the clot be performed. The results of the operation cannot yet be called encouraging (see Embolism). 3) Postoperative pneumonia. 4) Septic complications, in particular peritonitis. 5) Exhaustion of the heart muscle. 6) Failure of organ function: kidneys, liver, parathyroid glands, adrenal glands. 7) General exhaustion of the organism, cachexia, diabetic coma. The percentage of fatal outcomes during an operation and in the postoperative period thus depends on a combination of different factors; these factors can be reduced to two main ones: the contingent of those operated on and the experience and technique of the surgeon. The more severe the condition of those operated on, and the more difficult the operation, the higher the mortality figure in the surgical department. The more experienced the surgeon, and the more he masters the technique, the lower the percentage. However, a more experienced surgeon naturally takes on more complex, riskier operations; less complex, less risky operations are the lot of less experienced surgeons. Thus, the figure of operative mortality in itself does not provide the possibility or the right to judge the quality of a surgeon; it is also necessary to know the "average" severity of the condition of those operated on, and the severity of the operative interventions. A surgeon who carefully selects "easier" cases for operation and avoids operating on severe patients, even when there are persistent indications, will naturally be much "happier" in terms of the outcomes of operations than a surgeon who operates—if necessary—even in severe cases. Sometimes a deterioration of the patient's condition is observed after an operation. Thus, after an operation for a gastrointestinal anastomosis for a stomach ulcer, a peptic ulcer of the jejunum may arise; operations for hemorrhoids may lead to stricture of the rectum or incontinence of intestinal contents and gases, and operations on hollow organs may lead to the formation of fistulas, etc.

Operations may remain ineffective. Ineffectiveness in chronic diseases is very common, for example, the continuation of a cancerous or tuberculous process after the removal of a focus. Most so-called exploratory operations, undertaken with an unclear or imprecise diagnosis, should also be classified as ineffective. Exploratory laparotomies are especially frequent: before an operation, it is sometimes impossible to establish the extent of the spread of cancer of the stomach or another abdominal organ, and only upon opening the abdominal cavity is the impossibility of a radical operation established. It must be added, however, that the clarification of the diagnosis after an operation often makes it possible to apply the correct treatment. This applies especially to exploratory excisions. Incomplete recovery or improvement in the patient's condition must be classified as successful outcomes of operations in those numerous cases where internal and any other non-operative treatment cannot be of benefit. Here, for example, one should include many cases of operations for Basedow's disease, operations on peripheral nerves (suturing), etc. Finally, an operation may bring temporary improvement: a gastric feeding fistula in cancer of the esophagus, a gastrointestinal anastomosis in cancer of the pylorus (so-called palliative operations). In the vast majority of cases, an operation to one degree or another achieves the goal set by the operator. Besides these immediate goals, it is important to keep in mind the long-term results, which are the litmus test of surgical intervention. From the point of view of long-term results, the final evaluation of one or another operative method is made. Not a few new operative techniques have been proposed that gave excellent immediate results, which subsequently turned out to be unstable. Thus, the operation of denudation of an artery according to Leriche was initially popular, but then, after the not entirely satisfactory long-term results were clarified, interest cooled quite rapidly. A similar fate befell the operation of cutting off bladder papillomas, which are now preferably removed with the help of cold cautery. Many such examples can be cited. In the event of an unfavorable outcome of an operation, a surgeon may be subject to legal prosecution. The accumulated experience of such court cases shows that a surgeon is at risk of legal prosecution not only in the event of a fatal outcome or worsening of the disease after an operation, but also sometimes in the case of incomplete recovery. Laws and judicial practice distinguish between unfavorable outcomes resulting from a doctor's negligence and medical errors. The former are punished in one way or another, while the latter are considered possible even with attentive care by the doctor.