Surgery is a medical technology consisting of a physical intervention on tissues.

As a general rule, a procedure is considered surgical when it involves cutting of a patient's

tissues or closure of a previously sustained wound. Other procedures that do not necessarily fall
under this rubric, such as angioplasty or endoscopy, may be considered surgery if they involve
"common" surgical procedure or settings, such as use of a sterile environment, anesthesia,
antiseptic conditions, typical surgical instruments, and suturing or stapling. All forms of surgery
are considered invasive procedures; so-called "noninvasive surgery" usually refers to an excision
that does not penetrate the structure being excised (e.g. laser ablation of the cornea) or to a
radiosurgical procedure (e.g. irradiation of a tumor).

Types of surgery

Surgical procedures are the commonly categorized by urgency, type of procedure, body system
involved, degree of invasiveness, and special instrumentation.

• Based on timing: Elective surgery is done to correct a non-life-threatening condition, and is

carried out at the patient's request, subject to the surgeon's and the surgical facility's
availability. Emergency surgery is surgery which must be done promptly to save life, limb,
or functional capacity. A semi-elective surgery is one that must be done to avoid
permanently disability or death, but can be postponed for a short time.
• Based on purpose: Exploratory surgery is performed to aid or confirm a diagnosis.
Therapeutic surgery treats a previously diagnosed condition.
• By type of procedure: Amputation involves cutting off a body part, usually a limb or digit.
Replantation involves reattaching a severed body part. Reconstructive surgery involves
reconstruction of an injured, mutilated, or deformed part of the body. Cosmetic surgery is
done to improve the appearance of an otherwise normal structure. Excision is the cutting
out of an organ, tissue, or other body part from the patient. Transplant surgery is the
replacement of an organ or body part by insertion of another from different human (or
animal) into the patient. Removing an organ or body part from a live human or animal for
use in transplant is also a type of surgery.
• By body part: When surgery is performed on one organ system or structure, it may be
classed by the organ, organ system or tissue involved. Examples include cardiac surgery
(performed on the heart), gastrointestinal surgery (performed within the digestive tract
and its accessory organs), and orthopedic surgery (performed on bones and/or muscles).
• By degree of invasiveness: Minimally invasive surgery involves smaller outer incision(s) to
insert miniaturized instruments within a body cavity or structure, as in laparoscopic
surgery or angioplasty. By contrast, an open surgical procedure or laparotomy requires a
large incision to access the area of interest.
• By equipment used: Laser surgery involves use of a laser for cutting tissue instead of a
scalpel or similar surgical instruments. Microsurgery involves the use of an operating
microscope for the surgeon to see small structures. Robotic surgery makes use of a
surgical robot, such as the Da Vinci or the Zeus surgical systems, to control the
instrumentation under the direction of the surgeon.

Terminology

• Excision surgery names often start with a name for the organ to be excised (cut out) and
end in -ectomy.
• Procedures involving cutting into an organ or tissue end in -otomy. A surgical procedure
cutting through the abdominal wall to gain access to the abdominal cavity is a laparotomy.
• Minimally invasive procedures involving small incisions through which an endoscope is
inserted end in -oscopy. For example, such surgery in the abdominal cavity is called
laparoscopy.
• Procedures for formation of a permanent or semi-permanent opening called a stoma in the
body end in -ostomy.
• Reconstruction, plastic or cosmetic surgery of a body part starts with a name for the body
part to be reconstructed and ends in -oplasty. Rhino is used as a prefix for "nose", so
rhinoplasty is basically reconstructive or cosmetic surgery for the nose.
• Reparation of damaged or congenital abnormal structure ends in -rraphy. Herniorraphy is
the reparation of a hernia, while perineorraphy is the reparation of perineum.

Description of surgical procedure

At a hospital, modern surgery is often done in an operating theater using surgical instruments,
an operating table for the patient, and other equipment. The environment and procedures used
in surgery are governed by the principles of aseptic technique: the strict separation of "sterile"
(free of microorganisms) things from "unsterile" or "contaminated" things. All surgical
instruments must be sterilized, and an instrument must be replaced or re-sterilized if it becomes
contaminated (i.e. handled in an unsterile manner, or allowed to touch an unsterile surface).
Operating room staff must wear sterile attire (scrubs, a scrub cap, a sterile surgical gown, sterile
latex or non-latex polymer gloves and a surgical mask), and they must scrub hands and arms
with an approved disinfectant agent before each procedure.

Prior to surgery, the patient is given a medical examination, certain pre-operative tests, and their
physical status is rated according to the ASA physical status classification system. If these results
are satisfactory, the patient signs a consent form and is given a surgical clearance. If the
procedure is expected to result in significant blood loss, an autologous blood donation may be
made some weeks prior to surgery. If the surgery involves the digestive system, the patient may
be instructed to perform a bowel prep by drinking a solution of polyethylene glycol the night
before the procedure. Patients are also instructed to abstain from food or drink (an NPO order
after midnight on the night before the procedure, to minimize the effect of stomach contents on
pre-operative medications and reduce the risk of aspiration if the patient vomits during or after
the procedure.

In the pre-operative holding area, the patient changes out of his or her street clothes and is
asked to confirm the details of his or her surgery. A set of vital signs are recorded, a peripheral
IV line is placed, and pre-operative medications (antibiotics, sedatives, etc.) are given. When the
patient enters the operating room, the skin surface to be operated on is cleaned and prepared by
applying an antiseptic such as chlorhexidine gluconate or povidone-iodine to reduce the
possibility of infection. If hair is present at the surgical site, it is clipped off prior to prep
application. The patient is assisted by an anesthesiologist or resident to make a specific surgical
position, then sterile drapes are used to cover all of the patient's body except for the surgical site
and the patient's head; the drapes are clipped to a pair of poles near the head of the bed to form
an "ether screen", which separates the anesthetist/anesthesiologist's working area (unsterile)
from the surgical site (sterile).

Anesthesia is administered to prevent pain from incision, tissue manipulation and suturing.
Based on the procedure, anesthesia may be provided locally or as general anesthesia. Spinal
anesthesia may be used when the surgical site is too large or deep for a local block, but general
anesthesia may not be desirable. With local and spinal anesthesia, the surgical site is
anesthetized, but the patient can remain conscious or minimally sedated. In contrast, general
anesthesia renders the patient unconscious and paralyzed during surgery. The patient is
intubated and is placed on a mechanical ventilator, and anesthesia is produced by a combination
of injected and inhaled agents.

An incision is made to access the surgical site. Blood vessels may be clamped to prevent
bleeding, and retractors may be used to expose the site or keep the incision open. The approach
to the surgical site may involve several layers of incision and dissection, as in abdominal surgery,
where the incision must traverse skin, subcutaneous tissue, three layers of muscle and then
peritoneum. In certain cases, bone may be cut to further access the interior of the body; for
example, cutting the skull for brain surgery or cutting the sternum for thoracic (chest) surgery to
open up the rib cage.

Work to correct the problem in body then proceeds. This work may involve:

• excision - cutting out an organ, tumor,[1] or other tissue.

• resection - partial removal of an organ or other bodily structure.
• reconnection of organs, tissues, etc., particularly if severed. Resection of organs such as
intestines involves reconnection. Internal suturing or stapling may be used. Surgical
connection between blood vessels or other tubular or hollow structures such as loops of
intestine is called anastomosis.
• ligation - tying off blood vessels, ducts, or "tubes".
• grafts - may be severed pieces of tissue cut from the same (or different) body or flaps of
tissue still partly connected to the body but resewn for rearranging or restructuring of the
area of the body in question. Although grafting is often used in cosmetic surgery, it is also
used in other surgery. Grafts may be taken from one area of the patient's body and
inserted to another area of the body. An example is bypass surgery, where clogged blood
vessels are bypassed with a graft from another part of the body. Alternatively, grafts may
be from other persons, cadavers, or animals.
• insertion of prosthetic parts when needed. Pins or screws to set and hold bones may be
used. Sections of bone may be replaced with prosthetic rods or other parts. Sometime a
 plate is inserted to replace a damaged area of skull. Artificial hip replacement has become
more common. Heart pacemakers or valves may be inserted. Many other types of
prostheses are used.
• creation of a stoma, a permanent or semi-permanent opening in the body
• in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the
recipient's body and reconnected to the recipient in all necessary ways (blood vessels,
ducts, etc.).
• arthrodesis - surgical connection of adjacent bones so the bones can grow together into
one. Spinal fusion is an example of adjacent vertebrae connected allowing them to grow
together into one piece.
• modifying the digestive tract in bariatric surgery for weight loss.
• repair of a fistula, hernia, or prolapse
• other procedures, including:

• clearing clogged ducts, blood or other vessels

• removal of calculi (stones)
• draining of accumulated fluids
• debridement- removal of dead, damaged, or diseased tissue

• Surgery has also been conducted to separate conjoined twins.

• Sex change operations

Blood or blood expanders may be administered to compensate for blood lost during surgery.
Once the procedure is complete, sutures or staples are used to close the incision. Once the
incision is closed, the anesthetic agents are stopped and/or reversed, and the patient is taken off
ventilation and extubated (if general anesthesia was administered).

After completion of surgery, the patient is transferred to the post anesthesia care unit and
closely monitored. When the patient is judged to have recovered from the anesthesia, he/she is
either transferred to a surgical ward elsewhere in the hospital or discharged home. During the
post-operative period, the patient's general function is assessed, the outcome of the procedure is
assessed, and the surgical site is checked for signs of infection. If removable skin closures are
used, they are removed after 7 to 10 days post-operatively, or after healing of the incision is well
under way.

Post-operative therapy may include adjuvant treatment such as chemotherapy, radiation

therapy, or administration of medication such as anti-rejection medication for transplants. Other
follow-up studies or rehabilitation may be prescribed during and after the recovery period.

History
Main articles: History of surgery, Prehistoric medicine, and History of general anesthesia

At least two prehistoric cultures had developed forms of surgery. The oldest for which there is
evidence is trepanation,[2] in which a hole is drilled or scraped into the skull, thus exposing the
dura mater in order to treat health problems related to intra cranial pressure and other diseases.
Evidence has been found in prehistoric human remains from Neolithic times, in cave paintings,
and the procedure continued in use well into recorded history. Surprisingly, many prehistoric and
premodern patients had signs of their skull structure healing; suggesting that many survived the
operation. Remains from the early Harappan periods of the Indus Valley Civilization (c. 3300 BCE)
show evidence of teeth having been drilled dating back 9,000 years.[3] A final candidate for
prehistoric surgical techniques is Ancient Egypt, where a mandible dated to approximately 2650
BCE shows two perforations just below the root of the first molar, indicating the draining of an
abscessed tooth.

The oldest known surgical texts date back to ancient Egypt about 3500 years ago. Surgical
operations were performed by priests, specialized in medical treatments similar to today. The
procedures were documented on papyrus and were the first to describe patient case files; the
Edwin Smith Papyrus (held in the New York Academy of Medicine) documents surgical
procedures based on anatomy and physiology, while the Ebers Papyrus describes healing based
on magic. Their medical expertise was later documented by Herodotus: "The practice of
medicine is very specialized among them. Each physician treats just one disease. The country is
full of physicians, some treat the eye, some the teeth, some of what belongs to the abdomen,
and others internal diseases."[4]

Other ancient cultures to have surgical knowledge include India, China and Greece.
Sushruta (also spelled Susruta or Sushrutha), c. 6th century BCE,is known as the Father of Surgery. He was a
renowned surgeon of Ancient India and the author of the book Sushruta Samhita. In his book written in
Sanskrit, he described over 120 surgical instruments, 300 surgical procedures and classifies human surgery
into 8 categories. He performed Plastic Surgeries, Cataract operations and Cesarean. He used to give a kind
of herbal juice equivalent to anesthetics. He was a surgeon from the Dhanvantari school of Ayurveda.
[citation needed]

In ancient Greece, temples dedicated to the healer-god Asclepius, known as Asclepieia (Greek:
Ασκληπιεία, sing. Asclepieion Ασκληπιείον), functioned as centers of medical advice, prognosis, and
healing.[5] At these shrines, patients would enter a dream-like state of induced sleep known as
"enkoimesis" (Greek: ενκοίμησις) not unlike anesthesia, in which they either received guidance
from the deity in a dream or were cured by surgery.[6] In the Asclepieion of Epidaurus, three large
marble boards dated to 350 BCE preserve the names, case histories, complaints, and cures of
about 70 patients who came to the temple with a problem and shed it there. Some of the
surgical cures listed, such as the opening of an abdominal abscess or the removal of traumatic
foreign material, are realistic enough to have taken place, but with the patient in a state of
enkoimesis induced with the help of soporific substances such as opium.[7]

The Greek Galen was one of the greatest surgeons of the ancient world and performed many
audacious operations — including brain and eye surgery — that were not tried again for almost
two millennia.

In China, Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms
era who performed surgery with the aid of anesthesia, albeit of a rudimentary and
unsophisticated form.

In the Middle Ages, surgery was developed to a high degree in the Islamic world. Abulcasis (Abu
al-Qasim Khalaf ibn al-Abbas Al-Zahrawi), an Andalusian-Arab physician and scientist who
practised in the Zahra suburb of Córdoba, wrote medical texts that shaped European surgical
procedures up until the Renaissance.[8][unreliable source?]

In Europe, the demand grew for surgeons to formally study for many years before practicing;
universities such as Montpellier, Padua and Bologna were particularly renowned. Guy de Chauliac
was one of the most eminent surgeons of the Middle Ages. His Chirurgia Magna or Great Surgery
(1363) was a standard text for surgeons until well into the seventeenth century.[9] By the
fifteenth century at the latest, surgery had split away from physic as its own subject, of a lesser
status than pure medicine, and initially took the form of a craft tradition until Rogerius
Salernitanus composed his Chirurgia, laying the foundation for modern Western surgical manuals
up to the modern time. Late in the nineteenth century, Bachelor of Surgery degrees (usually
ChB) began to be awarded with the (MB), and the mastership became a higher degree, usually
abbreviated ChM or MS in London, where the first degree was MB, BS.

Barber-surgeons generally had a bad reputation that was not to improve until the development
of academic surgery as a specialty of medicine, rather than an accessory field.[10] Basic surgical
principles for asepsis etc., are known as Halsteads principles

Modern surgery

Modern surgery developed rapidly with the scientific era. Ambroise Paré (sometimes spelled
"Ambrose"[11]) pioneered the treatment of gunshot wounds, and the first modern surgeons were
battlefield doctors in the Napoleonic Wars. Naval surgeons were often barber surgeons, who
combined surgery with their main jobs as barbers. Three main developments permitted the
transition to modern surgical approaches - control of bleeding, control of infection and control of
pain (anaesthesia).
Bleeding
Before modern surgical developments, there was a very real threat that a patient would
bleed to death before treatment, or during the operation. Cauterization (fusing a wound
closed with extreme heat) was successful but limited - it was destructive, painful and in
the long term had very poor outcomes. Ligatures, or material used to tie off severed blood
vessels, originated as early as ancient Rome[12], and were improved by Ambroise Paré in
the 16th century. Though this method was a significant improvement over the method of
cauterization, it was still dangerous until infection risk was brought under control - at the
time of its discovery, the concept of infection was not fully understood. Finally, early 20th
century research into blood groups allowed the first effective blood transfusions.
Pain
 Modern pain control through anesthesia was discovered by two American dental surgeons,
Horace Wells (1815–1848) and William T. G. Morton. Before the advent of anesthesia,
surgery was a traumatically painful procedure and surgeons were encouraged to be as
swift as possible to minimize patient suffering. This also meant that operations were
largely restricted to amputations and external growth removals. Beginning in the 1840s,
surgery began to change dramatically in character with the discovery of effective and
practical anaesthetic chemicals such as ether and chloroform, later pioneered in Britain by
John Snow. In addition to relieving patient suffering, anaesthesia allowed more intricate
operations in the internal regions of the human body. In addition, the discovery of muscle
relaxants such as curare allowed for safer applications.
Infection
Unfortunately, the introduction of anesthetics encouraged more surgery, which
inadvertently caused more dangerous patient post-operative infections. The concept of
infection was unknown until relatively modern times. The first progress in combating
infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that
medical students fresh from the dissecting room were causing excess maternal death
compared to midwives. Semmelweis, despite ridicule and opposition, introduced
compulsory handwashing for everyone entering the maternal wards and was rewarded
with a plunge in maternal and fetal deaths, however the Royal Society in the UK still
dismissed his advice. Significant progress came following the work of Louis Pasteur and his
advances in microbiology, when the British surgeon Joseph Lister began experimenting
with using phenol during surgery to prevent infections. Lister was able to quickly reduce
infection rates, a reduction that was further helped by his subsequent introduction of the
techniques of Robert Koch (such as the Steam Steriliser, which proved more successful
than the carbolic acid spray that Lister had been using previously) to sterilize equipment,
have rigorous hand washing and a later implementation of rubber gloves. Lister published
his work as a series of articles in The Lancet (March 1867) under the title Antiseptic
Principle of the Practice of Surgery. The work was groundbreaking and laid the foundations
for a rapid advance in infection control that saw modern aseptic operating theatres widely
used within 50 years (Lister himself went on to make further strides in antisepsis and
asepsis throughout his lifetime)

An appendectomy (sometimes called appendisectomy or appendicectomy) is the surgical

removal of the vermiform appendix. This procedure is normally performed as an emergency
procedure, when the patient is suffering from acute appendicitis. In the absence of surgical
facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now
recognized that many cases will resolve when treated non-operatively. In some cases the
appendicitis resolves completely; more often, an inflammatory mass forms around the appendix.
This is a relative contraindication to surgery.

Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or

as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to
hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with
laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery
and generally takes a little longer, with the (low in most patients) additional risks associated with
pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally
requires a lower midline laparotomy.

There have been some cases of auto-appendectomies, i.e. operating on yourself. One was
performed by dr Kane in 1921, but the operation was completed by his assistants. Another case
is Leonid Rogozov who had to perform the operation on himself as he was the only surgeon on a
remote Arctic base.[1]

In general terms, the procedure for an open appendectomy is as follows.

1. Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of
prophylactic intravenous antibiotics is given immediately prior to surgery.
2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation,
and the patient is positioned supine.
3. The abdomen is prepared and draped and is examined under anesthesia.
4. If a mass is present, the incision is made over the mass; otherwise, the incision is made
over McBurney's point, one third of the way from the anterior superior iliac spine (ASIS)
and the umbilicus; this represents the position of the base of the appendix (the position of
the tip is variable).
5. The various layers of the abdominal wall are then opened.
 6. The effort is always to preserve the integrity of abdominal wall. Therefore, the External
Oblique Aponeurosis is slitted along its fiber, and the internal oblique muscle is split along
its length, not cut. As the two run at right angles to each other, this prevents later
Incisional hernia.
7. On entering the peritoneum, the appendix is identified, mobilized and then ligated and
divided at its base.
8. Some surgeons choose to bury the stump of the appendix by inverting it so it points into
the caecum.
9. Each layer of the abdominal wall is then closed in turn.
10.The skin may be closed with staples or stitches.
11.The wound is dressed.
12.The patient will be brought to the recovery room.

Prophylactic appendectomy

To find the cause of unexplained abdominal pain, exploratory surgery is sometimes performed. If
the appendix is not the cause of symptoms, the surgeon will thoroughly check the other
abdominal organs and remove the appendix anyway, to prevent it from becoming a problem in
the future.

When abdominal surgery is performed for an entirely different reason (e.g. hysterectomy or
bowel resection), the surgeon sometimes decides to perform an appendectomy in addition to the
intended procedure, to eliminate the possible need of a future surgery just to remove the
appendix. However, recent findings on the possible usefulness of the appendix has led to an
abatement of this practice.

Pregnancy If appendicitis develops in a pregnant woman, an appendectomy is usually performed and

should not harm the fetus.[2] The risk of fetal death in the perioperative period after an
appendectomy for early acute appendicitis is 3% to 5%. The risk of fetal death is 20% in perforated
appendicitis. [3]

Recovery

Recovery time from the operation varies from person to person. Some will take up to three
weeks before being completely active; for others it can be a matter of days. In the case of a
laparoscopic operation, the patient will have three stapled scars of about an inch in length,
between the navel and pubic hair line. When a laparotomy has been performed the patient will
have a 2-3 inch scar, which will initially be heavily bruised.[4

Cholecystectomy (pronounced /ˌkɒləsɪsˈtɛktəmi/, plural: cholecystectomies) is the surgical

removal of the gallbladder. It is the most common method for treating symptomatic gallstones.
Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an
older more invasive procedure, called open cholecystectomy.

Open surgery

A traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes
the gallbladder through a 10-18 inch (41-72 cm) incision. Patients usually remain in the hospital
overnight and may require several additional weeks to recover at home.

Laparoscopic surgery

Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of

treatment for gallstones and inflammation of the gallbladder unless there are contraindications
to the laparoscopic approach. Sometimes, a laparoscopic cholecystectomy will be converted to
an open cholecystectomy for technical reasons or safety.

laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the
insertion of operating ports, small cylindrical tubes approximately 5-10 mm in diameter, through
which surgical instruments and a video camera are placed into the abdominal cavity. The camera
illuminates the surgical field and sends a magnified image from inside the body to a video
monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the
monitor and performs the operation by manipulating the surgical instruments through the
operating ports.
To begin the operation, the patient is anesthetized and placed in the supine position on the
operating table. A scalpel is used to make a small incision at the umbilicus. Using either a Veress
needle or Hasson technique the abdominal cavity is entered. The surgeon inflates the abdominal
cavity with carbon dioxide to create a working space. The camera is placed through the umbilical
port and the abdominal cavity is inspected. Additional ports are placed inferior to the ribs at the
epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified,
grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is
retracted laterally to expose and open Calot's Triangle (the area bound by the cystic artery,
cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal
covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are
identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from
the liver bed and removed through one of the ports. This type of surgery requires meticulous
surgical skill, but in straightforward cases can be done in about an hour.

Recently, this procedure is performed through a single incision in the patient's umbilicus. This
advanced technique is called Laparoendoscopic Single Site Surgery or "LESS".

Procedural Risks and Complications

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in
less pain, quicker healing, improved cosmetic results, and fewer complications such as infection
and adhesions. Most patients can be discharged on the same or following day as the surgery,
and most patients can return to any type of occupation in about a week.

An uncommon but potentially serious complication is injury to the common bile duct, which
connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and
potentially dangerous infection. Many cases of minor injury to the common bile duct can be
managed non-surgically. Major injury to the bile duct, however, is a very serious problem and
may require corrective surgery. This surgery should be performed by an experienced biliary
surgeon.[1]

Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure
vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to
the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene, of
course, can be quite serious, but converting to open surgery does not equate to a complication.

A Consensus Development Conference panel, convened by the National Institutes of Health in

September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical
treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel
noted, however, that laparoscopic cholecystectomy should be performed only by experienced
surgeons and only on patients who have symptoms of gallstones.

In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly
influenced by the training, experience, skill, and judgment of the surgeon performing the
procedure. Therefore, the panel recommended that strict guidelines be developed for training
and granting credentials in laparoscopic surgery, determining competence, and monitoring
quality. According to the panel, efforts should continue toward developing a noninvasive
approach to gallstone treatment that will not only eliminate existing stones, but also prevent
their formation or recurrence.

One common complication of cholecystectomy is inadvertent injury to an anomalous bile duct

known as Ducts of Luschka, occurring in 33% of the population. It is non-problematic until the
gall bladder is removed, and the tiny supravesicular ducts may be incompletely cauterized or
remain unobserved, leading to biliary leak post operatively. The patient will develop biliary
peritonitis within 5 to 7 days following surgery, and will require a temporary biliary stent. It is
important that the clinician recognize the possibility of bile peritonitis early and confirm
diagnosis via HIDA scan to lower morbidity rate. Aggressive pain management and antibiotic
therapy should be initiated as soon as diagnosed.

Biopsy

After removal, the gall bladder should be sent for biopsy . (pathological examination) to confirm
the diagnosis and look for an incidental cancer. If cancer is present, a reoperation to remove part
of the liver and lymph nodes will be required in most cases. [2]

Long-Term Prognosis
A minority of the population, from 5% to 40%, develop a condition called postcholecystectomy
syndrome, or PCS.[3] Symptoms can include gastrointestinal distress and persistent pain in the
upper right abdomen.

As many as twenty percent of patients develop chronic diarrhea. The cause is unclear, but is
presumed to involve the disturbance to the bile system. Most cases clear up within weeks,
though in rare cases the condition may last for many years. It can be controlled with drugs. [4

Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting hernia. A

hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in
the muscle wall. Hernias can occur in the abdomen, groin, and at the site of a previous surgery.

An operation in which the hernia sac is removed without any repair of the inguinal canal is
described as a 'herniotomy'.

When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with
autogenous (patient's own tissue) or heterogeneous (like steel or prolene mesh) material it is
termed Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous
material is used for reinforcement.

Techniques

Herniorraphy, or hernioplasty, is now often performed as an ambulatory, or "day surgery,"

procedure in the USA. In other countries, however, it is more common to be admitted for a 2-3
day hospital stay. Almost 700,000 are performed each year in the United States.[citation needed]

These techniques can be divided into four groups.[1]

Groups 1 and 2: open "tension" repair

A workable technique of repairing hernia was first described by Bassini in the 1880s;[2][3] the
Bassini technique was a "tension" repair, in which the edges of the defect are sewn back
together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon
(formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle)
is approximated to the inguinal ligament and closed.[4]

Although tension repairs are no longer the standard of care due to the high rate of recurrence of
the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use
today; these include the Shouldice and the Cooper's ligament/McVay repair.[5][6]

The Shouldice techniques is a complicated four layer reconstruction; however, it has relatively
low reported recurrence rates.[7]

Group 3: open "tension-free" repair

Almost all repairs done today are open "tension-free" repairs that involve the placement of a
synthetic mesh to strengthen the inguinal region; some popular techniques include the
Lichtenstein repair (flat mesh patch placed on top of the defect)[8], Plug and Patch (mesh plug
placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed
behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the
defect). This operation is called a 'hernioplasty'. The meshes used are typically made from
polypropylene or polyester, although some companies market Teflon meshes and partially
absorbable meshes. The operation is typically performed under local anesthesia, and patients go
home within a few hours of surgery, often requiring no medication beyond aspirin or
acetaminophen. Patients are encouraged to walk and move around immediately post-
operatively, and they can usually resume all their normal activities within a week or two of the
operation. Recurrence rates are very low - one percent or less, compared with over 10% for a
tension repair. Rates of complications are generally low but they can be quite serious, and can
include chronic pain, ischemic orchitis, and testicular atrophy.[9][10]

Group 4: laparoscopic repair

In recent years, as in other areas of surgery, laparoscopic repair of inguinal hernia has emerged
as an option. "Lap" repairs (sometimes called "keyhole" surgery or minimally invasive surgery)
are also tension-free, although the mesh is placed within the pre-peritoneal space behind the
defect as opposed to in or over it. Advantages of lap over the open method include a faster
recovery time and a lower post-operative pain score.

Like the open method, laparoscopic surgery may involve local or general anesthesia, depending
on the size and related factors of the hernia. Lap is usually more expensive as it requires more
Operating Room time than open repair, but a shorter hospitalization period.

There is no definitive consensus as to the comparative risk of complications, or comparative rate

of recurrence compared to the open tension-free repairs.[citation needed] However, most non-emergent
abdominal surgeries are moving to laproscopic methodologies, as the smaller incisions used
result in less bleeding, less infection, faster recovery, reduced hospitalization and reduced pain.
[11]

One specific method of laparoscopic repair is totally extraperitoneal (TEP) repair. TEp repair has
been associated with fewer complications and a significantly shorter duration of post-operative
analgesia than Lichtenstein repair for recurrent inguinal hernia.[12]

Laparoscopic herniorrhaphy, as compared to open surgery

Advantages Disadvantages
• Quicker recovery[13][14]
• Less pain during first days[14]
• Fewer postoperative
• Longer operating time[13]
complications[13]
• Increased recurrence of primary
such as infections, bleeding and
hernias[13]
seromas[14]

• Less risk of chronic pain[14]

Comparisons

Mesh repairs have shown reduced recurrences or early recovery compared to tension repairs.
Mesh repair complications include infection, mesh migration, adhesion formation, erosion into
intraperitoneal organs, and chronic pain - due probably to entrapment of nerves, vessels, or the
vas deferens.[16] Such complications usually become apparent weeks to years after the initial
repair, presenting as abscess, fistula, or small bowel obstruction.[17][18] More recently, concerns
have been raised about the possibility of obstruction of the vas deferens as a result of the
fibroblastic reaction to the mesh.[1

What is a Fistula?

A fistula is the name given to an abnormal connection between two organs or vessels which are
not normally connected. Fistulas can develop in a wide range of locations all over the body. For
example, a fistula can develop between the stomach and duodenum, or between the rectum and
the surface of the skin.
Fistulas can develop for a variety of reasons, depending on the location of the fistula. Rectal and
anal fistulas, for example, are most commonly caused by bowel diseases such as ulcerative
colitis and Crohn’s disease. Fistulas may develop as a complication of certain types of surgery, or
as a result of traumatic physical injury.

Treatments for Fistulas

Fistulas are usually treated with surgery to remove the fistula and repair the damage it has
caused. Following surgical treatment the patient is given a course of antibiotics to prevent
infection and ensure the area heals properly. In conjunction with surgery to treat fistulas, it is
also important that the underlying condition causing the fistula is managed properly to prevent a
recurrence.

Fistulotomy and fistulectomy are the two most common surgical treatments for fistulas.

Fistulotomy and Fistulectomy

Surgical treatments for fistulotomy are carried out with the goal of achieving several things: the
fistula must be drained to remove pus and other fluid, the fistula tract itself must be opened or
removed, and the damage must be repaired to prevent further recurrence of fistulas. Finally, the
procedure is carried out with the hope that form and function of the damaged tissue can be
restored to normal.
Depending on the location and nature of a specific fistula, either a fistulotomy or a fistulectomy
is performed as a surgical treatment.

Generally, a fistulotomy is performed in cases where the fistula is located close to the skin. For
example, when an anal fistula is located close to the rectum and anal tract, the fistulotomy is the
preferred surgical treatment. This is carried out by opening the anal fistula, draining pus and
other fluid, and then merging the fistula tract with the anal canal to allow the fistula to heal.

In cases where the fistula is located deeper within the body, the preferred surgical treatment is a
fistulectomy, in which the fistula is removed entirely. This is often the preferred option in cases
where a fistula has developed between two organs, for example.

Both procedures are usually carried out under general anesthetic, but side effects and risks vary
depending on the type of procedure that has been performed, and the location of the fistula. As
a general rule, there are fewer risks and shorter recovery times associated with fistulotomy as
compared to fistulectomy.

A Fistulotomy is the surgical opening of a fistulous tract. They can be performed by excision of
the tract and surrounding tissue, simple division of the tract, or gradual division and assisted
drainage of the tract by means of a seton; a cord passed through the tract in a loop which is
slowly tightened over a period of days or weeks.

Fistulas can occur in various areas of the human body, and the location of the fistula influences
the necessity of the procedure. Some, such as ano-vaginal and perianal fistulas are chronic
conditions, and will never heal without surgical intervention.

A burn is a type of injury to the skin caused by heat, electricity, chemicals, light, radiation or
friction.[1][2][3] Most burns only affect the skin (epidermal tissue and dermis). Rarely deeper
tissues, such as muscle, bone, and blood vessels can also be injured. Managing burns is
important because they are common, painful and can result in disfiguring and disabling scarring.
Burns can be complicated by shock, infection, multiple organ dysfunction syndrome, electrolyte
imbalance and respiratory distress. Large burns can be fatal, but modern treatments, developed
in the last 60 years, have significantly improved the prognosis of such burns, especially in
children and young adults.[4][5]

Classification

A number of different classification systems exist. The traditional system divided burns in first-,
second-, or third-degree.[6] This system is however being replaced by one reflecting the need for
surgical intervention. The burn depths are described as either superficial, superficial partial-
thickness, deep partial-thickness, or full-thickness.[7]

The following are brief descriptions of these classes:

Three degrees of burns

• First-degree burns are usually limited to redness (erythema), a white plaque and minor
pain at the site of injury. These burns involve only the epidermis. Most sunburns can be
included as first-degree burns.
• Second-degree burns manifest as erythema with superficial blistering of the skin, and
can involve more or less pain depending on the level of nerve involvement. Second-degree
burns involve the superficial (papillary) dermis and may also involve the deep (reticular)
dermis layer. Deep dermal burns usually take more than three weeks to heal and should
be seen by a surgeon familiar with burn care, as in some cases severe hypertrophic
scarring can result. Burns that require more than three weeks to heal are often excised
and skin grafted for best result.
• Third-degree burns occur when the epidermis is lost with damage to the subcutaneous
tissue. Burn victims will exhibit charring and extreme damage of the epidermis, and
sometimes hard eschar will be present. Third-degree burns result in scarring and victims
will also exhibit the loss of hair shafts and keratin. These burns may require grafting.
These burns are not painful, as all the nerves have been damaged by the burn and are not
sending pain signals; however, all third-degree burns are surrounded by first and second-
degree burns, which are painful.
• Fourth-degree burns occur when heat damage destroys the dermis and muscle is
affected. Like third-degree burns, fourth degree burns result in scarring and the loss of
hair shafts; skin grafting will be needed and permanent motor damage may occur.
 • Fifth-degree burns occur when all the skin and subcutaneous tissues are destroyed,
exposing muscle. These burns can be fatal due to breaches of major arteries and veins.
These burns also may require amputation due to damage to muscles. If amputation is not
needed, skin grafting will be needed, and permanent and prominent scarring with loss of
keratin and hair shafts in the area of the burn.
• Sixth-degree burns occur when heat destroys the muscles, charring and exposing the
bone. These burns are almost always fatal, and if death does not occur, amputation will be
required.

Other classifications

A newer classification of "Superficial Thickness", "Partial Thickness" (which is divided into

superficial and deep categories) and "Full Thickness" relates more precisely to the epidermis,
dermis and subcutaneous layers of skin and is used to guide treatment and predict outcome.

A description of the traditional and current classifications of burns.

Traditional
Nomenclatur Exam
nomenclatur Depth Clinical findings
e ple
e
Superficial Erythema, significant
first degree Epidermis involvement
thickness pain, lack of blisters
Partial
second Blisters, clear fluid, and
thickness – Superficial (papillary) dermis
degree pain
superficial
Whiter appearance or
Partial
second fixed red staining (no
thickness – Deep (reticular) dermis
degree blanching), reduced
deep
sensation
Epidermis, Dermis, and complete
Charred or leathery,
destruction to subcutaneous fat,
Full thickness third degree thrombosed blood
eschar formation and minimal pain,
vessels, insensate
requires skin grafts

An even simpler, more accurate and more descriptive classification is epidermal, dermal and full
thickness.[clarification needed][citation needed] Dermal injuries are subdivided into superficial, mid and deep.

It is most common for high percentage burns to only be classified as Superficial, Partial thickness
and Full Thickness. The reasoning behind this is that in an emergency setting such as a burn
trauma room or ambulance it is more important to protect the patient from dehydration,
hypothermia and infection rather than calculating the exact depth of a burn.

Burn surface area

Main article: Total body surface area

Burns can also be assessed in terms of total body surface area (TBSA), which is the percentage
affected by partial thickness or full thickness burns (erythema/superficial thickness burns are not
counted). The rule of nines is used as a quick and useful way to estimate the affected TBSA.
More accurate estimation can be made using Lund & Browder charts which take into account the
different proportions of body parts in adults and children.[8] The size of the patient's hand print
(palm and fingers) is approximately 1% of their TBSA. The actual mean surface area is 0.8% so
using 1% will slightly over estimate the size.[9] Burns of 10% in children or 15% in adults (or
greater) are potentially life threatening injuries (because of the risk of hypovolaemic shock) and
should have formal fluid resuscitation and monitoring in a burns unit.

Causes

Burns are caused by a wide variety of substances and external sources such as exposure to
chemicals, friction, electricity, radiation, and heat.

Chemical burn
Main article: Chemical burn
Most chemicals that cause severe chemical burns are strong acids or bases.[10] Chemical burns
can be caused by caustic chemical compounds such as sodium hydroxide or silver nitrate, and
acids such as sulfuric acid.[11] Hydrofluoric acid can cause damage down to the bone and its
burns are sometimes not immediately evident.[12]

Electrical burn

Electrical burns are caused by either an exogenous electric shock or an uncontrolled short
circuit. (A burn from a hot, electrified heating element is not considered an electrical burn.)
Common occurrences of electrical burns include workplace injuries, or being defibrillated or
cardioverted without a conductive gel. Lightning is also a rare cause of electrical burns. Since
normal physiology involves a vast number of applications of electrical forces, ranging from
neuromuscular signaling to coordination of wound healing, biological systems are very
vulnerable to application of supraphysiologic electric fields. Some electrocutions produce no
external burns at all, as very little current is required to cause fibrillation of the heart muscle.
Therefore, even when the injury does not involve any visible tissue damage, electrical shock
survivors may experience significant internal injury.[13] The internal injuries sustained may be
disproportionate to the size of the burns seen (if any), and the extent of the damage is not
always obvious. Such injuries may lead to cardiac arrhythmias, cardiac arrest, and unexpected
falls with resultant fractures.[14]

Radiation burn
Main article: radiation burn

Radiation burns are caused by protracted exposure to UV light (as from the sun), tanning booths,
radiation therapy (as patients who are undergoing cancer therapy), sunlamps, radioactive fallout,
and X-rays. By far the most common burn associated with radiation is sun exposure, specifically
two wavelengths of light UVA, and UVB, the latter being more dangerous. Tanning booths also
emit these wavelengths and may cause similar damage to the skin such as irritation, redness,
swelling, and inflammation. More severe cases of sun burn result in what is known as sun
poisoning. Microwave burns are caused by the thermal effects of microwave radiation.

Scalding

Scalding is caused by hot liquids (water or oil) or gases (steam), most commonly occurring from
exposure to high temperature tap water in baths or showers or spilled hot drinks.[15] A so called
immersion burn is created when an extremity is held under the surface of hot water, and is a
common form of burn seen in child abuse.[16] A blister is a "bubble" in the skin filled with serous
fluid as part of the body's reaction to the heat and nerve damage. The blister "roof" is dead.
Steam is a common gas that causes scalds. The injury is usually regional and usually does not
cause death. More damage can be caused if hot liquids enter an orifice. However, deaths have
occurred in more unusual circumstances, such as when people have accidentally broken a steam
pipe. The demographics that are of the highest risk to suffering from scalding are young children,
with their delicate skin, and the elderly over 65 years of age.

Management

Burns over 10% in children and 15% in adults need hospital admission and fluid resuscitation due
to the risk of hypovolaemic shock.[17] Most countries have explicit criteria for the transfer and
management of burns patients.[citation needed] Major burns should be managed using the principles of
Advanced Trauma Life Support (ATLS). This consists of a primary survey to identify and treat
immediately life threatening conditions and then a secondary survey. The primary survey in
burns patients should follow the ABCDE guidelines (Airway & axial spine control, Breathing &
ventilation, Circulation and arrest of haemorrhage, neurological Disability, Exposure to allow
accurate assessment and Estimation of burn surface area and Fluid resuscitation).[citation needed] If
the patient was involved in a fire accident in an enclosed space, then it must be assumed that he
or she has sustained an inhalation injury until proven otherwise, and treatment should be
managed accordingly. At this stage of management, it is also critical to assess the airway status.
Any suspicion of burn injury to the lungs (e.g. through smoke inhalation) is considered a potential
medical emergency and the patient should be reviewed by an anaesthetist. Patients with these
types of injuries may receive Rapid Sequence Induction, either in the field by a trained
Paramedic, or in the hospital upon arrival.

First Aid
Regardless of the cause, the first step in managing a person with a burn is to stop the burning
process at the source, and cool the burn wound (but not the patient. It is essential to avoid the
"lethal triad" of hypothermia, acidosis and coagulopathy).[18] For instance, with dry powder burns,
the powder should be brushed off first. With other burns the affected area should be rinsed
thoroughly with a large amount of clean water. Cold water should not be applied to a person with
extensive burns for a prolonged period (greater than 20 minutes), however, as it may result in
hypothermia. Do not directly apply ice to a burn wound as it may compound the injury. Iced
water, creams, or greasy substances such as butter, should not be applied either.[19]

To help ease pain people may be placed in a special burn recovery bed which evenly distributes
body weight and helps to prevent painful pressure points and bed sores. Survival and outcome of
severe burn injuries is remarkably improved if the patient is treated in a specialized burn
center/unit rather than a hospital.

Intravenous fluids

Children with TBSA >10% and adults with TBSA > 15% need formal fluid resuscitation and
monitoring (blood pressure, pulse rate, temperature and urine output).[20] Once the burning
process has been stopped, the patient should be volume resuscitated according to the Parkland
formula . This formula is 4 ml lactated ringers/kg x % of Total body surface area burned, with half
this volume given in the first 8 hours. Children also require the addition of maintenance fluid
volume. Such injuries can disturb a person's osmotic balance. This formula dictates the amount
of Lactated Ringer's solution or Hartmann's Solution[21] to deliver in the first twenty four hours
after time of injury. This formula excludes first degree burns, so erythemia alone is discounted.
Half of the fluid should be given in the first eight hours post injury and the rest in the subsequent
sixteen hours. Inhalation injuries in conjunction with thermal burns initially require up to 40–50%
more fluid. The formula is a guide only and infusions must be tailored to the urine output and
central venous pressure. Inadequate fluid resuscitation causes renal failure and death but over-
resuscitation also causes morbidity and mortality. All resuscitation formulae should be delivered
as a goal directed therapy to prevent the complications of hypovolaemic shock or over-
hydration.

Wound management

The key to the management of all burn injuries is the management of the burn wound itself. The
wound is the cause of the morbidity and mortality of burn injuries and until the wound is healed
the patient remains at risk of complications. The essential aspects of wound management are an
initial assessment, to determine burn area and depth, and then debridement (removing
devitalised tissue and contamination), cleaning and then dressings. Burn wounds are painful so
analgesia (pain relief) should be given. The management of burns over 10% in children and 15%
in adults, and of important areas (hands, face and perineum) is more complex and requires
specialist help. Circumferential burns of digits, limbs or the chest may need urgent surgical
release of the burnt skin (escharotomy) to prevent problems with distal circulation or ventilation.
The wound should then be regularly re-evaluated until it is healed. Wounds requiring surgical
closure with skin grafts or flaps should be dealt with as early as possible. One of the major
advances in burn care has been the early excision and skin grafting of full thickness and deep-
dermal burn wounds.[3]

In the management of first and second degree burns little quality evidence exists to determine
which type of dressing should be used.[22] Silver sulfadiazine (Flamazine) is not recommended as
it potentially prolongs healing time[22] while biosynthetic dressings may speed healing.[23]

Antibiotics

Intravenous antibiotics may improve survival in those with large severe burns however due to
the poor quality of the evidence routine use is not currently recommended.[24]

Analgesics

A number of different options are used for pain management. These include simple analgesics
( such as ibuprofen and acetaminophen ) and narcotics. A local anesthetic may help in managing
pain of minor first-degree and second-degree burns.[25]

Alternative treatments
Hyperbaric oxygenation has not been shown to be a useful adjunct to traditional treatments.[26]
Honey has been used since ancient times to aid wound healing and may be beneficial in first and
second degree burns, but may cause infection.[27]

Prognosis

The outcome of any injury or disease depends on three things: the nature of the injury, the
nature of the patient and the treatment available. In terms of injury factors in burns the
prognosis depends primarily on the burn surface area (% TBSA) and the age of the patient. The
presence of smoke inhalation injury, other significant injuries such as long bone fractures and
serious co-morbidities (heart disease, diabetes, psychiatric illness, suicidal intent etc.) will also
adversely influence prognosis. Advances in resuscitation, surgical management, control of
infection, control of the hyper-metabolic response and rehabilitation have resulted in dramatic
improvements in burn mortality and morbidity in the last 60 years. Following a major burn injury,
heart rate and peripheral vascular resistance increase. This is due to the release of
catecholamines from injured tissues, and the relative hypovolemia that occurs from fluid volume
shifts. Initially cardiac output decreases. At approximately 24 hours after burn injuries (for
patients receiving fluid resuscitation) cardiac output returns to normal, then increases to meet
the hypermetabolic needs of the body.

Infection is a major complication of burns. Infection is linked to impaired resistance from

disruption of the skin's mechanical integrity and generalized immune suppression. The skin
barrier is replaced by eschar. This moist, protein rich avascular environment encourages
microbial growth. Migration of immune cells is hampered, and there is a release of intermediaries
that impede the immune response. Eschar also restricts distribution of systemically administered
antibiotics because of its avascularity.

Risk factors of burn wound infection include:

• Burn > 30% TBS

• Full-thickness burn
• Extremes in age (very young, very old)
• Preexisting disease e.g. diabetes
• Virulence and antibiotic resistance of colonizing organism
• Failed skin graft
• Improper initial burn wound care
• Prolonged open burn wound

Burn wounds are prone to tetanus. A tetanus booster shot is required if individual has not been
immunized within the last 5 years.

Circumferential burns of extremities may compromise circulation. Elevation of limb may help to
prevent dependent edema. An Escharotomy may be required.