Summer Brief research

A Brief History Of. Summer Brief 2012.

David Gaskell.

History of surgery Surgery is the branch of medicine that deals with the physical manipulation of a bodily structure to diagnose, prevent, or cure an ailment. Ambroise Paré, a 16th century French surgeon, stated that there were to perform surgery: “To eliminate that which is superfluous, restore that which has been dislocated, separate that which has been united, join that which has been divided and repair the defects of nature.”

Since humans first learned to make and handle tools, they have employed their talents to develop surgical techniques, each time more sophisticated than the last; however, until the industrial revolution, surgeons were incapable of overcoming the three principal obstacles which had plagued the medical profession from its infancy — bleeding, pain and infection. Advances in these fields have transformed surgery from a risky “art” into a scientific discipline capable of treating many diseases and conditions.

Origins The first surgical techniques were developed to treat injuries and traumas. A combination of archaeological and anthropological studies offer insight into man’s early techniques for suturing lacerations, amputating insalvageable limbs, and draining and cauterizing open wounds. Many examples exist: some Asian tribes used a mix of saltpeter and sulfur that was placed onto wounds and lit on fire to cauterize wounds; the Dakota Indians used the quill of a feather attached to an animal bladder to suck out purulent material; the discovery of needles from the stone age seem to suggest they were used in the suturing of cuts (the Maasai used needles of acacia for the same purpose); and tribes in India and South America developed an ingenious method of sealing minor injuries by applying termites or scarabs who ate around the edges of the wound and then twisted the insects neck leaving their heads rigidly attached like staples

Trepanation The oldest operation for which evidence exists is trepanation [2] (also known as trepanning, trephination, trephining or burr hole from Greek τρύπανον and τρυπανισμός), in which a hole is drilled or scraped into the skull for exposing the dura mater to treat health problems related to intracranial pressure and other diseases. In the case of head wounds surgical intervention was implemented for investigating and diagnosing the nature of the wound and the extend of the impact while bone splinters were removed preferably by scraping followed by post operation procedures and treatments for avoiding infection and aiding in the healing process.[3][4] Evidence has been found in prehistoric human remains from Proto-Neolithic [5] and Neolithic times, in cave paintings, and the procedure continued in use well into recorded history (being described by ancient Greek writers such as Hippocrates among others). Out of 120 prehistoric skulls found at one burial site in France dated to 6500 BCE, 40 had trepanation holes.[6] Folke Henschen, a Swedish doctor and historian, asserts that Soviet excavations of the banks of the Dnieper River in the 1970s show the existence of trepanation in Mesolithic times dated to approximately 12000 BCE.[7] The remains suggest a belief that trepanning could cure epileptic seizures, migraines, and mental disorders.[8] Many prehistoric and premodern patients had signs of their skull structure healing, suggesting that many of those that proceeded with the surgery survived their operation. In some studies the rate of survival surpassed 50%.

Setting bones Among some treatments used by the Aztecs, according to Spanish texts during the conquest of Mexico, was the reduction of fractured bones: “...the broken bone had to be splinted, extended and adjusted, and if this was not sufficient an incision was made at the end of the bone, and a branch of fir was inserted into the cavity of the medulla...”[10] Modern medicine developed a technique similar to this in the 20th century known as medullary fixation.

Bloodletting Bloodletting is one of the oldest medical practices, having been practiced among diverse ancient peoples, including the Mesopotamians, the Egyptians, the Greeks, the Mayans, and the Aztecs. In Greece, bloodletting was in use around the time of Hippocrates, who mentions bloodletting but in general relied on dietary techniques. Erasistratus, however, theorized that many diseases were caused by plethoras, or overabundances, in the blood, and advised that these plethoras be treated, initially, by exercise, sweating, reduced food intake, and vomiting. Herophilus advocated bloodletting. Archagathus, one of the first Greek physicians to practice in Rome, practiced bloodletting extensively and gained a most sanguinary reputation. The art of bloodletting became very popular in the West, and during the Renaissance one could find bloodletting calendars that recommended appropriate times to bloodlet during the year and books that claimed bloodletting would cure inflammation, infections, strokes, manic psychosis and more.

Antiquity Mesopotamia Berossus, a 3rd century BCE Assyrian philosopher wrote considerably about the traditional Babylonian medical techniques (principally in the archives of Borsippa) and went on to assert that the god Oannes taught the Sumerian people all that was to be known about civilization and that nothing new had been invented. This assertion seemed hyperbolic until analysis of Sumerian tablets showed that the Mesopotamian civilization had developed or invented numerous medical techniques thousands of years before they were re-developed or re-invented by the Europeans.

Some 4000 BCE the Sumerian civilization was established in Mesopotamia between the Tigris and Euphrates rivers, creating the oldest form of writing, cuneiform. Of the 30,000 or so cuneiform tablets that have been discovered, about 800 of them deal with medical themes (one of these being the first prescription known to have been written). The name of the first surgeon is Urlugaledin, from the 4000 BCE, whose personal seal depicts two knives encircled by medicinal plants. This seal is now housed in the Louvre.

The Sumerians saw sickness as a divine punishment imposed by different demons when an individual broke a rule. For this reason, to be a physician, one had to learn to identify approximately 6,000 possible demons that might cause health problems.

To do this, the Sumerians employed divining techniques based on the flight of birds, position of the stars and the livers of certain animals. In this way, medicine was intimately linked to priests, relegating surgery to a second-class medical specialty.[ Nevertheless, the Sumerians developed several important medical techniques: in Ninevah archaeologists have discovered bronze instruments with sharpened obsidian resembling modern day scalpels, knives, trephines, etc. Hammurabi’s Code itself contains specific legislation regulating surgeons and medical compensation as well as malpractice and victim’s compensation: 215. If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money. 217. If he be the slave of some one, his owner shall give the physician two shekels. 218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off. 220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.

India Archaeologists made the discovery that the people of Indus Valley Civilization, even from the early Harappan periods (c. 3300 BCE), had knowledge of medicine and dentistry. The physical anthropologist that carried out the examinations, Professor Andrea Cucina from the University of Missouri-Columbia, made the discovery when he was cleaning the teeth from one of the men.

Later research in the same area found evidence of teeth having been drilled, dating back 9,000 years to 7000 BCE.[ Sushruta (c. 600 BCE) taught and practiced surgery on the banks of the Ganges in the area that corresponds to the present day city of Benares in Northern India. Much of what is known about Sushruta is in Sanskrit contained in a series of volumes he authored, which are collectively known as the Susrutha Samhita. It is the oldest known surgical text and it describes in exquisite detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of plastic surgery, such as cosmetic surgery and rhinoplasty.[14] In the Sushruta school, the first person to expound Āyurvedic knowledge was Dhanvantari who then taught it to Divodasa who, in turn, taught it to Sushruta, Aupadhenava, Aurabhra, Paushakalāvata, Gopurarakshita, and Bhoja.

Because of his seminal and numerous contributions to the science and art of surgery, Sushruta is also known by the title “Father of Surgery”. The Samhita has some writings that date as late as the 1st century, and some scholars believe that there were contributions and additions to his teachings from generations of his students and disciples. Susrutha is also the father of Plastic Surgery and Cosmetic Surgery since his technique of forehead flap rhinoplasty (repairing the disfigured nose with a flap of skin from the forehead),that he used to reconstruct noses that were amputated as a punishment for crimes, is practiced almost unchanged in technique to this day.[citation needed] This knowledge of plastic surgery existed in India up to the late 18th century as can be seen from the reports published in Gentleman’s Magazine (October 1794).

The Sushruta Samhita contains the first known description of several operations, including the uniting of bowel, the removal of the prostate gland, the removal of cataract lenses and the draining of abscesses. Susrutha was also the first surgeon to advocate the practice of operations on inanimate objects such as watermelons, clay plots and reeds; thus predating the modern practice of the surgical workshop by half a millennium.

Egypt Around 3100 BCE Egyptian civilization began to flourish when Narmer, the first Pharaoh of Egypt, established the capital of Memphis. Just as cuneiform tablets preserved the knowledge of the ancient Sumerians, hieroglyphics preserved the Egyptian’s.

In the first monarchic age (2700 BCE) the first treaty on surgery was written by Imhotep, the vizier of Pharaoh Djoser, priest, astronomer, physician and first notable architect. So much was he famed for his medical skill that he was deified, becoming the Egyptian god of medicine.[15] Other famous physicians from the Ancient Empire (from 2500 to 2100 BCE) were Sachmet, the physician of Pharaoh Sahure and Nesmenau, whose office resembled that of a medical director.

On one of the doorjambs of the entrance to the Temple of Memphis there is the oldest recorded engraving of a medical procedure: circumcision and engravings in Kom Ombo, Egypt depict surgical tools. Still of all the discoveries made in ancient Egypt, the most important discovery relating to ancient Egyptian knowledge of medicine is the Ebers Papyrus, named after its discoverer Georg Ebers.

The Ebers Papyrus, conserved at the University of Leipzig, is considered one of the oldest treaties on medicine and the most important medical papyri. The text is dated to about 1550 BCE and measures 20 meters in length. The text includes recipes, a pharmacopoeia and descriptions of numerous diseases as well as cosmetic treatments. It mentions how to surgically treat crocodile bites and serious burns, recommending the drainage of pus-filled inflammation but warns against certain diseased skin.

The Edwin Smith Papyrus is a lesser known papyrus dating from the 1600 BCE and only 5 meters in length. It is a manual for performing traumatic surgery and gives surprisingly accurate advice given the time. For example, it gives instructions for dealing with dislocated vertabra: Thou shouldst bind it with fresh meat the first day. Thou shouldst loose his bandages and apply grease to his head as far as his neck, (and) thou shouldst bind it with ymrw . Thou shouldst treat it afterwards with honey every day, (and) his relief is sitting until he recovers.

Greece Surgeons are now considered to be specialized physicians, whereas in the early ancient Greek world a trained general physician had to use his hands (χείρ in Greek) to carry out all medical and medicinal processes including for example the treating of wounds sustained in the battle field, or the treatment of broken bones (a process called in Greek: χειρουργείν). The Hippocratic Oath,[16] written in the 5th century BC provides the earliest protocol for professional conduct and ethical behavior a young physician needed to abide by in life and in treating and managing the health and privacy of his patients. The multiple volumes of the Hippocratic corpus [17] and the Hippocratic Oath elevated and separated the standards of proper Hippocratic medical conduct and its fundamental medical and surgical principles from other practitioners of folk medicine often laden with superstitious constructs, and/or of specialists of sorts some of whom would endeavor to carry out invasive body procedures with dubious consequences, such as lithotomy. Galen of Pergamum (Greek: Γαληνός)[18] is an excellent paradigm of a very accomplished Greek surgeon and physician of the Roman period (2nd century), who carried out very complex surgical operations and added significantly to the corpus of animal and human physiology and the art of surgery.

China Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms era. He was the first person to perform surgery with the aid of anesthesia, some 1600 years before the practice was adopted by Europeans.[19] Bian Que (Pien Ch’iao) was a “miracle doctor” described by the Chinese historian Qima Nan in Shi Ji who was credited with many skills. Another book, Liezi (Lieh Tzu) describes that Bian Que conducted a two way exchange of hearts between people.[20] This account also credited Bian Que with using general anaesthesia which would place it far before Hua Tuo, but the source in Liezi is questioned and the author may have been compiling stories from other works.[21] Nonetheless, it establishes the concept of heart transplantation back to around 300 CE.

Middle Ages Eastern world Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi) was an Andalusian-Arab physician and scientist who practised in the Zahra suburb of Cordoba. He is considered a great medieval surgeon, whose comprehensive medical texts, combining Islamic medicine with Greco-Roman, shaped European surgical procedures until the Renaissance. He is often regarded as the Father Of Surgery.[22] Patients and students from all parts of Europe came to him for treatment and advice. According to Will Durant, Cordoba was in this period the favorite resort of Europeans for surgical operations.

Western world By the 13th century, many European towns were demanding that physicians have several years of study or training before they could practice. Montpellier, Padua and Bologna Universities were particularly interested in the academic side to Surgery, and by the 15th century at the latest, Surgery was a separate university subject to Physic (Medicine). Surgery had a lower status than pure medicine, beginning as a craft tradition until Rogerius Salernitanus composed his Chirurgia, which laid the foundation for the species of the occidental surgical manuals, influencing them up to modern times.

Ambroise Paré pioneered the treatment of gunshot wounds. Among the first modern surgeons were battlefield doctors in the Napoleonic Wars who were primarily concerned with amputation. Naval surgeons were often barber surgeons, who combined surgery with their main jobs as barbers.

In London, an operating theatre or operating room from the days before modern anaesthesia or antiseptic surgery still exists, and is open to the public. It is found in the roof space of St Thomas Church, Southwark, London and is called the Old Operating Theatre.

Foundations of modern surgery To make the transition to the modern era, the art of surgery had to solve three major problems — bleeding, infection, and pain — that effectively prevented surgery from progressing into modern science.

Bleeding Before modern surgical developments, there was a very real threat that a patient would bleed to death on the table during an operation or while being attended after an accident or wound. The first real progress in combating bleeding had come when early cultures realized they could close wounds using a procedure called cauterizing. The early cauterization was successful, but only usable in a limited fashion, highly destructive, and painful, with very poor long term outcomes.

The next real breakthrough to come was the invention of ligatures, widely believed to have originated with Abulcasis[23] in the 10th century and improved by Ambroise Paré in the 16th century. A ligature is a piece of material used to tie closed the end of a severed blood vessel to prevent further bleeding. Ligatures form the basis of modern bleeding control, but at the time, they were more of a hazard than a help because the surgeons using them had no concept of infection control.

Another barrier to be overcome was the problem of replacing blood lost. Limiting bleeding is important, but ultimately, a surgeon is fighting a losing battle if blood cannot be replaced, and this final barrier was only conquered when early 20th century research into blood groups allowed the first effective blood transfusions.

The ultimate problem, however, was for the medical profession to recognize that blood loss was a major threat to the survival of the patient. In fact, doctors would typically bleed patients. Bloodletting was used to treat almost every disease and it was thought to prevent infection. Before surgery blood was removed to prevent inflammation. Before amputation it was customary to remove a quantity of blood equal to the amount believed to circulate in the limb that was to be removed.[24] The practice was abandoned only in the late 19th century.

Available at: [2]</ref> Groves developed his aseptic technique because he considered surgical infections to be transmitted by fluids as he knew typhoid was spread. The gradual development of germ theory has allowed the final step to be taken to create the highest quality of aseptic conditions in modern hospitals, allowing modern surgeons to perform nearly infection-free surgery.

Pain Anesthesia was discovered by two American dentists, Horace Wells (1815–48) and William 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. In Britain, John Snow pioneered the use of these two anaesthetics. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body. The further discovery of muscle relaxants such as curare also facilitated safer applications. Improvements in control of pain were brought by discovery of anesthesia by inhalation. J.Priestley discovered Nitrous Oxide also known as laughing gas which produces dizziness and giggling. People inhaled it for fun. This led a dentist, H.Davy, to try it on himself to relieved the pain of the inflamed gum. Yet, he did not pursue this intriguing idea. About 40 years later another dentist, H.Wells, wanted to demonstrate a painless tooth extraction. Unfortunately, the patient shrieked in pain. His friend W.T.G. Morton was not so easily discouraged. He called Ether the most volatile and most inflammable of all known liquids. Just like nitrous oxide, ether was a fad. Morton noticed that ether with alcohol gave good results. Other Americans like Clarke and Long used ether successfully and conducted painless procedures. Long was also the first one to use ether in obstetrical procedure in 1845. The administration of ether had yet to be systematized. Soon thereafter, operations were done in the absence of pain.

Surgery Surgery (from the Greek: χειρουργική cheirourgikē, via Latin: chirurgiae, meaning “hand work”) is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.

An act of performing surgery may be called a surgical procedure, operation, or simply surgery. In this context, the verb operate means to perform surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments or surgical nurse. The patient or subject on which the surgery is performed can be a person or an animal. A surgeon is a person who practises surgery.

Persons described as surgeons are commonly physicians, but the term is also applied to podiatrists, dentists (known as oral and maxillofacial surgeons) and veterinarians. A surgery can last from minutes to hours, but is typically not an ongoing or periodic type of treatment. The term surgery can also refer to the place where surgery is performed, or simply the office of a physician, dentist, or veterinarian.

Elective surgery generally refers to a surgical procedure that can be scheduled in advance because it does not involve a medical emergency. Cosmetic surgeries are common elective procedures.

Definitions of surgery Surgery is a 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; socalled “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 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 permanent 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; castration is also an example. 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 or removal 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”, therefore a rhinoplasty is 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, called the operating field, 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 head and the surgical site or at least a wide area surrounding the operating field; 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.

Reduction - the movement or realignment of a body part to its normal position. e.g. Reduction of a broken nose involves the physical manipulation of the bone and/or cartilage from their displaced state back to their original position to restore normal airflow and aesthetics. 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. There are several risk factors associated with post operative complications, such as immune deficienty and obesity. Obesity has long been considered a risk factor for adverse post-surgical outcomes. It has been linked to many disorders such as obesity hypoventilation syndrome, atelectasis and pulmonary embolism, adverse cardiovascular affects, and wound healing complications.[2] 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.

In special populations Elderly people Older adults have widely varying physical health. Frail elderly people are at significant risk of post-surgical complications and the need for extended care. Assessment of older patients before elective surgeries can accurately predict the patients’ recovery trajectories.[3] One frailty scale uses five items: unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking speed. A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes.[3] Frail elderly patients (score of 4 or 5) have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.

History The earliest known compendium on Surgery were penned down by ancient Indians. Sushruta was an in ancient Indian sage who had extensively described about various surgeries in Sushruta Samhita ranging from rhinoplasties, labioplasties and caesarians.

At least two prehistoric cultures had developed forms of surgery. The oldest for which there is evidence is trepanation,[4] 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.[5] 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.”

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.[7] At these shrines, patients would enter a dream-like state of induced sleep known as “enkoimesis” (Greek: ἐγκοίμησις) not unlike anesthesia, in which they either received guidance from the deity in a dream or were cured by surgery.[8] 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.

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.

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.

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. According to Peter Elmer and Ole Peter Grell, “Guy de Chauliac (1298-1368) 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.”[10] 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.[11] 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”[12]) 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. The works of Giovanni Battista Morgagni laid the foundations for modern anatomical pathology and first described the concept of disequilibrium linked to internal organic dysfunctions. 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,[13] 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 Crawford Long. 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, discovered by James Young Simpson and 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).

Cognitive and memory decline Surgery may cause post-operative decline in memory and cognitive function due that inflammatory proteins may cause damage to the blood–brain barrier and allow for immune competent blood cells to interfere with memory functions, but may be prevented with a pre-operative dosage of a nicotine alike medicine. This affects 20 - 25% of the patients for a few months, but very few are affected for more than 1 year.

Surgical specialties and sub-specialties General surgery Cardiothoracic surgery Vascular surgery Plastic surgery Paediatric surgery Colorectal surgery Transplant surgery Surgical oncology Trauma surgery Endocrine surgery Breast surgery Skin surgery Otolaryngology Gynaecology Oral and maxillofacial surgery Dental Surgery Orthopaedic surgery Neurosurgery Ophthalmology Podiatric surgery Urology Some other specialties involve some forms of surgical intervention, especially gynaecology. Also, some people consider invasive methods of treatment/diagnosis, such as cardiac catheterization, endoscopy, and placing of chest tubes or central lines â&#x20AC;&#x153;surgeryâ&#x20AC;?.

In most parts of the medical field, this view is not shared.

A-Z Surgical Specialties All surgeons are not the same. There are many types of surgeons, with a variety of specialties and levels of training. The education of surgeons ranges from training in many types of procedures, such as general surgery, to highly specialized such as pediatric neurosurgery.

Surgeons can also specialize within their chosen specialty. Cardiac surgeons may focus on performing heart bypass surgery, heart valve repairs, transplants or any other heart surgery or they may practice many types of heart surgery.

In some cases, the specialties of surgeons overlap. A good example of this is spinal surgery, which can be performed by both neurosurgeons and orthopedic surgeons. The neurosurgeon might be more appropriate for surgery on the spine itself, while the orthopedic surgeon could be more appropriate for problems with the bones of the spine.

Anesthesiology The specialty of anesthesia during surgery and pain management.

Bariatric Surgery The specialty of treating obesity with surgery.

Cardiac Surgery The specialty of treating heart problems with surgery.

Cardiothoracic Surgery The specialty of treating heart, lung and other problems in the chest with surgery.

Colon & Rectal Surgery The specialty of treating problems of the small and large intestine, the rectum and anus with surgery.

General Surgery The specialty of treating common abdominal problems such as hernias and appendicitis with surgery.

Gynecologic Surgery The specialty of treating problems with the female reproductive system with surgery.

Maxillofacial Surgery The specialty of treating problems of the mouth, jaw, neck and facial bones with surgery.

Neurosurgery The specialty of treating the central nervous system, including the brain and spinal cord, with surgery.

Obstetrics The specialty of treating women before, during and after childbirth which may include surgery such as a C-section.

Oncology The specialty of treating cancer with surgery.

Ophthalmology The specialty of treating conditions of the eye with surgery.

Oral Surgery The specialty of treating dental problems with surgery, such as wisdom tooth removal and root canals.

Orthopedic Surgery The specialty of treating problems of the bones, joints, ligaments and tendons with surgery.

Otolaryngology (Ear, Nose and Throat, ENT ) The specialty of treating problems of the ears, nose and throat with surgery.

Pediatric Surgery The specialty of treating health problems of children with surgery.

Plastic Surgery: Cosmetic & Reconstructive Surgery The specialty of improving the appearance for cosmetic reasons, or to correct defects for a more appealing appearance.

Podiatry Surgery (Podiatry) The specialty of treating problems of the feet with surgery.

Thoracic Surgery The specialty of treating problems in the chest cavity, except the heart, with surgery.

Transplant Surgery The specialty of replacing failing organs with donated organs with surgery.

Trauma Surgery The specialty of treating injuries from car crashes, gunshot wounds, stabbings and other traumatic injuries with surgery.

Vascular Surgery The specialty of treating problems of the blood vessels with surgery.

Elective surgery Elective surgery or elective procedure (from the Latin eligere, meaning to choose[1]) is surgery that is scheduled in advance because it does not involve a medical emergency. Semi-elective surgery is a surgery that must be done to preserve the patientâ&#x20AC;&#x2122;s life, but does not need to be performed immediately.

By contrast, an urgent surgery is one that can wait until the patient is medically stable, but should generally be done today or tomorrow, and an emergency surgery is one that must be performed without delay; the patient has no choice other than immediate surgery, if they do not want to risk permanent disability or death.

Types Elective surgeries include all optional surgeries performed for non-medical reasons, i.e., cosmetic surgery. They also include most surgeries necessary for medical reasons.

Cosmetic surgery, such as a facelift or the placement of breast implants, is typically performed to subjectively improve a patientâ&#x20AC;&#x2122;s physical appearance. Cosmetic and aesthetic surgeries are elective surgeries are pre-scheduled at a time that is mutually convenient for the patient, the surgeon, and the medical facility.

Many medically necessary surgeries are also elective surgeries. For example, inguinal hernia surgery, cataract surgery, mastectomy for breast cancer, and the donation of a kidney by a living donor are performed as elective surgeries.

Increasing urgency When a condition is worsening, but has not yet reached the point of a true emergency, surgeons speak of semi-elective surgery: the peccant part must be dealt with, but a delay is not expected to affect the outcome.

In a patient with multiple medical conditions, problems classified as needing semi-elective surgeries may be postponed until emergent conditions have been addressed and the patient is medically stable. For example, whenever possible, pregnant women typically postpone all elective and semi-elective procedures until after giving birth. In some situations, an urgently needed surgery will be postponed briefly to permit even more urgent conditions to be addressed. In other situations, emergency surgery may be performed at the same time as life-saving resuscitation efforts.

Semi-elective procedures are typically scheduled within a time frame deemed appropriate for the patientâ&#x20AC;&#x2122;s condition and disease.

Removal of a malignancy, for example, is usually scheduled as semi-elective surgery, to be performed within a set number of days or weeks. Urgent surgery is typically performed with 48 hours of diagnosis. Emergency surgery is performed as soon as a surgeon is available.

Many surgeries can be performed as either elective or emergency surgeries, depending on the patientâ&#x20AC;&#x2122;s needs. A sudden worsening of gallbladder disease may require immediate removal of the gallbladder by emergency surgery, but this surgery is more commonly scheduled in advance.

Exploratory surgery Exploratory surgery is a diagnostic method used by doctors when trying to find a diagnosis for an ailment. It can be performed in both humans and animals, but it is far more common in animals. It is used most commonly to diagnose or locate cancer in humans, but it can be used for other ailments as well.

The use of new technologies such as MRIs have made exploratory surgeries less frequent.

Exploratory surgery and cancer Sometimes, cancer is located in a place where standard tests cannot detect it. In this case, doctors must go into surgery and look for the cancerous mass manually. This procedure, which is what is commonly associated with exploratory surgery, is not used for treatment at all.[citation needed] Instead, it is used chiefly to identify the location of the tumor and the extent of its damage. If a tumor is found, a biopsy is performed and tests are run to see what type of cancer was found.[citation needed] [edit]Exploratory surgery in animals Because animals cannot voice their symptoms as easily as humans, exploratory surgery is more common in animals. Exploratory surgery is done when looking for a foreign body that may be lodged in the animalâ&#x20AC;&#x2122;s body, when looking for cancer, or when looking for various other gastrointestinal problems. It is a fairly routine procedure that is done only after tests and bloodwork reveal nothing abnormal.

Minimally invasive procedure A minimally invasive procedure is any procedure (surgical or otherwise) that is less invasive than open surgery used for the same purpose. A minimally invasive procedure typically involves use of laparoscopic devices and remote-control manipulation of instruments with indirect observation of the surgical field through an endoscope or similar device, and is carried out through the skin or through a body cavity or anatomical opening. This may result in shorter hospital stays, or allow outpatient treatment.[3] However, the safety and effectiveness of each procedure must be demonstrated with randomized controlled trials. The term was coined by John EA Wickham in 1984, who wrote of it in British Medical Journal in 1987 [4]. A minimally invasive procedure is distinct from a non-invasive procedure, such as external imaging instead of exploratory surgery. When there is minimal damage of biological tissues at the point of entrance of instrument(s), the procedure is called minimally invasive.

Minimal incision technique The minimal incision technique is a specialized surgical technique practiced by some physicians to remove masses or growths with minimal scarring and less recovery time. Most surgeons usually cut along 3/4 to the full length of the mass to access it or remove it. With the minimal incision technique the incision is usually about 1/10 the size of the underlying mass and the surgeon carefully dissects the mass out through this very small incision. A smaller incision forms a much smaller scar and results in less recovery time for the patient. This technique is useful for cysts or lipomas. Patients with such lesions on cosmetically or functionally important areas such as the face can gain great benefit from such techniques.

Specific procedures Many medical procedures are called minimally invasive, such as hypodermic injection, air-pressure injection, subdermal implants, endoscopy, percutaneous surgery, laparoscopic surgery, arthroscopic surgery, cryosurgery, microsurgery, keyhole surgery, endovascular surgery (such as angioplasty), coronary catheterization, permanent spinal and brain electrodes, stereotactic surgery, The Nuss Procedure, radioactivity-based medical imaging methods, such as gamma camera, Positron emission tomography and SPECT (single photon emission tomography). Related procedures are image-guided surgery, robotic surgery[5] and interventional radiology.

Benefits Minimally invasive surgery should have less operative trauma for the patient than an equivalent invasive procedure. It may be more or less expensive (for dental implants, a minimally invasive method reduces the cost of installed implants and shortens the implant-prosthetic rehabilitation time with 4–6 months[6]). Operative time is longer, but hospitalization time is shorter. It causes less pain and scarring, speeds recovery, and reduces the incidence of post-surgical complications, such as adhesions. Some studies have compared heart surgery.[7] However, minimally invasive surgery is not necessarily minor surgery that only regional anesthesia is required. In fact, most of these procedures still require general anesthesia to be administered beforehand.

Risks Minimally invasive procedures are not completely safe, and some have complications ranging from infection to death. Risks and complications include the following: Anesthesia or medication reactions Bleeding Infection Internal organ injury Blood vessel injury Vein or lung blood clotting Breathing problems Death All of these risks are present also in open, more invasive surgery.

There may be an increased risk of hypothermia and peritoneal trauma due to increased exposure to cold, dry gases during insufflation. The use of heated and humidified CO2 may reduce this risk.

Prevalence Due to these advantages, surgeons are attempting to perform more procedures as minimally invasive procedures. Some procedures, such as gall bladder removal, can be done very effectively as minimally invasive surgery.[citation needed] Other procedures, such as endarterectomy, have a higher incidence of strokes in some studies.[citation needed] The first successful minimally invasive aortic aneurysm surgery was performed by Dr. Michael L. Marin at Mount Sinai Hospital, New York.[10] “Lapraroscopic surgery has been around for a long time. We’ve been using laparoscopy for appendectomies, for taking out gall bladders and for removing cysts on the ovaries. But it’s been in very limited use for hysterectomies.”[11] Laparoscopic hysterectomy, with incisions measuring less than 10 mm, is used for less than 10% of the roughly 800,000 hysterectomies annually performed in the United States, according to the American Association of Gynecological Laparoscopists (AAGL).

Equipment Special medical equipment may be used, such as fiber optic cables, miniature video cameras and special surgical instruments handled via tubes inserted into the body through small openings in its surface. The images of the interior of the body are transmitted to an external video monitor and the surgeon has the possibility of making a diagnosis, visually identifying internal features and acting surgically on them.

Open surgery An invasive procedure is one which penetrates or breaks the skin or enters a body cavity. Examples of invasive procedures include those that involve perforation, an incision, a catheterization, or other entry into the body. Surgery is a typical medical invasive procedure. An open surgery means cutting skin and tissues so the surgeon has a direct access to the structures or organs involved. The structures and tissues involved can be seen and touched, and they are directly exposed to the air of the operating room. Examples of open surgery include the removal of organs, such as the gallbladder (though cholecsytectomy is now mostly done laproscopically) or kidney, and most types of cardiac surgery and neurosurgery. Open surgery involves large incisions, in which the tissues are exposed to the air.

Cosmetic surgery Aesthetic plastic surgery, also called Medical aesthetics, involves techniques intended for the “enhancement” of appearance through surgical and medical techniques, and is specifically concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward some aesthetic ideal.

In 2006, nearly 11 million cosmetic procedures were performed in the United States alone. The number of cosmetic procedures performed in the United States has increased over 50 percent since the start of the century. Nearly 12 million cosmetic procedures were performed in 2007, with the five most common surgeries being breast augmentation, liposuction, nasal surgery, eyelid surgery and abdominoplasty. The American Society for Aesthetic Plastic Surgery looks at the statistics for thirty-four different cosmetic procedures. Nineteen of the procedures are surgical, such as rhinoplasty or facelift. The nonsurgical procedures include Botox and laser hair removal. In 2010, their survey revealed that there were 9,336,814 total procedures in the United States. Of those, 1,622,290 procedures were surgical (p. 5). They also found that a large majority, 81%, of the procedures were done on Caucasian people (p. 12).[12] The increased use of cosmetic procedures crosses racial and ethnic lines in the U.S., with increases seen among African-Americans and Hispanic Americans as well as Caucasian Americans. In Europe, the second largest market for cosmetic procedures, cosmetic surgery is a $2.2 billion business.[13] Cosmetic surgery is now very common in countries such as the United Kingdom, France, and Germany. In Asia, cosmetic surgery has become an accepted practice, and countries such as China and India has become Asia’s biggest comestic surgery markets.[14] Children undergoing cosmetic eye surgery can be seen in Japan and South Korea.[15][16] Thailand is also one of the main cosmetic surgery markets in Asia, in particular for affordable breast augmentation and sex reassignment surgery, with international patients coming from Australia, Europe and neighboring Asian countries.

The most prevalent aesthetic/cosmetic procedures include: Abdominoplasty (“tummy tuck”): reshaping and firming of the abdomen Blepharoplasty (“eyelid surgery”): reshaping of the eyelids or the application of permanent eyeliner, including Asian blepharoplasty Phalloplasty (“penile liposuction”) : construction (or reconstruction) of a penis or, sometimes, artificial modification of the penis by surgery, often for cosmetic purposes Mammoplasty: Breast augmentations (“breast implant” or “boob job”): augmentation of the breasts by means of fat grafting, saline, or silicone gel prosthetics, which was initially performed to women with micromastia Reduction mammoplasty (“breast reduction”): removal of skin and glandular tissue, which is done to reduce back and shoulder pain in women with gigantomastia and/or for psychological benefit men with gynecomastia Mastopexy (“breast lift”): Lifting or reshaping of breasts to make them less saggy, often after weight loss (after a pregnancy, for example). It involves removal of breast skin as opposed to glandular tissue Buttock augmentation (“butt implant”): enhancement of the buttocks using silicone implants or fat grafting (“Brazilian butt lift”) and transfer from other areas of the body Buttock lift: lifting, and tightening of the buttocks by excision of redundant skin Chemical peel: minimizing the appearance of acne, chicken pox, and other scars as well as wrinkles (depending on concentration and type of agent used, except for deep furrows), solar lentigines (age spots, freckles), and photodamage in general. Chemical peels commonly involve carbolic acid (Phenol), trichloroacetic acid (TCA), glycolic acid (AHA), or salicylic acid (BHA) as the active agent.

Labiaplasty: surgical reduction and reshaping of the labia Lip enhancement: surgical improvement of lips’ fullness through enlargement

Rhinoplasty (“nose job”): reshaping of the nose Otoplasty (“ear surgery”/”ear pinning”): reshaping of the ear, most often done by pinning the protruding ear closer to the head.

Rhytidectomy (“face lift”): removal of wrinkles and signs of aging from the face Browplasty (“brow lift” or “forehead lift”): elevates eyebrows, smooths forehead skin Midface lift (“cheek lift”): tightening of the cheeks Chin augmentation (“chin implant”): augmentation of the chin with an implant, usually silicone, by sliding genioplasty of the jawbone or by suture of the soft tissue Cheek augmentation (“cheek implant”): implants to the cheek Orthognathic Surgery: manipulation of the facial bones through controlled fracturing Fillers injections: collagen, fat, and other tissue filler injections, such as hyaluronic acid Laser skin resurfacing Liposuction (“suction lipectomy”): removal of fat deposits by traditional suction technique or ultrasonic energy to aid fat removal Brachioplasty (“Arm lift”): reducing excess skin and fat between the underarm and the elbow

Reconstructive surgery Reconstructive surgery is, in its broadest sense, the use of surgery to restore the form and function of the body, although maxillofacial surgeons, plastic surgeons and otolaryngologists do reconstructive surgery on faces after trauma and to reconstruct the head and neck after cancer.

Other branches of surgery (e.g., general surgery, gynecological surgery, pediatric surgery, cosmetic surgery) also perform some reconstructive procedures. The common feature is that the operation attempts to restore the anatomy or the function of the body part to normal.

Reconstructive plastic surgeons use the concept of a reconstructive ladder to manage increasingly complex wounds. This ranges from very simple techniques such as primary closure and dressings to more complex skin grafts, tissue expansion and free flaps.

Cosmetic surgery procedures include breast enhancement, reduction and lift, face lift, forehead lift, upper and lower eyelid surgery (blepharoplasty), laser skin resurfacing (laser resurfacing), chemical peel, nose reshaping (rhinoplasty), reconstruction liposuction, nasal reconstruction using the paramedian flap, as well as tummy tuck (abdominoplasty).

Many of these procedures are constantly being improved. Recent literature in medline also has noted implementation of barbed suture in these procedures.

Replantation Replantation is the surgical reattachment of a body part by microsurgical means, most commonly a finger, hand or arm, that has been completely cut from a person’s body. Replantation of amputated parts has been performed on fingers, hands, forearms, arms, toes, feet, legs, ears, avulsed scalp injuries, a face, lips, penis and a tongue.

The first replantation performed in the world with microvascular repair of vessels was done by a team of chief residents led by Dr. Ronald Malt at Massachusetts General Hospital in Boston, MA, USA in 1962. The arm of a 12 year old child severed at the level of the proximal humerus was reattached. The first report of a replantation published in a peer reviewed medical journal was reported by a team led by Zhong Wei Chen of the Sixth People’s Hospital in Shanghai in 1963 writing in the Chinese Medical Journal. A machinist’s hand was reattached at the level of the distal forearm. In this case vascular couplers were used for the vessels as the Chinese did not have good micro sutures available at that time. As there was little communication between China and the Western World in those years, Ronald Malt and Charles McKhann published in JAMA in 1964 their first two replantations without referencing the earlier published article from China.

Replantation requires microsurgery and must be performed within several hours of the part’s amputation at a center with specialized equipment, surgeons and supporting staff. To improve the chances of a successful replantation, it is necessary to preserve the amputate as soon as possible in a cool(close to freezing, but not at or below freezing) and sterile or clean environment. Parts should be wrapped with moistened gauze and placed inside a clean or sterile bag floating in ice water. Dry ice should not be used as it can result in freezing of the tissue. There are so called sterile “Amputate-Bags” available which help to perform a dry, cool and sterile preservation.

Parts without muscles such as fingers can be preserved for many hours, while major muscled containing parts such as arms need to be re attached and revascularized within 6-8 hours to survive. Outcome of major limb replantations can be predicted by the potasium level of the blood which flows out of the replanted part after revascularization as a high level can be a marker of muscle and tissue death.

It is important to also collect and to preserve those amputates which do not look like being “replantable”.

A microsurgeon needs all available parts of human tissue to cover the wound at the stump and thus to prevent further shortening of the stump. In some cases (e.g. forearm) the task of an important joint (e.g. elbow) can be conserved for improved prosthetic success.

Severe crush injuries, multilevel injuries, avulsion injuries, and in some cases jagged tearing of tissue, can preclude replantation and salvage, requiring revision amputation of the stump.

Organ Transplantation Organ transplantation is the moving of an organ from one body to another or from a donor site on the patient’s own body, for the purpose of replacing the recipient’s damaged or absent organ. The emerging field of regenerative medicine is allowing scientists and engineers to create organs to be re-grown from the patient’s own cells (stem cells, or cells extracted from the failing organs).

Organs and/or tissues that are transplanted within the same person’s body are called autografts. Transplants that are recently performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source.

Organs that can be transplanted are the heart, kidneys, liver, lungs, pancreas, intestine, and thymus. Tissues include bones, tendons (both referred to as musculoskeletal grafts), cornea, skin, heart valves, and veins. Worldwide, the kidneys are the most commonly transplanted organs, followed closely by the liver and then the heart. The cornea and musculoskeletal grafts are the most commonly transplanted tissues; these outnumber organ transplants by more than tenfold.

Organ donors may be living, or brain dead. Tissue may be recovered from donors who are cardiac dead – up to 24 hours past the cessation of heartbeat. Unlike organs, most tissues (with the exception of corneas) can be preserved and stored for up to five years, meaning they can be “banked”. Transplantation raises a number of bioethical issues, including the definition of death, when and how consent should be given for an organ to be transplanted and payment for organs for transplantation.[1][2] Other ethical issues include transplantation tourism and more broadly the socio-economic context in which organ harvesting or transplantation may occur. A particular problem is organ trafficking.[3] Some organs, such as the brain, cannot yet be transplanted in humans.

In the United States of America, tissue transplants are regulated by the U.S. Food and Drug Administration (FDA) which sets strict regulations on the safety of the transplants, primarily aimed at the prevention of the spread of communicable disease. Regulations include criteria for donor screening and testing as well as strict regulations on the processing and distribution of tissue grafts. Organ transplants are not regulated by the FDA.[citation needed] Transplantation medicine is one of the most challenging and complex areas of modern medicine. Some of the key areas for medical management are the problems of transplant rejection, during which the body has an immune response to the transplanted organ, possibly leading to transplant failure and the need to immediately remove the organ from the recipient. When possible, transplant rejection can be reduced through serotyping to determine the most appropriate donor-recipient match and through the use of immunosuppressant drugs.

History Successful human allotransplants have a relatively long history of operative skills were present long before the necessities for post-operative survival were discovered. Rejection and the side effects of preventing rejection (especially infection and nephropathy) were, are, and may always be the key problem.

Several apocryphal accounts of transplants exist well prior to the scientific understanding and advancements that would be necessary for them to have actually occurred. The Chinese physician Pien Chi’ao reportedly exchanged hearts between a man of strong spirit but weak will with one of a man of weak spirit but strong will in an attempt to achieve balance in each man. Roman Catholic accounts report the 3rd-century saints Damian and Cosmas as replacing the gangrenous leg of the Roman deacon Justinian with the leg of a recently deceased Ethiopian. Most accounts have the saints performing the transplant in the 4th century, decades after their deaths; some accounts have them only instructing living surgeons who performed the procedure.

The more likely accounts of early transplants deal with skin transplantation. The first reasonable account is of the Indian surgeon Sushruta in the 2nd century BC, who used autografted skin transplantation in nose reconstruction rhinoplasty. Success or failure of these procedures is not well documented. Centuries later, the Italian surgeon Gasparo Tagliacozzi performed successful skin autografts; he also failed consistently with allografts, offering the first suggestion of rejection centuries before that mechanism could possibly be understood. He attributed it to the “force and power of individuality” in his 1596 work De Curtorum Chirurgia per Insitionem.

The first successful corneal allograft transplant was performed in 1837 in a gazelle model; the first successful human corneal transplant, a keratoplastic operation, was performed by Eduard Zirm at Olomouc Eye Clinic, now Czech Republic, in 1905. Thyroid gland tissue was transplanted in 1882 by Theodor Kocher.[5] Pioneering work in the surgical technique of transplantation was made in the early 1900s by the French surgeon Alexis Carrel, with Charles Guthrie, with the transplantation of arteries or veins. Their skilful anastomosis operations, the new suturing techniques, laid the groundwork for later transplant surgery and won Carrel the 1912 Nobel Prize in Physiology or Medicine. From 1902 Carrel performed transplant experiments on dogs. Surgically successful in moving kidneys, hearts and spleens, he was one of the first to identify the problem of rejection, which remained insurmountable for decades.

Major steps in skin transplantation occurred during the First World War, notably in the work of Harold Gillies at Aldershot.

Among his advances was the tubed pedicle graft, maintaining a flesh connection from the donor site until the graft established its own blood flow. Gillies’ assistant, Archibald McIndoe, carried on the work into the Second World War as reconstructive surgery.

In 1962 the first successful replantation surgery was performed – re-attaching a severed limb and restoring (limited) function and feeling.

The first attempted human deceased-donor transplant was performed by the Ukrainian surgeon Yu Yu Voronoy in the 1930s; rejection resulted in failure. Joseph Murray and J. Hartwell Harrison performed the first successful transplant, a kidney transplant between identical twins, in 1954, successful because no immunosuppression was necessary in genetically identical twins.

In the late 1940s Peter Medawar, working for the National Institute for Medical Research, improved the understanding of rejection. Identifying the immune reactions in 1951 Medawar suggested that immunosuppressive drugs could be used. Cortisone had been recently discovered and the more effective azathioprine was identified in 1959, but it was not until the discovery of cyclosporine in 1970 that transplant surgery found a sufficiently powerful immunosuppressive.

Dr. Murray’s success with the kidney led to attempts with other organs. There was a successful deceased-donor lung transplant into a lung cancer sufferer in June 1963 by James Hardy in Jackson, Mississippi. The patient survived for eighteen days before dying of kidney failure. Thomas Starzl of Denver attempted a liver transplant in the same year but was not successful until 1967.

The heart was a major prize for transplant surgeons. But over and above rejection issues, the heart deteriorates within minutes of death, so any operation would have to be performed at great speed. The development of the heart-lung machine was also needed.

Lung pioneer James Hardy attempted a human heart transplant in 1964, but when a premature failure of the recipient’s heart caught Hardy with no human donor, he used a chimpanzee heart, which failed very quickly. The first success was achieved on December 3, 1967, by Christiaan Barnard in Cape Town, South Africa. Louis Washkansky, the recipient, survived for eighteen days amid what many[who?] saw as a distasteful publicity circus. The media interest prompted a spate of heart transplants. Over a hundred were performed in 1968–69, but almost all the patients died within sixty days. Barnard’s second patient, Philip Blaiberg, lived for 19 months.

It was the advent of cyclosporine that altered transplants from research surgery to life-saving treatment. In 1968 surgical pioneer Denton Cooley performed seventeen transplants, including the first heart-lung transplant. Fourteen of his patients were dead within six months. By 1984 two-thirds of all heart transplant patients survived for five years or more. With organ transplants becoming commonplace, limited only by donors, surgeons moved on to riskier fields, including multiple-organ transplants on humans and whole-body transplant research on animals. On March 9, 1981, the first successful heart-lung transplant took place at Stanford University Hospital. The head surgeon, Bruce Reitz, credited the patient’s recovery to cyclosporine-A. As the rising success rate of transplants and modern immunosuppression make transplants more common, the need for more organs has become critical. Transplants from living donors, especially relatives, have become increasingly common. Additionally, there is substantive research into xenotransplantation, or transgenic organs; although these forms of transplant are not yet being used in humans, clinical trials involving the use of specific cell types have been conducted with promising results, such as using porcine islets of Langerhans to treat type 1 diabetes. However, there are still many problems that would need to be solved before they would be feasible options in patients requiring transplants.

Recently, researchers have been looking into means of reducing the general burden of immunosuppression. Common approaches include avoidance of steroids, reduced exposure to calcineurin inhibitors, and other means of weaning drugs based on patient outcome and function. While short-term outcomes appear promising, long-term outcomes are still unknown, and in general, reduced immunosuppression increases the risk of rejection and decreases the risk of infection.

Many other new drugs are under development for transplantation The emerging field of regenerative medicine promises to solve the problem of organ transplant rejection by regrowing organs in the lab, using the patients’ own cells (stem cells or healthy cells extracted from the donor site.)

Timeline of successful transplants 1905: First successful cornea transplant by Eduard Zirm [Czech Republic] 1954: First successful kidney transplant by J. Hartwell Harrison and Joseph Murray (Boston, U.S.A.) 1966: First successful pancreas transplant by Richard Lillehei and William Kelly (Minnesota, U.S.A.) 1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.) 1967: First successful heart transplant by Christian Barnard (Cape Town, South Africa) 1981: First successful heart/lung transplant by Bruce Reitz (Stanford, U.S.A.) 1983: First successful lung lobe transplant by Joel Cooper (Toronto, Canada) 1984: First successful double organ transplant by Thomas Starzl and Henry T. Bahnson (Pittsburgh, U.S.A.) 1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper (Toronto, Canada) 1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and Louis Kavoussi (Baltimore, U.S.A.) 1997: First successful allogeneic vascularized transplantation of a fresh and perfused human knee joint by Gunther O. Hofmann 1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota, U.S.A.) 1998: First successful hand transplant by Dr. Jean-Michel Dubernard (Lyon, France) 1999: First successful Tissue Engineered Bladder transplanted by Anthony Atala (Boston Children’s Hospital, U.S.A.) 2005: First successful ovarian transplant by Dr P N Mhatre (wadia hospital mumbai,India) 2005: First successful partial face transplant (France) 2006: First jaw transplant to combine donor jaw with bone marrow from the patient, by Eric M. Genden Mount Sinai Hospital, New York 2008: First successful complete full double arm transplant by Edgar Biemer, Christoph Höhnke and Manfred Stangl (Technical University of Munich, Germany) 2008: First baby born from transplanted ovary by James Randerson 2008: First transplant of a Vertebrate trachea|human windpipe using a patient’s own stem cells, by Paolo Macchiarini (Barcelona, Spain) 2008: First successful transplantation of near total area (80%) of face, (including palate, nose, cheeks, and eyelid by Maria Siemionow (Cleveland, USA) 2010: First full facial transplant, by Dr Joan Pere Barret and team (Hospital Universitari Vall d’Hebron on July 26, 2010 in Barcelona, Spain.)

2011: First double leg transplant, by Dr Cavadas and team (Valencia’s Hospital La Fe, Spain)

Types of transplant Autograft Transplant of tissue to the same person. Sometimes this is done with surplus tissue, or tissue that can regenerate, or tissues more desperately needed elsewhere (examples include skin grafts, vein extraction for CABG, etc.) Sometimes an autograft is done to remove the tissue and then treat it or the person, before returning it (examples include stem cell autograft and storing blood in advance of surgery). In a rotationplasty a distal joint is used to replace a more proximal one, typically a foot and ankle joint is used to replace a knee joint. The patient’s foot is severed and reversed, the knee removed, and the tibia joined with the femur.

Allograft and allotransplantation An allograft is a transplant of an organ or tissue between two genetically non-identical members of the same species. Most human tissue and organ transplants are allografts. Due to the genetic difference between the organ and the recipient, the recipient’s immune system will identify the organ as foreign and attempt to destroy it, causing transplant rejection. The Risk of transplant rejection can be estimated by measuring the Panel reactive antibody level.

Isograft A subset of allografts in which organs or tissues are transplanted from a donor to a genetically identical recipient (such as an identical twin). Isografts are differentiated from other types of transplants because while they are anatomically identical to allografts, they do not trigger an immune response.

Xenograft and xenotransplantation A transplant of organs or tissue from one species to another. An example is porcine heart valve transplant, which is quite common and successful. Another example is attempted piscine-primate (fish to non-human primate) transplant of islet (i.e. pancreatic or insular tissue) tissue. The latter research study was intended to pave the way for potential human use, if successful. However, xenotransplantion is often an extremely dangerous type of transplant because of the increased risk of non-compatibility, rejection, and disease carried in the tissue.

Split transplants Sometimes a deceased-donor organ, usually a liver, may be divided between two recipients, especially an adult and a child. This is not usually a preferred option because the transplantation of a whole organ is more successful.

Domino transplants In patients with cystic fibrosis, where both lungs need to be replaced, it is a technically easier operation with a higher rate of success to replace both the heart and lungs of the recipient with those of the donor. As the recipient’s original heart is usually healthy, it can then be transplanted into a second recipient in need of a heart transplant.[7] Another example of this situation occurs with a special form of liver transplant in which the recipient suffers from familial amyloidotic polyneuropathy, a disease where the liver slowly produces a protein that damages other organs. The recipient’s liver can then be transplanted into an older patient for whom the effects of the disease will not necessarily contribute significantly to mortality.[8] This term also refers to a series of living donor transplants in which one donor donates to the highest recipient on the waiting list and the transplant center utilizes that donation to facilitate multiple transplants. These other transplants are otherwise impossible due to blood type or antibody barriers to transplantation. The “Good Samaritan” kidney is transplanted into one of the other recipients, whose donor in turn donates his or her kidney to an unrelated recipient. Depending on the patients on the waiting list, this has sometimes been repeated for up to six pairs, with the final donor donating to the patient at the top of the list. This method allows all organ recipients to get a transplant even if their living donor is not a match to them. This further benefits patients below any of these recipients on waiting lists, as they move closer to the top of the list for a deceased-donor organ. Johns Hopkins Medical Center in Baltimore and Northwestern University’s Northwestern Memorial Hospital have received significant attention for pioneering transplants of this kind.

In February 2012 the last link in a record sixty-person domino chain of thirty kidney transplants was completed.

Major organs and tissues transplanted Thoracic organs Heart (Deceased-donor only) Lung (Deceased-donor and living-related lung transplantation) Heart/Lung (Deceased-donor and Domino transplant)

Abdominal organs Kidney (Deceased-donor and Living-Donor) Liver (Deceased-donor and Living-Donor) Pancreas (Deceased-donor only) Intestine (Deceased-donor and Living-Donor) Stomach (Deceased-donor only) Testis

Tissues, cells, fluids Hand (Deceased-donor only), see the first recipient Clint Hallam Cornea (Deceased-donor only) see the ophthalmologist Eduard Zirm Skin including Face replant (autograft) and Face transplant (extremely rare) Islets of Langerhans (Pancreas Islet Cells) (Deceased-donor and Living-Donor) Bone marrow/Adult stem cell (Living-Donor and Autograft) Blood transfusion/Blood Parts Transfusion (Living-Donor and Autograft) Blood vessels (Autograft and Deceased-Donor) Heart valve (Deceased-Donor, Living-Donor and Xenograft[Porcine/bovine]) Bone (Deceased-Donor and Living-Donor)

Types of donor Organ donors may be living, or brain dead. Brain dead means the donor must have received an injury (either traumatic or pathological) to the part of the brain that controls heartbeat and breathing. Breathing is maintained via artificial sources, which, in turn, maintains heartbeat. Once brain death has been declared the person can be considered for organ donation. Criteria for brain death vary. Because less than 3% of all deaths in the U.S. are the result of brain death, the overwhelming majority of deaths are ineligible for organ donation, resulting in severe shortages. Tissue may be recovered from donors who are cardiac dead. That is, their breathing and heartbeat has ceased. They are referred to as cadaveric donors. In general, tissues may be recovered from donors up to 24 hours past the cessation of heartbeat. In contrast to organs, most tissues (with the exception of corneas) can be preserved and stored for up to five years, meaning they can be “banked.” Also, more than 60 grafts may be obtained from a single tissue donor. Because of these three factors—the ability to recover from a non-heart beating donor, the ability to bank tissue, and the number of grafts available from each donor—tissue transplants are much more common than organ transplants. The American Association of Tissue Banks estimates that more than one million tissue transplants take place in the United States each year.

Living donor In “living donors”, the donor remains alive and donates a renewable tissue, cell, or fluid (e.g. blood, skin), or donates an organ or part of an organ in which the remaining organ can regenerate or take on the workload of the rest of the organ (primarily single kidney donation, partial donation of liver, small bowel). Regenerative medicine may one day allow for laboratory-grown organs, using patient’s own cells via stem cells, or healthy cells extracted from the failing organs.

Deceased donor Deceased (formerly cadaveric) are donors who have been declared brain-dead and whose organs are kept viable by ventilators or other mechanical mechanisms until they can be excised for transplantation. Apart from brain-stem dead donors, who have formed the majority of deceased donors for the last twenty years, there is increasing use of Donation after Cardiac Death Donors (formerly non-heart beating donors) to increase the potential pool of donors as demand for transplants continues to grow.[citation needed] These organs have inferior outcomes to organs from a brain-dead donor; however given the scarcity of suitable organs and the number of people who die waiting, any potentially suitable organ must be considered.

Allocation of donated organs The overwhelming majority of deceased-donor organs in the United States are allocated by federal contract to the Organ Procurement and Transplantation Network (OPTN), held since it was created by the Organ Transplant Act of 1984 by the United Network for Organ Sharing or UNOS. (UNOS does not handle donor cornea tissue; corneal donor tissue is usually handled by various eye banks.) Individual regional organ procurement organizations (OPOs), all members of the OPTN, are responsible for the identification of suitable donors and collection of the donated organs. UNOS then allocates organs based on the method considered most fair by the scientific leadership in the field. For kidneys, for instance, that is by waiting time; for livers, it is by MELD (Model of End-Stage Liver Disease), an empirical score based on lab values indicative of the sickness of the patient from liver disease.

Experiencing somewhat increased popularity, but still very rare, is directed or targeted donation, in which the family of a deceased donor (often honoring the wishes of the deceased) requests an organ be given to a specific person. If medically suitable, the allocation system is subverted, and the organ is given to that person. In the United States, there are various lengths of waiting due to the different availabilities of organs in different UNOS regions. In other countries such as the UK, only medical factors and the position on the waiting list can affect who receives the organ. If this is not the desired person, it is noted that this puts them higher on the list.

One of the more publicized cases of this type was the 1994 Chester and Patti Szuber transplant. This was the first time that a parent had received a heart donated by one of their own children. Although the decision to accept the heart from their recently killed child was not an easy decision, the Szuber family agreed that giving Patti’s heart to her father would have been something that she would have wanted.[14] Access to organ transplantation is one reason for the growth of medical tourism.

Reasons for donation and ethical issues Living related donors Living related donors donate to family members or friends in whom they have an emotional investment. The risk of surgery is offset by the psychological benefit of not losing someone related to them, or not seeing them suffer the ill effects of waiting on a list.

Paired exchange A “paired-exchange” is a technique of matching willing living donors to compatible recipients using serotyping. For example a spouse may be willing to donate a kidney to their partner but cannot since there is not a biological match. The willing spouse’s kidney is donated to a matching recipient who also has an incompatible but willing spouse. The second donor must match the first recipient to complete the pair exchange. Typically the surgeries are scheduled simultaneously in case one of the donors decides to back out and the couples are kept anonymous from each other until after the transplant.

Paired exchange programs were popularized in the New England Journal of Medicine article “Ethics of a paired-kidney-exchange program” in 1997 by L.F. Ross.[15] It was also proposed by Felix T. Rapport [4] in 1986 as part of his initial proposals for livedonor transplants “The case for a living emotionally related international kidney donor exchange registry” in Transplant Proceedings.[16] A paired exchange is the simplest case of a much larger exchange registry program where willing donors are matched with any number of compatible recipients [5]. Transplant exchange programs have been suggested as early as 1970: “A cooperative kidney typing and exchange program.”.

The first pair exchange transplant in the U.S. was in 2001 at Johns Hopkins Hospital[6]. The first complex multihospital kidney exchange involving 12 patients was performed in February 2009 by The Johns Hopkins Hospital, Barnes-Jewish Hospital in St. Louis and Integris Baptist Medical Center in Oklahoma City.[18] Another 12-patient multihospital kidney exchange was performed four weeks later by Saint Barnabas Medical Center in Livingston, New Jersey, Newark Beth Israel Medical Center and New York-Presbyterian Hospital.[19] Surgical teams led by Johns Hopkins continue to pioneer in this field by having more complex chain of exchange such as eight-way multihospital kidney exchange.[20] In December 2009, a 13 organ 13 recipient matched kidney exchange took place, coordinated through Georgetown University Hospital and Washington Hospital Center, Washington DC. Paired-donor exchange, led by work in the New England Program for Kidney Exchange as well as at Johns Hopkins University and the Ohio OPOs may more efficiently allocate organs and lead to more transplants.

Good Samaritan Good Samaritan or “altruistic” donation is giving a donation to someone not well-known to the donor. Some people choose to do this out of a need to donate. Some donate to the next person on the list; others use some method of choosing a recipient based on criteria important to them. Web sites are being developed that facilitate such donation. It has been featured in recent television journalism that over half of the members of the Jesus Christians, an Australian religious group, have donated kidneys in such a fashion.

Compensated donation In compensated donation, donors get money or other compensation in exchange for their organs. This practice is common in some parts of the world, whether legal or not, and is one of the many factors driving medical tourism.

An article by Gary Becker and Julio Elias on “Introducing Incentives in the market for Live and Cadaveric Organ Donations”[24] said that a free market could help solve the problem of a scarcity in organ transplants. Their economic modeling was able to estimate the price tag for human kidneys ($15,000) and human livers ($32,000).

In the United States, The National Organ Transplant Act of 1984 made organ sales illegal. In the United Kingdom, the Human Organ Transplants Act 1989 first made organ sales illegal, and has been superseded by the Human Tissue Act 2004.

In 2007, two major European conferences recommended against the sale of organs.[25] Recent development of web sites and personal advertisements for organs among listed candidates has raised the stakes when it comes to the selling of organs, and have also sparked significant ethical debates over directed donation, “good-Samaritan” donation, and the current U.S. organ allocation policy. Bioethicist Jacob M. Appel has argued that organ solicitation on billboards and the internet may actually increase the overall supply of organs.[26] Two books, Kidney for Sale By Owner by Mark Cherry (Georgetown University Press, 2005); and Stakes and Kidneys: Why markets in human body parts are morally imperative by James Stacey Taylor: (Ashgate Press, 2005); advocate using markets to increase the supply of organs available for transplantation. In a 2004 journal article Economist Alex Tabarrok argues that allowing organ sales, and elimination of organ donor lists will increase supply, lower costs and diminish social anxiety towards organ markets.[ Iran has had a legal market for kidneys since 1988,[28] and the market price is of the order of US$1,200 for the recipient.[29] The Economist[7] and the Ayn Rand Institute[8] approve and advocate a legal market elsewhere. They argued that if 0.06% of Americans between 19 and 65 were to sell one kidney, the national waiting list would disappear (which, the Economist wrote, happened in Iran). The Economist argued that donating kidneys is no more risky than surrogate motherhood, which can be done legally for pay in most countries.

In Pakistan, 40 percent to 50 percent of the residents of some villages have only one kidney because they have sold the other for a transplant into a wealthy person, probably from another country, said Dr. Farhat Moazam of Pakistan, at a World Health Organization conference. Pakistani donors are offered $2,500 for a kidney but receive only about half of that because middlemen take so much.[30] In Chennai, southern India, poor fishermen and their families sold kidneys after their livelihoods were destroyed by the Indian Ocean tsunami on December 26, 2004. About 100 people, mostly women, sold their kidneys for 40,000–60,000 rupees ($900–$1,350).[31] Thilakavathy Agatheesh, 30, who sold a kidney in May 2005 for 40,000 rupees said, “I used to earn some money selling fish but now the post-surgery stomach cramps prevent me from going to work.” Most kidney sellers say that selling their kidney was a mistake.

In Cyprus in 2010 police closed a fertility clinic under charges of trafficking in human eggs. The Petra Clinic, as it was known locally, imported women from Ukraine and Russia for egg harvesting and sold the genetic material to foreign fertility tourists.[33] This sort of reproductive trafficking violates laws in the European Union. In 2010 the Pulitzer Center on Crisis Reporting and the magazine Fast Company explored illicit fertility networks in Spain, the United States and Israel.

Forced donation There have been various accusations that certain authorities are harvesting organs from those the authorities deem undesirable, such as prison populations. The World Medical Association stated that individuals in detention are not in the position to give free consent to donate their organs [36][dead link]. Illegal dissection of corpses is a form of body-snatching and may have taken place to obtain allografts.

According to the Chinese Deputy Minister of Health, Huang Jiefu,[37][dead link] approximately 95% of all organs used for transplantation are from executed prisoners. The lack of public organ donation program in China is used as a justification for this practice. However reports in Chinese media raised concerns if executed criminals are the only source for organs used in transplants.

In October 2007, bowing to international pressure, the Chinese Medical Association agreed on a moratorium of commercial organ harvesting from condemned prisoners, but did not specify a deadline. China agreed to restrict transplantations from donors to their immediate relatives.

People in other parts of the world are responding to this availability of organs, and a number of individuals (including US and Japanese citizens) have elected to travel to China or India as medical tourists to receive organ transplants which may have been sourced in what might be considered elsewhere to be unethical ways (see later).

Organ transplantation in different countries Demographics Despite efforts of international transplantation societies, it is not possible to access an accurate source on the number, rates and outcomes of all forms of transplantation globally; the best that we can achieve is estimations. This is not a sound basis for the future and thus one of the crucial strategies for the Global Alliance in Transplantation is to foster the collection and analysis of global data.

According to the Council of Europe, Spain through the Spanish Transplant Organization led by Dr Rafael Matesanz shows the highest worldwide rate of 35.1[40][41] donors per million population in 2005 and 33.8[42] in 2006. In 2011, was 35.3 http:// www.agenciasinc.es/Noticias/Espana-alcanza-un-record-historico-de-trasplantes-en-2011 In addition to the citizens waiting for organ transplants in the US and other developed nations, there are long waiting lists in the rest of the world. More than 2 million people need organ transplants in China, 50,000 waiting in Latin America (90% of which are waiting for kidneys), as well as thousands more in the less documented continent of Africa. Donor bases vary in developing nations.

Traditionally, Muslims believe body desecration in life or death to be forbidden, and thus many reject organ transplant.[43] However most Muslim authorities nowadays accept the practice if another life will be saved.

In Latin America the donor rate is 40–100 per million per year, similar to that of developed countries. However, in Uruguay, Cuba, and Chile, 90% of organ transplants came from cadaveric donors. Cadaveric donors represent 35% of donors in Saudi Arabia. There is continuous effort to increase the utilization of cadaveric donors in Asia, however the popularity of living, single kidney donors in India yields India a cadaveric donor prevalence of less than 1 pmp.

Organ transplantation in China has taken place since the 1960s, and China has one of the largest transplant programmes in the world, peaking at over 13,000 transplants a year by 2004.[45] Organ donation, however, is against Chinese tradition and culture,[46][47] and involuntary organ donation is illegal under Chinese law.[48] China’s transplant programme attracted the attention of international news media in the 1990s due to ethical concerns about the organs and tissue removed from the corpses of executed criminals being commercially traded for transplants.

With regard to organ transplantation in Israel, there is a severe organ shortage due to religious objections by some rabbis who oppose all organ donations and others who advocate that a rabbi participate in all decision making regarding a particular donor.

One third of all heart transplants performed on Israelis are done in the Peoples’ Republic of China; others are done in Europe. Dr. Jacob Lavee, head of the heart-transplant unit, Sheba Medical Center, Tel Aviv, believes that “transplant tourism” is unethical and Israeli insurers should not pay for it. The organization HODS (Halachic Organ Donor Society) is working to increase knowledge and participation in organ donation among Jews throughout the world.

Transplantation rates also differ based on race, sex, and income. A study done with patients beginning long term dialysis showed that the sociodemographic barriers to renal transplantation present themselves even before patients are on the transplant list.[53] For example, different groups express definite interest and complete pretransplant workup at different rates. Previous efforts to create fair transplantation policies had focused on patients currently on the transplantation waiting list.

Comparative costs One of the driving forces for illegal organ trafficking and for “transplantation tourism” is the price differences for organs and transplant surgeries in different areas of the world. According to the New England Journal of Medicine, a human kidney can be purchased in Manila for $1000–$2000, but in urban Latin America a kidney may cost more than $10,000. Kidneys in South Africa have sold for as high as $20,000. Price disparities based on donor race are a driving force of attractive organ sales in South Africa, as well as in other parts of the world.

In China, a kidney transplant operation runs for around $70,000, liver for $160,000, and heart for $120,000 [15][dead link].

Although these prices are still unattainable to the poor, compared to the fees of the United States, where a kidney transplant may demand $100,000, a liver $250,000, and a heart $860,000, Chinese prices have made China a major provider of organs and transplantation surgeries to other countries.

In India, a kidney transplant operation runs for around as low as $5000.

Safety Compensation for donors also increases the risk of introducing diseased organs to recipients because these donors often yield from poorer populations unable to receive health care regularly and organ dealers may evade disease screening processes. The majority of such deals include one major payment and no follow up care for the donor. Some cases argue that there is a possibility of 1:18 to acquire HIV from such transplants.

In November 2007, the CDC reported the first-ever case of HIV and Hepatitis C being simultaneously transferred through an organ transplant. The donor was a 38-year-old male, considered “high-risk” by donation organizations, and his organs transmitted HIV and Hepatitis C to four organ recipients, none of whom had been told he was “high-risk.” Experts say that the reason the diseases did not show up on screening tests is probably because they were contracted within three weeks before the donor’s death, so antibodies would not have existed in high enough numbers to detect. The crisis has caused many to call for more sensitive screening tests, which could pick up antibodies sooner. Currently, the screens cannot pick up on the small number of antibodies produced in HIV infections within the last 90 days or Hepatitis C infections within the last 18–21 days before a donation is made.

NAT (nucleic acid testing) is now being done by many organ procurement organizations and is able to detect antibodies for HIV and Hepatitis C within seven to ten days of exposure to the virus.

Organ transplant laws Both developing and developed countries have forged various policies to try to increase the safety and availability of organ transplants to their citizens. Brazil, France, Italy, Poland and Spain have ruled all adults potential donors with the “opting out” policy, unless they attain cards specifying not to be. However, whilst potential recipients in developing countries may mirror their more developed counterparts in desperation, potential donors in developing countries do not. The Indian government has had difficulty tracking the flourishing organ black market in their country and have yet to officially condemn it. Other countries victimized by illegal organ trade have implemented legislative reactions. Moldova has made international adoption illegal in fear of organ traffickers. China has made selling of organs illegal as of July 2006 and claims that all prisoner organ donors have filed consent.

However, doctors in other countries, such as the United Kingdom, have accused China of abusing its high capital punishment rate. Despite these efforts, illegal organ trafficking continues to thrive and can be attributed to corruption in healthcare systems, which has been traced as high up as the doctors themselves in China, Ukraine, and India, and the blind eye economically strained governments and health care programs must sometimes turn to organ trafficking. Some organs are also shipped to Uganda and the Netherlands. This was a main product in the triangular trade in 1934.

Starting on May 1, 2007, doctors involved in commercial trade of organs will face fines and suspensions in China. Only a few certified hospitals will be allowed to perform organ transplants in order to curb illegal transplants. Harvesting organs without donor’s consent was also deemed a crime.[ On June 27, 2008, Indonesian, Sulaiman Damanik, 26, pleaded guilty in Singapore court for sale of his kidney to CK Tang’s executive chair, Mr Tang Wee Sung, 55, for 150 million rupiah (S$ 22,200). The Transplant Ethics Committee must approve living donor kidney transplants. Organ trading is banned in Singapore and in many other countries to prevent the exploitation of “poor and socially disadvantaged donors who are unable to make informed choices and suffer potential medical risks.” Toni, 27, the other accused, donated a kidney to an Indonesian patient in March, alleging he was the patient’s adopted son, and was paid 186 million rupiah (20,200 US). Upon sentence, both would suffer each, 12 months in jail or 10,000 Singapore dollars (7,600 US) fine.

In an article appearing in the Econ Journal Watch, April 2004.[27] Economist Alex Tabarrok examined the impact of direct consent laws on transplant organ availability. Tabarrok found that social pressures resisting the use of transplant organs decreased over time as the opportunity of individual decisions increased. Tabarrok concluded his study suggesting that gradual elimination of organ donation restrictions and move to a free market in organ sales will increase supply of organs and encourage broader social acceptance of organ donation as a practice.

Ethical concerns The existence and distribution of organ transplantation procedures in developing countries, while almost always beneficial to those receiving them, raise many ethical concerns. Both the source and method of obtaining the organ to transplant are major ethical issues to consider, as well as the notion of distributive justice. The World Health Organization argues that transplantations promote health, but the notion of “transplantation tourism” has the potential to violate human rights or exploit the poor, to have unintended health consequences, and to provide unequal access to services, all of which ultimately may cause harm. Regardless of the “gift of life”, in the context of developing countries, this might be coercive. The practice of coercion could be considered exploitative of the poor population, violating basic human rights according to Articles 3 and 4 of the Universal Declaration of Human Rights. There is also a powerful opposing view, that trade in organs, if properly and effectively regulated to ensure that the seller is fully informed of all the consequences of donation, is a mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of Articles 3 and 29 of the Universal Declaration of Human Rights.

Even within developed countries there is concern that enthusiasm for increasing the supply of organs may trample on respect for the right to life. The question is made even more complicated by the fact that the “irreversibility” criterion for legal death cannot be adequately defined and can easily change with changing technology.

Artificial organ transplantation Surgeons in Sweden performed the first implantation of a synthetic trachea in July 2011, for a 36-year-old patient who was suffering from cancer. Stem cells taken from the patient’s hip were treated with growth factors and incubated on a plastic replica of his natural trachea.

Surgical instrumentS A surgical instrument is a specially designed tool or device for performing specific actions of carrying out desired effects during a surgery or operation, such as modifying biological tissue, or to provide access for viewing it. Over time, many different kinds of surgical instruments and tools have been invented. Some surgical instruments are designed for general use in surgery, while others are designed for a specific procedure or surgery. Accordingly, the nomenclature of surgical instruments follows certain patterns, such as a description of the action it performs (for example, scalpel, hemostat), the name of its inventor(s) (for example, the Kocher forceps), or a compound scientific name related to the kind of surgery (for example, a tracheotome is a tool used to perform a tracheotomy).

The expression surgical instrumentation is somewhat interchangeably used with surgical instruments, but its meaning in medical jargon is really the activity of providing assistance to a surgeon with the proper handling of surgical instruments during an operation, by a specialized professional, usually a surgical technologist or sometimes a nurse or radiologic technologist.

Classification There are several classes of surgical instruments: Graspers, such as forceps Clamps and occluders for blood vessels and other organs Retractors, used to spread open skin, ribs and other tissue Distractors, positioners and stereotactic devices Mechanical cutters (scalpels, lancets, drill bits, rasps, trocars, Ligasure, Harmonic scalpel etc.)

Dilators and specula, for access to narrow passages or incisions Suction tips and tubes, for removal of bodily fluids Sealing devices, such as surgical staplers Irrigation and injection needles, tips and tubes, for introducing fluid Tyndallers, to help “wedge” open damaged tissues in the brain.

Powered devices, such as drills, dermatomes Scopes and probes, including fiber optic endoscopes and tactile probes Carriers and appliers for optical, electronic and mechanical devices Ultrasound tissue disruptors, cryotomes and cutting laser guides Measurement devices, such as rulers and calipers An important relative distinction, regarding surgical instruments, is the amount of bodily disruption or tissue trauma that their use might cause the patient. Terms relating to this issue are ‘atraumatic’ and minimally invasive. Minimally invasive systems are an important recent development in surgery.

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