Article first published online: 21 FEB 2013
© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd
British Journal of Surgery
Volume 100, Issue 6, pages 721–723, May 2013
How to Cite
Nelson, H. (2013), Surgical innovation. Br J Surg, 100: 721–723. doi: 10.1002/bjs.9093
- Issue published online: 2 APR 2013
- Article first published online: 21 FEB 2013
- Accepted manuscript online: 21 FEB 2013 12:00AM EST
- Manuscript Accepted: 9 JAN 2013
The Oxford English Dictionary defines innovation as ‘… the introduction of a new thing; the alteration of something established …’ and there can be no doubt that the past century has been a time of great innovation. Just as society has witnessed the introduction of air travel, digital electronics, computers and robotics, surgical innovations have been equally transformative. Some of the innovations have come as changes in surgical practice necessitated by alterations in other aspects of healthcare, such as the declining importance of infectious diseases and rising importance of neoplastic diseases, whereas others have been truly novel surgical innovations, such as the introduction of vascular anastomoses and transplant surgery. It exceeds the bounds of this article to review all surgical advances over the past century or to credit all worthy surgeon innovators; there are so many. Instead, this article describes key changes in practice, illustrated using a few examples of fields that have evolved dramatically, and ends with a summary of the Nobel Laureate surgeons and their unique contributions to surgical innovations.
Major transformations of surgery over the past century followed sharply on the heels of three critical discoveries of the preceding century, namely anaesthesia, antisepsis and anatomical pathology. To consider the magnitude of the impact of these discoveries, one must only recall a statement made by Sir John Erichsen, Surgeon Extraordinaire to Queen Victoria in 1837, who stated that ‘… the chest, and the abdomen will forever be shut from the intrusion of the wise and humane surgeon …’. It is within this context that the surgical procedure for appendicitis, appendicectomy, was thought to be aggressive by the people of 1880. Anaesthesia, antisepsis and anatomical knowledge revolutionized the practice of surgery, not only expanding its scope but also increasing surgical safety and efficacy. From this start it can be seen how much the established practice of surgery shifted to a new normal through the past 100 years. For example, A Manual of Modern Surgery, General and Operative (1895) is dominated by the description of bacteriology, the management of infectious, inflammatory and injurious diseases and wounds, with only 33 of the 785 text pages devoted to ‘tumors or morbid growths’. By 1906, Operative Surgery, For Students and Practitioners illustrated an abundance of procedures within diverse body cavities and, by 1913, Surgery: Its Principles and Practice required numerous volumes to cover all the many and diverse surgical diseases and procedures. Life expectancy increased as infectious diseases came under better control with antibiotics and modern forms of hygiene, and with it conditions of advanced age such as heart disease, organ failure and cancer became dominant, prompting the development of new procedures and entirely new fields of surgery.
The management of rectal cancer illustrates how a field of surgery, essentially defined by a single procedure, came to be transformed by innovations in surgical tools, including stapling devices, endoscopes, laparoscopes and robots. At the turn of the last century the Miles abdominoperineal resection (APR) was described as a desperate measure for managing the debilitating and life-threatening complications resulting from progressive, obstructing rectal cancer. Based on anatomical considerations, oncological principles and lymphatic mapping studies, the APR procedure became the standard of care. Today the APR remains relevant, but is no longer the preferred procedure, nor is it even the most common operation performed for rectal cancer. Within a few decades surgeons found that they could safely hand sew an anastomosis in the upper rectum (anterior resection), patients had an alternative to a permanent colostomy, and data confirmed that cancer outcomes were equivalent. So the new procedure was adopted and new oncological standards for bowel margins were established. Almost immediately, even more sophisticated procedures (low anterior resection and coloanal anastomosis) were facilitated by the introduction of linear and circular staplers. The concept of mechanical stapling is credited to Humer Hutle of Budapest, who developed the mechanical suture around 1908, and Russian surgeons appear to be the first to have employed linear and circular staplers[8, 9]. By the 1970s and 1980s, technical innovations in fibreoptic endoscopy and computed tomography enabled early detection and accurate staging of rectal cancer, ushering in local excision and transluminal endoscopic microsurgery as alternative approaches to early-stage disease. Indeed, by 2003 nearly half of patients in the USA with T1 N0 M0 disease were managed in this way. Abdominal surgery was revolutionized in the 1980s when surgeons demonstrated that laparoscopes could be used for more than diagnostic procedures. Indeed, soon after the laparoscopic cholecystectomy had been popularized, these same techniques were applied to patients with cancer of the colon and rectum, offering advantages of smaller incisions and shorter time to recovery.
For breast cancer, as for rectal cancer, the treatments of the past century bear little resemblance to modern practice. Radical mastectomy evolved to modified radical mastectomy, then to lumpectomy and axillary node dissection, and finally to sentinel node biopsy. The exclusive use of surgery has gradually been complemented by the use of combinations of therapies including radiation, biological therapy and chemotherapy. Elegant and comprehensive clinical trials have led to logical combinations and treatment sequencing algorithms, and to a greater understanding of the genetic and biological basis of the disease. Surgeons have been at the forefront, challenging the need for radical surgery and creating alternative strategies, such as the sentinel lymph node approach to lymphatic mapping. Rectal and breast cancer serve as just two examples of practices that changed radically over the century, and yet they illustrate just how difficult it would be to acknowledge all the surgeons, or measure all the surgical innovations that have benefited society, medicine and individual patients.
Yet, there are several surgeons whose discoveries and innovations have gained worldwide recognition and who deserve a special mention; these are the nine Nobel Laureate surgeons who were selected for their achievements in the field of physiology or medicine from 1901 to 2005. Three of the recipients were recognized for their sentinel and noteworthy contributions in advancing a clinical or surgical practice. First was Theodore Kocher (Nobel Laureate 1909), a general surgeon from Switzerland who was considered a master surgeon and recognized for his contributions in advancing thyroid surgery and pathology, and for defining the highest surgical standards of the times. Next, Allvar Gullstrand (1911) was a Swedish ophthalmological surgeon who received the prize for dioptrics of the eye. His knowledge of both physics and ophthalmology led him to introduce the slit lamp technique of focal illumination. Robert Barany (1914), an ear, nose and throat surgeon from Austria, received the award for his landmark work on caloric nystagmus, work that evolved from his practice.
Three Nobel Laureate surgeons were rewarded for research advances that improved understanding of specific physiological and pathophysiological processes. Frederick Banting (1923) was a non-practising orthopaedic surgeon from Canada who was credited for his dedication to the study of diabetes and his discovery of insulin. Walter Hess (1949) from Switzerland received the award for his work in mid-brain function localization and efforts in understanding the vegetative nervous system. Finally, Charles Huggins (1966) was the eighth surgeon recipient, claiming credit in both Canada and the USA for his work on the hormonal dependence of cancer cells.
The final three surgeon Nobel Laureates were noteworthy for how they advanced the world of medicine through technical innovations and essentially started new chapters in the textbooks of surgery. Alexis Carrel and Joseph Murray are credited with the sentinel efforts that delivered the first successful organ transplantation in 1954. Alexis Carrel (1912), the third surgeon Nobel Laureate, born and trained in Lyon, France, and employed in the USA at the Rockefeller Institute for Medical Research, was recognized for his development of the vascular anastomosis. Before Carrel's work on techniques of triangulated vascular anastomosis and vein patching, connecting arteries and veins was considered impossible. Although Carrel is credited with being the father of transplant surgery for his vital work on vascular anastomosis and organ preservation, it was Joseph Murray (1990) who recognized the importance of matching donor and recipient to avoid rejection, and who conducted the first successful human renal transplant. Lastly, Werner Forssmann (1956), a German surgeon, received the Nobel Prize for being the first to perform human heart catheterization, one of several important steps that led to a more comprehensive understanding of cardiac physiology. There can be no doubt that these three innovations had a profound impact on nearly all aspects of surgical care during the past 100 years.
Thanks to our surgical predecessors, today's operating room resembles more the high-tech world we live in, with only vestiges of the basic elements of the past (scalpels, sutures, large incisions and bulky retractors). The trajectory for tomorrow's operating room is already set, defined by the innovations of the past and tightly bound by digital technologies that are still evolving. Imaging, robotics and minimal access surgery will come together to offer a ‘global positioning systems’ option for surgeons to define and execute precise targets, thereby reducing collateral damage and complications. Surgical practice will continue to shift to meet the needs of patients by integrating new biological information, and technologies will incrementally realize the benefits of combining percutaneous, endoluminal and transcutaneous procedures. Breakthrough discoveries and technologies will deliver the day when surgeons are called upon to implant devices that can monitor and restore normal and real-time physiology. The landscape of medicine is evolving rapidly with increasing emphasis on regenerative medicine, genomics and the human microbiome. Surgeons must continue to engage in research in which they can explore, discover and contribute as they have in the past, and perhaps it is time, as suggested by Krummel and colleagues, that surgeons consider new working models to bring relevant technologies to the practice of surgery in pursuit of new healthcare solutions.
- 1New Shorter Oxford English Dictionary. Oxford University Press: New York, 1993.
- 2A Century of Surgeons and Surgery. The American College of Surgeons 1913–2012. American College of Surgeons: Chicago, 2012., .
- 3A Manual of Modern Surgery, General and Operative. WB Saunders: Philadelphia, 1895..
- 4Operative Surgery, For Students and Practitioners (2nd edn). FA Davis: Philadelphia, 1906..
- 5Surgery: Its Principles and Practice, Vol. IV. WB Saunders: Philadelphia, 1919..
- 6A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908; ii: 1812–1813..
- 7Surgical removal of lesions occurring in the sigmoid and rectosigmoid. Am J Surg 1939; 46: 12–17..
- 8Current Practice of Surgical Stapling. Lea & Febiger: Philadelphia, 1991., , .