Chapter 1. A Focused History of Surgery

The word surgery derives from the French term “chirurgien,” which came from the Latin and in turn from the Greek words “cheir,” meaning “hand” and “ergon,” meaning work. Surgery has a long history beginning with what is said to be the earliest scientific document known, The Edwin Smith Surgical Papyrus, dating from the 17th century before Christ, actually a copy of an Egyptian manuscript originally written circa 3000–2500 bc. The document deals with a variety of wounds and cauterization for breast cancer. No intraperitoneal operation is mentioned.

Although Maingot's Abdominal Operations had its genesis in England, elective abdominal operations had their beginning in Danville, Kentucky, a town of 1000 at the time, with the removal of a 22½-lb ovarian tumor by Ephraim McDowell on December 25, 1809. Throughout the 19th century, surgeons from Great Britain and the United States, the two countries that would eventually play major roles in the development of the multiple editions of Maingot's Abdominal Operations, contributed significantly to the evolution of abdominal operations. In 1804, Sir Astley Cooper published a Treatise on Hernia. In 1833, William Beaumont, an American military surgeon, published Experiments and Observations on the Gastric Juice and the Physiology of Digestion. The experiments conducted through a permanent gastric fistula constituted the first controlled clinical study on a human being and defined the process of intragastric digestion. On October 16, 1846, at the Massachusetts General Hospital, the birth of ether anesthesia took place and ushered in a new generation of possibilities for all of surgery. In 1867, John Stough Bobbs of Indianapolis reported the first successful elective operation on the gallbladder, a cholecystostomy with removal of stones and closure of the organ. The patient remained relatively asymptomatic for over 40 years. The 1886 landmark paper by the Boston pathologist Reginald H. Fitz established the entity of appendicitis and championed early operation. As the 19th century came to a close, the German schools of surgery became increasingly dominant, in large part related to Theodor Billroth and the surgeons he trained. Billroth is often referred to as “the father of abdominal surgery” based on his first resection of cancer of the pylorus in 1881 and also the numerous intestinal resections and enterorrhaphies that he performed.

As the first decade of the 21st century has come to an end, it is appropriate to focus on the developments that took place during the preceding 20th century, by dividing this period into two time spans: one before 1940, the year that the first edition of Maingot's Abdominal Operations was published, and the other considering the progress that has taken place in the ensuing 60 years.

In discussing the history of surgical advances pertaining to the gastrointestinal tract per se, it is reasonable to proceed aborally from esophagus to rectum. In regard to the esophagus, the first significant operation was reported in 1913 by Franz Torek of New York City, who removed the entire thoracic esophagus and connected the cervical esophagus with the stomach by means of an external tube. Although in 1935 Winkelstein first defined the clinical picture of esophageal reflux and indicted the erosive action of gastric juice as the culprit, the issue of a functioning gastroesophageal sphincter was not appreciated. Consequently, no corrective operation was devised prior to the publication of Maingot's first edition.

The surgical treatment of reflux esophagitis was first popularized by Allison, who defined a repair in 1951, mainly consisting of correction of the hiatal herniation. The high recurrence rate associated with that operation led to a consideration of fundoplication procedures, which were introduced in 1966 by Nissen and subsequently modified by Belsey, Hill, and Toupet. Since the advent of minimally invasive surgery in 1989, the majority of these fundoplications have been performed laparoscopically.

During the first four decades of the 20th century, there was considerable interest in the surgical treatment of peptic ulcer disease. Gastric resection was often the most commonly performed indexed operative procedure in a residency program. The operations were outgrowths of the procedures that were initially applied by Billroth and his associates for gastric cancer. In the early decades of the 20th century, excision of a gastric ulcer was widely practiced. When the excision, as was frequently the case, was extensive, there were problems with gastric emptying, prompting William Mayo in 1911 to add a complemental gastrojejunostomy. Then as now, the indications for surgical intervention in patients with peptic ulcer were obstruction, bleeding, perforation, and intractability. Pyloroplasty and gastrojejunostomy were the most frequently performed procedures for obstruction, and as early as 1925 Lewisohn reported a 34% incidence of neostomal ulcer after gastrojejunostomy. Before 1940, the surgeons at the Mayo Clinic continued to champion the procedure for duodenal ulcer. In 1937, R.R. Graham introduced his patch procedure for perforation. Gradually partial gastrectomy became the preferred surgical treatment for the complications of peptic ulcer disease.

The modern era of vagotomy in the management of peptic ulcer began in January 1943, when Dragstedt performed a subdiaphragmatic resection of the vagal trunks in a patient with an active duodenal ulcer. Dragstedt's earlier approach was transthoracic. Later, when he appreciated that a significant percentage of his patients developed gastric stasis, Dragstedt added a drainage procedure, either gastroenterostomy or pyloroplasty, as an accompaniment to the truncal vagotomy. Farmer and Smithwick recommended a two-pronged attack against the ulcer diathesis, combining truncal vagotomy with hemigastrectomy. In 1960, Griffith introduced the concept of selective gastric vagotomy, preserving the nerve of Laterjet and thereby obviating the need for a gastric drainage procedure.1

The applicability of vagotomy and partial gastric resection has been greatly reduced over the past two decades by the introduction of acid suppressive pharmaceuticals, including the histamine receptor antagonists and proton pump inhibitors. The use of these preparations has also generally obviated partial gastrectomy for ulcer diathesis and total gastrectomy for the intractable ulcers associated with the Zollinger–Ellison syndrome. Perhaps the most significant factor causing a marked reduction in the need for surgical management of peptic ulcer disease was the discovery by Warren and Marshall in 1983 of an association between Helicobacter pylori and peptic ulcer that is readily treatable with the hopes of totally eradicating peptic ulcer disease. This transition of gastric surgery from the 19th-century understanding of anatomy, to the 20th-century understanding of physiology and pathophysiology, to the 21st-century understanding of pharmacology mirrors the growth, development, and progress of the understanding of surgical diseases.2

The greatest increase in gastric surgery since 1940 is the application of gastric reduction for obesity. The initial surgical approach to the management of extreme obesity, jejunoileal bypass, was introduced by Kremen, Linner, and Nelson in 1954. The procedure was popularized by Payne and DeWind in 1969, but had many hazardous consequences and has been essentially discarded. Gastric bypass, introduced by Mason in 1966, has been the preferred method of surgical management for the past four decades and has become increasingly popular with the advent of minimally invasive surgery.

The principles of intestinal anastomosis are in large part based on Halsted's late-19th century studies on the importance of the submucosa as the layer providing strength for the suture line. Most of the early-20th century procedures on the small intestine were related to the treatment of obstruction. In 1932, Crohn, Ginzburg, and Oppenheimer introduced a newly recognized pathologic entity they called regional ileitis, which has come to be known as Crohn's disease or regional enteritis.

The major operative changes in small intestinal surgery that have taken place over the past two decades have been brought about by the introduction of stapling techniques. These were preceded by John B. Murphy's button, when it was described in 1892. Mechanical suture instruments using staples began with Humer Hültl of Budapest, who in 1908 described an instrument for use in distal gastrectomy. It was modified by von Petz in 1924 and enjoyed a period of popularity in many centers. The next major step in stapling was the result of the dedicated efforts of the Scientific Research Institute for Experimental Surgical Apparatus and Instruments in Moscow. The investigators developed magazine-loaded instruments for vascular anastomosis, side-to-side intestinal anastomosis, and end-to-end intestinal anastomosis. These were imported to the United States and modified, beginning in 1958, largely due to the leadership of Ravitch and Steichen.3 The introduction and widespread application of stapling devices helped revolutionize the technical aspects of surgery that have allowed minimally invasive procedures to be developed.

In the realm of colorectal surgery, although in 1883 Czerny introduced a technique for combined abdominal-peritoneal excision of rectal tumors, Miles' method, reported in 1907, popularized the procedure. The advent of stapling techniques during the past two decades has allowed for more anal preservation operations. The ileal pouch procedure represents a significant advance in the management of ulcerative colitis and familial polyposis. In 1947, Ravitch and Sabiston performed total colectomy, proximal proctectomy, mucosal distal proctectomy, and ileal anal anastomosis, but the results were generally not satisfactory with regard to frequency of defecation. The introduction in 1978 of a valveless ileal reservoir anastomosed to the anus addressed the problem and has become the standard.4

Over the past two decades, there have also been changes in the pathologic definitions of tumors of the gastrointestinal (GI) tract and there has been an increased recognition of gastrointestinal stromal tumors (GIST) in all regions of the GI tract.

The first successful elective hepatic resection for tumor was performed by Langenbuch in 1888. The first collective review of hepatic resections for tumor was reported by Keen in 1899 and included only 20 cases. In 1911, Wendell reported the first case of near total right lobectomy for a primary hepatic tumor, but the modern age of hepatic resection is generally dated to the 1952 report of Lortat-Jacob and Robert that detailed a right lobectomy using a technique designed to control hemorrhage with ligation of the blood vessels and bile ducts to the right lobe in the hepatoduodenal ligament followed by extrahepatic ligation of the right hepatic vein prior to transection of the hepatic parenchyma. In 1967, using corrosion casts, Couinaud demonstrated that the liver is made up of eight distinct segments, thereby opening the door for segmental hepatic resections. The recent applications of new instruments such as the harmonic scalpel and LigaSure vessel sealing system have expedited the performance of major hepatic resections without a need for transfusion.5

The year 1945 marked the beginning of the modern era of surgical intervention for portal hypertension with the report by Whipple and associates of the performance of end-to-side portacaval anastomoses and end-to-end splenorenal anastomoses. In 1953 Marion and in 1955 Clatworthy and colleagues independently described a shunt between the proximal transected end of the inferior vena cava and the side of the superior mesenteric vein. In 1967, Gleidman performed the first Dacron interposition mesocaval shunt, and the same year, Warren and colleagues introduced the selective (distal) splenorenal shunt as a method of preserving flow to the liver. The shunt procedures are now performed infrequently, and are generally reserved for patients with massively bleeding esophagogastric varices and normal hepatocellular function. By contrast, in patients with uncontrollable bleeding varices and significant hepatocellular dysfunction, a TIPS (transjugular intrahepatic portosystemic shunt) procedure is generally used as a bridge to orthotopic liver transplantation. In 1959, Kasai and Suzuki introduced hepatic portoenterostomy for the management of biliary atresia. More recently, orthotopic liver transplantation has been employed for these patients because of uncorrectable hepatocellular dysfunction.

Fifteen years elapsed between Bobbs' cholecystotomy and the first successful cholecystectomy, which was performed by Carl Langenbuch in 1882. By 1919, William J. Mayo was able to report on 2147 cholecystectomies. In 1923, Graham and Cole introduced cholecystography, leading to a marked increase in biliary surgery. Operations for injuries and strictures of the common duct have undergone many refinements over the past century. An obstructed common bile duct was first successfully drained by a lateral anastomosis to the duodenum by Sprengel in 1891. A variety of plastic procedures and intestinal flap advancements were applied to bridge a gap between the common duct and the duodenum with minimal success. Beginning in 1941, Vitallium tubes were inserted into bile ducts as conduits, but all the tubes eventually became obstructed with sludge. The groups at the Mayo Clinic and Lahey Clinic, who both had extensive experience with these procedures, expressed a preference for choledochoduodenostomy, while most surgeons now employ a mucosal-to-mucosal anastomosis between the proximal duct and a Roux limb of jejunum.

Operations on the pancreas directed at the management of pancreatitis and neoplasms generally evolved subsequent to the publication of the first edition of Maingot's textbook. In 1958, Puestow introduced the popular lateral pancreaticojejunostomy. In 1965, Fry and Child reported their results with a 95% distal pancreatectomy. In 1985, Beger proposed resection of the head of the pancreas with duodenal preservation for pathology that was most marked in the head of the pancreas. In regard to the neuroendocrine tumors of the pancreas, Roscoe Graham performed the first successful resection of an insulinoma in 1929. In 1955, Zollinger and Ellison reported that nonbeta islet cell tumors produced an “ulcerogenic humoral factor.” The pathophysiology often mandated total gastrectomy to control the massive gastric hypersecretion, but the therapy has been markedly altered with the advent of proton pump inhibitors.6,7

Although in 1912 Kausch successfully performed a partial pancreatectomy in two stages, the name of Allen O. Whipple has achieved eponymic status as far as resection of pancreatic neoplasms is concerned. In 1935, Whipple initially carried out a two-stage operation for carcinoma of the ampulla consisting of an initial cholecystojejunostomy followed by total duodenectomy. By 1945, he advocated a one-stage pancreatoduodenectomy as the treatment of choice.

Splenectomy is performed for trauma or hematologic disorders. The first recorded successful splenectomy for trauma is credited to a British naval surgeon, E. O'Brien, in 1816, who tied off the pedicle and removed a protruding spleen while stationed in San Francisco. In 1892, Reigner performed the first successful intraperitoneal splenectomy for trauma. In 1867, Péan successfully removed a spleen containing a large cyst. In 1911, Micheli reported the first splenectomy for a hematologic disorder in a patient with hemolytic anemia. Five years later, at the suggestion of Kaznelson, a Czech medical student, Schloffer, performed the first splenectomy for idiopathic thrombocytopenic purpura, the most common hematologic indication. The most recent changes in splenic surgery relate to an increased willingness to observe patients, particularly children, with blunt trauma to the spleen, and the fact that elective splenectomies are generally being performed laparoscopically, as championed by Phillips and Carroll, Cuschieri and associates, and Thibault and coworkers.8

Intra-abdominal vascular surgery traces its modern origin to Dubost and colleagues' 1951 resection of an abdominal aortic aneurysm with reestablishment of continuity. The introduction of a prosthetic material to create a conduit is credited to Voorhees, Jaretzki, and Blakemore, who used Vinyon “N” cloth in 1969. The same year, Wylie and associates described autogenous tissue revascularization techniques for correction of renovascular hypertension.

The major advances in abdominal surgery that took place in the second half of the 20th century relate to the fields of organ transplantation and minimally invasive procedures. On December 23, 1954, Murray, Merrill, and Harrison performed the first renal transplant in identical twins. Eight years later, the first successful cadaveric kidney transplant was performed by Murray in an immunosuppressed patient. The liver was the second visceral organ to be transplanted. In 1963, Starzl performed the first human liver transplant in a patient with biliary atresia. The patient died as did four other patients operated on by Starzl and one by Moore that year. In 1968, Starzl achieved the first success. The field recently has been extended by the use of live donors who provide a lobe for the recipient.

The first successful clinical pancreas transplant was performed by Kelly and Lillehei in 1966. In 1973, Gliedman and associates suggested using the ureter for exocrine pancreatic drainage. In 1982, the group at the University of Wisconsin developed the technique of direct drainage of the pancreas into the urinary bladder. Now, most whole organ pancreas transplants use the intestine for drainage. Recently improved results have been reported with islet cell transplants.

The small intestine was the last of the abdominal organs to be transplanted successfully. In 1987, Starzl and associates performed a multivisceral organ transplant, including the small intestine. The following year, the same group performed a successful combined liver and small intestine transplant, and Grant reported a successful isolated intestinal transplant from a live donor. In 1989, the Pittsburgh group performed the first successful cadaveric small intestinal transplant.

Doubtless, the most dramatic development in abdominal surgery is the introduction and expansion of laparoscopic procedures. Kelling was the first to examine the peritoneal cavity with an endoscope. In 1901, using a Nitze cystoscope, he entered and visualized the peritoneal cavity of a dog and referred to the procedure as “Koelioskopie.” The first major series of laparoscopies in humans is attributed to Jacobaeus, who in 1911 reported examining both the abdominal and thoracic cavities with a “Lapaothorakoscopie.” In 1937, Ruddock published a paper on “Peritoneoscopy” in which he detailed his experience with 500 cases including 39 in which biopsies were performed.

Laparoscopy essentially remained a procedure performed by gynecologists for many years. In fact, it was a gynecologist, Mouret, who in 1987 performed the first laparoscopic cholecystectomy, using four trocars. But credit is generally assigned to Dubois, who described the procedure in 1988, for initiating interest in the procedure. In the 25 years that have ensued, there has been an explosive increase in the use of laparoscopic techniques for abdominal operations. Basic laparoscopic procedures include cholecystectomy, appendectomy, and hernia repair. Advanced procedures include fundoplication, Heller myotomy, gastrectomy, bariatric surgery, esophagectomy, enteral access, bile duct exploration, partial hepatectomy, partial pancreatectomy, colectomy, splenectomy, adrenalectomy, and nephrectomy in addition to the standard gynecologic applications.9

The most recent refinement has been the addition of robotics, or more currently, computer-assisted remote mechanical devices. The appropriateness of the application of robotics to cholecystectomy has not been demonstrated. An advantage, however, has been ascribed to robotics for adrenalectomy.10 Paralleling the expansion of laparoscopic surgery, there has been an increased application of endovascular techniques for the repair of aneurysm of the abdominal aorta. Endovascular abdominal aortic repair was introduced independently by Parodi and associates and Volodos and coworkers in 1991. Over a dozen endovascular grafts have been developed, and in 2002, there were more abdominal aortic aneurysms repaired in the state of New York by endovascular procedures than open operations.11

The expansion in surgery that has occurred during the 20th and early 21st centuries has been a consequence of contributions by surgeons, unrelated to technical improvements. The critical maintenance of blood volume was instated by James Blundell in London over 150 years ago. In 1883, Halsted reported the first successful autoreinfusion of blood. In 1908, George W. Crile published a book detailing his laboratory and clinical experiences with transfusion. In 1915, Richard Lewisohn, a New York surgeon, introduced the sodium citrate method of blood preservation. The use of frozen blood was first reported in 1965 by Charles Huggins of Massachusetts General Hospital.

In reference to the use of intraoperative and postoperative fluid therapy, early contributions were made by John H. Gibbons in 1907, and Wilder Penfield and David Teplitsky in 1923. A year later, Rudolph Matas prescribed the intravenous administration of 4000–5000 mL of 5% glucose solution over 24 hours. After a period in which saline was avoided, the importance of saline and potassium was demonstrated by Francis D. Moore, Henry T. Randall, and G. Tom Shires. In 1959, Moore's Metabolic Care of the Surgical Patient brought into focus the importance of body composition, homeostasis, and endocrinology of the traumatized and surgical patient. The problem of nutritional support was resolved by Dudrick and associates in 1968 when they demonstrated that nutritional requirements could be satisfied totally by administration of high caloric fluid by a catheter position in the superior vena cava.

Over seven decades have elapsed since the first edition of Maingot's Abdominal Operations was published. As is true for all of the sciences, growth recently has been geometric. During the time from the initial publication to the present, there have been more new and refined operations introduced than throughout the preceding years. The accelerated rate of change can only ensure the viability of future editions.