Defining Moments In Medicine

MJA 2001; 174: 12-13

Intensive care units: Although surgical procedures have become more complex and comorbid conditions more frequent, postoperative outcomes have improved dramatically in the past 50 years, thanks to the development of intensive care units, with nursing expertise and technological advances to support patients in the critical postoperative period after major surgery.

Staplers: Surgical staplers are more expensive than conventional sutures, but they make surgery faster, anastomoses more secure, and allow even surgeons without exceptional ability to perform anastomoses in inaccessible locations in the oesophagus and rectum.

Theatre techniques: Infection control, morbidity reviews and medicolegal issues have transformed theatre practice. In the 1950s, theatres were not air-conditioned. Scalpels, syringes, needles, catheters and endotracheal tubes were routinely reused, and caps, masks, bandages, abdominal sponges and even gloves were recycled. Ureteric catheters and cystoscopes were stored in formalin and reused. All this is a far cry from theatre practice today, where disposable technology prevails.

Cardiac surgery: The combined skills of cardiologists, anaesthetists, biomedical mechanics, intensive care staff and cardiac surgeons were all harnessed in developing cardiac surgical units. This collaboration was exemplified by Darcy Sutherland and colleagues at the Royal Adelaide Hospital. Harry Windsor, and later Victor Chang at St Vincent's Sydney, successfully pioneered cardiac transplantation.

Transplantation: Organ transplantation was science fiction in 1951. The first renal transplant in Australia was performed by a team led by Peter Knight and James Lawrence at The Queen Elizabeth Hospital, Adelaide, in 1965. Such advances in surgery in the past half-century have resulted from adaptation of new technology and improved medication rather than to any change in manual dexterity.

Hospitalisation: Patients entering hospital 50 years ago anticipated a stay of 10-14 days. Now 60%-70% of all surgery is day surgery. Admission on the day of surgery is the norm and early discharge from hospital is supported by hospital-in-the-home services. Hospitals have changed from dormitories to treatment centres.

Prosthetics: The past five decades have seen an explosion in the number and variety of implantable surgical devices. Prosthetic hip and knee replacements and heart valve replacements are now routine. Artificial hearts have been developed, implantable stents are placed in gastrointestinal lumens and arteries. The development and commercial adaptation of the artificial cochlea by Graeme Clarke in Melbourne is one such outstanding achievement.

Treatment of the physically impaired: The treatment of patients with paraplegia at Stoke Mandeville in England by Ludwig Guttmann showed the benefits of combining surgery with strict nursing and physiotherapeutic regimens. George Bedbrook pioneered the development of a paraplegic unit in Perth, and similar units followed rapidly in other States. The benefits were soon extended to quadraplegic patients and to those with other physical impairment.

Optics: In 1951 endoscopes were in regular use, but their limited field of view provided limited treatment opportunities. Surgeons anticipated improvements, but none foresaw the current flexibility, field of view, purity of colour, magnification, and small calibre of operative devices. The incorporation of video-chip technology and video monitors has enabled clear visualisation and teaching possibilities unimaginable 50 years ago.

Instruments: Instrumentation has followed the "key hole" revolution. Since 1990, surgeons at the Royal Brisbane Hospital have pioneered much of the minimally invasive surgery now used in Australia. Operating microscopes allow microsurgery on nerves and vessels previously thought inoperable. Extracorporeal shock-wave lithotripsy, first available in Australia in the mid-1980s, represents the ultimate in minimally invasive surgery.

Cancer treatment: In the early 1950s, it was generally thought that improvements in cancer survival would require more radical and at times disfiguring surgery. Now some cancers no longer require surgery, and adjuvant radiotherapy and chemotherapy have provided cures and palliation undreamed of even 25 years ago.

Diagnostics: 50 years ago diagnostic radiology was still more art than science. Now computed tomography, magnetic resonance imaging, positron emission tomography and ultrasound give almost limitless access to the "secrets" of a patient presenting with poorly defined symptoms. While radiography was primitive, pathological diagnosis was little better: operative specimens were needed for a definitive diagnosis, and reoperation was sometimes needed. The advent of frozen sections and, more recently, fine-needle aspirations and cytology make errors of diagnosis exceptional.

Surgical radiology: This discipline has developed from interventional radiology. The heart, brain, aorta and distal vessels have become accessible to those trained in manipulating an array of new devices, such as balloons and stents. New subspecialties are evolving.

Evidence-based practice: The threat of litigation, with the need to document all steps of care, obtain detailed informed consent and even take on responsibility for recalcitrant patients, has distracted surgeons from their central function, but it has improved standards and made decision making more transparent. At the same time, evidence-based surgery remains in its infancy -- wise dogma from senior surgeons sufficed for most of the previous century. However, information technology has exposed how little quality evidence exists for much accepted surgical practice. In response, in 1997, the Royal Australasian College of Surgeons established the Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) to provide an evidence base for new surgical techniques.

John P Maddern
Retired Urologist
Royal Adelaide Hospital, Adelaide, SA

Guy J Maddern
R P Jepson Professor of Surgery
University of Adelaide, Adelaide, SA

©MJA 2001
Make a comment