Surgical Wisdom Research Articles

Scrubbing With Aristotle: Cultivating Surgical Wisdom through Inflection Points

Surgical educators and researchers have well-considered a breadth of topics related to surgery. However, there is one concept that is notably absent in this corpus: surgical wisdom. In this perspective, we draw on work from Aristotle and psychology research to introduce the concept of phronesis, which we believe is useful for understanding surgical wisdom. We further illustrate how this concept can be a useful tool for surgical educators through the discussion of four distinct functions of phronesis, and illustrating the ability of these functions to help learners cultivate knowledge at important decision points, or inflection points, in surgical training and a surgical career.

Characteristics of preoperative and postoperative anxiety in adults undergoing surgical extraction of impacted third molars

Background/Aim: Surgical removal of impacted third molars is associated with possible complications that are primarily comprehended as expected. Increase in incidence and severity of complications is directly related to the depth of impaction, and to the age of the patient as well. The aim of this research was to investigate the possible influence of the treatment duration relating to age and gender of the patients, the occurrence of pain, and the existence of previous anxiety experience connected with surgical wisdom tooth removal. Material and Methods. The study included adults of both gender indicated for surgical removal of impacted third molars. The existence of previous wisdom tooth removal experience was determined during the first examination, and the subjects' anxiety and pain levels were determined pre-, and postoperatively. Results: There were no differences concerning the place of treatment (dental office/operating room) and the duration of surgery. Younger participants showed the lowest levels of preoperative anxiety and the highest levels of postoperative anxiety, and frequently reported postoperative pain. Female participants showed higher levels of preoperative and postoperative anxiety, and also frequently reported postoperative pain. Conclusions: Anxiety and pain scores were lower when there was a previous experience with removal of impacted wisdom teeth.

Uncommon Colorectal Challenges.

Surgeons are physicians who can operate. As colorectal surgeons, we have extensive training in the physiological basis of gastrointestinal disorders and augment this core knowledge with a technical skillset. Some of us are fortunate to have formidable mentors who inspire us with their balance of surgical wisdom, finesse and flair that they refined over decades of practice. We are taught to consider outcomes ahead of the present and to do so independently, because when we are faced with a complex patient, it is simply too late to start thinking in the operating room.

EVALUATION OF ANALGESIC EFFECT OF TAB TRAILOKYA VIJAYA VATI IN POST-OPERATIVE PAIN IN KSHARKARMA PATIENTS: AN OBSERVATIONAL STUDY

Despite the advances in technology and robotics, the basics of surgical management are not changed drastically. The science of life, Ayurveda has extensive knowledge of surgeries, including complicated procedures mentioned in the classical texts. However, with time, the ability of anaesthetics and analgesic agents has been lost. This resulted in the lagging of Ayurvedic Surgical wisdom and the rise of modern analgesics and anaesthetics in the market. These current products have potential side effects, and hence a safer and better alternative to these products can boost Ayurveda Surgery worldwide. Trailokya Vijaya Vati (TVV) is one such Ayurvedic formulation that is explained for its potent analgesic activity. The present study was conducted to evaluate the safety and efficacy of TVV in post-operative pain management in patients undergoing anorectal procedures. The observational trial suggested a reduction in time to sleep (p < 0.05), less incidence of insomnia and undisturbed sleep in the treatment group than the control. The formulation was also well tolerated with no or minimal requirement of rescue analgesics. The efficacy observed in the study suggests the formulation can be explored further on a larger population with a diverse activity profile.

Salivary Alpha-Amylase and Calcium levels Evaluation as a Biomarker in Stress Patients Undergoing Surgical Wisdom Tooth Extraction

The salivary enzyme alpha-amylase has been proposed as a biomarker for stress-induced activity of the sympathetic nervous system. In the growing field of amylase research, recent studies have underscored the usefulness of salivary alpha-amylase in this regard. Calcium is the major component of bones and teeth, and it is not surprising that disturbances in calcium metabolism have been implicated in most of the major chronic diseases, including renal disease, osteoporosis; and periodontal tissues.Twenty healthy Iraqi male undergo wisdom tooth extraction from undergraduates dental students were considered in this study with age mean of 22 years old, 2 ml samples of stimulated saliva were collected prior ten mints of surgical wisdom tooth removal, and recollected after one week fromsurgery from these students, the samples were analyzed to assess changes in ∝-amylase and calcium ion concentration under controlled conditions. The collected data predicted elevation of amylase level from ((7652.965 ±34.0410) to (7674.710 ± 68.8958) IU/L) with a significant change. And also increase in the calcium ion concentration level from (0.1465 ± 0.048) to reach level (0.1975± 0.100) mmol/L. Positive correlation were recorded between alpha amylase and calcium concentration when plotted the correlations values of stress and no stress individual's. In a conclusion. Acute stresscaused by wisdom tooth removal will elevate level of amylase in saliva significantly, howeverSignificant increasing in calcium concentration was observed in the stimulated saliva in comparison with the non-stimulated saliva with significant mean changes. However, our result predicted elevated levels of calcium concentration of the stimulated saliva than the non-stimulated (after extraction).

A REVIEW OF ACHARYA SUSHRUTA’S APPROACH IN DISSECTION FOR THE STUDY OF NETRA SHAREERAM

Recent literature suggests that the dissected cadaver remains the most powerful means of delivering fun-damental regional, relational and topographical anatomical knowledge to medical students, which is indis-pensable to ensure safe and efficient clinical practice. Acharya Sushruta is best known for his surgical wisdom, practices and tools. He described a systematic method for the dissection of the human cadaver. Netra is one of the most briefly described anatomical structure by Sushruta. Anatomically, eye is divided into five Mandalas, six Sandhis and six Patalas. Selection of appropriate cadaver was very necessary for the detailed study of human anatomy; hence Acharya Sushruta had described various conditions for the selection and preservation of the cadaver. In this paper the potentially possible scientific reason for such selection criteria, as well as an attempt to understand the anatomy of eye in prospect to the ancient text by our acharyas is made. In addition, an approach is made to study importance of eyes with respect to knowledge about Dirghayu, Madhyamayu & Heenayu of a person, to know about the Arishta Suchaka Lakshana in patient, to know the Sadhyaasadhyata of a Vyadhi, & to decide the Sara of a person.

DIFFERENTIATED APPROACH TO THE SURGICAL EXTRACTION OF WISDOM TEETH

Impaction and malposition of wisdom teeth and associated inflammatory and tumor-like complications occur in 35-50% of the able-bodied population. The operation of surgical extraction of the third molar of the mandible is indicated for these patients and this operation is one of the most common in surgical dentistry today.Alsoasignificant indication for wisdom teeth removaliscrowding of teeth.
 The classic operation of surgical wisdom tooth removal, even with careful planning, can be accompanied by different intraoperative and postoperative complications.
 Planning of removal of the third lower molar requires an individual approachwith mandatory consideration not only of the tooth position but also the topography of the causative tooth relative to the adjacent tooth and mandibular canal.
 Among the surgical procedures which are used to remove wisdom teeth, in addition to the classic surgery extraction, coronectomy and germectomy should be noted.
 The purpose of our study was to analyze the advantages and disadvantages of different techniques used for surgical extraction of impacted and malposition wisdom teeth.
 208 operations regarding the removal of the third lower molars have been performedduring 2016-2019, of which surgical wisdom teeth removal were 213, coronectomies – 23 and germectomies – 29.Patients' ages ranged from 13 to 26 years.
 A germectomy was performed in 13-16 years old patient, usually at the stage of a fully formed tooth crown or at the beginning of root formation.
 The choice of surgery in patients with fully formed roots was dependent on the ratio of the root of the tooth and mandibular canal, which was evaluated after a preliminary computer examination, taking into account the complexity of the surgery and the prognosis of complications. Acoronectomy operation was performed with the close location of the roots of the wisdom tooth with the mandibular canal, taking into account the risk of the damage of lower alveolar nerve.
 Germectomy and surgery of wisdom teeth removal were performed according to the classical method with cutting of mucoperiostal flaps, preparation of bone, if necessary – separation of crown and roots with subsequent removal of the germ or tooth. The crown of wisdom tooth was separated with a coronectomy, (and cut in height with insufficient access) and the tooth crown was removed, leaving the roots in the jaw.
 Patients were observed on the next day after surgery, a week later, and as needed. The course of the postoperative period was evaluated: the presence of pain, swelling, complications. The duration of follow-up was up to 2 years.
 Conclusions:
 To the choice of surgery in patients with impaction and malposition of wisdom teeth should be approached in a differentiated manner, taking into account topographic and anatomical features, including the ratio of the roots of the teeth to the mandibular canal and assessing the risks of possible complications.
 Germectomy and coronectomy surgery can be recommended as surgery of choice for orthodontic indications in the treatment of patients with crowded teeth.

Outcomes of Antibiotics as Primary Therapy in Uncomplicated Acute Appendicitis at PUMHS Nawabshah

Objective: Over bearing, appendectomies have continuously been pushing the surgical wisdom to connote on non-operative option of treatment so this study was designed with an objective to assess the outcomes of antibiotics as primary therapy for un–complicated acute appendicitis. Methods: A total of 96 patients of both genders from 16 to 60 years of age having uncomplicated acute appendicitis enrolled in this study were treated with antibiotics and were discharged on third day with having oral treatment on ciprofloxacin (500mg) twice a day and metronidazole (400mg) thrice a day for 07 days. Routine follow up was taken on days 15, 30, 90 180 and 360 and outcomes were recorded. Results: Among 96 patients, 10 (10.41%) worsened in symptoms (pain on visual analogue scale) were confirmed with WBC & Ultrasound reports and under went for appendectomies during initial hospital stay. While within 9 months, during follow up 11 (11.45%) patients were readmitted in hospital and operated after confirmation on re-examination and re- investigations. Total of 21 (22%) patients were subjected to appendectomy. Conclusion: Under proper observation, antibiotic treatment can be safe and effective in un-complicated acute appendicitis with reduced recurrence.

Surgical wisdom and Genghis Khan's Pax Mongolica.

The unrivalled conquests of Genghis Khan (CE c.1162-1227) led to the establishment of the Greater Mongolian Empire. By 1279, the Mongol dynasty controlled a vast Empire which, for the first time in history, unified Europe and China via the famous Silk Road. The ensuing century of peace and stability is referred to by historians as the Pax Mongolica, which facilitated Europe's renaissance and remarkably contributed to the rise of modern medicine and surgery. Secondary sources from published literature, primary sources from manuscripts and illustrations courtesy of universities, museum libraries and archives. There is ample evidence detailing the Mongol Empire's power during the thirteenth century and the Silk Road's role as a vehicle of commercial, cultural and scientific exchange. Advances in medical knowledge and surgical skills were made in all parts of the Empire and exchanged from China to Constantinople and back. Prominent medical figures traversed these centres, and no doubt contributed to the spread of surgical science, including Rashid al-Din and Mansur Ibn Ilyas. Their works, it is argued, enriched the practice of surgery and may have indirectly ushered-in the rise of modern surgery in the early medical schools at Salerno, Bologna, Pavia, Oxford, Montpellier and Constantinople to name but a few. The blossoming and diversification of medical and surgical knowledge was an integral part of the great cultural exchange facilitated by the Pax Mongolica. This enhanced surgical practice in China, Persia and Arabia, while coinciding with the renaissance of surgical teaching in Europe.

Robotics & artificial intelligence : The future of surgeons & surgery

Robotics and Artificial Intelligence complement surgical technical expertise and judgement. A robot’s accuracy in the programmed performance of predesignated tasks is exquisite. Historically, with the evolution of microsurgery, senior surgeons designated delicate suture placement to more steady handed, sharper eyed young fellows or even nurses. Tactile feedback and ultrasensitive pressure velocity controls make robotics a viable but expensive option to fine surgical assistance. Autonomous surgical robots are however a distinct paradigm. Myriad unfathomed mysteries of human pathophysiology and anatomy confer upon surgical procedures complexities which defy stratification and simplification into sets of preordained tasks. In the current scenario where fuzzy logic, neural networks and intuitive computing are still in early evolution, robots replacing master surgeons seem as improbable as Google self driving cars in formula one racing. Robots have evolved as dextrous, fatigue and tremor free surgical tools. The data crunching capability of computers is improving in speed and in capability for machine learning. Human surgical maturity on the other hand is attained and matures through phases of information assimilation, knowledge consolidation and attainment of surgical wisdom. Human surgeons at the helm will, in this decade harness robotic capabilities and information template paradigms to fine tune many procedures and to augment surgical reach. Quantum leaps and paradigm shifts towards robotic surgical autonomy may be neither desirable nor practical.

Authors' reply: Surgical wisdom (Br J Surg 2012; 99: 3–5)

Authors' reply: Surgical wisdom (<i>Br J Surg</i> 2012; 99: 3–5)

Surgical wisdom (Br J Surg 2012; 99: 3–5)

Surgical wisdom (<i>Br J Surg</i> 2012; 99: 3–5)

Comparison of clonidine and midazolam as anxiolytic premedication before wisdom tooth surgery: a randomized, double-blind, crossover pilot study

Anxiolytic and possible side effects of clonidine 150μg compared to midazolam 7.5mg for premedication in surgical wisdom tooth extraction were evaluated. In a prospective, randomized, double-blind crossover trial, ten patients undergoing bilateral wisdom tooth surgery received clonidine or midazolam orally 1h before the treatment. Patients receiving midazolam for the first surgery received clonidine at the second surgery and vice versa. The anxiolytic efficacy was evaluated with a visual analogue scale (VAS) upon admission and 30, 50 and 60min after administration of the medication. Patient satisfaction was recorded on a VAS after surgery and 7days postoperatively. As soon as 30min after administration of midazolam (p < 0.03) and clonidine (p < 0.02), an anxiolytic effect was recorded. Both medications did not differ in patient satisfaction. Oral administration of clonidine 150μg and midazolam 7.5mg were rated as medications with equal anxiolytic effects before wisdom tooth surgery under local anesthesia.

A collection of surgical wisdom

A collection of surgical wisdom

Surgical wisdom

Surgical wisdom

Risk of Early Carotid Endarterectomy for Symptomatic Carotid Stenosis

Conclusion: Carotid endarterectomy (CEA) can be performed with slightly increased, but acceptable, risk in symptomatic patients within two weeks of stroke or transient ischemic attack. Summary: Current guidelines from the American Academy of Neurology and the American Heart Association indicate patients with symptomatic carotid stenosis should preferentially undergo CEA within 2 weeks of the symptomatic event (Chaturvedi S, et al. Neurology 2005;65:794-801, and Sacco RL, et al. Stroke 2006;37:577-617). However many patients are not operated within 2 weeks. In addition, traditional “surgical wisdom” has shied away from acute operation especially in stroke patients for fear of a higher incidence of complications (Naylor AR. Surgeon 2007;5:23-30). The authors examined their institutional experience with CEA with particular analysis of symptomatic patients operated within 2 weeks of symptoms. Symptomatic patients were not considered for early CEA if they had an infarct involving more than one third of the middle cerebral artery territory or if a patient had a fixed disabling deficit or an unstable medical condition. When those conditions were not present patients were operated soon after evaluation irrespective of the interval from the symptomatic event. The authors felt delays were usually related to delayed referral after symptom onset. The patients analyzed were those operated between January 2004 and May 2009. Patients were divided into three groups. Group 1 were asymptomatic, group 2 were symptomatic patients operated >2 weeks after their symptom, and group 3 were symptomatic patients operated on <2 weeks after their symptom (transient ischemic attack or stroke). Primary outcome was any myocardial infarction, stroke, or death within 30 days of the operation. A secondary endpoint was transient ischemic attack within 30 days postoperatively. There were 532 carotid endarterectomies performed in 507 patients. There were 500 patients with 525 CEA's who had 30 day follow up. There were 278 in group 1, 105 in group 2, and 142 in group 3. The primary outcome occurred in 5 patients in group 1 (1.8%); 1 patient in group 2 (1.0%); and 6 patients in group 3 (4.2%). There were no significant differences in the rate of primary outcome among the three groups (P = .17). There was also no significant difference comparing group 2 to group 3 (P = .24). Comment: This study has all the limitations of a single institution retrospective review. The biggest problem is insuring patients in group 2 and group 3 did in fact only differ primarily by referral pattern and not by other more pertinent medical conditions. The percentage of patients with stroke in group 2 and group 3 was similar (36.2% versus 35.2%), but we really don't know whether the severity of the strokes were the same and whether perioperative management and other co-morbidities were the same. Nevertheless, this study lends further support to a policy of performance of CEA in selected patients shortly after the onset of a neurologic symptom.

Historian's lecture: Nuggets of lasting surgical wisdom from the annals of the Portland caucus

Historian's lecture: Nuggets of lasting surgical wisdom from the annals of the Portland caucus

Surgical decision making

Decision making is an integral part of surgical practice and is a skill that is as important as the ability to operate. Sound decision making is the result of acquiring 'surgical wisdom', which is achieved through learning, experience and reflection. This paper reviews the processes of surgical decision making with respect to choosing the correct procedure and deciding when to operate, and how operative decisions are made, together with the factors that influence our surgical decisions.

Nomenclature of abbreviated acronyms (Naa…)—caveamus surgeones

Surgical endoscopy promotes appraisal of new ideas, questions old dogmas, nurtures critical thinking, facilitates continuing medical education, and provides a vent for the creativity inherent to the art of surgery and its practitioner. Endoscopic surgery (ES) gave a new lease of life to the dying species of general surgeons. The advent of minimally invasive surgery (MIS) was not only acute but infectious for society and contagious for our fraternity. The change was not universally welcomed by all, leaving a lot of work to be done by pioneers. Communication is a facilitator of change, and surgical endoscopy became an instrument of change by communicating the academic and clinical aspects of MIS. Surgeons not enamored by MIS were left with mostly residual surgery (MRS). The evolution of endoscopic surgery has been associated with the challenge of communication from the very beginning. Whether it should be baptized as minimally invasive surgery or minimal access surgery (MAS) was not as trivial as ‘‘a rose by any other name...’’ [1]. The issue was ably elucidated by Sir A. Cuschieri, who drove home the simple surgical wisdom that it was only the invasiveness of access that was minimised and not the holistic invasion of the human body [1]. He thus settled the issue in defining MAS and emphasized that an acronym has to be not only accurate but also nonrestrictive to be acceptable [1]. Communication should be precise and concise, and brevity should be to impress a point and not to impress. An abbreviation, i.e., a shortened word or phrase, is a useful tool to ensure brevity, especially to conserve time and space in publishing. An acronym, i.e., a word formed by the initial letters of a phrase, helps further as ‘‘a concise recollection of nomenclature yielding mnemonics.’’ In light of this background on communication, abbreviation, and acronym formation in MAS, the article by Zhu [2] needs to be discussed. The search for a ‘‘better acronym’’ is premised upon the taken-for-granted stature of the acronym ‘‘NOTES,’’ which is itself a phonetic wordsmithery of well-intentioned limelight-seekers driven by innovative zeal to be seen as pioneers in this era of shrinking volumes, curtailed reimbursements, and company budget considerations [3–5]. NOTES is a popular acronym for natural orifice translumenal endoscopic surgery, but in a real sense it is only endoscopic surgery (ES) [3]. As enunciated before, ES minimizes the physiological and phenotypical invasiveness of the access for the operation, thus resulting in a minimized scar. Surgery leaves a scar on the mind in addition to the phenotype of the patient [6]. The present discourse is on acronyms for innovations in ES aiming at either hiding the scar in the umbilicus or crowding them into a single incision, camouflaged at the umbilicus, or avoiding them parietally by making a visceral entry (transvaginal access not being applicable to all of humanity). All these cannot be universally acceptable, either due to patient-related esthetic/social/cultural reservations [7] or due to scientific ethical concerns regarding visceral suture lines [3–5]. Any innovation has to be evaluated in terms of potentially beneficial patient-reported outcomes [8]. So, an acronym should be generated only for the purpose of universal communication for a universally accepted approach for a universally beneficial patient-reported procedure. Until that time, acronyms are needed only to accommodate the need B. B. Agarwal K. C. Mahajan Sir Ganga Ram Hospital, New Delhi 110060, India

Combined Eyelid and Strabismus Surgery: Examining Conventional Surgical Wisdom

To determine whether satisfactory results of both eyelid surgery and strabismus surgery can be obtained when these procedures are performed in the same setting in selected patients. Nine patients (16 eyelids) who had undergone surgery in the same setting for eyelid malposition and strabismus of the horizontal rectus muscles, with or without concurrent vertical rectus muscle surgery, were retrospectively reviewed. Eyelid malposition surgery success was defined as a postoperative margin reflex distance (MRD1) within 1 mm of the target. Strabismus surgery success was defined as a postoperative deviation within 8 prism diopters of orthophoria or a decrease in binocular diplopia if the patient had a less than 8 prism diopters deviation in primary gaze preoperatively. Eyelid retraction repair was performed on 13 upper eyelids, levator advancement was performed on 2 eyelids, and frontalis suspension was performed on 1 eyelid. Four patients underwent bilateral medial rectus recession and the remaining 5 patients received varying strabismus surgery. Four patients received adjustable sutures. Mean follow-up was 11 months. Postoperatively, 13 of 16 eyelids (81%) achieved an MRD1 within 1 mm of the target. Eight of 9 patients (89%) demonstrated satisfactory strabismus correction. Combined eyelid malposition and strabismus surgery can be successfully performed in selected cases, particularly when the strabismus surgery involves the horizontal rectus muscles. Combined surgery is not recommended in cases that do not involve the horizontal rectus muscles.