General surgery evolution from Indian perspective.

1. History and Evolution of Surgery

2. 800BC Sushruta Performing Surgery

3. An Account Of Cataract Surgery
Performed By Sushruta
 It was a bright morning. The surgeon sat on a bench which was as high as his knees.
The patient sat opposite on the ground so that the doctor was at a comfortable
height for doing the operation on the patient's eye. After having taken bath and
food, that patient had been tied so that he could not move during the operation.
 The doctor warmed the patient's eye with the breath of his mouth. He rubbed the
closed eye of the patient with his thumb and then asked the patient to look at his
knees. The patient's head was held firmly. The doctor held the lancet between his
fore-finger, middle-finger and thumb and introduced it into the patient's eye towards
the pupil, half a finger's breadth from the black of the eye and a quarter of a
finger's breadth from the outer corner of the eye. He moved the lancet gracefully
back and forth and upward. There was a small sound and a drop of water came out.
 "The doctor spoke a few words to comfort the patient and moistened the eye with
milk. He scratched the pupil with the tip or the lancet, without hurting, and then
drove the 'slime' towards the nose. The patient got rid of the 'slime' by drawing it
into his nose.

4.  It was a matter of joy for the patient that the could see objects through his operated
eye and the doctor drew the lancet out slowly. He then laid cotton soaked in fat on
the wound and the patient lay still with the operated eye bandaged. It was the patient's
left eye and the doctor used his right hand for the operation."
 Does this not sound like the detailed procedure and steps of a cataract operation by an
ophthalmic surgeon? But this operation was performed around the 8th Century B.C. by
Shusruta.
An Account Of Cataract Surgery
Performed By Sushruta

5. Sushruta knew about:
 Importance of pain relief: He use alcohol and cannabis to numb pain
 Importance of dissection: He described the method of soaking a dead body in salt water
and peeling away layers one after another without using scalpels.
 Importance of simulation: He encouraged his pupils to practise on worm infested
vegetables.
 Importance of documentation and publication: Sushrut Samhita.
 Importance of Supervision: His students used to study under him for about six
years(residency).

6. Indian Rhinoplasty Technique

7. Hurdles Surgeons Faced
 Exhumations were a taboo all over the world and was sure to get one ostracized from
society as was Sushruta …or get you to the gallows, therefore many motivated students
were secretly grave robbers by the night and surgeons by the day.
 Dissections on dead bodies was frowned upon by the society and officially banned by the
church until the 12th and even 13th century.
 Anaesthesia was not available until mid 1800s
 Antiseptics were not available until 1860s
 Potent antibiotics were not available until mass production of Penicillin in1945
 Lack of Haemostatic techniques: No cautery until 1926.
 Lack of imaging techniques: No Xray until 1895, no USG until 1956.

8. Andreas Vesalius
1514 –1564
 Vesalius and other like-minded anatomy students would
raid the gallows of Paris for half-decomposed bodies and
skeletons to dissect. They would sometimes find the
courage to go outside of the walls of Paris, braving the feral
dogs and stench, in order to steal cadavers from the
mound of Monfaucon, where the bodies of executed
criminals were hung until they disintegrated.
 Rather than considering dissection a lowering of his
prestige as a doctor, Vesalius prided himself in being the
only physician to directly study human anatomy since the
ancients. During only his second anatomical lecture,
Vesalius stepped onto the dissecting floor, took the knife
away from the barber-surgeon, and began cutting at the
cadaver himself, demonstrating his great skill with the knife.

9. Joseph Lister,(1827 – 1912)
 Lister applied a piece of lint dipped in carbolic acid
solution onto the wound of a seven-year-old boy at
Glasgow Infirmary, who had sustained a compound
fracture after a cart wheel had passed over his leg.
After four days, he renewed the pad and discovered
that no infection had developed, and after a total of
six weeks he was amazed to discover that the boy's
bones had fused back together, without suppuration.
 He subsequently published his results in The
Lancet in a series of six articles, running from March
through July 1867.

10. Alexander Fleming
(1881-1955)
 In an article he submitted for the medical journal The Lancet during World
War I, Fleming described an ingenious experiment, which he was able to
conduct as a result of his own glass blowing skills, in which he explained why
antiseptics were killing more soldiers than infection itself during World War I.
Antiseptics worked well on the surface, but deep wounds tended to shelter
anaerobic bacteria from the antiseptic agent, and antiseptics seemed to
remove beneficial agents produced that protected the patients in these cases
at least as well as they removed bacteria, and did nothing to remove the
bacteria that were out of reach.
 By 1927, Fleming had been investigating the properties of staphylococci. On
3 September 1928, Fleming returned to his laboratory having spent August
on holiday with his family. Before leaving for his holiday, he had stacked all
his cultures of staphylococci on a bench in a corner of his laboratory. On
returning, Fleming noticed that one culture was contaminated with a fungus,
and that the colonies of staphylococci immediately surrounding the fungus
had been destroyed, whereas other staphylococci colonies farther away were
normal, famously remarking "That's funny"

11. Before whom, In all time, Surgery was Agony
By whom, pain in surgery was averted Since whom, science has control
over pain
— Morton's tombstone

12. William Thomas Green
Morton (1819 -1868)
 On September 30, 1846, Morton performed a painless tooth
extraction after administering ether to a patient. Upon
reading a favourable newspaper account of this event,
Boston surgeon Henry Jacob Bigelow arranged for a now-
famous demonstration of ether on October 16, 1846 at
the operating theatre of the Massachusetts General Hospital,
or MGH. At this demonstration John Collins
Warren painlessly removed a tumour from the neck of a
Mr. Edward Gilbert Abbott.
 In July 1868 he had suffered a major stroke which proved
fatal soon after.
 Morton was taken to nearby St. Luke's. It is reported by his
wife that upon recognizing Morton, the chief surgeon made
the following remark to his students:
 Young gentlemen, you see lying before you a man who has
done more for humanity and for the relief of suffering than
any man who has ever lived

13. William T. Bovie (1882 -1958)
 It was known, that electric current above certain
frequencies could cut tissue without inducing
muscular contraction. Bovie used such knowledge to
create his electrosurgical device and he first
employed it in neurosurgical cases with Harvey
Cushing, known as the father of
neurosurgery. Bleeding had been the significant
obstacle in neurosurgery until Bovie and Cushing
began to employ the device in 1926.
 As he was not motivated by financial gain, Bovie had
sold the patent rights to his electrosurgical device to
a manufacturer for one U.S. dollar.

14. Harvey Williams
Cushing (1869 -1939)
 Bovie's device allowed Cushing to reexplore
operations in patients with brain masses that had
been declared inoperable. While the device
revolutionized surgery, there were occasional technical
problems. Cushing recalled an instance in which the
current from Bovie's device short circuited through a
retractor. Electricity traveled up Cushing's arm and to
his headlight, an experience that Cushing described as
"unpleasant to say the least."
 In another case, the Bovie device briefly ignited ether
gas that was being given to a patient during surgery

15. Emil Theodor Kocher (1841 – 1917)
 Among his many accomplishments are the introduction and promotion of aseptic surgery and scientific
methods in surgery, specifically reducing the mortality of thyroidectomies below 1% in his operations.
 He was the first Swiss citizen and the first surgeon to ever receive a Nobel Prize. He was considered a
pioneer and leader in the field of surgery in his time.
 I have pondered the question for many years and conclude that the explanation probably lies in the
operative methods of the two illustrious surgeons. Kocher, neat and precise, operating in a relatively
bloodless manner, scrupulously removed the entire thyroid gland doing little damage outside its
capsule. Billroth, operating more rapidly and, as I recall, with less regard for the tissues and less
concern for haemorrhage, might easily have removed the parathyroids or at least have interfered with
their blood supply, and have left fragments of the thyroid.
 — William Stewart Halsted, Halstead WS. The operative story of goitre. Johns Hopkins Hosp Rep
1919;19:71–257. -- Quoted in Morris et al. [13]

16. Emil Theodor Kocher
 Kocher and others later discovered that the complete removal of the thyroid could lead
to cretinism (termed cachexia strumipriva by Kocher) caused by a deficiency of thyroid hormones. The
phenomena was reported to Kocher first in 1874 by the general practitioner August Fetscherin[14] and later in
1882 by Jacques-Louis Reverdin together with his assistant Auguste Reverdin (1848–1908).[2] Reverdin met
Kocher on 7 September in Geneva at the international hygienic congress (internationaler Hygienekongress)
and expressed his concerns about complete removal of the thyroid to Kocher.[15] Kocher then tried to contact
77 of his 102 former patients and found signs of a physical and mental decay in those cases where he had
removed the thyroid gland completely.[16] Ironically, it was his precise surgery that allowed Kocher to remove
the thyroid gland almost completely and led to the severe side effects of cretinism.
 Kocher came to the conclusion that a complete removal of the thyroid (as it was common to perform at the
time because the function of the thyroid was not yet clear) was not advisable, a finding that he made public
on 4 April 1883 in a lecture to the German Society of Surgery and also published in 1883 under the title Ueber
Kropfexstirpation und ihre Folgen (English: About Thyroidectomies and their consequences)

17. Emil Theodor Kocher
 In a hospital report from 1868, he attributed the lower mortality directly to the "antiseptic Lister's wound
bandaging method" and he could later as director of the clinic order strict adherence to the antiseptic method.
Bonjour (1981) describes how his assistants were worried about wound infection for fear of having to explain
their failure to Kocher himself. Kocher made it a matter of principle to investigate the cause of every wound
infection and remove every potential source of infection, he also banned visitors from his surgeries for this
reason.
 Kocher also contributed significantly to the field of neurology and neurosurgery. In this area, his research was
pioneering and covered the areas of concussion, neurosurgery and intracranial pressure (ICP). Furthermore, he
investigated the surgical treatment of epilepsy and spinal and cranial trauma. He found that in some cases, the
epilepsy patients had a brain tumor which could be surgically removed. He hypothesized that epilepsy was
caused by an increase in ICP and believed that drainage of cerebrospinal fluid could cure epilepsy.
 The Japanese surgeon Hayazo Ito came to Bern in 1896 in order to perform experimental research on epilepsy.
Kocher was especially interested in the ICP during experimentally induced epilepsy and after Ito returned to
Japan, he performed over 100 surgeries in epilepsy patients.
 The American surgeon Harvey Cushing spent several months in the lab of Kocher in 1900, performing cerebral
surgery and first encountering the Cushing reflex which describes the relationship between blood
pressure and intracranial pressure. Kocher later also found that decompressive craniectomy was an effective
method to lower ICP.

18. Emil Theodor Kocher
 Kocher's forceps – a surgical instrument with serrated blades and
interlocking teeth at the tips used to control bleeding[26]
 Kocher's point – common entry point for an intraventricular
catheter to drain cerebral spinal fluid from the cerebral ventricles
 Kocher manoeuvre – a surgical manoeuvre to expose structures in
the retroperitoneum
 Kocher–Debre–Semelaigne syndrome – hypothyroidism in infancy
or childhood characterised by lower extremity or generalized
muscular hypertrophy, myxoedema, short stature and cretinism
 Kocher's collar incision – is used in thyroid surgery
 Kocher's subcostal incision – Cholecystectomy
 Kocher's sign – eyelid phenomenon in hyperthyroidism and
Basedow's disease

19. Wilhelm Conrad
Röntgen (1845 –1923)
 Röntgen discovered medical use
of X rays when he made a picture
of his wife's hand on a
photographic plate formed due
to X-rays.
 The photograph of his wife's hand
was the first photograph of a
human body part using X-rays.
When she saw the picture, she
said "I have seen my death.“
 The discovery of X-rays
stimulated a veritable sensation.
Röntgen's biographer Otto
Glasser estimated that, in 1896
alone, as many as 49 essays and
1044 articles about the new rays
were published.
First medical X-
ray of his wife
Anna Bertha
Ludwig's hand

20. Ian Donald
(1910–1987)
All I wanted to know, quite simply, was whether these various masses
differed in their ultrasonic echo characteristics. The results were
beyond my wildest dreams and even with the primitive apparatus of
those days clearly showed that a cyst produced echoes only at depth
from the near and far walls, whereas a solid tumour progressively
attenuated echoes at increasing depths of penetration
An A-mode scan created by Ian Donald
in 1956. Note the large non-reflective
space between two echoes which marks
the presence of a large ovarian cyst

21. Alexis Carrel (1873 –1944)
A Product Of World War I
 French surgeon and biologist who was awarded the Nobel Prize in
Physiology or Medicine in 1912 for pioneering
vascular suturing techniques. He invented the first perfusion
pump with Charles A. Lindbergh opening the way to organ
transplantation.
 Carrel was a young surgeon in 1894, when the French president Sadi
Carnot was assassinated with a knife. Carnot bled to death due to
severing of his portal vein, and surgeons who treated the president felt
that the vein could not be successfully reconnected. This left a deep
impression on Carrel, and he set about developing new techniques for
suturing blood vessels. The technique of "triangulation", using three
stay-sutures as traction points in order to minimize damage to the
vascular wall during suturing, was inspired by sewing lessons he took
from an embroideress and is still used today. Julius Comroe wrote:
"Between 1901 and 1910, Alexis Carrel, using experimental animals,
performed every feat and developed every technique known to
vascular surgery today." He had great success in reconnecting arteries
and veins, and performing surgical grafts, and this led to his Nobel Prize
in 1912.
Carrel also advocated the use of wound
debridement (cutting away necrotic or otherwise
damaged tissue) and irrigation of wounds. His
method of wound irrigation involved flushing the
tissues with a high volume of antiseptic fluid so that
dirt and other contaminants would be washed away
(this is known today as "mechanical irrigation.")

22. Charles Augustus
Lindbergh (1902 –1974)
 Charles Augustus Lindbergh was an American aviator,
military officer, author, inventor, and activist. At age 25 in
1927, he went from obscurity as a U.S. Air Mail pilot to
instantaneous world fame by winning the Orteig
Prize for making a nonstop flight from New York to Paris.
Lindbergh covered the 33 1⁄2-hour, 3,600-statute-mile
(5,800 km) flight alone in a single-engine purpose-
built Ryan monoplane, the Spirit of St. Louis.
 In 1930, Lindbergh's sister-in-law developed a fatal heart
condition.Lindbergh began to wonder why hearts could
not be repaired with surgery. Starting in early 1931 at
the Rockefeller Institute and continuing during his time
living in France, Lindbergh studied the perfusion of
organs outside the body with Nobel Prize-winning
French surgeon Alexis Carrel. Although perfused organs
were said to have survived surprisingly well, all showed
progressive degenerative changes within a few
days.Lindbergh's invention, a glass perfusion pump,
named the "Model T" pump, is credited with making
future heart surgeries possible.

23. Georg Kelling
(1866 –1945)
 Kelling specialized
in gastrointestinal physiology and anatomy. He is credited
with performing the first laparoscopic examination, a
procedure he referred to as "celioscopy".
 In 1901 he performed the procedure on the abdomen of a
dog using a Nitze-cystoscope. Prior to cystoscopic viewing
of the abdomen, Kelling insufflated it with filtered air via a
device known as a trocar.
 Insufflation was used to create a pneumoperitoneum in
order to prevent intra-abdominal bleeding.

24. Philippe Mouret 1938-2008
• He is the inventor of surgical laparoscopy ,
sometimes called the second French
revolution.
• It opened the voice to minimally invasive
surgery which reduces surgical stress by
allowing the use of much smaller incisions
than "classic" laparotomy surgery.
• He performed a world first surgery with a
laparoscopic cholecystectomy in 1987 at
the Clinique de la Sauve in Lyon (France).

25. The Da Vinci: First Surgeon Console And Latest
Patient Cart(Xi)

26. The Da Vinci: Surgeon Console And Vision Cart

27. Prof. Hari Shankar Asopa
 He invented a one stage operation for Hypospadias, one in every
250 – 300 boys are born with this defect. About forty thousand
boys are born with this defect in India alone. This research was
published in the Journal “International Surgery” in June 1971.
 This Procedure known as Asopa Operation, was soon being done
all over the world by Urologists, Paediatric Surgeons, Plastic and
General Surgeons.
 An operation invented by Dr. Asopa in mid 1990’s for Stricture
Urethra, published in the Journal “UROLOGY” in 2001 Elsevier
Science Inc, Philadelphia, is being followed universally by
Urologists worldwide and has made Urethral Stricture Surgery
easy and safe to perform. It appears in Reference books and
International journals. It has been popularized among
Reconstructive Urologists in Europe and America as “Dorsal Inlay
Urethroplasty” or “Asopa Technique”.

28. Dr. Mohan Desarda
 Dr. Desarda MP, MS is
Professor of Surgery and
Division Head of the
"Hernia Center" at Poona
Hospital & Research
Center.
 His operation technique is
now called as "Dr. Desarda
Repair". This technique is
included in medical text
books of international
repute like "Baily & Love
and" "Shwartz"

29. Anecdotes of Surgeons performing Self
Surgery: Werner Theodor Otto Forssmann
 Werner Theodor Otto Forssmann was studying medicine in Germany in the 1920s when
a professor of his planted a question in his mind. That question was: Is it possible to
reach the heart through the veins or arteries without the need for traumatic surgery?
 Back then, the only way to access the heart was by conducting a fairly risky surgical
procedure.
 Forssmann came across an article describing how a veterinarian had reached a horse's
heart with a catheter via the internal jugular vein. This transports blood from the brain,
face, and neck to the heart.
 He came to the conclusion that in humans, he could use a ureteric catheter to reach
the heart via the cubital vein, which lies close to the surface of the arm and travels to
the heart.

30. Anecdotes of Surgeons performing Self
Surgery: Werner Theodor Otto Forssmann
 Excited, Forssmann told the chief of surgery that he planned to attempt the procedure on a patient.
 The chief was rightly concerned for the patient's safety and blocked his plans. So, Forssmann asked if
he could carry out the procedure on himself. Once again, the chief responded in the negative.
 Undeterred, the young surgeon spoke with the operating room nurse; as the keeper of the
equipment, he would need to have her permission.
 She was impressed with the idea and offered herself as a test subject. Despite her courage, Forssmann
was still determined to carry out the procedure on himself.
 He strapped the nurse down and pretended to make an incision on her, but he anesthetized his
own cubital vein. He managed to advance the catheter 30 centimeters up his arm before the
nurse realized that she had been duped.
 Forssmann asked her to call in an X-ray nurse so that he could chart the catheter's internal voyage
from his arm to his heart.
 The procedure was a success, but Forssmann had gone against the grain and was dismissed from his
residency. Unable to find any surgical position, he turned to urology.
 Then, 17 years later, alongside two others, he won the Nobel Prize for Physiology or Medicine for his
part in the invention of cardiac catheterization.

31. Forssmann's self-surgery was all in the
name of medical advancement, but the
next was a fight for survival.
 In 1960, Leonid Rogozov was a member of the 6th Soviet Antarctic expedition. He was the team's only medical
professional.
 Several weeks into the expedition, the 27-year-old surgeon noticed some of the telltale signs of appendicitis: fever,
weakness, nausea, and significant pain in his right lower abdomen.
 Drugs were not improving his situation; surgical intervention was needed. In his diary, he wrote:
 "I did not sleep at all last night. It hurts like the devil! A snowstorm whipping through my soul, wailing like a hundred
jackals."
 As winter deepened and the sea froze, Rogozov had no hope of returning to civilization for treatment. His only option
was to carry out an appendectomy on himself.
 This was an operation that he had completed many times, but certainly not under these circumstances.
 "Still no obvious symptoms that perforation is imminent," he wrote, "but an oppressive feeling of foreboding
hangs over me...This is it...I have to think through the only possible way out: to operate on myself...It's almost
impossible...but I can't just fold my arms and give up."
 He recruited three of his colleagues to assist him: one held the mirror and adjusted the lamp, one handed him the
surgical implements as he requested them, and one acted as a reserve in case either of the others should faint or
become nauseous.
 Rogozov also explained how to revive him with epinephrine in case he lost consciousness.

32. Leonid Rogozov

33. Most of these examples involve medically trained men, but this one bucks that
trend. The woman in question had no medical training.
:Self-caesarian
 This example of autosurgery took place in March 2000 in a remote Mexican village, where
access to healthcare is virtually nonexistent. A 40-year-old mother of eight was carrying
her ninth child.
 Around 2 years before this case of autosurgery, the woman had lost a child during labor
due to an obstruction. After hours of unproductive labor, she was concerned that she
might lose the baby again. So, in a desperate attempt to prevent this from happening
again, she decided to perform a cesarian on herself.
 First, she drank three strong alcoholic drinks. Then, using a kitchen knife, she opened her
abdomen with three strokes. According to a paper that describes the procedure, "[S]he
used her skills at slaughtering animals." In all, the procedure took 1 hour.
 Once free, the newborn boy breathed immediately. The woman then asked one of her
children to fetch a local nurse to patch her up. The nurse repositioned the woman's
intestines and sewed up the wound using a standard sewing needle and cotton.
 Then, finally, she arrived at the nearest hospital — some 8 hours away by road. She did
require extensive treatment, but she recovered enough to be released after 10 days.
 In the paper mentioned above, the authors write: "The natural, innate maternal instinct
for preservation of offspring may result in the mother's disregard for self-safety,
and even for her own life."

34. Thankyou….