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The Johns Hopkins Department of Surgery congratulates the American College of Surgeons on 100 years of excellence.

The Johns Hopkins Hospital is pleased to announce the opening of two new patient care buildings: Q

33 State-of-the-Art Operating Rooms

Integrated Audio and Visual Systems

Spacious Centralized Preparation and Recovery Areas

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Enhanced Operating Room Ceiling Booms

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Remembering Milestones and Achievements in Surgery: Inspiring Quality for a Hundred Years

1913-2012

Throughout the last century, our two organizations have worked hard to advance the medical profession and have successfully overcome so many challenges faced by surgeons and all physicians. We’ve come a long way together—however, our journey isn’t over. We look forward to working with you to shape the future of medicine on behalf of America’s physicians and patients for hundreds of years to come.

Introduction

by DAVID B. HOYT, MD, FACS

The leadership and staff of the American College of

during the ﬁrst 75 years, including Dr. William Stewart

Surgeons (ACS) are privileged to be part of the College’s

Halsted’s creation of true resident training system,

Centennial celebration.

advances in surgical patient safety, organ transplanta-

To help commemorate the College’s Centennial, we have

tion, and advances in breast and bowel procedures.

produced Remembering Milestones and Achievements in

UÊ Dr. Richardson’s predecessor as Chair of the Board of

Surgery: Inspiring Quality for a Hundred Years, 1913-2012,

Regents, Carlos Pellegrini, MD, FACS, picks up where Dr.

a collection of thoughts on the evolution of surgical prac-

Richardson leaves off, noting the stark contrast between

tice over the past century. In this publication, the authors

general surgery of the ﬁrst 75 years, when operations

write from their hearts and minds on a range of surgical

were highly invasive, and surgery of the last 25 years,

achievements as well as about selected College contribu-

which now revolves around the development of increas-

tions to the profession. Their personal recollections and

ingly less invasive procedures.

reﬂections provide a unique perspective on how surgical

UÊ Former ACS Governor Grace Rozycki, MD, FACS, and

care has changed across all specialties since the College

David V. Feliciano, MD, FACS, provide an overview of the

was established in 1913.

history of public hospitals.

Accompanying many articles are photographs of some

UÊ Past-President LaMar McGinnis, Jr., MD, FACS, shares

of the key ﬁgures who dedicated their time and leader-

his perspectives on the history of the Joint Commission,

ship to establish, expand, and sustain the College as

the successor to the College’s Hospital Standardization

the preeminent surgical association in North America.

program, and how its guidelines and policies have contrib-

Also depicted are the changing tools of our trade. This

uted in improved quality of care.

combination of remembrances, observations, and visual

UÊ Cliff Ko, MD, FACS, Director of the ACS Division of

ﬂourishes make this document a scrapbook, if you will,

Research and Optimal Patient Care, offers an overview

of our shared history.

of ACS quality programs and how they have developed

Some of the ACS luminaries who volunteered to help us

and changed over time.

compile this collection and their contributions to it are as follows:

UÊ Fabrizio Michelassi, MD, FACS, writes about the College’s

UÊ Patricia Numann, MD, FACS, and A. Brent Eastman, MD,

relationship with the international surgical community

FACS, share their thoughts as the outgoing and newly

and commitment to global health care issues.

elected Presidents, respectively, of the ACS.

In addition, leaders from each of the surgical specialties

UÊ Past-Chair of the Board of Governors and a former Interim

(all Fellows of the College) look back at the major historical

Director of the College, David L. Nahrwold, MD, FACS, has

achievements in their disciplines. Examples include the

written the authoritative account of the College’s history,

following: John E. Connolly on cardiothoracic surgery;

titled A Century of Surgeons and Surgery. He draws on

Herand Abcarian on colon and rectal surgery; Karl C.

that experience here to reﬂect on the College’s early days

Podratz on gynecologic and obstetric surgery; Edward R.

and its everlasting commitment to surgical education.

Laws on neurological surgery; Barrett G. Haik on ophthalmic

UÊ Past-President George F. Sheldon, MD, FACS, writes

surgery; David G. Murray on orthopaedic surgery; Gerald

about the ACS as a “university” and his experiences as a

B. Healy on otolaryngology; Thomas V. Whalen on pedi-

surgical educator who has held many leadership positions

atric surgery; Mary H. McGrath on plastic and maxillofacial

in this organization over the course of the past 50 years.

surgery; Jack W. McAninch on urology; and Mahmoud Malas

UÊ ACS Past-President L.D. Britt, MD, FACS, provides

and Julie Freischlag on vascular surgery.

a detailed summary of the many contributions that

The College is indebted to each and every one of these

surgeons of African-American heritage have made to

authors for taking the time to share their insights with all

this organization and to surgical patient care.

of us as we begin the observance of the American College

UÊ The current Chair of the Board of Regents, J. David

of Surgeons’ ﬁrst 100 years. I anticipate that you will ﬁnd

Richardson, MD, FACS, discusses the major historical

their views are enlightening and compelling and provide an

achievements that have occurred in general surgery

excellent launching pad for our Centennial celebration. Q

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ÂŠ2012 Loyola University Health System

Contents 7

Introduction By David B. Hoyt, MD, FACS

The Presidential View To celebrate its 100th anniversary, Dr. Patricia J. Numann and Dr. A. Brent Eastman lay out clear goals for the American College of Surgeons’ bright future based on its successful past. By Julie Sturgeon

The Role of the College in Surgical Education By David L. Nahrwold, MD, FACS

The American College of Surgeons as a University By George F. Sheldon, MD, FACS, FRCSEd (Hon), FRCSEng (Hon)

Michael O. Meyers, MD Associate Professor Division of Surgical Oncology & Endocrinology

Your trusted partner in surgical oncology.

Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African-American Heritage By L.D. Britt, MD, MPH, FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon)

Major Historical Achievements in General Surgery: The First 75 Years By J. David Richardson, MD, FACS

Minimally Invasive Surgery: General Surgery’s Revolution The Past 25 Years in General Surgery By Carlos A. Pellegrini, MD, FACS, FRCSI (Hon)

A History of Public Hospitals By Grace S. Rozycki, MD, MBA, FACS, and David V. Feliciano, MD, FACS

Something in the Air “American Surgery’s Noblest Experiment”—C. P. Schlike, JAMA, 1973 By LaMar S. McGinnis, Jr., MD, FACS

ACS Quality Programs By Clifford Y. Ko, MD, FACS

The American College of Surgeons’ Contributions to International Surgery By Fabrizio Michelassi, MD, FACS

Progress in Cancer Surgery By Murray F. Brennan, MD, FACS

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Contents 100

Historical Achievements in Cardiothoracic Surgery By John E. Connolly, MD, FACS

106

Advances in the Twentieth Century: Colon and Rectal Surgery By Herand Abcarian, MD, FACS

113

Degrees of Freedom Advances in Gynecological and Obstetrical Surgery By Karl C. Podratz, MD, PhD, FACS

121

Neurosurgery and the American College of Surgeons By Edward R. Laws, Jr., MD, FACS, DMedCh Naples (Hon), FRCSEd (Hon), FRCPSG (Hon)

126

Through the Lens: A Century of Innovation in Ophthalmic Surgery By Barrett G. Haik, MD, FACS

132

Orthopaedic Surgery 1913 to 2012 100 Years of Evolution, Invention, and Innovation By David G. Murray, MD, FACS

140

Milestones in Otolaryngology–Head and Neck Surgery From leaders to lasers, the ﬁeld of otolaryngology–head and neck surgery has impacted surgery in more ways than most patients—and fellow surgeons—would guess. By Gerald B. Healy, MD, FACS, FRCSEng (Hon), FRCSI (Hon)

147

The Large and the Small of It Advances in Pediatric Surgery By Thomas V. Whalen, MD, MMM, FACS

154

Plastic Surgery A Story of Innovation By Mary H. McGrath, MD, MPH, FACS

166

History of the Committee on Trauma “He who wishes to be a surgeon should go to war.”—Hippocrates By Donald D. Trunkey, MD, FACS

176

A Look Inside Advancements in Urologic Surgery By Jack W. McAninch, MD, FACS, FRCSEng (Hon)

184 No Roadblocks Advancements in Vascular Surgery By Mahmoud Malas, MD, MHS, FACS, and Julie Freischlag, MD, FACS

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Publisher, North America: Ross Jobson

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Publisher, Europe: Peter Antell

LaMar S. McGinnis, Jr., MD, FACS Mary H. McGrath, MD, MPH, FACS Fabrizio Michelassi, MD, FACS David G. Murray, MD, FACS David L. Nahrwold, MD, FACS Carlos A. Pellegrini, MD, FACS, FRCSI (Hon) Karl C. Podratz, MD, PhD, FACS J. David Richardson, MD, FACS Grace S. Rozycki, MD, MBA, FACS George F. Sheldon, MD, FACS, FRCSEd (Hon), FRCSEng (Hon) Julie Sturgeon Donald D. Trunkey, MD, FACS Thomas V. Whalen, MD, MMM, FACS

©Copyright Faircount LLC. All rights reserved. Reproduction of editorial content in whole or in part without written permission is prohibited. Faircount LLC does not assume responsibility for the advertisements, nor any representation made therein, nor the quality or deliverability of the products themselves. Reproduction of articles and photos, in whole or in part contained herein, is prohibited without express written consent of the publisher, with the exception of reprinting for news media use. Printed in the United States of America. None of the advertising contained herein implies American College of Surgeons endorsement of any private entity.

The Presidential View To celebrate its 100th anniversary, DR. PATRICIA J. NUMANN and DR. A. BRENT EASTMAN lay out clear goals for the American College of Surgeons’ bright future based on its successful past. by JULIE STURGEON

Presidents, no matter their organization or current status, bring one needed focus to the membership: vision. But as American College of Surgeons (ACS) President Patricia J. Numann and President-Elect A. Brent Eastman know, seeing into the future isn’t a matter of crystal balls or personal egos. Effective leadership guides the team in bridging the past with the future in a seamless way. Here’s a peek at how the outgoing and incoming leaders see the ACS’ strengths.

PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS

Patricia J. Numann, MD, FACS President

A. Brent Eastman, MD, FACS President-Elect

Lloyd S. Rogers Professor of Surgery

N. Paul Whittier Chair of Trauma, Scripps

Emeritus at Upstate Medical University in

Memorial Hospital La Jolla, CA; Chief

Syracuse, NY. Clinical interests: general,

Medical Ofﬁcer and Corporate Senior

endocrine, and breast surgery; women’s

Vice President, Scripps Health; Clinical

professional issues; and surgical

Professor of Trauma Surgery, University

education. Launched the Comprehensive

of California, San Diego. Clinical interests:

Breast Care Center at University Hospital

general, vascular, and trauma surgeon

(now renamed the Patricia J. Numann

and leader in trauma and emergency

Breast and Endocrine Surgery Center)

surgical care. Member of the ACS Board

in Syracuse more than 20 years ago.

of Regents 2001–10, and Chair 2009–10.

On health care reform

been introduced. So the College is doing very speciﬁc things

ow more than ever, the College has

that can be seen and measured to assure the public that

been actively involved as advisor to

they receive safe, effective care. Letting public ofﬁcials who

political leaders. As a surgeon working

are going to have to act on these bills know the quality and

in the system, you have a perspective on

value of care will allow them to make informed choices on

issues they may not have. You understand that some proposed

legislation regarding health care expenditures.

changes are problematic. So we try to help government ofﬁ-

The College isn’t just reacting. The College looks at

cials look at a system of paying for medicine that is equitable

what’s happening in all aspects of surgical care and tries

across the lines of specialties—within surgery and outside of

to improve it. The College gives you the roadmap for quality

surgery—look at the value delivered for that cost, and look

programs, but it’s the Fellows in their hospitals, in their

at developing systems of care that are more efﬁcient. The

communities, who make sure to follow these guidelines,

College makes sure the public and our elected ofﬁcials know

make sure their hospitals participate in these programs,

that quality of care is our foremost concern. The College has

and make sure the public can know that by seeking certi-

certiﬁcation and veriﬁcation programs for areas like the

ﬁcation and veriﬁcation of their programs.

bariatric care programs, trauma care, and cancer centers, which assure the public of the quality of these centers. Over the last couple of years, we’ve introduced and expanded

When I came to my ﬁrst College meeting in 1969, the

the ACS National Surgical Quality Improvement Program®

only women that I saw were spouses and nurses. There

(ACS NSQIP®) for hospitals. This program dramatically

were very few woman surgeons in the country. None of the

reduces the morbidity and mortality in hospitals that use

presentations were by women and none of the ofﬁcials were

it. The Surgeon Speciﬁc Registry (SSR), which can allow

women, which bothered me. I didn’t know many woman

individual surgeons to track their performance, has just

surgeons nor did I know if there were many women involved

On health care access

data-driven society and we have to turn that data into

he crux of managing surgical care

clinical information that supports best practice. What is

nearly everywhere in the world

the best way to treat a trauma patient? What is the best

is the problem of barriers to access—

way to treat a patient with cancer? These clinical guide-

whether for lack of insurance, as for millions of Americans,

lines, all of which fall under our very robust education

or for long wait times, or distances, or because of weather

division, are responsible for the continued updating of

and terrain and maldistribution of surgeons nearly every-

our surgeons in best surgical practice.

where in the world. The ACS is committed to a policy of

Regarding systems of care, I think the ACS and the public

high-quality, safe, appropriate, and affordable surgical

should recognize the value of the ACS trauma program led

care. This is expressed very clearly in the ACS Inspiring

by the Committee on Trauma since 1922. Injury, or trauma,

Quality initiative: Highest Standards, Better Outcomes.

is the leading cause of death up to age 45 in the United

Our Health Policy and Advocacy Committee gathers input

States and in most of the world. The optimal response to

on this issue, allowing the ACS to help determine what

the injured patient has been my life interest and the trauma

constitutes efﬁcient best surgical practices and appropriate

systems developed by the ACS have unequivocally reduced

surgical procedures. Who better than surgeons to make

death and disability. ATLS has absolutely set the worldwide

these critical decisions? That’s what we do every day and

standard for the initial care of the injured patient. The

every night. ACS NSQIP unequivocally addresses the value

inclusive trauma system model that has been so successful

equation. Dr. Numann has alluded to some of the speciﬁcs of

in optimizing the care of the injured patient may well be a

how we’re doing this at home; and we are also involved in

model for dealing with other emergent and time-sensitive

helping establish the best ways to practice surgery around

medical and surgical diseases.

the world. We are an international organization.

On women’s evolving role

I’m proud of the approach to surgical care the College

We help set standards of surgical care. We have regis-

has taken and indeed believe it is the only approach

tries in trauma. We have registries in cancer. We are a

that can be sustained. When I was Chair of the Board

with the College. So I posted a notice inviting women

surgeons in America are women. Of the incoming residents,

surgeons to come to breakfast to explore these issues. Out

more than 40 percent of them are women; in vascular, 60

of that, we ultimately formed the Association of Women

percent of the matched residents were women. So the repre-

Surgeons, which just celebrated its 32nd anniversary. My

sentation of women is changing dramatically. Fifty percent

original intent was that we would keep ourselves married

of medical students are women, and with that statistic, if

to the College. I do not believe in separatist organizations in

women don’t become surgeons, our profession will suffer.

that sense. Women did have interests and concerns that we

Certainly in my time in the College, we’ve moved not only

needed to address to make surgery an attractive career for

to incorporate women into the activities of the College, but

them. I felt having meetings separate from the College would

also to incorporate the residents and younger surgeons

be far less productive than to have them at the College and

more fully in the planning and the organization so that their

encourage women’s integration into the College.

views could come forward. Each generation is different in a

The College has been supportive—more than 10 years ago,

million other ways. You need to take that into consideration

it started a Women in Surgery Committee to look at areas

in your planning, in the programs that you offer, and in

such as maternity leave policies, aspects of leadership, and

their delivery. I can’t tell you how proud I am of how well

other issues important to women. The College has adopted a

the College really keeps up in these areas, even down to

lot of the suggestions, including ones on civility and behavior

using social media for communications. (You still get the

that we felt could be addressed better than they had been.

print copy if you want it.) We’re trying to be all things to all

Women have steadily been more visible within the College.

people, as best an organization can be.

Today I’m President, the second woman to hold that ofﬁce. There are a number of women Regents. Until 2000, there had

On serving multiple audiences

never been a woman ofﬁcer. The inclusion of women in the

One hundred years ago, the American College of

governance is important as in 2012 almost 28 percent of the

Surgeons was founded to look at the quality of care

of Regents, my colleague, Dr. Michael Zinner, Chair of

residents were claimed by World War II. Some of the

the Board of Governors, and I chose the keynote speaker

proudest moments of my career were my ﬁrst two years

for a joint meeting of the Board of Regents and Board of

in practice beside this deft and compassionate surgeon

Governors. Dr. Brent James, surgeon and chief quality

with excellent results and a legion of admirers.

ofﬁcer of the highly regarded Intermountain Healthcare,

Today, with over 50 percent of our medical school classes

told the surgeon leaders in no uncertain terms, “If you start

and 40 percent of our residency positions being held by

with the money, you will fail. If you start with quality, the

women, it is clear that the future of surgery will and should

money will follow.” He also said that only one generation

be heavily inﬂuenced by them. I believe the ﬁeld of surgery

every 100 years has the opportunity to make a major differ-

and our surgical patients will be the benefactors of this

ence in health care and we are that generation.

critically important diversity.

On women’s evolving role

On reaching multiple audiences

I have to say that I have always known what women

Dr. Numann said that our College is ultimately about

surgeons could do—or at the very least since 1972, when

the Fellows, and I couldn’t agree more. Our diversity is

my ﬁrst surgical partner was my mother-in-law, Dr. Anita

embodied in our very structure. We are the American

Figueredo. Anita was a pioneering surgeon in San Diego,

College of Surgeons of the United States and Canada, but

whose own mother brought her to New York from Costa

the Founders of 1913 truly considered ACS the College of

Rica as a 5-year-old child, speciﬁcally because she wanted

all the Americas, and we have chapters in Mexico and

to be a doctor and Costa Rica had no medical school. Anita

throughout Latin America, as well as around the world.

graduated from the Long Island College of Medicine in

At home, we continue to be cognizant of the different

1940 and was given the opportunity to become a resi-

demands on surgeons in rural versus urban versus

dent in surgery at the Memorial Cancer Hospital in New

suburban settings. And we must never forget that the ACS

York City (now Memorial Sloan-Kettering), after male

encompasses all surgical specialties. So we are focused at

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in hospitals and to accredit hospitals

delegate would not support adding surgical care for fear

because they wanted to be sure that

that it would take away from vaccination or some other part

surgeons worked in locations that could

of the program. But when you look at years of life and the

provide them the necessary resources.

quality of life lived, delivering surgical care may be even

Only 9 percent of the hospitals in America

more important than some vaccinations and immunizations.

met the standards at the beginning. Now, you have to meet the standards or you can’t be a hospital. Continuing to address the quality of surgical care in hospitals remains a prime focus of the College.

On standing out from other medical associations One value of the College is that if you, even as an individual, identify something you believe is important to the

Not only are the programs that have been developed

American people or surgery and you bring it to the organiza-

in America continuing to bring better quality care to our

tion, it will take it to heart, study it, and incorporate it if it

citizens, but they are also being adopted worldwide. Today

agrees on its merit. Just as I brought the women’s issue, the

we have 40 countries in addition to the United States with

rural surgeons recently brought their concerns to the Board

ACS chapters; they’re very robust and enthusiastic about

of Regents, which has agreed to work diligently to address

bringing, as they call them, American programs like our

them. Many years ago the issue of the poor coordination

cancer, education, and trauma programs to their countries.

and delivery of trauma care was brought to the College by

The NSQIP program in many ways closes the loop. It not only

a single Fellow. Within my career, Advanced Trauma Life

looks at the quality but provides feedback data that can be

Support® (ATLS®) and the nationwide system of trauma

used in an ever continuing loop for improvement. The public

centers were developed, which assures Americans the

can be assured that maximal safety and quality exist in that

ﬁnest trauma care. That’s why when I gave my presidential

hospital. So we’re starting the next century with yet another

address, I focused on stewardship and pointed out how

example of how the College develops programs that provide

individual Fellows have made incredible contributions.

the means to create and measure excellence in health care.

I wouldn’t want to lose that connection and ownership of

The College is very concerned about surgical care

the Fellows—it’s that which allows these quality program to

throughout the world. This last year at the Clinical Congress,

expand and new ones to be developed. Because you as an

the International Presidents went on record, as did the Board

individual Fellow work on these committees, help form the

of Regents, to make sure that the United Nations Healthcare

policy, and help implement the change, it belongs to you.

policies included surgical care. The U.N. wasn’t going to

The Fellows are the lifeblood of the organization. They make

include surgical care; we had heard that even the American

the College work and make it great. Q

the College on diversity in the broadest

possible outcome. Those are the broad shoulders on which

sense: in terms of gender, generations,

Dr. Numann and I and all surgeons stand today.

geographies, and specialties. Certainly,

What makes us different as a medical association is our

one of our greatest challenges today

potential to speak for surgery in its entirety—so crucial

is the engagement, recognition, and

in this era of health care reform with its emphasis on

support of those surgeons who serve in rural communi-

primary care. We must be able to speak with one voice

ties. Having grown up in Wyoming, the least populous

for all of surgery if we are to have sustainable health care

state in the U.S., I understand those challenges.

systems in our countries and an adequate workforce. We must inﬂuence public policy and collaborate with physi-

On standing out from other medical associations Looking back on our 100 years, one sees that a large

cians in all other disciplines for the beneﬁt of those who rely on us to safeguard their health.

part of our rich history is based on altruistic principles.

In the ﬁnal analysis, our actions in the ofﬁce, in the clinic,

Our courageous founding surgeons were willing to say that

in the operating room, and in the world must always address

we are committed to ensuring that every patient entering

the fundamental question, “What is best for my patient?” If

a hospital for surgery is safe and may experience the best

we are guided by that, we will never be wrong. Q

The Role of the College in Surgical Education by DAVID L. NAHRWOLD, MD, FACS

W hen the founders established the American College of Surgeons (ACS) in 1913, they envisioned it as an educational institution. The annual Clinical Congress, its weeklong educational meeting, consisted of lectures, panel discussions, and exhibits. But the centerpiece of the meeting was the operative clinics, where expert surgeons performed operations in local hospitals and Congress attendees observed and learned how to emulate them.

the American Board of Surgery (ABS), which set high standards for training that had to be met for admission to its rigorous examinations. The board required that candidates have the MD degree, complete an internship and a three-year residency plus two years of surgical study or surgical

Soon, three or four three-day education sessions were held in medium-

of surgical care and the education and

practice. A written exam covered the

training of surgeons.

basic sciences and the principles and

sized cities each year. But College leaders recognized that education alone would not elevate the level of

practice of surgery, and, if the candi-

The College Responds to Its Critics

surgical care in the country, because

date passed Part I, he was admitted to Part II, which consisted of two days of examinations in clinical and opera-

so many hospitals had inadequate

When the College was founded, the

tive surgery. Candidates who met the

administration, facilities, and staff,

requirements for fellowship included

board’s standards for training and

including their doctors. To rectify

graduation from an approved medical

passed the examinations received a

this, they implemented the College’s

school, a one-year internship at a “cred-

certiﬁcate and were designated as

hospital standardization program, in

itable” hospital, two years of service

“board certified.” Although many

which standards for hospitals were

as a surgical assistant or evidence of

modiﬁcations have been made in the

established and College surveyors

an equivalent apprenticeship, and ﬁve

structure and educational content

inspected them for their compliance

to eight years of practice. In the mid-

of the surgical residency, the basic

with the standards. Much later, in

1930s, the academic elite—professors

requirement of ﬁve years of training

the 1930s, its familiarity with hospi-

at major medical schools—led by Dr.

plus written and oral examinations,

tals through this program allowed

Evarts Graham, chair of surgery at

required today, was established by the

the College to also set standards

Washington University in St. Louis,

board’s founders in 1937.

for surgical residency programs in

MO, were increasingly critical of

The Regents of the College believed

approved hospitals and inspect them

the College and its leadership. They

that its “examination” of candidates,

for compliance. In both programs,

believed that the College leadership

consisting of reviewing 50 of the

the College emphasized improve-

was out of touch and inbred. But their

100 cases submitted by applicants,

ment, publishing materials and

main complaint was that the College

interviews of candidates by respected

holding conferences to assist hospitals

admitted individuals to fellowship

surgeons, and opinions on their qual-

and their medical staffs to improve

who were not adequately trained and

iﬁcations by fellows of the College in

the quality of care and of training.

whose surgical skills and knowledge

their local area, was more thorough

Through these programs, the College

were wanting. The dissidents’ solution

than the evaluation of the ABS. The

had a major inﬂuence on the quality

to the quality problem was to develop

College obtained information on the

A l ready vexed by t he you ng academics and the board certiﬁcation movement, the ACS Board of Regents was embarrassed that the College was not represented in the AMA initiative. The Regents decided that the College must be involved in the training of surgeons. To do so they appointed a Committee on Graduate Training in Surgery, chaired by Dr. Samuel C. Harvey, chairman of surgery at Yale and a protégé of the famous Dr. Harvey Cushing. The committee was charged to determine the best possible methods to train surgeons. The committee reviewed all the existing methods of training and rejected all of them except the residency system, then in use only in a few hospitals associated with medical schools. Residencies essentially prolonged the internship for several years and allowed the student to obtain a concentrated surgical experience,

Dr. Evarts Graham, founder of the American Board of Surgery and later President of the American College of Surgeons.

but the number of residency positions was insufﬁcient to populate the country with well-trained surgeons.

PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES

The committee asserted that hospitals ethics and moral fitness of appli-

and dermatology and syphilology,

with the proper personnel, facilities,

cants, whereas the ABS was more

and representatives of several other

and organization should offer surgical

concerned about training qualiﬁca-

organ izations. Many specialties

residencies and that minimum stan-

tions and the results of examinations.

were about to establish certifying

dards should be established for resi-

Most of the surgical specialties, such

boards, and the AMA wanted to

dency training. The committee also

as orthopaedic surgery and urology,

exert its control over the certiﬁcation

recommended that residents be taught

were also in the process of estab-

process by setting common standards

special knowledge pertinent to surgery,

lishing certifying boards, further

for the boards. The convened group

including the fundamental sciences of

challenging the College as the sole

established the Advisory Board for

anatomy, physiology, and pathology.2

arbiter of surgical credentials.

Medical Specialties (later to be called

The Committee on Graduate

In 1934, while the College lead-

the A merican Board of Medical

Training in Surgery made the auda-

ership was being criticized by its

Specialties [ABMS]). The Advisory

cious proposal that the College support

fel low su rgeons, t he A mer ica n

Board was given authority to oversee

the creation of the American Board of

Medical Association (AMA) Council

the examination and certification

Surgery and use board certiﬁcation as

on Medical Education and Hospitals

of physicians and surgeons by the

a criterion for admission to the College.

convened the leadersh ip of the

certifying boards, and by virtue of

The College, trying to mollify its critics,

existing certifying boards, which

the boards’ requirements to sit for

quickly adopted the ABS requirements

were opht ha l molog y, otola r y n-

examinations, the education and

for training, but allowed exceptions on

gology, obstetrics and gynecology,

training of specialists.

an individual basis. A few years earlier

We salute the

AMERICAN COLLEGE OF SURGEONS on its success of 100 years as an enduring

100

Leader in Quality Improvement. Surgical Excellence was created collaboratively by world renowned physicians deeply committed to making significant improvements to the quality, safety and effective management of the provision of surgical care. We share the mission of quality and safety with the American College of Surgeons and celebrate this centennial achievement.

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it would have been unthinkable for the Regents to allow a group of dissidents to inﬂuence how candidates for fellowship should be vetted.

Developing the Surgical Residency System Regent Allen Kanavel, a Past President of the College and editor of its journal, envisioned that the College’s hospital standardization program could be used to standardize the training of surgeons by requiring hospitals that had residencies to meet the College’s standards for training.3 Through this, the College could gain control of graduate surgical education and thereby minimize the inﬂuence of the new Board.

Dr. Malcolm MacEachern, Associate Director, American College of Surgeons, architect of the hospital standardization program and author of surgical residency requirements.

At Kanavel’s urging, Dr. Malcolm

PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES

MacEachern, leader of the hospital standardization program, developed

of residency program approval by

comprehensive standards for surgical

the College in conjunction with its

residencies and promulgated them in

hospital standardization program

symposia and in the Bulletin of the

was implemented, but was short

After a period of contentious nego-

American College of Surgeons, widely

lived. The AMA had inspected the

tiations, the AMA, the ABS, and

read by hospital administrators,

internships of hospitals since 1919

the College formed the Conference

beginning in 1938.4 MacEachern also

and residency programs since 1927,

Committee on Graduate Training

called for hospitals approved by the

and the ABS used the AMA’s list of

in Surgery in 1950, established to

College to develop residency programs

approved programs for its require-

inspect and approve surgical resi-

to ease the shortage of competent

ments. The AMA rejected College

dency programs. The Conference

surgeons and supplied them with

proposals to create a joint residency

Committee took over the functions

information on how to establish resi-

approval program.

of the AMA and the College, both of

Regulation of Graduate Medical Education

dencies. For the ﬁrst time, a list of

The College no longer had the ability

which had been accrediting programs

approved programs was published in

to inspect residency programs after

independently. Many programs were

the Bulletin, greatly facilitating the

1950, when its hospital standardiza-

inadequate and it took several years

ability of medical school graduates

tion program was eliminated for ﬁnan-

to eliminate them. To more accu-

then in internships to apply to quality

cial reasons and the Joint Commission

rately depict its function, the name

prog ra ms. Hospita ls responded

on Accreditation of Hospitals was

was changed to the Residency Review

immediately, and by late 1939 were

established by the College, the AMA,

Committee for Surgery (RRC) in 1953.

projected to produce almost 600

the American Hospital Association

RRCs for all the surgical specialties

trained surgeons annually, which the

(AHA), and the American College of

were established during the 1950s,

College thought would be sufﬁcient to

Physicians. The Joint Commission

with the respective specialty certi-

meet the needs of the public.5, 6

continues to set standards, inspect

fying board, the College, and the AMA

Although MacEachern’s efforts to

hospitals, and accredit them, but is

as sponsors, often called “parents.”

set standards for surgical residency

not involved in regulating graduate

Eventually, RRCs were established for

programs were successful, his vision

medical education.

all specialties of medicine.7

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In 1967, the Citizens Commission

term in 1975. His brilliance, careful

actively engage residents in the activi-

on Graduate Medical Education noted

preparation for meetings, and ability

ties of the College and to provide a

that there was wide variation in the

to develop reasonable solutions to difﬁ-

path leading to College fellowship.

residency program standards of

cult problems were recognized by the

Its activities in graduate medical

the specialties. It became clear that

CMSS and the other LCGME parents.

education enable the College to engage

certain standards were germane to

He restored the College’s influence

residents in its mission to improve the

all of them. For example, an adequate

in graduate education. In 1981, the

care of the surgical patient and to safe-

library, appropriate supervision, and

name of the LCGME was changed to

guard standards of care in an optimal

adequate compensation were essential

the Accreditation Council for Graduate

and ethical practice environment. Q

for the training and the well-being of

Medical Education (ACGME) and

residents. This led to the formation of

burdensome reporting functions were

the Liaison Committee on Graduate

eliminated. In 2000, the organization

Dr. Nahrwold is Emeritus Professor at

Medical Education (LCGME) in 1972,

was separately incorporated, lessening

Northwestern University, where he was

in an effort to improve graduate educa-

the inﬂuence of its parents and stream-

the Loyal and Edith Davis Professor and

tion by creating general requirements

lining its operations. Since then the

Chairman of the Department of Surgery

for all residency programs and stan-

ACGME has changed the paradigm of

and Surgeon-in-Chief at Northwestern

dardize the operations of the RRCs.

graduate medical education substan-

Memorial Hospital. He served as a

The sponsors of the LCGME were the

tially by imposing resident duty hours

Regent, Chairman of the Board of

AMA, Association of American Medical

and requiring programs to implement

Governors, First Vice-President, and

Colleges (AAMC), AHA, ABMS, and the

competency-based education.

Interim Director of the American

Council of Medical Specialty Societies (CMSS), of which the College was, and still is, a member. The RRCs received

College of Surgeons, and received

The College Continues Its Involvement

administrative support from the AMA,

its Distinguished Service Award. He represented the College at The Joint Commission, where he was Chairman

which also was the primary support

The College continues to support

for the LCGME, leading it to dominate

g raduate educat ion i n su rger y

the organization. The sponsors, each of

through a large number of publica-

which had veto power over decisions

tions, courses, and other educational

made by the organization, fought over

offerings designed to assist residents

the relationship of the RRCs to the

in learning and demonstrating the

LCGME, its method of ﬁnancing, and

six general competencies required by

a proposal by the AAMC that graduate

the ACGME. Especially popular are

medical education should be controlled

an ethics curriculum; the Surgical

by medical schools rather than hospi-

Educat ion a nd Sel f-A ssessment

tals. There were many more debates

Program (SESAP), which helps resi-

over lesser issues.

dents prepare for board examinations;

Before the LCGME was formed, the

Selected Readings in General Surgery,

College had lost its voice in graduate

a service providing information and

medical education. Dr. C. Rollins

commentary on surgical research;

“Rollo” Hanlon, then Director of the

and courses in surgical and tech-

College, was determined to get it back.

nical skills. The College also provides

He represented the College at CMSS

research scholarships for residents,

meetings, which were dominated by

a job bank, and many other offerings

discussions and arguments over the

directed toward graduate medical

role and actions of the LCGME. Hanlon

education. The Resident and Associate

became a leader in CMSS activities and

Society, which meets annually at the

was elected its president for a two-year

Clinical Congress, was created to

of the Board of Commissioners. References 1. American Medical Association, Minutes of the House of Delegates 84th Annual Session, Milwaukee, June 12-15, 1933. 1933; Available from: http://192.159.83.55:8080/AMA_NDLS/ jsp/vieweer2.jsp?doc. 2. Minutes of the Adjourned Meeting of the Board of Regents of October 19, 1934. 1934, Archives of the American College of Surgeons: Chicago. 3. Abstracted minutes of the Administrative Board, Archives of the American College of Surgeons: Chicago. 4. MacEachern M. Criteria for graduate training for surgery and a manual of graduate training in surgery. Bulletin of the American College of Surgeons, 1938. 5. Minutes of the meeting of the Board of Regents of October 29, 1939. 1939, Archives of the American College of Surgeons: Chicago. 6. Minutes of the meeting of the Board of Regents of October 20, 1939. 1939, Archives of the American College of Surgeons: Chicago. 7. Griffen WO Jr. The American Board of Surgery in the 20th Century—Then and Now. Philadelphia: American Board of Surgery; 2004.

The American College of Surgeons as a University by GEORGE F. SHELDON, MD, FACS, FRCSED (HON), FRCSENG (HON)

Franklin H. Martin, the founder of the American College of Surgeons (ACS), is properly recognized during the 100th anniversary of the College’s founding in 1913. In his book, Fifty Years of Medicine and Surgery, he notes that his 50 years “dwell brieﬂy upon cooperation with progressive men during the years of transition in medical care 1880 to 1920,” during which the “art was superseded by the science and art” of medicine.1

Franklin Martin traveled to London to observe the Fellowship ceremony of the RCS. Before the journey, Martin had proposed formal regalia for the ACS ceremony, an idea roundly criticized by Crile, C. J. Mayo, and the new Board of Regents as “undemocratic.” Martin records that as the RCS ceremony

For this article, I was asked to

the horrors of a lack of cleanliness

evolved, Crile, in the processional, was

describe some of my experiences

and hygienic practices in the Chicago

bedecked with full regalia. He raised his

during my nearly 50 years of working

stockyards, which led to the founding

hand in defeat when asked by Martin

in a variety of roles with the ACS. One

of the Food and Drug Administration.

how he could don such an “undemo-

of the themes that characterize this

The reforms of the Progressive Era

cratic” costume. The day was won and

largest organization of surgeons in

included medical education—notably

the formal regalia has been part of the

the world is that it offers its members

by the publication of the “Flexner

College ever since. Sir Rickman Godlee,

who choose to be active participants

Report” in 1910, which resulted in the

nephew of Lord Lister, was the College’s

a rich experience, which is a graduate

closing of marginal medical schools

ﬁrst honorary Fellow and presented the

education. Participation in the overall

and the lowering of the total number

ACS with a gavel of wood from Lister’s

work of the College is available to all

from 133 in 1890 to 85 in 1920.

chair for the opening ceremony, which

Fellows through its committees and

The practice of surgery by unqualiﬁed

through elected positions that are

and unethical doctors, characterized by

local, regional, and national in scope.

their widespread practice of fee splitting,

The surprising stature of the new

has been used in every convocation since that time.4

The ACS was founded during the

was one of the stimuli for the founding

organization was recognized within ﬁve

Progressive Era (1890–1920), which

of the ACS. The ethical practices and

years of its founding, when President

was a reaction to the Gilded Age (1865–

educational requirements for surgeons

Woodrow Wilson requested of Martin

1900) of Rockefeller, Gould, Carnegie,

who were admitted to Fellowship at the

that he organize hospitals for the

and Ford, an age that saw the birth of

founding of the College remain stan-

American Expeditionary Force (AEF)

unions and an unregulated economy.

dards to the present day.

in World War I. The bond between the

Government regulation of business

The founding of the ACS was heavily

British and American surgeons was

began to occur as evidenced by the

inﬂuenced by W. C. and C. J. Mayo

solidiﬁed through joint service during

1887 Interstate Commerce Act, the

and their expansive vision of health

World War I. In 1920, Lord Moynihan

Sherman Antitrust Act, the Commerce

care as embodied in the Mayo Clinic.

presented the ACS with the Great Mace

Commission, the Federal Trade

George Crile, Alfred Kanaval, and

to signify that connection; it has been

Commission, and others. Presidential

J.B. Murphy—the “stormy petrel of

used during the convocation ceremony

leadership

included

Theodore

Roosevelt and Woodrow Wilson.

surgery”—were also highly inﬂuential.

since that time.

The American College of Surgeons

Shortly after the founding of the

Health was highlighted by journalist

was heavily modeled after the Royal

ACS in 1913, the College estab-

“muckrakers” led by Upton Sinclair,

College of Surgeons (RCS) of England.

lished the Minimum Standards for

whose 1906 book The Jungle showed

Prior to the ﬁrst convocation of the ACS,

Hospitals, the precursor to The Joint

Commission, which itself was estab-

his entire tenure with the ACS, he timed

to assume the role of Director in

lished in 1951. True to the progressive

every formal presentation, including

November 1986. Linn’s role eventually

environment of its founding, the ACS

all of the Presidential Addresses! His

expanded into Director of the Division

has expanded the number of accredi-

administrative and meeting manage-

of Integrated Communications. There

tation programs during the course of

ment skills were without parallel.

was little in the ACS that Linn didn’t

its history to include the Advanced ®

From 1977 to 1981, I represented

inﬂuence positively. Always a construc-

Course, the

the Society of University Surgeons on

tive team player, she led a devoted staff

Trauma Center Veriﬁcation Program,

the ACS Board of Governors and also

of communications professionals who

the Commission on Cancer, and the

served as its Secretary. I learned a

did an excellent job in handling the

bariatric surgery and breast center

great deal during that experience from

Division’s expanded responsibilities.

veriﬁcation programs, among others.

the College’s outstanding Comptroller

An early innovation of Linn’s was to

In the quality area, the American

who functioned as the Chief Financial

have socioeconomic updates in each

College of Surgeons National Surgical

Officer, Robert G. Happ. That was

issue of the Bulletin of the ACS, which

Quality Improvement Program® (ACS

during the President Jimmy Carter

previously had been a limited circula-

NSQIP ) has injected modern stan-

inflation years, which had a major

tion, “yellow pages” type of publication.

dards with metrics for determining

impact on everyone. The ﬁrst of two

I was asked to be the ﬁrst Editorial

and developing quality surgical care.

main duties of the Secretary of the

Advisor for the Bulletin. In many

My mentors, Dr. J. Englebert

Board of Governors was to Chair the

ongoing readership surveys, socioeco-

Dunphy, President of the ACS; Francis

Governors’ Fiscal Affairs Committee,

nomic topics have retained a role as the

D. Moore, Vice President; and F. W.

which meant offering the dues recom-

most read part of the Bulletin.

Blaisdell, Chair of the Committee

mendation for the succeeding year to

In 1982, Dr. Loyal Davis, ACS

on Trauma, had all been active in

the nearly 300 Governors of the ACS.

President and long-term Editor of

the College. At that time, residents

Happ convinced the members of the

Surgery, Gynecology, and Obstetrics,

were encouraged to present papers

Fiscal Affairs Committee that a large

the precursor to the Journal of the

during the Surgical Forum sessions

dues increase ($50) was warranted

American College of Surgeons, died.

at the annual Clinical Congress. That

to secure the successful future of

A memorial service and reception

was my early involvement, followed

the College. The Governors had a

were held at the Murphy Memorial

by participation in local chapter

lively, open discussion, but ultimately

Auditorium and the Nickerson Mansion,

programs. In 1972, at the Clinical

approved the increase, which then

historic buildings owned by the College

Congress in San Francisco, I partici-

had to be validated by the Board of

and located across the street from its 55

pated in the last “wet clinics” that

Regents. I noted to Dr. Hanlon that it

E. Erie St. headquarters. The service

were part of the Clinical Congress

was appropriate that the second iden-

was attended by ACS leaders and guests

educational program.

Trauma Life Support

tiﬁable responsibility of the Secretary of

and by Dr. Davis’ daughter, Nancy

In 1978, I had the task of presenting

the Board of Governors—saying grace

Reagan, and her husband, President

the opening ceremony lecture at

during the annual banquet—was a

Ronald Reagan. Dr. Armand Hammer,

the Clinical Congress on Philip Syng

good marriage of the two duties! The

a friend of Dr. Davis, could only make

Physick, “the Father of American

dues increases during that period posi-

a brief appearance at the service as

Surgery.”5 C. Rollins Hanlon, MD, FACS,

tioned the ACS stock portfolio for the

he was on his way to attend Leonid

became one of my “professors” and

growth years of the 1980s and 1990s.

Brezhnev’s funeral in Russia! Hammer

advisors over many years. The letter

After I became a Regent in 1984, I

noted that he wanted to endow an

from Dr. Hanlon inviting me to speak

became Chair of the Communications

international scholarship in Dr. Davis’

at the opening ceremony noted that the

Committee. That Committee assumed

memory. The Scholarship Committee,

length of my talk would be precisely

enhanced importance as the Director of

chaired by Dr. Frank Spencer, had been

17½ minutes! A little known fact of Dr.

that department, Heinz Kuehn, retired.

developing more and better scholar-

Hanlon’s unmatched administrative

The Search Committee selected Linn

ships for residents and had a draft of a

skills as Executive Director, Regent, and

Meyer, Manager of Public Information

model close to Dr. Hammer’s vision. So

President of the College was that during

in the Communications Department,

a check was written, larger than most

of us have ever seen, and Dr. Hammer went on to Russia. Following my term on the Board of Governors, I became a member of the Board of Regents for the usual nine years. During that period, the “Dean” of the ACS, Dr. Hanlon, retired as Executive Director but fortunately remained as President for one year and then served as Executive Consultant. Our debt to him for education, example, and leadership is unparalleled. In 1985, I received an urgent call from Dr. Olga Jonasson (who would go on to Ohio State University to become the ﬁrst woman to head a department of surgery). Her call was derivative of a brief meeting at Chicago’s O’Hare Airport with Senator Dave Durenberger (R-MN), who was chair of the Senate Subcommittee on Finance. She had met him at a meeting of the Council of Medical Specialty Society (CMSS). At that time, the Consolidated Omnibus Reconciliation Act (COBRA) was being considered during the legislative process. At risk in the draft bill was funding for Graduate Medical Education (GME); the proposal was for only three years of funding, or no

Dr. George F. Sheldon presents testimony before the United States Senate Subcommittee on Finance on S.1158—the Dole, Durenberger, Bentsen Bill re: Medicare Payment for Cost of Graduate Medical Education. The presentation was televised on C-SPAN, June 1985.

funding at all. Senator Durenberger surgeons didn’t get behind ﬁve-year

extra year for three-year residencies

cuts in the plan outlined in the

funding and get involved in the legis-

that may extend an additional year.”

Bowles-Simpson Commission report,

lative process, a three-year maximum

I was asked by Senator Durenberger

the battle continues.

would be unavoidable.

to testify before the Senate Finance

As most of the ACS leadership was

Committee. At the same table, testi-

at a meeting in Australia, she called

fying for less generous support, was

me for advice. We managed to arrange

Dr. Henry Desmarais, at that time

a meeting with Senator Durenberger,

director of the Ofﬁce of Management 6

Blueprint for the Twenty-First Century The most important reorientation of

which was attended by Dr. Oliver

and Budget (OMB).

Of interest,

the ACS during my time of involvement

Beahrs of the Mayo Clinic, Dr. David

Dr. Desmarais eventually became

was the retreat held from June 16–18,

Sabiston of Duke University, and me.

director of the ACS Washington, DC,

1985, at the Harrison Conference Center

In Senator Durenberger’s ofﬁce, we

ofﬁce under Dr. Samuel Wells, and

in Lake Bluff, IL.7 It was a retreat of the

wrote language that exists in the

today he remains an ACS consultant.

Regents, staff, and Ofﬁcers of the Board

Medicare law to this day. It reads “ﬁrst

As funding of GME is again today

of Governors, led by the Chair of the

certiﬁcation or ﬁve years, with an

under question and targeted for

Board of Regents, Oliver Beahrs, MD,

USED WITH PERMISSION FROM MARY JANE KAGARISE AND COLIN THOMAS, JR., MD, FACS

let Dr. Jonasson know that if the

FACS. The conference was designed to

Committee was available to be shown

Dr. David Sabiston. Dr. Paul Ebert,

bring to deﬁnitive action three main

there because it had been on C-Span.

professor and chair of the Department

items that had been discussed for some

The third major item during the

of Surgery at the University of

time without closure. The ﬁrst was the

retreat was to develop a robust endow-

California-San Francisco, was hired

need to be active in Washington, DC,

ment program. Dr. Beahrs, familiar

as Executive Director. Dr. Ebert was

and to create a Washington ofﬁce as the

with the value of an endowment as a

well known to all as the preeminent

College’s advocacy arm. The College,

funding source from his time at the Mayo

pediatric heart surgeon in the world,

scrupulously compliant with its 501(c)

Clinic, made this his pet retreat project.

and he had been chair of the depart-

(3) tax status as a not-for-proﬁt organi-

Accordingly, funding for the position of

ment while I was at UCSF. Paul had

zation, had neither undertaken a move

an endowment ofﬁcer was approved,

a different style from Dr. Hanlon but

of its headquarters to Washington—

the scholarship funds were targeted for

was equally effective. He had a great

as had the Association of American

great expansion, and all of the Regents

knack of not getting too involved in

Medical Colleges (AAMC)—nor estab-

and Ofﬁcers were asked to pledge a

minutiae. As Dr. Hanlon described

lished a second organizational ofﬁce as

substantial contribution. The fund is

him, if you were behind one point in

had the American Medical Association

still known today as the Regents’ Fund.

a basketball game with 10 seconds

(AMA). The ACS, as an organiza-

It is difﬁcult to imagine the current

left, and you had a player at the free

tion respected in Washington, did

ACS without these important commit-

throw line with two shots, you would

participate in hearings at the request

ments from the 1985 retreat.

want it to be Paul Ebert. With Dr.

of Congress or the executive branch,

In 1986, Dr. Hanlon retired as

Gerald Austen as Chair of the Board

much like the model Franklin Martin

Executive Director. The Search

of Regents, Dr. Ebert established

established after World War I. However,

Committee Chair for his successor was

incredibly effective relationships

it was becoming apparent to many ACS

with industry, other organizations,

ofﬁcials that the “listening post,” which

and with Congress. In addition, Paul

was the limit of our political involve-

almost single handedly negotiated the

ment, was insufﬁcient. As a result, the

bold move from 55 E. Erie St. to the

idea of buying a building in Georgetown was endorsed and money accumulated in the building fund was used for that purpose. A budget was developed and additional staff was hired, under the direction of Dr. Hanlon and James Haug, the Director of the Socioeconomic Affairs Department. Several years later, when Dr. Samuel Wells was Executive Director, Dr. Desmarais was hired as the Director following Mr. Haug’s retirement from the College. With the opening of the College’s new building in Washington, DC, in June 2010, the structure and complexion of the staff continues to evolve. The second major focus of the 1985 Regents’ retreat was on GME, with its funding threatened then as now under Medicare. The retreat followed our work with Senator Durenberger, and my testimony before the Senate Finance

In Senator Durenberger’s office, we wrote language that exists in the Medicare law to this day. It reads “first certification or five years, with an extra year for three-year residencies that may extend an additional year.”

College’s current headquarters location of 633 N. Saint Clair St. In 1992, I was invited to present the Scudder Oration on Trauma. This was especially memorable as trauma was my clinical focus and I had served on the Committee on Trauma (COT). At the time of my award, current ACS President Brent Eastman was COT Chair. This was my second opportunity to present a major named ACS lecture. My title was “Trauma Manpower in the Decade of Aftershock.”8 Dr. Ebert served 12 years and was succeeded by Dr. Samuel Wells. Dr. Wells had a great vision for the ACS. The cancer research program, the ﬁrst NIH-funded clinical trials awarded to a professional organization, still thrives today. Dr. Wells also recruited Dr. Desmarais for leadership of the Washington ofﬁce.

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www.FloridaHospital.com

The Resident and Associate Society (RAS) was founded in 1999 during my year as ACS President, to involve surgeons in the ACS at the beginning of their careers. I worked with Dr. Olga Jonassen, who was the ACS staff member for this organization. Dr. Michael DeBakey was the inaugural speaker at the ﬁrst meeting of the RAS. Following Dr. Wells, Dr. Tom Russell, a Regent of the College, was selected as Executive Director by a search committee during my year as President (1998–1999). Dr. Russell’s strong administrative skills, hands-off management style, and energetic contact with chapters, Fellows, and other organizations created a wonderful environment for Fellows and staff. His new management model allowed contracted program

Andy C. Kiser, MD, from UNC Cardiothoracic, the ﬁrst President of the Resident and Associates Society (RAS), is pictured at the inaugural meeting of the RAS with guest speaker Michael E. DeBakey, MD, FACS.

development to be led by surgeons

outside the Chicago ofﬁce; previously all program development was done by

In 2009, I was invited by the Advisory

from 10 Downing St. speciﬁcally high-

surgeons located in the Chicago ofﬁce

Committee on General Surgery to give

lighted his service to the American

under full-time contracts. Dr. Russell

the Edward D. Churchill Lecture of

College of Surgeons’ Health Policy

also negotiated a unique arrangement

the Excelsior Surgical Society. My

Research Institute as one of the reasons

by which the Nickerson Mansion and

topic dealt with surgical workforce

for his elevation. The funding for the

the Murphy Auditorium, properties

in the era of health reform.

HPRI provided access to more than 160

of important sentimental and historic

A second new initiative was a product

investigators who provide expertise

value, could be retained without

of the Health Policy Committee led by

part-time to the ACS. The institute has

continuing to be a major burden on

Dr. Charles Mabry. It was a search,

produced more than 70 publications,

the College’s budget. In addition, Dr.

chaired by Dr. LaMar McGinnis, for

congressional testimonies, and other

R. Scott Jones, who had been ACS

a Director to found a Health Policy

consultations to Congress. After six

President, was recruited to found

Research Institute (HPRI). I was asked

years of being located at UNC, it has

the Division of Research and Optimal

to become the inaugural Director, a

since been relocated to the Washington,

Patient Care, now brilliantly led by Dr.

task I shared with Tom Ricketts, Ph.D.,

DC, ofﬁce under Christian Shalgian, the

Clifford Ko. After a search committee

of the Cecil G. Sheps Center for Health

Director of the Division of Advocacy

for an Editor of e-FACs.org, the online

Services Research at the University of

and Health Policy.

portal recommended by the Committee

North Carolina at Chapel Hill. A distin-

A tradition of the ACS is at termi-

on Informatics led by Dr. Peter Greene

guished advisory board was recruited,

nation of service to provide some

of Johns Hopkins, concluded its work, I

which included the president of the

concluding observations.

was asked to take on this responsibility.

Royal College of Surgeons of England,

I believe it has been a useful adjunct to

Sir Bernard Ribeiro, an Honorary

the ACS, as it includes more than 28

Fellow of the American College of

communities and nearly 300 editors

Surgeons. When Sir Ribeiro was later

and associate editors, with 3,702,666

elevated to the peerage (his title now

1. Globalization. For more than

page views since launching.

being Lord Ribeiro), the announcement

30 years, efforts have been made

For the Future: Some Areas of Opportunity

to bring the surgical colleges from

is important that peer-reviewed health

member of the Institute of Medicine of

across the world into a uniﬁed group

policy research with metrics continues

the National Academy of Science, and

to address global health and surgical

to be developed, under the direction

he is the ﬁrst Surgeon—not dean—to

quality. In 1963, the Joint Conference

of Medical Director Dr. Don Detmer.

be Chair of the Association of American

of Surgical Colleges (JCSC) was formed,

Currently, the Washington office is

Medical Colleges since 1879. He holds

bringing together the presidents of

developing health services expertise.

Honorary Fellowship in the Royal

the American, English, Edinburgh,

It is essential to understand that good

College of Surgeons of both England

Glasgow, Irish, Canadian, South

health policy is good advocacy and

and Edinburgh.

African, and Australasian colleges, as

is the future. This may be the most

well as the presidents of the surgical

important developmental challenge

academies of Hong Kong, Singapore,

for the College for the next 25 years.

and Malaysia. In 2000, Royal College

I extend thanks for the friendship

of Surgeons of England President Sir

and help of the ACS staff over the many

Barry Jackson presided over the bicen-

years I served as an Ofﬁcer, Governor,

tennial celebration of the RCS, which

Regent, and program leader. I especially

included a meeting of the JCSC. The

note Robert Happ, Dr. Ed Gerrish, Dr.

JCSC has not met since 2002. Perhaps

Frank Padberg, Jack Lynch, Barbara

we could follow the example set by the

Dean, and Maxine Rogers, long-serving

RCS at its bicentennial in 2000, and

and loyal staff who provided excellent

invite the JCSC to meet during the ACS’

assistance in all things. Linn Meyer,

Centennial celebration. The timing of

a colleague with whom I worked in

greater international collaboration is

a variety of capacities, was always

propitious with the communication

constructive, insightful, and institution-

advances of the Internet.

oriented. In more recent years, my

2. Challenges of an umbrella orga-

colleague, Jerry Schwartz, Managing

nization. Efforts continue to educate

Editor of e-FACs.org, has been an

surgeons, especially young surgeons,

outstanding resource for the ACS.

about the importance of participating

The portal would not have succeeded

in the ACS as well as their specialty

without him. Howard Tanzman, always

societies. Attraction to the College as

helpful in informatics, continues to be a

the leading organization of surgeons

resource as we evolve into more depen-

in the world requires coalition

dence on technology. Q

building. It also requires the production of health service products with metrics that shape policy.

Dr. George F. Sheldon’s career with

3. Washington influence. The

the ACS includes Secretary of the

Washington office staff has been

Board of Governors, Regent, President,

active in advocacy efforts. Its large

and Scudder and Excelsior Surgical

staff and magnificent new building

Society Orator. He was Founding Editor

provide an imposing statement of the

of the portal e-FACS.org and Founding

College’s determination to become

Director of the ACS Institute for Health

an important source of input for

Policy Research. He has also been Chair

Congress, the executive branch, and

of the American Board of Surgery and

the bureaucracy. With a decision

President of the American Surgical

to make the Washington office the

Association, the American Association

source site for health policy research,

for the Surgery of Trauma, and the

a different paradigm is in evolution. It

Society of Surgical Chairmen. He is a

Bibliography Sheldon GF. Trauma manpower in the decade of aftershock. Scudder Oration On Trauma. Bull Am Coll Surg. May 1992;77(5):6-12. Sheldon GF. The A merican Col lege of Surgeons In The Millennium: An Analysis. Handout to the Board of Regents. Oct 1999. Sheldon GF. The Su rgeon Shor t age: Constructive Participation during Health Reform. Excelsior Surgical Society Edward D. Churchill Lecture. J Am Coll Surg. June 2010; 210(6):887-894. References 1. Martin FH. Fifty Years of Medicine and Surgery: An Autobiographical Sketch. Chicago, IL: The Surgical Publishing Company of Chicago; 1934. 2. Bowles MD and Dawson VP. With One Voice: The Association of American Medical Colleges 1876-2002. Washington, DC: Association of American Medical Colleges; 2003. 3.D av i s L . Fel l o w s h i p o f Su r g e o n s: A Hi stor y of the Amer ican College of Surgeon s. Spr i ng f ield, IL: C h a rle s C. Thomas Books; 1960. 4. Jackson B. The American College of Surgeons and the Royal College of Surgeons of England: Eighty Years of Friendship. J Am Coll Surg. Oct 2000; 191(4):435-440. 5. Sheldon GF. Philip Syng Physick, M.D. (1768-1837): The Father of American Surgery. Bull Am Coll Surg. May 1979; 64:16-27. 6. Sheldon GF. Statement of the American College of Surgeons regarding S. 1158—To Amend Title XVIII of the Social Security Act with Respect to Medicare Payment for Direct Costs of Approved Educational Activities. Washington, DC: June 1985. 7. Report on a Planning Meeting held by the Board of Regents, June 16–18, 1985, at the Harrison Conference Center, Lake Bluff, IL. ACS internal document courtesy of Susan Rishworth, ACS Archivist. 8. Sheldon GF. Trauma manpower in the decade of af tershock. Scudder Oration On Trau ma. Bull Am Coll Surg. May 1992;77(5):6-12.

Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African-American Heritage by L.D. BRITT, MD, MPH, FACS, FCCM, FRCSENG (HON), FRCSED (HON), FWACS (HON), FRCSI (HON), FCS(SA) (HON)

As the American College of Surgeons (ACS) celebrates its Centennial and underscores its legacy of being a beacon for quality and patient safety, the Fellowship earnestly reﬂects on the innumerable contributions of individual surgeons of diverse backgrounds who have played pivotal roles in advancing American surgery before and after the College’s inception. Many surgeons of AfricanAmerican heritage have played key roles in these developments. Because several of their stories have been well chronicled recently, this article serves as brief tribute to these other individuals, rather than as a comprehensive historical account. Nonetheless, during this Centennial celebration, the stalwart efforts of past, current, and future leaders should be recognized. The list of surgeons of African-American heritage continues

Kenneth Forde, MD, FACS – one of the founding members

to grow and transcend generations. Table I highlights those

of the Society of American Gastrointestinal and Endoscopic

surgeons of African-American heritage who have ascended

Surgeons and its ﬁrst and only African-American presi-

to the top leadership positions in major organizations.

dent; first African-American professor of surgery at

Table II presents an impressive list of surgeons of AfricanAmerican heritage who are members of the Institute of Medicine of the National Academies.

Columbia University Alexa I. Canady, MD, FACS – the ﬁrst African-American woman to be accepted into a U.S. neurosurgery residency program

In addition, the number of surgeons of A frican-

Clive Callender, MD, FACS – one of the foremost special-

American heritage who have been selected to chair

ists in organ transplant medicine, he founded the Minority

departments of surgery has grown exponentially in

Organ Tissue Transplant Education Program (MOTTEP),

the past few decades. Current chairs of departments of

which aims to increase the number of donors among all

surgery are listed in Table III.

minority groups in the U.S.

Many of the leading surgeons of African-American heri-

Arthur Fleming, MD, FACS – thoracic surgeon; one of the

tage headed the Society of Black Academic Surgeons (Table

founding fathers of the Society of Black Academic Surgeons

IV)—building a strong foundation for this organization.

Lenworth Jacobs, MD, MPH, FACS – recognized leader

The following list (although incomplete) of notables and

in trauma and critical care, founder of the College’s

“ﬁrsts” truly reﬂects the depth and breadth of contributions

Advanced Trauma Operative Management program and

made by African-American surgeons:

current ACS Regent Velma Scantlebury, MD, FACS – the first African-

Notables

American woman to be a transplant surgeon

Levi Watkins, Jr., MD, FACS – cardiac surgeon, professor

Sharon M. Henry, MD, FACS – an endowed professor at

of surgery, and associate dean at the Johns Hopkins

the University of Maryland Shock Trauma Center; ﬁrst

University School of Medicine; performed the world’s ﬁrst

African-American woman to be a member of the American

implantation of the automatic deﬁbrillator

Association for the Surgery of Trauma

TABLE I

The Top Leadership Positions in Major Organizations Held by Surgeons of African-American Heritage

LaSalle Leffall, Jr., MD, FACS

President, American College of Surgeons (1995-1996); President, Society of Black Academic Surgeons; President, Society of Oncologic Surgeons; President, American Cancer Society (1978-1979)

Claude Organ, Jr., MD, FACS*

President, American College of Surgeons (2003-2004); Chair, American Board of Surgery; President, Society of Black Academic Surgeons

Haile Debas, MD, FACS

President, American Surgical Association (2000-2001); President, Society of Black Academic Surgeons

Samuel Kountz, MD, FACS*

President, Society of University Surgeons (1974)

Adam Robinson, Jr., MD, FACS

Surgeon General, U.S. Navy (2007-2011)

Kenneth Forde, MD, FACS

President, Society of Gastrointestinal Endoscopic Surgeons

Eddie Hoover, MD, FACS

President, Society of Black Academic Surgeons; Editor-in-Chief, Journal of the National Medical Association (2004-present)

Steven Stain, MD, FACS

Chair, American Board of Surgery (2009-2010); President, Society of Black Academic Surgeons

Henri Ford, MD, FACS

President, Association of Academic Surgeons (2002-2003); President, Society of Black Academic Surgeons

Robert Higgins, MD, FACS

President, UNOS (2008-2009); President, Society of Black Academic Surgeons

Fiemu Nwariaku, MD, FACS

President, Association for Academic Surgery (2007-2008)

L.D. Britt, MD, MPH, FACS

President, American College of Surgeons (2010-2011) President, Southern Surgical Congress (2007-2008); President, Southeastern Surgical Congress (2008-2009); Chair, Residency Review Committee-Surgery (2005-2007); President, American Association for the Surgery of Trauma (2011); President, Halsted Society; President, Society of Surgical Chairs (2004-2005); President, Society of Black Academic Surgeons (19992001), Executive Director (present); President, American Surgical Association (present); Commissioner, The Joint Commission (present)

*deceased

Patricia L. Turner, MD, FACS – recently hired as the Director of the ACS Division of Member Services, the highest

professor of surgery at the University of Illinois, Chicago, and Rush University

salaried position held by an African-American at the College

Debra Ford, MD, FACS – the ﬁrst fellowship-trained,

Cato Laurencin, MD, PhD, FACS – the consummate

board-certified, African-American woman colorectal

academic orthopedic surgeon is recognized as one of the

surgeon, she is a professor of surgery at Howard University.

premier thought leaders in American medicine. He is a

Robert Higgins, MD, FACS – recently elected to both the

proliﬁc researcher and innovator, with an impressive track

American Board of Thoracic Surgery and the Residency

record of extramural funding and patent acquisitions.

Review Committee–Thoracic Surgery

Butch Rosser, MD, FACS – an accomplished innovator in

L.D. Britt, MD, MPH, FACS – the ﬁrst surgeon of African-

advanced minimally invasive surgery and simulation and

American heritage to serve as Chair of the ACS Board of

a professor of surgery at Morehouse School of Medicine

Regents and the ﬁrst African-American to have an endowed

Kimberly Joseph, MD, FACS – ﬁrst woman to serve in the

chair in surgery—the Henry Ford Professor and Edward

National Medical Association–Surgical Section; associate

Brickhouse Chair of Surgery at Eastern Virginia Medical School

CONGRATULATIONS to the American College of Surgeons for 100 Years of Improving Surgical Patient Care

Covidien is proud to collaborate with the American College of Surgeons as we continue our mission to improve the standard of patient care. Visit us at this year’s ACS Annual Meeting — Booth #1819 www.covidien.com COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and/or internationally registered trademarks of Covidien AG. All other brands are trademarks of a Covidien company. © 2012 Covidien 8.12 M120784

TABLE II

Surgeons of African-American Heritage Who Are Members of the Institute of Medicine LaSalle Leffall, Jr., MD, FACS

Howard University School of Medicine

Asa G. Yancey, Sr., MD, FACS

Grady Memorial Hospital and Emory University

Cato Laurencin, MD, PhD, FACS

University of Connecticut

Danny O. Jacobs, MD, MPH, FACS

Duke University

Selwyn Vickers, MD, FACS

University of Minnesota

TABLE III

Current Departmental Chairs of Surgery Danny O. Jacobs, MD, MPH, FACS

Duke University

Steven Stain, MD, FACS

Albany Medical College

Selwyn Vickers, MD, FACS

University of Minnesota

Edward Cornwell, MD, FACS

Howard University

James H. Thomas, MD, FACS

University of Missouri-Kansas City

Lynt Johnson, MD, FACS

Georgetown University

Ed Childs, MD, FACS

Morehouse School of Medicine

Selwyn Rogers, MD, FACS

Temple University

L.D. Britt, MD, FACS

Eastern Virginia Medical School

“Rising Stars”

Presidential Early Career Award for Scientists and Engineers.

Fortunately, the pipeline is replete with a legion of estab-

Electron Kebebew, MD, FACS – head of the endocrine

lished surgeons and “rising stars” who have distinguished

section at the National Cancer Institute, National Institutes

themselves in the major surgical disciplines. Fortunately,

of Health

the list is too long to adequately underscore their many

Terrence Fullum, MD, FACS – a prominent advanced

accomplishments and contributions. However, the following

minimally invasive surgeon, he is associate professor of

are some of the future leaders in American surgery:

surgery at Howard University.

Lisa Newman, MD, FACS – professor of surgery at the

David Jacobs, MD, FACS – executive director of the

University of Michigan and a highly regarded surgical

National Medical Association – Surgical Section, he is a

oncologist

trauma surgeon at Carolinas Medical Center.

Patricia L. Turner, MD, FACS (see “Notables” section) Carla Pugh, MD, PhD, FACS – vice-chair of education and patient safety, department of surgery, University of Wisconsin,

André Campbell, MD, FACS – acute care surgeon and surgical educator, professor of surgery at the University of California, San Francisco (UCSF)

Madison; she is also director of the university simulation center.

Kenneth Davis, Jr., MD, FACS – recently elected presi-

President Barack Obama recently presented Dr. Pugh with the

dent of the Society of Black Academic Surgeons, he is a

But for Ohio State, the field of surgery wouldn’t have been shaped by so many legends. As the American College of

in cancer, critical care, heart,

Surgeons celebrates 100 years of

imaging, neurosciences and

accomplishments, we at The Ohio

transplant, the Department of

State University Wexner Medical

Surgery is improving people’s

Center were inspired to reflect on

lives through personalized

our own legacy.

surgical care. Olga Jonasson, MD, FACS

The Department of Surgery at Robert M. Zollinger, MD, FACS

Ohio State’s Wexner Medical

The completion of the

Center has a long and respected

$1.1 billion expansion project

tradition of excellence in clinical

at Ohio State’s Wexner

practice, research and education. Many surgical greats,

Medical Center will expand

including the legendary Robert M. Zollinger, MD, and

the Department of Surgery’s

Edwin Ellison, MD, have walked

clinical care, create more

the department’s halls.

research opportunities, and

H. William Clatworthy, Jr., MD, FACS

allow our experts to continue educating and Thanks to the accomplishments

training the next generation of surgical legends.

of our outstanding faculty, staff,

Visit medicalcenter.osu.edu to learn more.

residents and medical students, Ohio State’s Department of Surgery is nationally and

Arthur G. James, MD, FACS

internationally recognized for its exemplary clinical care, educational programs and innovative research. In partnership with the Medical Center’s signature programs

TABLE IV

professor of surgery and anesthesia and vice-chairman of the department of surgery at the University of Cincinnati College of Medicine. Ronda Hendry-Tillman, MD, FACS – an accomplished

Past-Presidents of the Society of Black Academic Surgeons 1989-1991

Arthur Fleming, MD, FACS

1991-1993

Onye E. Akwari, MD, FACS

Sherilyn Gordon-Burroughs, MD, FACS – an academic

1993-1995

Eddie L. Hoover, MD, FACS

transplant surgeon and program director in the depart-

1995-1997

Claude H. Organ, Jr., MD, FACS

ment of surgery at Methodist Hospital in Houston, TX

1997-1998

LaSalle D. Leffall, Jr., MD, FACS

1998-1999

Haile T. Debas, MD, FACS

1999-2001

L.D. Britt, MD, MPH, FACS

Michael Watkins, MD, FACS – academic vascular surgeon

2001-2003

Clive O. Callender, MD, FACS

at the Massachusetts General Hospital and assistant

2003-2004

Edward Cornwell III, MD, FACS

2004-2005

Robert L. McCauley, MD, FACS

2005-2006

Selwyn M. Vickers, MD, FACS

2006-2007

Michael T. Watkins, MD, FACS

2007-2008

Steven C. Stain, MD, FACS

2008-2009

Robert S. Higgins, MD, FACS

2009-2010

W. Lynn Weaver, MD, FACS

2010-2011

Henri Ford, MD, MHA, FACS

2011-2012

Danny O. Jacobs, MD, MPH, FACS

breast surgeon and professor of surgery at the University of Arkansas

Hobart Harris, MD, FACS – professor of surgery and chief of the division of general surgery in the department of surgery at UCSF

professor of surgery at Harvard Medical School Raphael Lee, MD, FACS – prolific investigator and professor of surgery at the University of Chicago Karyn Butler, MD, FACS – trauma surgeon and director of surgical critical care at Hartford Hospital Edward Barksdale, MD, FACS – chief of pediatric surgery at Rainbow Children’s Hospital and professor of surgery at Case Western Reserve University Orlando Kirton, MD, FACS – professor of surgery at the University of Connecticut Jeffrey Upperman, MD, FACS – pediatric surgeon and associate professor of surgery at the University of Southern

in Nashville, TN, which encompasses George W. Hubbard

California Fred Cason, MD, FACS – chief of surgery at the Cleveland VA and professor of surgery at Case Western Malcolm V. Brock, MD, FACS – associate professor of thoracic surgery at Johns Hopkins Raymond Bynoe, MD, FACS – professor of surgery at the University of South Carolina, Columbia

Hospital, founded in 1909, were, for many years, the only major training facilities that freely accepted AfricanAmerican applicants. These institutions, along with Homer G. Phillips Hospital in St. Louis, MO, trained and produced a competent cadre of African-American surgeons. In addition, several black surgeons who trained in other countries returned to the U.S. during this time period.

A Rich History

Luminaries who emerged during this renaissance period

The rich history of surgeons of African-American heritage

included Charles R. Drew, MD, FACS, professor of surgery

can never be downplayed. Each chapter was essential in

at Howard, chief of surgery at Freedman’s, and a pioneer

providing the formidable foundation necessary to enhance

researcher in the use of blood plasma for transfusion; and

our involvement in American surgery and establish the

Daniel Hale Williams, MD, FACS, founder of Provident

necessary avenues to leadership positions.

Hospital in Chicago, the ﬁrst black-owned and -operated

In the 19th and early 20th centuries, several institutions provided a cultivating environment where young

U.S. hospital. Dr. Williams is credited with performing the ﬁrst successful open-heart surgery in 1893.

physicians of African-American heritage could train to

Other important ﬁgures from this era include John Henry

become surgeons. Freeman’s Hospital in Washington, DC

Hale, MD, and Matthew Walker, MD, of Meharry Medical

(which in 1868 became the ofﬁcial teaching hospital of

School—both giants in surgery and great surgical educators.

Howard University College of Medicine, now known as

The list of 20th century pioneers who followed is equally

Howard University Hospital), and Meharry Medical College

impressive and includes the following:

Congratulations to the

American College of Surgeons 0n its centennial anniversary Since 1885, the Keck School of Medicine of USC has been dedicated to providing quality care and advanced educational programs, while conducting innovative research that will advance the future of surgical practice. Our outstanding faculty include many active fellows and associate fellows of the American College of Surgeons. The Keck Medical Center of USC includes Keck Hospital of USC, USC Norris Cancer Hospital and USC Norris Comprehensive Cancer Center, one of the original eight comprehensive cancer centers designated by the National Cancer Institute. For more information, please visit surgery.usc.edu.

Vaugh Starnes, MD Chair, Department of Surgery

Anthony Senagore, MD Vice Chair, Department of Surgery

TABLE V

Honorary Fellows of the Society of Black Academic Surgeons Õ iÊ Ài ÃV >}]Ê ]Ê * «Ê Ìi ]Ê ]Ê -

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Dr. Britt is the Brickhouse Professor and Chairman,

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Department of Surgery, Eastern Virginia Medical School,

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Norfolk, VA. He is a general and acute care surgeon and

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Past-President and Past-Chair of the Board of Regents of

À ÃÊ Ã ]Ê ]Ê -

the American College of Surgeons.

*deceased

Major Historical Achievements in General Surgery: The First 75 Years by J. DAVID RICHARDSON, MD, FACS

Any attempt to briefly describe the major highlights in general surgery is difficult on several fronts: The field is so broad that categorization of “major achievements” is difficult and most of the noteworthy advances in “general surgery” have often morphed into specialty areas that will be detailed by other authors in the chapters of this publication. However, it is important to note that general surgery was the progenitor of most advances that eventually led to subspecialty development.

Care of the injured was initially provided by general surgeons rather than

to deﬁne the technical expertise required by

trauma surgeons per se: the ﬁrst abdominal aortic aneurysm operation

surgical oncologists or hepatobiliary surgeons,

was done by a generalist; the pancreatoduodenectomy, which is often used

was developed by general surgeons, etc. This contribution will attempt to briefly define some of the achievements in general surgery made in the first 75 years of the A mer ica n Col lege of Su rgeons’ (ACS) existence. In the following article, Carlos Pellegrini, MD, will review some of the contributions of the last 25 years, including the revolution in care of our patients engenby endoscopy and minimal access surgery.

The Model for Surgical Training One of the major achievements in general surgery must clearly be the development of the training model by which future surgeons, and indeed future physicians in all disciplines, would be trained. William Stewart Halsted of Johns Hopkins in Baltimore, MD, William Stewart Halsted and his residents.

is considered the father of the American

PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS

dered by the technologic changes afforded

residency system. Halsted came to Baltimore a f ter t ra i n i ng ex ten sively i n Eu rope visiting prominent continental surgeons. In Baltimore, he developed a system by which trainees did a surgical internship followed by five or six years of junior residency. This was followed by two years as a chief resident. The concept of “concentrated responsibility” was inculcated in the chief residency years—a concept that has remained intact for the past century. Residents who trained under the Halstedian system then populated major surgical chairs throughout the United States and instituted similar residency systems. The concept of a residency system then became the established norm for training surgeons and this educational concept spread from the surgical disciplines to eventually include non-surgical disciplines as well. By the late 1920s, the American Medical Association (AMA) had begun to set standards for residencies in several disciplines. For the first several decades of the existence of the ACS, surgical training could be broadly categorized into two types: extensive (for that time) and difficult to obtain at elite institutions; or relatively brief training, often contained in a one-year internship. As the population

Halsted, the “father of the American residency system,” performing surgery.

grew and hospitals improved through early attempts at standardization, patients were

increased considerably and the training further evolved. Although

more willing to undergo operative proce-

the ACS eventually relinquished its surgical residency accreditation

dures but there was clearly a shortage of

role to the Accreditation Council on Graduate Medical Education—a

well-trained surgeons.

partnership with the AMA and the American Board of Surgery—the

By the late 1930s, it was recognized that

development of high-quality resident training in general surgery must

more defined standards for the training

stand as one of the major historical achievements in the ﬁrst 75 years

of surgeons needed to be developed. The

of the existence of the ACS. This model for training and its accredita-

ACS had already established a committee

tion was adopted by all of the surgical specialties in the United States

for the standardization of hospitals and in

and similar models have been adopted worldwide. Millions of patients

1937 the Clinical Congress held a session on

have clearly beneﬁted from this focus on improved surgical training.

the accreditation of hospitals for graduate medical education. The ACS then began to

Toward Safer General Surgical Operations

accredit hospitals and deﬁne standards for residency training in general surgery. For a

Most of the common general surgical procedures—appendectomy,

number of years there were woefully small

hernia repair, mastectomy, cholecystectomy, colectomy, thyroidectomy,

numbers of hospitals approved for residency

etc.—were developed prior to the founding of the ACS. While the develop-

training, and after World War II, as the popu-

ment of general anesthesia and antiseptic principles had made surgery

lation grew, the number of programs was

safer and more humane, mortality from most surgical procedures was

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American College of Surgeons ŽŶ ϭϬϬ ǇĞĂƌƐ ŽĨ ĞǆĐĞůůĞŶĐĞ͘ We are proud to partner with you in the science of saving lives.

Following World War II, there were dramatic changes in safety for surgical patients. Hospitals improved through a variety of forces including the accreditation processes. Surgical training was dramatically ramped up as previously noted. Anesthesia safety was markedly enhanced. Improved knowledge of ﬂuid and electrolyte balance, the introduction of antibiotics, and the concept of “intensive care” allowed for better outcomes irrespective of the technical performance of operations. still high. The founding principles of the ACS

The other common general surgical procedure, then as now, was

included the education of surgeons to enhance

cholecystectomy. Gallbladder removal, which today has a mortality of

the safety of surgical operations.

far less than 1 percent even in patients with multiple comorbidities,

A review of the literature on surgical

had a mortality of 2.6 percent in the 16,980 cases reported in 1923 from

mortality for common operations performed

the Mayo Clinic. Those who required common bile duct procedures had

the ﬁrst few decades following the founding

7.8 percent mortality. In 1930, a report of 500 cholecystectomies from

of the ACS is illustrative of the high death rate

Memphis, TN, noted a 4 percent death rate.

of the day. Appendectomy, which today has a

Cancer of the stomach treated by operation also had a high likeli-

mortality rate of about 0.01 percent and often

hood of a fatal outcome, particularly when viewed from the perspec-

a one-day length of hospital stay, was still a

tive of our current relatively low mortality. A report from 1939 on the

very dangerous operation even two decades

experience of the previous decade with gastric resection disclosed

after the formation of the ACS. A 1929 report

11.5 percent mortality. By the end of World War II, the Mayo Clinic

from New York City disclosed that 755 cases of

performed partial removal of the stomach with a 3.2 percent death rate

appendicitis carried an operative mortality of

while one in six died when the entire stomach was removed. Five years

6.37 percent; Barnes Hospital in St. Louis, MO,

later, those numbers still had shown little improvement (6.2 percent

reviewed 1,824 cases performed during the

and 12.9 percent, respectively). Operations on the pancreas were very

years 1915 to 1932 with an overall mortality

uncommon, but a collected series of opening of the pancreas to remove

of 3.4 percent. Both of these reports noted

stones had a death rate greater than 17 percent.

much higher death rates in patients who were

By the mid-20th century, the death rate for elective operations on

“elderly.” Of interest today as our population

younger patients had declined dramatically but for operations done on

ages, the deﬁnitions of elderly were over age 51

older patients, particularly when performed on an emergency basis, it was

and greater than 60 years of age in these two

still very high. A 1950 review of patients requiring emergency operations

reports; the mortality rate was 25 percent and

disclosed a mortality of 17.3 percent. Interestingly, operations for injury

42 percent respectively in these older patients.

were not among the top ﬁve indications for emergency operation: The

Perforated appendicitis was the most

primary indications were cholecystitis, bowel obstruction, appendicitis,

common cause of peritonitis in the 1920s

complications of inguinal hernia, and amputation for extremity gangrene.

and an extensive literature review covering

In those patients who were over 60 years of age, nearly 40 percent died.

the years 1920 to 1924 disclosed a 30 percent

In 1955, Carl A. Moyer, MD, and J. Albert Key, MD, reported on the

mortality rate for those requiring operation.

changes in mortality over a time period that coincided closely with the

Operations for removal of the large intestine

founding of the ACS to the then present. They examined the Barnes

as reported by the Mayo Clinic in 1920 had a

Hospital mortality rate for a number of common general surgical proce-

mortality of 17 percent, while another report

dures from 1916 to 1938 and compared those outcomes to those results

from the same year noted a 12.5 percent

achieved from 1948 to 1953. The death rates from operations on the bile

death rate. Cancers that required removal of

ducts had declined from 16.5 percent to 2 percent; emergency opera-

the rectum had an even higher mortality: A

tions for perforated ulcers decreased from 41 percent to 7 percent; and

report from cases done from 1928 to 1932 had

appendectomy mortality had decreased to 0.7 percent. Operations outside

a death rate of 30 percent, which decreased

the chest and abdomen, namely thyroidectomy and mastectomy, had

to 17 percent in the ensuing ﬁve-year-period.

marked improvement in death rate. The death rate for removal of the

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thyroid decreased from 6 percent to 1 percent

been extraordinary. This is the greatest achievement in the ﬁeld of

while mastectomy mortality declined ﬁvefold

general surgery in my opinion.

from 1 percent to 0.2 percent over this period. Removal of the esophagus for cancer, still a

The Development of Organ Transplantation

formidable procedure today, improved from 55 deaths per 100 patients in the earlier era to 16.

The transplanting of diseased organs has long been a dream for

It should be noted that these mortality rates

surgeons. The ﬁrst corneal transplant was done in 1905 but solid organs

were reported by some of the best institutions

were a different matter. In 1909, a French surgeon transplanted a

in America; undoubtedly the death rates in

rabbit kidney into a young girl who died two weeks later. In 1913, a

other hospitals throughout the country were

monkey kidney was unsuccessfully transplanted into a child as well.

much higher. Following World War II, there

Alexis Carrell, who later won the Nobel Prize, performed canine kidney

were dramatic changes in safety for surgical

transplants at about the time of the founding of the ACS and devel-

patients. Hospitals improved through a variety

oped vascular suture techniques still used today. In 1933, a Ukrainian

of forces including the accreditation processes.

surgeon named Yurii Voronoy performed the ﬁrst human-to-human

Surgical training was dramatically ramped

kidney transplant, which failed after two days. During the 1940s, Sir

up as previously noted. Anesthesia safety was

Peter Brian Medawar in England performed seminal work on immu-

markedly enhanced. Improved knowledge of

nology that greatly enhanced the understanding of rejection and eventu-

ﬂuid and electrolyte balance, the introduction

ally led to his recognition with awarding of a Nobel Prize.

of antibiotics, and the concept of “intensive

The ﬁrst successful kidney transplantation was performed in the

care” allowed for better outcomes irrespec-

United States in 1954 by Joseph Murray, MD, at the Peter Bent Brigham

tive of the technical performance of operations.

Hospital in Boston. Identical twins who were 23 years old, one of

Surgical procedures such as appendecto-

whom had glomerulonephritis, comprised the donor and recipient,

mies, cholecystectomies, and emergency

thus avoiding the problem with rejection. Both of the twins went on

hernia operations now rarely result in death.

to long, successful lives. This team of surgeons performed multiple

Complicated cancer operations that would not

kidney transplants in twins in the 1950s, and a recent article in the

have been contemplated during the ﬁrst 50

New England Journal of Medicine outlined the history of the Nightingale

years of existence of the ACS are now done

twins, one of whom received a transplant from her sister at age 12 in

routinely with a mortality of 2 percent or less.

1960. Both sisters had returned to the Brigham and Women’s Hospital in

Equally remarkable is the incredible distribu-

2011, and the recipient, who is now 63 years old, is the longest-surviving

tion of high-quality surgical care throughout

kidney transplant patient. In 1962, the Brigham team performed the

the country. While highly complex procedures,

ﬁrst cadaveric kidney transplant using the immunosuppressive drug

such as removal of the pancreas or esophagus,

azathioprine. The patient lived for 21 months.

may be regionalized to specialty centers, the

During the 1960s, a host of “ﬁrsts” were accomplished in the ﬁeld of

operations that were commonly performed at

solid organ transplantation. In 1963, James Hardy, MD, performed a lung

the time of the ACS founding (with often high

transplant at the University of Mississippi and three years later a team at

death rates at excellent hospitals) are now

the University of Minnesota conducted the ﬁrst pancreas transplant. In

done routinely throughout this country with a

1967, Thomas Starzl, MD, performed the ﬁrst successful liver transplant

mortality far less than 1 percent.

after an initial failure in 1963. The successful graft functioned for 13

While reports in the 1930s categorized

months. Heart transplantation had pioneering laboratory work done by

patients over age 50 as “elderly,” octogenar-

Norman Shumway, MD, of Stanford University, but the ﬁrst human effort

ians now routinely undergo both elective

was achieved by Dr. Christiaan Barnard in South Africa in 1967. A number

and emergency operations with remarkably

of operations in America by Dr. Shumway followed, beginning in 1968.

low death rates that often approach that of

The enhanced understanding of immunology and mechanisms of

much younger patients. While it is vital to

rejection with the addition of new immunosuppressant agents such as

continue to make operative care safer—from

cyclosporine and tacrolimus led to organ transplantation becoming a

morbidity as well as a mortality standpoint—

relatively common procedure that has been lifesaving to thousands of

the advances made in these regards have

patients. The transplant community has performed remarkable services

a modiﬁed total mastectomy including lymph node removal to removal of the lump with or without breast radiation. This trial, initiated in 1976, disclosed the safety of so-called “lumpectomy” with radiation; a recently published 20-year follow up has continued to show the safety of lumpectomy plus radiation compared to removal of the entire breast. The project has also been involved with a variety of other studies such as chemoprevention for breast cancer and a number of Kidney transplant, 1996.

studies on colon cancer. The NSABP has, through its network of surgeons and other

to patients in its organized approach to ethically obtaining organs and

healthcare workers, had an enormous positive

ensuring fair distribution of organs to those who are most in need

impact on the lives of thousands of patients

of transplantation. While donor shortage remains a huge issue, live

and their families. These studies have also

donors as opposed to cadaveric retrieval has greatly expanded the pool

demonstrated the power of a network of physi-

of available organs for some forms of transplantation. In 2008, there

cians with strong leadership asking important

were more than 16,000 kidney transplants performed in the United

clinical questions to ﬁnd answers to queries

States—10,551 from cadaver donors and 5,966 from living donors. In

that could never be determined through even

the same year, the United States had 6,069 liver transplants performed

the best single-institution trials.

and more than 1,200 lung and 1,800 heart transplants.

Summary The National Surgical Adjuvant Breast and Bowel Project (NSABP)

General surgery can certainly be viewed as

While surgical oncologists may attempt to lay claim to this topic, when

today. This brief review could have focused

the NSABP was founded in 1958, the specialty of cancer surgery had

on hundreds of topics of importance during

not been clearly deﬁned, and even today many of the participants are

the ﬁrst 75 years of the history of the ACS.

general surgeons working in community hospitals. It is no exaggeration

Many of these will undoubtedly be discussed

to state categorically that this endeavor dramatically changed surgical

in other sections of this report. The focus on

practice particularly in the ﬁeld of breast cancer treatment.

surgical education, the safety of operative

Dr. Halsted, whose impact on residency education was previously noted,

procedures, the development of transplanta-

developed an operation to remove the breast, underlying muscle, and

tion, and the use of large-scale clinical trials

lymph nodes from the axilla. This “radical mastectomy” was designed

to answer important clinical questions are

to treat the far-advanced cancers often seen at that time, but it was a

topics of great importance to our patients.

disﬁguring operation and its use was extended in subsequent years to

The last 25 years of the century of the ACS

women whose tumors were less advanced. Bernard Fisher, MD, led a

have seen the explosion of minimally invasive

clinical trial, beginning in 1971, to test whether a radical mastectomy

procedures, which have added a new dimen-

provided superior results to removal of the breast alone, a so-called “total

sion of safety and comfort for our patients and

mastectomy.” The preliminary results of the 1,600 women entered in

will be reviewed in the following article. Q

the trial were published in 1975. The ﬁndings disclosed no difference in outcome between the more radical procedure and the lesser one. Longterm follow up after 25 years published in 2003 showed the same results.

J. David Richardson, MD, FACS, is Professor

Having demonstrated the utility of total mastectomy, the project

and Vice-Chair of the Department of Surgery at

embarked on an extension of the hypothesis that more radical opera-

the University of Louisville and currently serves

tions might not offer advantages over lesser procedures by comparing

as the Chair of the Board of Regents of the ACS.

PHOTO BY DAVID JOEL; COURTESY OF RUSH-PRESBYTERIAN-ST. LUKE’S MEDICAL CENTER

the parent of many of the surgical specialties

For 100 years of the highest standards, our highest praise. Cleveland Clinic congratulates The American College of Surgeons. Thank you for 100 years of clinical excellence and an abiding commitment to advancing patient care.

clevelandclinic.org/refer123 Same-day appointments available.

Minimally Invasive Surgery: General Surgery’s Revolution by CARLOS A. PELLEGRINI, MD, FACS, FRCSI (HON)

A high-level overview of general surgery’s evolution during the last 100 years shows a stark contrast between the ﬁrst 75 years and the last 25. While the ﬁrst period was characterized by relative stability in techniques and instrumentation, the second is characterized by constant change in approaches, new techniques, and frequent introduction of new devices. The landmark event that divides these two eras was the introduction and rapid adoption of minimally invasive techniques. This article

with both hands, which made the performance of more complex procedures possible.

reviews the revolutionary impact that minimally invasive surgery (MIS)

The advent of widespread minimally invasive

had in general surgery—in its appeal, its philosophy, its patients, and

surgery has transformed everything about the

among those who practice or are training to do so—and highlights the

ﬁeld of general surgery—its effect on patients,

role our College had in this revolution.

its appeal to students and trainees, the introduction of additional new technologies, and the

Background

ways in which surgery is taught today—and MIS still represents one of the most exciting

The concept of accessing the abdomen or chest through a small incision

frontiers in medical science.

and performing procedures directed by an endoscope was introduced at the beginning of the twentieth century, but the innovation was slow to

Patient Care

take hold. Surgeons found early laparoscopes too limiting; the direct view simply didn’t reveal tissues as well as needed for most procedures, and the

The ﬁrst clear beneﬁt of minimally invasive

scopes were difﬁcult to manipulate—one hand was typically used to move

surgery was faster patient recovery. Rather

the scope around while the surgeon operated with the other. With marginal

than disrupt several layers of tissue, surgeons

exposure, cumbersome instrumentation, and access to the ﬁeld limited to

could, using specially designed instruments,

the operating surgeon, the use of these techniques remained limited for

enter the cavity through a very small portal

the most part to examination of the peritoneal cavity or the performance

and navigate existing interior margins and

of a limited operation (liver biopsy, tubal ligation, etc.).

spaces. An abdominal operation causes

In the late 1980s, the widespread use of minimally invasive procedures was

two sorts of trauma: incisional trauma and

enabled by digital imaging technology. A camera with a microchip, attached

so-called “target trauma” that occurs in

to the telescope and capable of capturing an image that could be projected

the area of operation itself. For more than

onto a monitor, made viewing the operating ﬁeld possible to the surgeon and

a century, the surgical wound had been the

all other members of the operating team. This innovation was the centerpiece

site of major concerns regarding postopera-

of the disruptive technology that set this revolution in motion. It was now

tive pain, discomfort, and complications such

possible for the assistant to operate the camera and for the surgeon to operate

as sepsis, hemorrhage, or herniation. After

most laparoscopic procedures, a patient could

the same extent as the surgeon. It allowed students and trainees to partici-

immediately re-enter society, return to work,

pate mentally and emotionally in the operation. It showed anatomy, and the

and otherwise resume normal living with

effect of surgery on it, in a way that had not previously been experienced,

minimal pain, rapid postoperative recovery,

and it reversed the downward trend that had been observed in the interest

and a dramatically reduced risk of direct or

in surgery among students.

indirect wound-related complications. These beneﬁts, in turn, sparked an immediate change of attitude among all physicians.

Constant Innovation Changes the Practice of General Surgery

The absence of a wound, the lack of need for substantial pain medication, and the perceived

This new generation of surgeons immediately set to improve on the

reduced risk of complication promised better

early stages of laparoscopy. Working in close collaboration with device

outcomes—lower morbidity and mortality

manufacturers, surgeons and engineers from these companies explored

rates. General internists, gastroenterologists,

areas in instrumentation that had remained stable for the last 100 years.

and others became less resistant to indications

Almost anything that was being done was questioned and improved, and

for procedures known to be more effective than

new devices that facilitated the performance of laparoscopic operations led

medical therapy, but also known to carry the risk

to more surgeons adopting the new technology. The advent of the automati-

of an operation. The substantial reduction of

cally advancing clip applier, for example, motivated more general surgeons

“incisional trauma” became particularly notice-

to perform laparoscopic cholecystectomy—today still one of the most

able in operations that had a relatively small

used laparoscopic procedures. For the ﬁrst time in a century, completely

target trauma and in which the greatest burden

new instruments were developed that bore only passing resemblance

posed by the intervention on the recovery of

to anything that had come before them. Devices that would allow rapid

the patient was incisional trauma (i.e., Heller

suturing, better dissection, and stapling of tissues allowed for more and

myotomy, Nissen fundoplication). In these opera-

more applications of these techniques to more complex procedures. Soon,

tions, postoperative recovery was dictated by the

the focus turned to developing ways to further minimize the invasiveness of

course of incisional healing more than by the

surgery—smaller incisions, better and smaller cameras, higher resolution

trauma inﬂicted at the operative site.

monitors, and smaller and fewer portals. In just a few years, a new concept evolved: the idea of accessing the

Appeal to Students and Trainees

abdominal cavity through natural oriﬁces and thus eliminating altogether the need for an incision in the abdomen. Natural oriﬁce translumenal endoscopic

The interest in minimally invasive proce-

surgery (NOTES) arose in the midst of this revolution as an experimental

dures, post-1989, was sudden and widespread

surgical method in which an operation was performed by instruments

in general surgery, a ﬁeld that had, since the

inserted through a natural oriﬁce—the mouth, anus, urethra, or vagina—and

early twentieth century, lacked a certain spice,

then into the abdominal cavity via perforation of, respectively, the stomach,

while other ﬁelds, such as cardiac and vascular

colon, bladder, or vaginal wall. The method has been used for both diagnostic

surgery, plastic surgery, and neurosurgery,

and therapeutic purposes; in 2007, the ﬁrst transgastric cholecystectomy

had experienced quantum leaps. Students and

and transvaginal appendectomies were performed in the U.S.

trainees of general surgery had only experienced

NOTES procedures generally require the use of ﬂexible endoscopes that

closeness to the operative ﬁeld by holding retrac-

must be piloted through more complex structures, over longer distances. For

tors, a demanding and feared task, with minimal

surgeons experienced in the use of rigid laparoscopes, the two-dimensional

opportunity for learning. General surgery was,

images projected through these endoscopes can create problems in depth

compared to other ﬁelds of study, boring; proce-

perception and spatial orientation. Just as they have with laparoscopy,

dures were for the most part hurdles for students

however, surgeons and engineers are working together on new technologies

to overcome if they wanted to be surgeons.

—three-dimensional and off-axis imaging systems, for example—that may

The new digital imaging, however, allowed

help formulate an accurate representation of the surgical site in NOTES.

medical students and surgical residents—and

While NOTES is seen by some as the new frontier in minimally

anyone else who wanted to look—the ability to

invasive surgery, its advantages are still being debated. The potential

“insert themselves” into the operative ﬁeld, to

for “scarless” abdominal surgery and for limiting the complications

associated with transabdominal wounds is still being weighed by the

extended the use of the computerized environ-

surgical community against the relative safety and simplicity—and in

ment. A robot essentially became an “informa-

many cases the closer proximity to the surgical site—offered by other

tion systems with arms”—just as the CT scanner

effective MIS options such as laparoscopy.

years earlier had become an information system

One of the ideas that spun off NOTES was the use of the umbilicus (by

“with eyes.” The main advantages to robotic

extension considered a “natural oriﬁce”) as the single access site through

surgery are the ﬁner calibration of movements;

which an operation could be done. Using a slightly larger (which is the

tremor and slippage are virtually eliminated

Achilles heel of this new concept) albeit “natural” portal, the surgeon

by the ﬁltering software of robotic systems, the

was now able to introduce the endoscope and at least two sets of instru-

representation in a three-dimensional ﬁeld,

ments. Additional instruments were placed directly through punctures

and the “wrist” provided to its instruments.

to aid in the performance of the operation. While this concept has the

The ﬁrst robotically assisted surgery—a heart

advantage of using rigid endoscopes that provide better spatial orienta-

bypass—was performed in 1998, almost a

tion when compared to ﬂexible endoscopes, and while manufacturers

decade after the ﬁrst MIS procedure, and in the

have developed a slew of new instruments that can access the target from

years since, other surgical specialists—cardio-

the side, a lot of difﬁculties associated with the current techniques will

thoracic, gynecological, gastrointestinal, ortho-

have to be surmounted before these procedures will be broadly adopted.

paedic, vascular, and neurosurgeons—have all

They reﬂect, however, the rapid and almost constant innovation that has

pioneered their own robot-assisted procedures.

characterized surgery in the last quarter-century.

In early 2000, surgeons at Ohio State University

The electronics and computerization enabling MIS procedures have natu-

began exploring the use of robotic systems in

rally led to the development of surgical procedures performed with the aid

esophageal and pancreatic surgeries. In April

of robots. In robotic surgery, the surgeon does not directly manipulate the

2008, a group of surgeons at the University of

instruments, but does so through an interface with either a computer or tele-

Illinois at Chicago performed the ﬁrst mini-

manipulator that commands a set of mechanical arms. While utilizing the

mally invasive, robot-assisted liver resection

concept of MIS in terms of access to the chest or abdomen, robotic surgery

on a living donor, removing 60 percent of the

PHOTOS COURTESY OF DR. CARLOS PELLEGRINI

Robot-assisted surgery at the University of Washington. Simulation-based training is increasingly being used to train surgeons to perform such minimally invasive surgical procedures.

patient’s liver and yet allowing him to leave the

immediate and widespread use of that technique to remove the gallbladder

hospital—with four stitched punctures, rather

in the late ’80s and the beginning of the 1990s also had a downside: a

than an abdominal incision—within two days

substantial increase in injuries of the bile duct. It soon became clear that this

of the procedure.

increase was due to the fact that the new method of operating also required

Robotic systems have enabled science

a new method of training. For decades, surgical students learned procedures

ﬁction to become reality. On September 7,

by imitating the procedures of others and by performing operations with

2001, a surgeon in New York performed the

the hands-on guidance of a mentor. With laparoscopy, this approach has

“Lindbergh Operation”—a minimally invasive

two distinct obstacles: First, the use of digital imaging projects images that

cholecystectomy on a 68-year-old woman more

tend to make procedures seem simpler than they are. These images create a

than 3,800 miles away in Strasbourg, France—

two-dimensional world, but the surgeon’s actions—pulling, pushing, lifting,

using sophisticated surgical robotics and a

shifting—are performed in three dimensions, and are often not processed

high-speed ﬁber-optic communications link.

accurately by those observing the procedures on a monitor. Second, the

As more expert surgeons use such special-

complete absence of peripheral vision impairs situational awareness, and

ized systems, procedural data may be stored

when this is combined with image distortion, it can lead to misinterpretation

in computerized systems. In 2006, a surgeon

or misidentiﬁcation of structures.

in Boston, using a software program that

Laparoscopy also precludes the old-school collaboration between

combined data compiled by several surgeons

teacher and student. Before, the trained surgeon and untrained surgeon

over thousands of operations, monitored from

shared access, with their hands, through the abdomen of the patient

a computer as a robotic system performed the

while the trained surgeon coached and directed—exposing certain

world’s ﬁrst unmanned robotic surgery—the

tissues, manipulating tissues closer to the trainee’s instruments, even

placement of a deﬁbrillator—on a 34-year-old

manipulating and placing the hands of the trainee. In laparoscopy, these

patient in Milan, Italy.

methods are not possible; each individual performing a portion of the

The surgeon who performed the Lindbergh

operation has his or her own instruments and tasks, and those instru-

Operation, Dr. Jacques Marescaux, stated after

ments are manipulated independently of others’ actions. Further, the

his team’s procedure that the transatlantic

focus on safety that sprang from the Institute of Medicine report at the

operation was the third revolution the surgical

turn of the century simply dictated that an untrained surgeon should not

ﬁeld had experienced in the past remarkable

be performing a procedure on a patient, even with guidance from a more

decade. “The ﬁrst,” he said, “was the arrival

seasoned surgeon. MIS practitioners quickly realized that the best way

of minimally invasive surgery, enabling proce-

to adequately teach these operations was to combine task analysis with

dures to be performed with guidance by a

laboratory-based simulations. Task analysis broke complex procedures

camera, meaning that the abdomen and thorax

into discrete psychomotor skills—knot tying, tissue handling, or vascular

do not have to be opened.”

division, for example. Some operations were decomposed into 50 to 60

The second, said Marescaux, was the intro-

smaller pieces. Each of these smaller elements was learned in a labora-

duction of computer-assisted surgery, in which

tory under simulated conditions, and then integrated and combined into

artiﬁcial intelligence could be used to both

procedures that were performed on mannequins, or animals, or, more

enhance and control a surgeon’s movements

recently, in virtual reality created by computerized simulators.

during a procedure. Operation Lindbergh, he

It wasn’t until the year 2000, however, that the ﬁrst study of simulation-

said, was “a richly symbolic milestone. It lays

based training in laparoscopy was published. That study, and more than

the foundations for the globalization of surgical

two dozen other studies since, have validated the effectiveness of the

procedures, making it possible to imagine that

simulation-based approach in enabling the transfer of learned skills to

a surgeon could perform an operation on a

the clinical environment. In 2002, for example, a validation trial revealed

patient anywhere in the world.”

that residents who demonstrated expertise in virtual reality laparoscopic skills training performed laparoscopic cholecystectomies 29 percent faster,

Teaching Surgeons

and with six times fewer errors, than did a control group who underwent traditional on-the-job training.

The unbridled enthusiasm that followed the

With the evidence mounting in validation of simulation-based training,

introduction of laparoscopic surgery and the

several national initiatives have been launched, such as the joint laparoscopic

SAGES Congratulates

the American College of Surgeons on 100 Years Join SAGES. SAGES is an unconventional surgical association in the best sense of the word. It is a collegial group in which newcomers are welcomed like long-term members of the “family.” SAGES Annual Meetings are filled with formal and informal networking opportunities. If you participate, you are valuable. If you work for the Society, you are invited into its leadership circle. SAGES is inclusive while preserving quality. It is statistically more difficult to have a paper accepted for podium presentation at a SAGES meeting than almost any other group, but new ideas are welcome. We have a service oriented staff. SAGES was founded FOR our members, and its primary responsibility is TO our members. Visit www.sages.org for more information or to join today.

R e s ou rc e s & P ro g r a m s : iMAGES

SAGES

iMAGES provides access to vast library of digital images, photos and graphics. SAGES TV is a central “searchable and fully navigational” depository for SAGES videos S-Wiki is a surgical “Wikipedia” that has signicant potential to become the most authoritative surgical reference on the web.

SAGES Webinars

SAGES Webinars have been developed specifically for residents and will feature expert panelists from SAGES. SAGESPAGES is a surgeon-to-surgeon social network that has replaced the previous SAGES member area. SAGES University facilitates online education content for MOC Part 2 Self assessment CME credit.

MYCME SAGES Guidelines

MYCME/MYMOC is a central repository to track all SAGES awarded MOC Part 2 CME credit. A complete list of all currently published SAGES Guidelines on the SAGES publication page. SAGES International Proctoring Courses are a vehicle for SAGES to “give back” to the world community by leveraging its leading educational and training activities to become a leader in bringing safe minimally invasive surgery to the developing world.

MIS Safety Checklist

The MIS Safety Checklist was developed by SAGES and AORN to aid operating room personnel in the preparation of equipment and other duties unique to laparoscopic surgery cases.

SAGES Pearls Series – Step by Step Short Video Clips · Expert Narratives Tips · Tricks · Important Steps SAGES Top 21 DVD contains the most common minimally invasive procedures performed by general surgeons, as determined by the SAGES Educational Resources Committee. SAGES Top 21 replaces the very popular SAGES Top 14 DVD, with all new videos and commentaries. SAGES Grand Rounds Master Series offers video, slide presentations, discussion and in depth education. The SAGES Educational Resources Committee developed these patient information brochures to assist surgeons in preparing their patients for surgery. Given the variations in technique, SAGES designed these handouts to describe the most commonly performed techniques. Fundamentals of Laparoscopic Surgery is an on-line based education module designed to teach physiology, fundamental knowledge & technical skills. The Fundamentals of Endoscopic Surgery (FES) Program is a test of knowledge and skills in flexible gastrointestinal (GI) endoscopy. FES is the flexible endoscopy equivalent of the Fundamentals of Laparoscopic Surgery™ (FLS) Program developed by SAGES. The Fundamental Use of Surgical Energy (FUSE) Program is an educational program/ curriculum that will cover the use of energy in interventional procedure in the operating room and endoscopic procedure areas.

Society of American Gastrointestinal and Endoscopic Surgeons 11300 West Olympic Blvd., Suite 600 · Los Angeles, CA 90064 Phone: 310-437-0555 · Fax: 310-437-0585 · www.sages.org

skills training curriculum launched in 2004 by

that would set standards for educational institutes. Shortly thereafter, this

the American College of Surgeons (ACS) and

committee became the ofﬁcial accreditation body for those centers that met

the Society of American Gastrointestinal and

its standards. As more centers became “ACS certiﬁed,” it became obvious

Endoscopic Surgeons (SAGES). In the mean-

that each had a different pool of individuals with expertise in different

time, validation of the method has led to its

areas of MIS education and training, and the idea was born to create an

adoption among other surgical ﬁelds; in 2008,

ACS Consortium of Accredited Institutes that would further standardize

the Residency Review Committee for Surgery

curricula, validate new methods of training, and determine the overall

mandated that all residency programs should

direction of simulation-based training and assessment for the future.

have access to simulation centers. The close collaboration with industry in the development

Conclusion

of new tools and techniques led to a substantial investment by commercial entities in the devel-

MIS has introduced an explosion in surgical innovation that may have

opment of training centers around the country.

some surgeons longing for the stability of the decades prior to 1989, when

Over time, the simulation-based education

the unrelenting uniformity and standardization of procedures facilitated

and training models necessitated by MIS have

teaching, allowed for predictable outcomes, and ensured surgical residents

grown—and will continue to grow—more

that the skills they were learning would be applied for at least the next ﬁve

comprehensive and sophisticated throughout

or six years. Today, with surgery continuing to revolutionize itself from the

the continuum of surgical careers. Simulation

inside of the patient outward, residents have little idea when their newly

is now speculated as a means by which surgery

acquired skills will be outdated.

residents might be selected and screened,

Despite these uncertainties, surgeons continue to innovate new MIS proce-

and various models for conducting long-term

dures. Cardiac and vascular surgeons have beneﬁted greatly from the advent

follow-up with simulation-based learners are

of digital endoscopes and catheters, which have allowed them to swap out

being debated among the surgical community.

heart valves or deploy grafts or stents through single puncture sites. In summary, the introduction of MIS had a substantial impact on general

The Role of the ACS

surgery. It became, almost overnight, a philosophy that was embraced by most practicing general surgeons in this country and that increased the

The American College of Surgeons played a

utilization of surgery, as its beneﬁts remained the same but its complications

substantial role in this revolution. Shortly after

and sequelae were lessened. It provided a new environment in the OR: one

the ﬁrst successful laparoscopic cholecystec-

characterized by a team approach now that all members could follow every

tomy had been reported in France, at the Clinical

step of the operation. It provided the “spice” that had been slowly dwindling

Congress the ﬁrst movie of this technique was

away from the specialty and captured the imagination of young students and

shown. The enthusiasm that it sparked was

surgeons-to-be. It brought together surgeons and device manufacturers,

evident by the overﬂow at the room where this

both groups feeling the need to continue to innovate and to move the ﬁeld

movie was shown. Conscious of its mission to

forward at a fast pace. Finally, it opened the door to safer and more effective

provide the safest and most efﬁcient surgical

methods of training surgeons in all specialties. And this is just the tip of the

care for patients, the ACS focused its efforts in

iceberg—a lot more is in store for the next 100 years. Q

the education and training of surgeons. Working in collaboration with SAGES—the professional organization that had made MIS the core of

Carlos A. Pellegrini, MD, FACS, FRCSI (Hon), is the current Henry

its existence—the development and validation

N. Hawkins Professor and Chair of the Department of Surgery at the

of the Fundamentals of Laparoscopic Surgery

University of Washington, a position that he has held since 1993. Prior

(now a requirement of the American Board of

to it, he was a Professor of Surgery at the University of California, San

Surgery for proffering certiﬁcation) was made

Francisco. Dr. Pellegrini has played an important role in the American

available throughout the myriad of educational

College of Surgeons in several capacities including its Board of Regents,

institutes that had formed around the country.

which he chaired in 2010–2011. He was President of the American Surgical

In 2005, the Board of Regents directed the

Association in 2006. He is a Senior Director of the American Board of

Division of Education to create a committee

Surgery and a former Chair of the Residency Review Committee for Surgery.

A History of Public Hospitals by GRACE S. ROZYCKI, MD, MBA, FACS, AND DAVID V. FELICIANO, MD, FACS

Much has been written about public hospitals relative to their mission to care for the underserved, their role in medical education, and the continuous ﬁnancial challenges that they encounter.1,2,3,4 But, despite doubts about their viability, public hospitals not only have withstood the test of time but have thrived and have evolved into a new entity, i.e., the safety net hospital. The Mission At the core of any public hospital is the mission of caring for the vulnerable (from the Latin word, “vulnus,” meaning “wound”) or underserved patient.5 The Agency for Healthcare Research and Quality defines underserved or vulnerable patients as “… those who face barriers to timely access to health services which provide the best possible health outcomes. Populations… include racial and ethnic minorities, low-income groups, women, children, elderly, residents of rural areas, and individuals with special health care needs.”6 In addition, there are geographical or population-based variables used to designate a medically underserved area, and these include the following: 1) percentage of the population below poverty level; 2) percentage of the population 65 years or older; 3) infant mortality rate; and 4) the ratio of primary care physicians per 1,000 population.7 Therefore, vulneradequate medical care, are socioeconomically, culturally, or geographically isolated from the Civil War surgeons of the Union Army’s 3rd Division pictured before a hospital tent in Petersburg, VA, 1864.

health care system (i.e., the disenfranchised population); and those who encounter severe barriers to accessing services. 7

LIBRARY OF CONGRESS

able patients are those who have not received

For more than 200 years, public hospitals have stayed true to their mission to care for the underserved. Although all hospitals care for the underserved, public hospitals are unique in that: 1) they are mission critical to the care of the underserved and to the education of health care providers; 2) they are mission centric to the community for the provision of resources during crises and disasters, making them a valuable community resource for both insured and uninsured patients; and 3) they are ﬁnancially challenged despite external support. Core safety net providers have a legal mandate or explicit mission to offer patients access to services regardless of their ability to pay. Additionally, a substantial share of their patient mix must be uninsured, have Medicaid, and be other vulnerable patients.8

The Evolution of Public or Safety Net Hospitals Public hospitals have their roots in the

IMAGE COURTESY OF THE ARCHIVES OF THE FREDERICK L. EHRMAN MEDICAL LIBRARY

almshouses, a British practice of estab-

A view of Bellevue Hospital from the East River, 1879.

City Inﬁrmary, established in 1736), and Charity Hospital (New Orleans Almshouse, established in 1736).9,10

lishing a speciﬁc institution for those who

At the time, most medical care occurred in patients’ homes (doctors

were viewed as “failures of society”.9,10

practiced medicine by making house calls), but doctors were encouraged

These so-called “poorhouses” were institu-

to give of their time and skill to treat patients in public hospitals. This

tions designed to assist and house the poor,

arrangement beneﬁtted the patients, but was also valuable to the doctors,

disabled, and homeless, and to provide them

who gained experience in treating a wide range of maladies.11

with medical care in the event of serious

Whereas surgeons previously practiced in isolation, during the Civil

medical and surgical illnesses. In this regard,

War they functioned as a team, which contributed to the sharing of

they also served as a line of defense against

ideas and the setting of standards.12,13 They also recorded new surgical

infectious diseases that, if left uncontrolled,

techniques—such as the use of tourniquets to control acute hemorrhage

could become epidemics affecting greater

and arterial ligation for deﬁnitive vascular control—in manuals so they

numbers of people—including the wealthy—

could be shared with other surgeons and incorporated into medical

and disrupting commerce.11 Eventually,

school curricula.14,15

social reforms dictated that people housed

Hand-washing when caring for patients (Ignaz Philipp Semmelweis,

in almshouses for social reasons should

MD), the proposal that microorganisms cause disease (Louis Pasteur),

reside in other institutions, leaving only

and the advent of antiseptic surgery (Joseph Lister, MD) were signiﬁcant

those with medical problems to inhabit the

medical contributions from Europe during this time period.16,17 These

almshouses. Dedicated to serving the medi-

ﬁndings revolutionized care of the sick and injured, and their imple-

cally underserved, the almshouses held fast

mentation meant surgical procedures were more often met with positive

to their mission and became predecessors

outcomes, which bolstered respect for medical practitioners and the

of some monumental public hospitals in the

hospitals in which they practiced.12

United States, including Philadelphia General

The second half of the nineteenth century saw a rising need for

Hospital (Friends Almshouse, established in

public hospitals and their services.12 Those who were wounded in war

1713), Bellevue Hospital Center (New York

required care, as did many of the immigrants coming to American

Gundersen Lutheran— more than a century of surgical excellence Since pioneering appendectomy surgery in Wisconsin more than 120 years ago, Gundersen Lutheran has had a long history of being a leader in cutting-edge surgery. In more recent years, this has included multiple vessel minimally invasive coronary bypass surgeries, coiling for brain aneurysms, robotic surgery, and one of the ﬁrst to perform the LINX procedure to treat GERD. Our surgical outcomes and innovations have not gone unnoticed. Gundersen Lutheran has been named one of America’s 100 Best for Specialty Care in General Surgery* by HealthGrades in 2012.

gundluth.org/surgery *For 2012 by HealthGrades®

The American Hospital Association congratulates the

for its 100 years of inspiring quality As part of the American Hospital Association’s ongoing mission to improve the health of patients and communities, we introduced the Physician Leadership Forum to engage and partner with physicians to collaboratively advance excellence in patient care. The AHA’s Physician Leadership Forum also seeks to gather input from physicians to inform AHA policy and advocacy efforts while advancing physician leadership within the health care delivery system. Learn more about our resources for physicians at www.ahaphysicianforum.org.

shores, and urbanization contributed to the need as well. As a result, many public hospitals were established or expanded to meet the demand. Rotations at the Ellis Island Immigrant Hospital (opened in 1902) and Bellevue Hospital Center, to name two such institutions, were desirable due to the variety and complexity of patient cases, and medical schools increasingly established afﬁliations with public hospitals to enrich their students’ education.2,18,19 After World War II, new drugs such as penicillin and the Salk vaccine were available to treat and prevent disease, and effective outcomes from their use inspired respect and authority for the medical profession.12 By this time, the public’s perception of hospitals— particularly public hospitals—had changed; no longer just places where the ailing poor or “failures of society” were treated or housed, now hospitals could—and did—evaluate and treat with increasing success ill and injured patients of all income levels using medicine and surgical techniques made possible by medical advances made over the years.2,12,20

President Lyndon B. Johnson, with Harry S. Truman by his side, signs the Medicare bill into law, July 30, 1965.

Though they faced chronic ﬁnancial hardship, public hospitals continued in their mission to provide care to the underserved.

located in urban areas—this meant a decrease in critical funding, even

Afﬁliations with medical and nursing schools

as outpatient visits rose (310 percent from 1944 to 1965).12

helped them weather monetary issues.12 The Hill-Burton Act of 1946 made funds

Medicaid to provide health insurance for the elderly and the poor. With

available to hospitals for the purpose of reno-

this publicly funded coverage, citizens who previously relied on public

vation or construction on the condition that

hospitals’ services could choose to spend their insurance beneﬁts at

the hospitals provided a reasonable amount of

private or not-for-proﬁt hospitals.11 Private and not-for-proﬁt hospi-

uncompensated care to the indigent in return.

tals also had the ability to “cherry-pick” their patients—accepting

Many public hospitals had been in existence

those with coverage and turning away those who could not afford care,

for decades and were in need of repairs,

whereas public hospitals did not.2,11 Even though public expenditures on

upgrades, and expansions in order to continue

health care climbed, fewer dollars were ﬁnding their way into public

providing quality care to their large numbers

hospitals.11 The need for public hospitals persisted, however; some

of patients. As a survival measure, many such

citizens didn’t qualify for Medicare and/or Medicaid, and those who

public hospitals agreed to the stipulations and

did qualify found that the insurance didn’t necessarily cover all their

continued to serve the underserved.12,21

health care costs—costs that were rising (the consumer price index

Prosperity and the low unemployment rate ASSOCIATED PRESS

In the mid-1960s, the federal government enacted Medicare and

rose 300 percent between 1960 and 1980).12

following World War II saw many citizens

In addition to the uncompensated care, the number of admissions to

leaving the cities and moving to the suburbs,

public hospitals continued to rise and public hospitals struggled to fulﬁll

resulting in eroded tax bases in urban

their mission to serve the vulnerable. In 1976, the Commission on Public-

communities. For public hospitals—generally

General Hospitals was created to address this problem. Although its

The Duke Department of Surgery Congratulates the American College of Surgeons on Its Centennial Anniversary Celebrating 100 Years of the Highest Surgical Standards in Improving Patient Care

surgery.duke.edu

report recognized that urban public-general hospitals were unique in their needs and that special assistance was required, no concrete solutions were developed.12 Another major ﬁnancial blow to public hospitals was the enactment of the 1981 Omnibus Reconciliation Act, which discontinued Medicaid reimbursement based on “reasonable costs.”22 But, the Act also included a provision for states to consider a reimbursement plan for hospitals that served a disproportionate number of low-income patients with special needs. These provisions became known as the DSH, or the Disproportionate Share Hospital, program.22,23 As state and federal funding were still far from adequate, public hospitals needed an advocate. In 1980, the National Association of Public Hospitals (NAPH) was established as an advocacy group to lobby for safety net health systems to have adequate resources to respond to the needs of their patients and

Dr. Karl Radke examines a patient at the Community Health Center of Central Wyoming in March 2011. Community health centers play an important role in meeting the health care needs of poor, uninsured, and rural populations.

communities.24 NAPH members were able to tap into a network of hospitals and experts who were familiar with their struggles and

Safety Net Hospitals Today

could provide support. Further, their voices

ASSOCIATED PRESS PHOTO BY TIM KUPSICK

were heard in Washington, DC.

Today’s safety net hospitals provide resources that beneﬁt all members

During this period, some hospitals closed

of a community—such as trauma centers, burn care centers, HIV/AIDS

due to lack of funding, but others found ways

care, substance abuse counseling, and disaster response—and they are

to survive. Cutbacks in stafﬁng and number

instrumental in training doctors since they are often sites for graduate

of beds were common. In some cases, changes

medical education.2,12,20,26 However, their mission to administer care to

in ownership or management aided struggling

the vulnerable remains at the forefront.

facilities, with some hospitals coming under

Vulnerable patients face many problems when it comes to accessing health

the control of medical schools or other orga-

care and in trying to aid this population, those problems become challenges

nizations.2,12 Importantly, this period also saw

for safety net hospitals, too. Some barriers to access include: geography

the development of trauma centers (the ﬁrst

(for instance, lack of facilities in rural areas, or closure of a community’s

were established in 1966 at San Francisco

hospital due to lack of funds); language barriers; or immigration status.11,26

General Hospital and at Chicago’s Cook

When vulnerable individuals are able to access health care, they often

County Hospital—now the John H. Stroger,

present with advanced disease, increasing the acuity and complexity of their

Jr. Hospital of Cook County), many of which

medical or surgical conditions. Further, health issues can be compounded

were located within or afﬁliated with public

by socioeconomic factors like homelessness or poor nutrition.26

1,25

Offering such specialized care

Community health centers (CHCs) have a history of ﬁlling in health

helped public institutions compete in the

care gaps for poor or uninsured or those who otherwise lack ready

health care provider marketplace, but of even

access to other facilities, offering a place where people can receive

more signiﬁcance: In providing care neces-

mainly family and primary care (though some, like women’s clinics,

sary to the insured and uninsured alike, the

have a more specialized focus). While CHCs do help in addressing issues

public hospital became a safety net for the

of access, they face challenges as well, particularly securing funding

hospitals.

whole community.

2,12,26

to continue providing services.11

th AN AN NNI NIVE N NI IIVE VER VE RS SAR S ARY AR

1913-201 13 3

Over the decades, safety net hospitals have examined alternative methods of operation with cost savings and efﬁciencies as end points. These potential solutions include a reduction of services and/or personnel, enhancement of efﬁciency through mergers and streamlining of internal operations, and the development of collaborative initiatives with other health care facilities.27,28,29,30,31,32,33,34 One of the more successful strategies was that initiated by Cleveland MetroHealth, which developed a comprehensive public hospital system to include the MetroHealth Medical Center, Center

A medical student checks a patient in the emergency room at Harborview Medical Center. Safety net hospitals are important sites for graduate medical education.

for Rehabilitation, Center for Skilled Nursing Care, Clement Center for Family Care, and the MetroHealth Life Flight.35 But with all of the

San Francisco General Hospital; and the ﬁrst civilian burn center—from which

problems that public hospitals face, including

the first civilian intensive care unit and the first post-burn fluid resuscitation

budget reductions, rapid growth of Medicaid

protocol formed—was founded in 1947 at the Medical College of Virginia

managed care, an ideology that promotes

(now Virginia Commonwealth University Medical Center).12,37,38,39,40,33,41 And

privatization of the safety net hospital, and the

while doctors training at safety net hospitals gain valuable experience in both

socioeconomic factors of language barriers,

the physiological and social issues that affect health—thanks to the often

homelessness, and illegal immigrants, it is

complex cases they take on—such settings also engender in them a sense of

doubtful that there is one best solution. Effective

commitment to and compassion for their patients.20,26

advocacy and the continuous collection of data

Public hospitals have a remarkable history, as described. And, although

speciﬁc to the safety net hospital that validates

each hospital may be unique, they are united in heritage and destiny. If

their unique problems may be the most effective

safety net hospitals engage the community successfully, continue to build

24,

trust, establish new capability and capacity, and continue in their educa-

The NAPH conducts an annual survey of its

tional mission, they will survive, evolve, and continue their tradition of

member hospitals with the purpose of identi-

service. This will further enrich their heritage and future generations

fying trends in challenges and care. Selected

will be proud to be part of the mission to care for the underserved. Q

avenues to potential solutions in the long run. 34

results from its 2010 survey show that safety net hospitals continue to provide billions of dollars in uncompensated care while continuing in their mission to care for the underserved.36 Aside from their commendable mission to

This article is based in part on Dr. Rozycki’s Southeastern Surgical Congress Presidential Address, which was originally published in The American Surgeon.

ASSOCIATED PRESS PHOTO BY ELAINE THOMPSON

serve those in need, public hospitals have been sites of medical innovation and education that

Grace S. Rozycki, MD, MBA, FACS, is Professor of Surgery at Emory

beneﬁt all of society: The nation’s ﬁrst ambulance

University School of Medicine. For the past 17 years, Dr. Rozycki has

service was instituted at Bellevue Hospital Center

served as the Director of Trauma and Surgical Critical Care at Grady

in 1869; the ﬁrst blood bank (initially called the

Memorial Hospital in Atlanta, GA.

Blood Preservation Laboratory) was established at Cook County Hospital in Chicago in 1937;

David V. Feliciano, MD, FACS, is Past Chair of the ACS Advisory Council

groundbreaking research on blood ﬂow within

for General Surgery from 2007–2011 and is General Surgery Community

the heart (use of cardiac catheterization) was

Editor, ACS Web portal. He is an attending surgeon at Atlanta Medical Center,

conducted at Bellevue Hospital Center starting

Professor of Surgery at Mercer University School of Medicine (Macon, GA),

in the mid-1940s; the ﬁrst trauma centers were

and Adjunct Professor of Surgery at the Uniformed Services University of

developed in 1966 at Cook County Hospital and

the Health Sciences (Bethesda, MD).

References 1. Blaisdell FW. Changes in county hospitals during Sheldon’s tenure. Am J Surg. 2002;185:30-4. 2. Burns RP. The historic role and questionable future of public hospitals. J Am Coll Surg. 2008;206:767-81. 3. Friedman E. Problems plaguing public hospitals: Uninsured patient transfers, tight funds, mismanagement and misperception. JAMA. 1987:257:1850-7. 4. Gage LS, Andrulis DP. Our nation’s great public hospitals. JAMA. 1987;257:1942-3. 5. Random House Compact Unabridged Dictionary. Special Second Edition. New York: Random House; 1996. 6. U.S. Department of Health and Human Services. 2010 National Healthcare Disparities Report. AHRQ Publication No. 11-0005. 7. King TE Jr., Wheeler MB, Bindman AB, et al. Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations. New York; McGraw-Hill; 2007. 8. Lewin M, Altman S, eds. Institute of Medicine, America’s Health Care Safety Net: Intact but Endangered. Washington, DC: National Academy Press; March 2000. 9. Fr iedman E. Pu bl ic hospitals: Doing what everyone wants done but few others wish to do. JAMA. 1987;257:1437-1444. 10. Law rence C. History of the Philadelphia Almshouses and Hospitals (1905). Whitefish, MT: Kessinger Publishing LLC; 2010. 11. Waitzkin H. The history and contradictions of the health care safety net. Health Serv Res. 2005; 40:941–952. 12. National Association of Public Hospitals and Health Systems. A place of trust: Two centuries of care in America’s public hospitals. The Safety Net. Spring 2006;20:1-37. 13. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 3, Civil War Surgery: Desperate Measures for Desperate Wounds, pp 75-92. 14. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 6, Learning to Treat Wounds: The Surgeons, the Operations, and the Results, pp 161-166. 15. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 1, In the Beginning: Ill-Prepared and Overwhelmed, pp 22-25. 16. Alexander JW. The contributions of infection control to a century of surgical progress. Ann Surg. 1985;201:423-8. 17. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 7, Wound Infections: Laudable and Not-So-Laudable Pus, p 199. 18. Conway L. Forgotten Ellis Island: The Extraordinary Story of America’s Immigrant Hospital. New York: Harper Collins; 2007. Chapter 1, Constructing the Immigrant Hospital, pp 1-30.

19. Stetten D Jr. Bellevue Hospital: New York, July 1934–December 1936. PBM. 28:543–558, 1985. 20. Gourevitch M, Malaspina D, Weitzman M, Goldfrank L. The public hospital in American medical education. Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol. 85, No. 5: 779–786. 21. Opdycke S. No One Was Turned Away: The Role of Public Hospitals in New York Since 1900. New York: Oxford University Press; 1999. Chapter 3, Help in Time of Trouble, 1930-1950, pp 71-86. 22. Altman SH, Brecher C, Henderson MG, Thorpe KE, eds. Competition and Compassion: Conﬂicting Roles for Public Hospitals. Ann Arbor: Health Administration Press 1989; Chapter 1. Introduction. pp 6-8. 23. McKethan A, Nguyen N, Sasse BE, Kocot SL. Reforming the Medicaid disproportionate-share hospital program. Health Aff. 2009;W926 – W936. Available at content. healthaffairs.org/cgi/content/full/28/5/w926. Accessed February 2, 2012. 24. Available at: http://www.naph.org/. Accessed August 13, 2012 25. Trunkey DD. History and development of trauma care in the United States. Clin Orthop. 2000;374:36-46. 26. Meyer J. Safety Net Hospitals: A Vital Resource for the United States. November 2004. Available at http://www.esresearch.org/publications/NAPH_ﬁnal.pdf. Accessed August 13, 2012. 27. Zuckerman S, Bazzoli G, Davidoff A, LoSasso A. How did safety-net hospitals cope in the 1990s? Health Aff. 2001;20:159-68. 28. Brown ER. Public hospitals on the brink: Their problems and their options. J. Health Politics, Pol Law. 1983:7;927-43. 29. Gabow P, Eisert S, Wright R. Denver Health: A model for the integration of a public hospital and community health centers. Ann Int Med. 2003;138:143-150. 30. Cousineau MR, Tranquada RE. Crisis & commitment: 150 years of service by Los Angeles County Public Hospitals. Am J Public Health. 2007;97:606-15. 31. Hall MA, Hwang W, Jones AS. Model safety-net programs could care for the uninsured at one-half the cost of Medicaid or private insurance. Health Aff. 2011;30:1697-1707. 32. Taylor R, Blair S. Public hospitals: Options for reform through publicprivate partnerships, 2002. Available at http://siteresou rces.worldbank.org/ EXTFINANCIALSECTOR/Resources/282884-1303327122200/241Taylo-010802.pdf. Accessed August 13, 2012. 33. Felland LE, Lesser CS, Staiti AB, et al. The resilience of the health care safety net, 1996-2001. Health Serv Res. 2003;38:489-502. 34. Felland LE, Ginsburg PB, Kishbauch GM. Improving health care access for lowincome people: Lessons from Ascension Health’s community collaboratives. Health Aff. 2011;30:1290-8. 35. Suchetka, D. MetroHealth, Cuyahoga County’s safety net health system, reports earnings for third year in a row. http://blog.cleveland.com/health_impact/print. html?entr y=/2011/01/metrohealth_system_repor ts_ear.html. Dow nloaded on February 8, 2012. 36. Zaman OS, et al. America’s Safety Net Hospitals and Health Systems, 2010: Results of the Annual NAPH Hospital Characteristics Survey. Washington, DC: May 2012, www.NAPH.org. 37. National Association of Public Hospitals and Health Systems. First Hospital Ambulance Service. Available at http://www.naph.org/Homepage-Sections/Explore/ History/First-Hospital-Ambulance-Service.aspx. Accessed August 13, 2012. 38. Telischi M. Evolution of Cook County Hospital Blood Bank. Transfusion. 1974;14:623-28. 39. Opdycke S. No One Was Turned Away: The Role of Public Hospitals in New York Since 1900. New York: Oxford University Press; 1999. Chapter 4, Many Voices, Many Claims 1950-1965, pp 99-100. 40. Feliciano, DV. Nobel Prize winners who were trained as surgeons. American Surgeon. 2009. Jan;75(1):15-9. 41. Dimick AR, Brigham PA, Sheehy EM. The development of burn centers in North America. J Burn Care Rehabil. 1993;14:284-99.

Something in the Air “American Surgery’s Noblest Experiment”—C. P. Schlicke, JAMA, 1973 BY L AMAR S. MCGINNIS, JR., MD, FACS

This American College of Surgeons (ACS) Centennial publication is replete with the proud accomplishments of our chosen profession over the past 100 years. These sentinel achievements in surgery represent the vision, creativity, determination, hard work, ethos, and brilliance of those who preceded us. Their achievements, scientiﬁc and technical, have revolutionized the standard of surgical patient care and the esteem in which surgeons are held. However, it’s worth remembering that progress isn’t guaranteed. The

The same year, Thomas Cullen, MD, FACS,

early 1900s setting in which the ACS’ founders worked might well have

another founder of the Clinical Congress of

deterred hope for improvement. The medical profession was fraught with

Surgeons of North America and the chair of

problems. Medical education consisted largely of diploma mills. Surgery

the Cancer Campaign Committee, joined with

was to be avoided as infections often resulted and outcomes were dismal.

Clement Cleveland, MD, FACS, the president

With exceptions, hospitals were likewise to be avoided.

of the American Gynecologic

Care decisions were not based on evidence as records and

Society, and others to form

outcomes were largely unavailable. Cancer was a death

the American Society for the

sentence, the word itself evoking justiﬁable terror.

Control of Cancer (ASCC, later, the American Cancer Society). The new organization revo-

professionals recognized that progress was possible. There

lutionized public awareness of

was something in the air. Still, change is never easy and

cancer, established systemic

resistance to change is ever-present. Observant, dynamic,

patient data collection, and

persistent visionaries are capable of and did succeed in

trumpeted the importance of

initiating beneﬁcial change processes that persist today.

early recognition and treat-

Abraham Flexner’s review of the state of medical

Franklin Martin

ment. Subsequently, the College

education, reported in 1910, revolutionized this ﬁeld and

formed its own Committee on

resulted in modern medical education. William Halsted,

the Treatment of Malignant

MD, established a new paradigm for surgical education and training and

Disease by X ray and Radium, chaired by

established a new American approach to surgical technique.

Robert Greenough, MD, FACS, which even-

Franklin Martin’s concern regarding the lack of available continuing

tually evolved into the ACS Committee on

surgical education propelled him to establish the journal Surgery,

Cancer and then into the present multidisci-

Gynecology and Obstetrics (SG&O, now the Journal of the American

plinary Commission on Cancer.

College of Surgeons—JACS). He established the Clinical Congress of

The American Joint Committee on Cancer

Surgeons of North America (now the ACS Clinical Congress, the largest

(AJCC) was yet another, later, ACS offshoot,

annual surgical meeting in the world) and, with others, the American

chaired initially by Murray Copeland, MD,

College of Surgeons in 1913.

FACS. R. Lee Clark, MD, FACS, was also very

PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES

But opportunities abounded. The Industrial Revolution was changing the world and thoughtful, observant medical

Hospital (MGH). He had many fields of interest and expertise, from the diagnostic X ray to anesthesia (he formulated the anesthesia record with Harvard classmate Harvey Cushing), bone sarcoma, the shoulder, duodenal ulcer, tumor registries, and more. His impact on all of these areas was profound and long lasting, yet his most significant contribution was also his most controversial. He believed that surgeons and institutions should be accountable for their surgical results. Dr. Codman established the first mortality and morbidity conference at the MGH, where he famously declared, “Every hospital should follow every patient it treats long enough to determine whether or not the treatment has been successful, and then to inquire, ‘if not, why not?’” In other words, don’t just operate and discharge the patient; see what happens and learn from that. Dr. Codman strongly believed that health care professionals and their institutions should maintain accurate records, document and analyze their findings, and be very transparent with these findings. He also had the unusual belief (for that time) that

Ernest Amory Codman

hospitals should have quality standards. Though Dr. Codman reckoned that it might be 100 years before it would ﬁnd acceptance, he established

NIH NATIONAL LIBRARY OF MEDICINE / THE BOSTON MEDICAL LIBRARY IN THE FRANCIS A. COUNTWAY LIBRARY OF MEDICINE

involved in the early days of the AJCC. The

the “end result” idea (outcomes studies, evidence-based medicine).

resulting emphasis on the proper staging

He was brilliant, different, challenging, and outspoken. He could also

of cancer became the basis for modern

be direct, abrasive—even offensive—but was always highly principled.

stage-based cancer therapy. Our College

Dr. Codman’s personally drawn cartoon lampooning the medical estab-

also formed, in 1922, the Committee on the

lishment for its disinterest in outcome data is a classic. His surgical

Treatment of Fractures, chaired by Charles

professional career unfortunately suffered as a result of his views. He

Scudder, MD, FACS. It ultimately became the

died in 1940, of melanoma, and his body is buried in an unmarked grave

ACS Committee on Trauma (in 1949) that

in his wife’s family plot in the Mount Auburn Cemetery in Cambridge, MA.

has contributed to a century of improvement in the offerings of this surgical discipline. So transcendent has been the evolution of these early 20th cent u r y development s t hat

Dr. Codman established the ﬁrst mortality and morbidity conference at the MGH, where he famously declared, “Every hospital should follow every patient it treats long enough to determine whether or not the treatment has been successful, and then to inquire, ‘if not, why not?’”

today we take them for granted. Similarly, I suspect many Fellows and the public are unaware of the role our College has played in this evolution. That role is exempliﬁed by the formation of The Joint Commission (originally the Joint Commission on Accreditation of Hospitals) and its chief architect, Ernest Amory Codman, MD, FACS. A Harvard-educated Boston Brahmin, Dr. Codman became a most successful staff surgeon

Ernest Amory Codman’s Back Bay golden goose cartoon.

at the Massachusetts General

Dr. Craig R. Smith and the Columbia University Department of Surgery

Congratulate the

American College of Surgeons 100th year in the pursuit of excellence in surgery

Clinical Congress of Surgeons

was formulated from

of North America President

ideals advanced by Dr.

Edward Martin, MD, FACS,

Codman and codified by

learned of Dr. Codman’s “end

John Bowman, PhD, the

result” idea and felt that a

ACS’ first Director. This

newly formed college would

Minimum Standard focused

be an excellent instrument to

on medical staff organiza-

introduce this concept into

tion, critical evaluation

hospitals and to standardize

of clinical practice, and

those hospitals. As our College

medical records standards.

was forming, its leaders had

Though it was decided

the great foresight to appoint

implementation of the

Dr. Codman as the ﬁrst chair

Minimum Standard should

of the Standards Committee.

be voluntary, not manda-

Upon helping to found the College, Franklin Martin, MD, FACS, decided it should

In 1918, the College began

include among its original

surveying hospitals of 100

purposes the betterment of

beds or more, ﬁnding that

surgical education and of the

only 12.9 percent (89 out of

clinical practice of surgery.

the 692 hospitals surveyed)

He recognized that successful

met this Minimum Standard.

work is most easily and reliably accomplished in a proper environment.

IMAGE COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES

tory, it achieved international fame and acclaim.

The survey findings were reported at a 1919 meeting at the Waldorf-Astoria hotel in New York

The absence of such an environment was

City, but information about individual hospitals’ identities and their

illustrated by the dilemma facing applicants

particular results were burned in the furnace the night before, an act

for fellowship in the ACS. Applicants were

infamously referred to as the “pyre in the Waldorf cellar.”

required to submit case records of their

The College continued surveying on an annual basis with a slow but

surgical work, but due to the absence of

steady improvement in compliance. By 1923, 86.2 percent of hospitals of

hospital documentation most could not. Many

100 beds or more met the Minimum Standard and 46.9 percent of hospitals

hospitals lacked central record-keeping facili-

under 100 beds met it. Dr. Franklin Martin reported the survey ﬁndings at

ties. Cases were either inadequately recorded

the 1923 Clinical Congress, with President Harvey Cushing presiding. Dr.

or not at all. Laboratory and radiologic

Franklin Martin later reﬂected, “The American College of Surgeons, with the

facilities were deﬁcient, medical staffs were

exuberance of youth and unhampered by tradition, decided to make itself

unorganized, and educational requirements

responsible for the standardization of its own environment – the hospital.”

were undeﬁned. Professional medical work

In the beginning, the College accumulated valuable data through

was generally unsupervised.

conferences, correspondence, and carefully conducted research into

Admirably, the College accepted the respon-

hospital management. This information suggested that not only was

sibility for correcting this deﬁciency. In 1917,

there a need for the application of the Minimum Standard, but also

the first Minimum Standard for Hospitals

the need for a personal visit to each institution by a representative of

In 1924, Dr. Franklin Martin observed, “The Minimum Standard has become to hospital betterment what the Sermon on the Mount is to great religion.” A movement had begun, with great beneﬁt to all. 69

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at his hospital from the program. On the major problem of the time, fee splitting, he observed, “I do not know that it exists in New Brunswick, perhaps because a good many of the men down there are Scotch and hate to part with any money. You know they say that the difference between a Scotchman and a horse cart is that the cart tips.” The College initially wanted the American Medical Association (AMA) to run the standardization program but was turned down. Despite his organization’s refusal to participate, the chairman of the AMA Council of Evarts Graham

Medical Education stated at the time, “… this problem that confronts the American College of Surgeons, along with medical education, is the most

BECKER MEDICAL LIBRARY, WASHINGTON UNIVERSITY SCHOOL OF MEDICINE / PHOTO COURTESY OF THE JOINT COMMISSION

important thing in American medicine.” the standardizing agency and an accurate

That importance was demonstrated by the College’s commitment as

record of the ﬁndings of the representatives

sole executor of the hospital standardization program from 1918 to

that would be made available to the public.

1951. From 89 approved hospitals (12.9 percent of hospitals of 100 beds

The Carnegie Foundation, which had funded

or more surveyed) in 1918 to 2,067 approved hospitals (93.6 percent of

Flexner’s medical school survey and report,

hospitals of 100 beds or more) by 1945, rapid acceptance of the program

joined the ACS in funding this hospital survey

was apparent. The theme was “the proper care of the sick and injured.”

process over a ﬁve-year period, 1918–1923.

Nevertheless, opposition to standards and measurement remained,

This was complemented by cooperation from the

particularly with respect to transparency, a problem that continues to

American Hospital Association and the Catholic,

this day. Supporting the movement, Will Mayo, MD, FACS, said in 1929,

Protestant, and Methodist hospital associations.

“when hospitals and physicians accept standardization, the millennium

Assuming the hospital standardization move-

will have arrived.” Well, we are here. Over the years, cost became a

ment was destined to extend far into the future,

mounting concern. By 1950, total College investment in the program

the College shouldered the full ﬁnancial and

came to $2 million, yet pride was taken in the fact that 3,290 hospitals

labor burden for this process beginning in 1923.

had been accredited by that year.

Bowman, the ﬁrst ACS Director, set the

But that year, the ACS Board of Regents determined it was no longer

precedent of visiting hospitals. Subsequently,

possible to maintain the program solely from dues collected from Fellows. A

Malcolm MacEachern, MD, Associate ACS

power dance had begun. The American Hospital Association was determined

Director, took on this responsibility and main-

to take over the program. The AMA was as determined that they should

tained it for 28 years. The service was rendered

not. The College became the arbiter of the debate and after nine months of

free of charge to hospitals of more than 50

oft times acrimonious deliberation, Evarts Graham, MD, FACS, offered an

beds in the U.S. and Canada. Compliance

ultimately acceptable solution.

required competent laboratory and radiology

Dr. Graham proposed a new inde-

services, adequate medical documentation,

pendent, not-for-profit corporation

data analysis, and a culture of learning.

with governance to be split equally

In 1924, Dr. Franklin Martin observed, “The

between the AMA, the American

Minimum Standard has become to hospital

Hospital Association, and an equal

betterment what the Sermon on the Mount

number of representatives from the

is to great religion.” A movement had begun,

ACS and the American College of

with great beneﬁt to all.

Physicians, along with one repre-

Joh n McKenzie, M D, FACS, of New

sentative from the Canadian Medical

Brunswick, Canada, proclaimed at that

Association (withdrew in 1959). The

time, “I have heard it said, and said it myself

A merican Hospital Association’s

through lack of knowledge, that the College

George Bugbee suggested the phrase,

program on hospital standardization is of

the “Joint Commission.”

very little value.” He then offered six sound points of beneﬁcial impact that had occurred

Edwin L. Crosby

The idea was adopted and the Joint Commission on Accreditation

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Today, The Joint Commission accredits more than 19,500 health care organizations and programs in the United States, including more than 10,500 hospitals and home care organizations (encompassing 86 percent of U.S. hospital beds) and more than 6,500 other health care organizations that provide long-term care, behavioral health care, and laboratory and ambulatory care services. It certifies more than 2,400 disease-specific care programs, primary stroke centers, and health care staffing services.

of Hospitals (JCAH) was formed in 1951 with

on Accreditation of Healthcare Organizations (JCAHO), as an expanded

funding from the member organizations.

coterie of health care organizations were made eligible for accreditation.

Surveys were to be carried out by a JCAH staff

In the 1990s, standards began to embrace performance improvement

of trained surveyors. The ACS transferred the

concepts, and ﬁve additional public members were added to the Board,

hospital standardization program in 1952, and

along with an at-large nursing representative. Unannounced random

in 1953, the JCAH began offering accreditation

surveys began, smoking in hospitals was prohibited, and laptop tech-

and published its ﬁrst Standards for Hospital

nology was introduced to the survey process, bringing greater objectivity

Accreditation. As the JCAH scope of activity

and efﬁciency. Sentinel events reporting began, Sentinel Event Alerts

expanded, an increasing number of hospitals

were published, and the standards manual was revised to focus on

sought accreditation and costs increased. As a

processes and outcomes of care rather than standards of care.

result, in 1964, the JCAH began charging fees to organizations seeking accreditation.

In the ﬁrst decade of the 21st century, international accreditation expanded rapidly, as did the number of health care sites eligible for

With the advent of Medicare in 1965, accred-

accreditation. Signiﬁcant “white papers” were published and disease-

ited hospitals were “deemed” to be in compli-

speciﬁc care certiﬁcation programs began. In 2007, the organizational

ance with requirements set for eligibility to

name was simpliﬁed to The Joint Commission. A number of new Board

participate in Medicare and Medicaid. To differ-

Members representing other areas of health care were added to the

entiate accreditation from just meeting govern-

Commission, and accreditation manuals were offered electronically. The

ment requirements, the JCAH determined to

Center for Transforming Healthcare was launched to develop solutions

focus its standards on the “optimum achievable”

through the application of Robust Process ImprovementTM methods and

rather than, as formerly, the “minimum essen-

subsequently these solutions have been offered to accredited institutions.

tials.” The standards were revised beginning

Today, The Joint Commission accredits more than 19,500 health care

in 1966 to reﬂect this new focus, and optimal

organizations and programs in the United States, including more than

achievable standards were published in 1970.

10,500 hospitals and home care organizations (encompassing 86 percent

Whether “optimal” or “minimum,” Edwin L.

of U.S. hospital beds) and more than 6,500 other health care organizations

Crosby, MD, the JCAH’s ﬁrst President, asserted

that provide long-term care, behavioral health care, and laboratory and

in 1972 that “no other single idea has done as

ambulatory care services. It certiﬁes more than 2,400 disease-speciﬁc

much to upgrade American hospitals and to

care programs, primary stroke centers, and health care stafﬁng services.

assure that the facilities of the hospital maintained high standards of quality and safety.”

From its inception, The Joint Commission’s mission has been to help health care organizations improve the quality and safety of care through

By 1970, the hospital accreditation stan-

accreditation. But in recent years, accreditation itself has often been

dards manual had evolved from the one-page

perceived by health care professionals more as a “regulatory” activity

Minimum Standard of 1918 to 152 pages

than a quality improvement activity. Consequently, the Commission has

representing the state of the art of hospital

reframed its mission to improve health care by evaluating health care

care. The JCAH continued its evolution with

organizations and inspiring them to excel in providing safe and effective

the American Dental Association becoming a

care of the highest quality and value, with accreditation becoming but

corporate member in 1979 and the ﬁrst public

one of the Commission’s tools for achieving this goal.

Board Member appointed in 1982. In 1987, the

The Commission reinvented its on-site survey process by tracing the

name was changed to the Joint Commission

care of patients throughout their hospital experience—from the emergency

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of the organization. Mark C ha ssi n, M D, a ssu med t he presidenc y of The Joint Commission in 2008, bringing surveys with a strong collaborative, educational tilt—and a sense of aspiration—that is today hera lded by accred ited organizations. The introduction of Robust Process Dennis O’Leary

Mark Chassin

Improvement pr i nciples along with problem-solving tools offers a bright outlook

department and the operating room, through

toward moving health care to a “high reliability industry.”

to the recovery or intensive care unit, all the

The Commission also shares its quality improvement and evaluation

way to the discharge planning process. The use

expertise internationally, currently accrediting 450 health care organiza-

of this “tracer” methodology enables surveyors

tions in more than 50 countries.

to provide expert guidance to staff that visibly

The Joint Commission’s vision is an environment in which “All people

impacts the quality and safety of patient care.

always experience the safest, highest quality, best-value health care

Even with this guidance, organizations

across all settings.” It has dedicated its resources, along with those

frequently are unable to implement and

of Joint Commission Resources, Inc., and the Center for Transforming

sustain effective solutions to some of the most

Healthcare, to help health care organizations achieve this goal.

intractable problems in health care, including

That “something in the air” in the early 20th century wrought multiple

some whose solutions appear straightforward,

institutions that persist today. Perhaps “American Surgery’s Most Noble

such as hand hygiene, prevention of surgical

Experiment” has been the most impactful. The standardization of hospitals

site infections, and prevention of wrong

(now virtually all health care organizations) was inspired by Dr. Codman

person/wrong site procedures.

and adopted by our College alone. ACS staffed, nurtured, ﬁnanced, and

The underlying causes frequently differ

oversaw standardization during more than half of The Joint Commission’s

from organization to organization, such that

existence. This was done out of a sense of professionalism—yet never

a solution for one would not necessarily be

designed to be profession serving—and steadily advanced in the face of

effective for another. As such, Robust Process

both internal and external resistance. We should take pride in all that our

Improvement problem-solving methods (LEAN

College created and the capabilities and opportunities that continue for

Six Sigma, change management) are critical

further betterment of patient care in the 21st century.

to identifying organization-speciﬁc problems

Renowned anthropologist Margaret Mead once said, “We are continually

and designing cause-specific solutions. A

faced with great opportunities which are brilliantly disguised as unsolvable

Targeted Solutions ToolTM is made available

problems.” Our College and its Fellows are up to the challenge. Q

PHOTOS COURTESY OF THE JOINT COMMISSION

at no cost to accredited organizations to facilitate problem solving speciﬁc to that organiza-

LaMar S. McGinnis, Jr., MD, FACS, practiced general and oncologic

tion. However, a vigorous change management

surgery in Atlanta for 40 years. He is a former President of both the

process is crucial for the successful and

American College of Surgeons and the American Cancer Society and

sustained implementation of these solutions.

is presently a member of the Board of Commissioners of The Joint

The Joint Commission was led for 20

Commission and Vice-Chair of the Board of Joint Commission Resources.

years by President Dennis O’Leary, MD, who

Dr. McGinnis is Adjunct Professor of Surgery at the Emory University

bridged the centuries and began the changes

School of Medicine and former Medical Director of the Eberhart Cancer

necessary to bring the organization into

Center in Atlanta. He is presently serving as Senior Medical Advisor and

the “modern era” while becoming the face

Liaison for the National Home Ofﬁce of the American Cancer Society.

ACS Quality Programs by CLIFFORD Y. KO, MD, FACS

Quality was the issue around which the American College of Surgeons (ACS) was formed, and it is embedded in the organization’s mission statement: to improve the quality of surgical patient care by setting high standards for surgical education and practice. Optimal patient care is the chief objective of the surgeon’s professional life—and of the College’s fellowship.

In the early 20th century, surgeons were initially

and Prevention (CDC) to reduce surgical complica-

drawn to join the ACS because of a goal advanced

tions. The ACS is also an active member of the Surgical

by its founders: to implement quality assurance and

Quality Alliance (SQA), a collaboration among more

standardization measures that were sadly lacking in

than 20 surgical specialty societies for the purpose

American health care. By 1917, the College had devel-

of improving the quality of surgical patient care, for

oped its ﬁrst set of minimum standards for hospitals,

deﬁning principles of surgical quality measurement

and began conducting inspections under its Hospital

and reporting, and for developing awareness about

Standardization Program in an effort to ensure safe

unique issues related to surgical care in all settings.

care environments and an effective system of care

While devising its own quality improvement initia-

for surgical patients. Of the 692 hospitals surveyed

tives, the College has remained a leader since its 1913

by the ACS, only 89 met its minimum standards.

inception. In 2000, as a result of the ACS’ long-range

The growing complexity of the accreditation

strategic planning process, the College was reorganized

program led to the establishment of what is known

into four divisions: the Division of Advocacy and Health

today as The Joint Commission, which began offering

Policy, the Division of Education, the Division of Member

accreditation in 1953. The ACS remains thoroughly

Services, and the Division of Research and Optimal

involved in the accreditation process, however;

Patient Care (DROPC). The DROPC encompasses all the

not only do three ACS commissioners serve on The

cancer and trauma programs, as well as the section of

Joint Commission, but the College conducts other

Continuous Quality Improvement (CQI), which houses the

accreditation services through its many programs.

American College of Surgeons National Surgical Quality

In addition to its internal programs, the College

Improvement Program® (ACS NSQIP®), the Metabolic and

participates in several other national-level quality

Bariatric Surgery Accreditation and Quality Improvement

improvement efforts. For example, it’s one of the 10

Program (MBSAQIP), the Surgeon Speciﬁc Registry (SSR),

organizations on the steering committee of the Surgical

and the ACS Clinical Scholars in Residence Program.

Care Improvement Project (SCIP), a partnership initi-

The following sections are brief descriptions

ated in 2003 by the Centers for Medicare and Medicaid

of these programs and highlight some of the

Services (CMS) and the Centers for Disease Control

quality and safety efforts ongoing in the ACS.

Committee on Trauma The

of trauma care. Using the infra-

care settings to measure cancer care

structure of the NTDB, TQIP, which

quality; uses data to monitor treat-

C om m it t e e

now has 1,245 participating trauma

ment patterns and outcomes and

on Trau ma (COT )

centers, collects data, provides feed-

enhance cancer control and clinical

develops the stan-

back to participants, and identiﬁes

surveillance activities; and develops

dards used to verify

the institutional characteristics asso-

effective educational interventions

trau ma

centers.

ciated with improved outcomes in

to improve cancer prevention, early

The evaluation of trauma centers is

trauma care. The program includes

detection, cancer care delivery, and

accomplished through on-site reviews

a site visit analysis of the trauma

outcomes in health care settings.

by a peer-review team experienced

center’s data quality to prov ide

The Commission coordinates

in the field of trauma. There are

external data validation. Web confer-

national studies on care patterns and

currently more than 350 ACS-veriﬁed

ences, an online course, and monthly

patient outcomes through the annual

trauma centers. The Trauma Systems

quizzes offer ongoing education. An

collection, analysis, and dissemina-

Consultation Program provides an

annual meeting provides hospitals an

tion of data for all cancer care sites

on-site trauma system review of a

opportunity to share best practices

through the National Cancer Data

state or region by a multispecialty

for performance improvement. Case

Base (NCDB). Established in 1989, the

team. This review provides critical

studies are also presented.

NCDB is a nationwide, facility-based

analysis of the current system and recommendations for improvement.

oncology data set that captures about 75 percent of all newly diagnosed

Cancer Programs

Since 1989, the COT has compiled

cancer cases in the United States, and

information about traumatic inju-

now contains approximately 26 million

r ies from par ticipati ng trau ma

records from hospital cancer registries

centers, and the resulting database,

across the United States. Data on all

the National Trauma Data Bank ®

types of cancer—including data on

ALL LOGOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS

(NTDB ), is the largest aggregation

patient characteristics, tumor staging

of U.S. and Canadian trauma registry

and characteristics, first course

data ever assembled; it now contains

The multidisciplinary Commission

treatment, disease recurrence, and

more than 5 million records. In 2012

on Cancer (CoC ®) was established

survival—are tracked and analyzed by

alone, 733 facilities submitted records

by the ACS in 1922 to set standards

the NCDB, and then used to explore

to the NTDB, which is used by the

for high-quality cancer care. Today,

trends in cancer care. The data is

COT to synthesize reports analyzing

more than 100 people, representing

disseminated to CoC-accredited hospi-

both site-speciﬁc and national perfor-

49 national professional organiza-

tals in the form of regional and state

mance in trauma medicine.

tions, comprise the Commission—the

benchmark reports, survival reports,

Ultimately, the goal of the NTDB

only multidisciplinary accreditation

program practice proﬁle reports, and

is to inform the medical community,

organization for cancer programs in

other formats, serving as a basis for

the public, and decision-makers

the United States—which has estab-

quality improvement.

about the variety of issues involved

lished patient-centered standards and

In 1998, the American College of

in the care of injured patients—

conducted the accreditation of more

Surgeons Oncology Group (ACOSOG)

i nclud i ng epidem iolog y, i nju r y

than 1,500 hospital cancer programs.

was established with the primary

control, research, education, acute

The CoC provides clinical oversight for

focus of improving the care of the

care, and resource allocation.

standard-setting and the development

surgical oncology patient. The

of patient care guidelines; conducts

Group is a cooperative effort to

The COT has built on the NTDB with the establishment of the Trauma

surveys in health care settings to

Quality Improvement Program (TQIP),

assess compliance with those

piloted in 2008 and developed as a

standards and g u idel i nes;

validated, risk-adjusted, outcome-

collects standardized data

based measurement of the quality

from CoC-accredited health

conduct randomized clinical trials, and it includes a broad cross-section of

ALLIANCE

FOR CLINICAL TRIALS IN ONCOLOGY

medical professionals: general and specialty

Weâ&#x20AC;&#x2122;re ready for the greatest challenges.

8&+ RU UCHOSPITALS.EDU

surgeons, professionals from related

education. As it matures, the program

Rigorous data collection methods, data

oncolog ic disciplines, and allied

will strengthen the scientiﬁc basis for

collector training and annual testing,

health professionals in academic

improving quality of care, develop

data audits, the use of clinical data,

medical centers and community prac-

consensus on criteria for quality

as well as some of the most advanced

tices throughout the United States and

performance and monitoring, and

risk-adjustment methods are just some

foreign countries. In 2000, ACOSOG

establish a National Breast Disease

of the reasons for ACS NSQIP being

become one of nine adult cooperative

Database to report patterns of care

recognized as “best in the nation.”

groups funded by the National Cancer

and enable quality improvement.

Institute to develop and coordinate multi-institutional clinical trials. In 2011, ACOSOG merged with two other

Today, the ACS NSQIP is available to all private-sector hospitals. Participating

Continuous Quality Improvement

hospitals and their surgical staffs can use ACS NSQIP data to make valid

adult cooperative groups to form the

comparisons among hospitals in the

Alliance as part of a national initia-

program and make informed decisions

tive to consolidate the NCI groups into

about their quality improvement efforts,

a clinical trials network. The Alliance

with the overarching principle being the

maintains its close relationship with

use of risk-adjusted outcomes data to

the ACS and the CoC to continue the focus on improving the care of the

drive improvement. ACS NSQIP: With the vision and

ACS NSQIP has numerous built-in

long-term goal of establishing and

mechanisms for providing feedback to

In 2004 and 2005, the CoC submitted

maintaining a repository of the best

participating hospitals and the program

quality of care measures for breast

evidence for the practice of surgery,

as a whole, including annual data

and colorectal cancer to the National

the College was a curious and careful

audits, site visits, and the sharing of best

Quality Forum in response to the

student of a program pioneered

practices. This structured response,

Forum’s solicitation. The revised care

in 1994 by the Veterans Health

orchestrated by program staff, ensures

measures helped to serve as a basis

Administration (VHA). The program,

consistent reporting of data across sites

for another ACS effort, ﬁrst proposed

which became known as the National

and the rapid dissemination of informa-

in 2005, to develop a program for the

Su rg ica l

I mprovement

tion about the surgical practices and

recognition of breast centers in the

Program (NSQIP), was the ﬁrst and

environments that produce the highest

United States.

on ly prospective, risk-adjusted,

quality of care.

surgical oncology patient.

Q ua l it y

The resulting initiative, the National

validated database for quantifying

The College has expanded ACS

Accreditation Program for Breast

30-day surgical outcomes. Led by

NSQIP to more than 500 private-sector

Centers (NAPBC), was established

the innovative thought leaders in the

hospitals, including pediatric surgery

as a consortium of national profes-

VHA, the use of NSQIP in VA hospitals

hospitals that have implemented the

sional organizations dedicated to

has decreased 30-day postoperative

pediatric module of ACS NSQIP, and

the improvement in quality of care,

mortality following major surgery by

the results have been dramatic. Studies

and in monitoring of outcomes of

27 percent, and 30-day morbidity by

have shown that in a given year, the

patients with diseases of the breast.

45 percent; postoperative lengths of

average adult hospital using ACS NSQIP

The consortium pursues this mission

stay have been reduced, on average,

prevents 250–500 complications, saves

through activities such as stan-

from nine to four days.

12–36 lives, reduces costs by millions

dards-setting, validation through

After several pilot tests of NSQIP

of dollars, and provides an ongoing

research, and patient and professional

methods at nonfederal university

learning cycle that enables continuous

hospitals, the College launched its own

improvement. More than 80 percent

version of the program in 2003; during

of hospitals improve their complica-

this time, the Institute of Medicine

tion rates statistically significantly,

declared ACS NSQIP the “best in the

and more than two-thirds statistically

nation” for measuring and reporting

signiﬁcantly improve their mortality

surgical quality and outcomes.

rates. The top 12 American hospitals in

UnitedHealth Group congratulates the

AMERICAN COLLEGE OF SURGEONS on their 100-year anniversary.

Helping people live healthier lives and making the health system work better for everyone.

the U.S. News & World Report’s rank-

support the surgeon with evaluating

(ASMBS) approached College leader-

ings participate in ACS NSQIP.

and improving his/her quality of care.

ship regarding the possible unifi-

Mea nwh i le, recog n i z i ng t hat

To their credit, thousands of surgeons

cation of its program with the ACS

different hospitals may take different

have participated in the registry. More

program to achieve one standard

paths to quality improvement based

recently, an increasing number of

in accreditation for metabolic and

on their setting or specialty, the ACS

regulatory items have been created

bariatric surgery. This proposal

continues to reﬁne ACS NSQIP. The

that require individual surgeon data.

was accepted, and in April 2012,

College has developed six program

The SSR has been advanced and modi-

the uniﬁed bariatric program was

options designed for all hospitals and

ﬁed to address many of these regula-

unveiled. Under the newly uniﬁed

quality-improvement goals, regard-

tory items, including but not limited to

program, a Standards Committee

less of size, hospital type, patient

Maintenance of Certiﬁcation by various

was formed and charged with devel-

population, and type and number of

boards of surgery, and the Physician

oping a uniﬁed set of standards and

procedures performed.

Quality Reporting System, put forth

writing a standards manual. Once

The success of ACS NSQIP has

by the CMS. There are currently more

the standards have been vetted and

caught the attention of the federal

than 4,000 surgeons participating in

approved, all new bariatric centers

government’s non-veteran health care

the SSR, and the registry contains in

seeking accreditation and those

agencies. In 2011, CMS announced a

excess of 1 million cases. Ongoing

coming up for re-accreditation will

measure to encourage participation

work is being performed to enhance

do so under the new standards. A

in a general surgery registry, such as

the registry’s use for other regula-

goal of January 2013 has been set for

ACS NSQIP, and expressed its inten-

tory items such as Ongoing Practice

implementation of the new standards.

tion to move toward the reporting of

Performance Evaluation from The

As of June 2012, there were more

clinical data and outcome measures.

Joint Commission, and Maintenance of

than 750 facilities in the program,

In the spring of 2012, the ACS and

Licensure from individual state boards.

now ca l led t he Meta bol ic a nd

the CDC joined in a three-year project

Bariatric Surgery Accreditation and

that will combine the strengths of both

Quality Improvement Program. This

organizations’ quality improvement

partnering of the ACS with the ASMBS

programs—ACS NSQIP and the CDC’s

again shows how surgical societies

National Healthcare Safety Network—

are able to work together to improve

to target surgical-site infections and related complications. Other important

surgical quality, outcomes, and safety. Metabolic

and

Bariatric

partnerships to further surgical quality

Surgery Accreditation and Quality

improvements have been developed

Improvement: In 2006, the ACS

with The Joint Commission Center

developed an accreditation program

for Transforming Healthcare and the

to evaluate and improve the quality of

Institute for Healthcare Improvement.

Surgical Safety: Nora Institute for Surgical Patient Safety

care in bariatric surgery. More speciﬁ-

Safety in surgery is an impor-

R eg i s t r y:

cally, the program sought to establish

tant aspect of the ﬁeld. To this end,

Increasingly, there are a number of

standards of care, provide reliable

the Nora Institute champions the

advantages for evaluating provider-

outcome data, delineate approvals/

reduction and elimination of safety

speciﬁc quality of care. To this end,

verification processes for hospitals

issues within surgery. Advances in

the SSR, which has grown out of the

and outpatient facilities, and establish

the use of checklists, the surgical

ACS Case Log system, has become

credentialing criteria for surgeons.

time out, and pre-surgical brief-

a means for surgeons to record and

Since the inception of this program,

ings have been important topics in

review their cases—with risk adjust-

the outcomes of bariatric surgery

ment and benchmarking an important

have markedly improved, including

hallmark of the system.

decreased mortality rates.

Su r ge o n

Sp e c i f i c

Since the inception of this registry,

In late 2011, the American Society

the aim has always been to assist and

for Metabolic and Bariatric Surgery

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this regard. Through the Institute,

NTDB, guideline development, and

Scholars program. These individuals

the ACS published a patient safety

accreditation programs.

have noted that they have had excel-

manual titled Surgical Patient Safety:

In addition, participants earn a

lent, productive experiences that have

Essential Information for Surgeons in

master’s degree in health services

been useful in launching their careers

Today's Environment. This manual

and outcomes research or health

in the field of academic surgery.

provides information and guidance

care quality and patient safety during

With many scholars having already

for surgeons and others involved in

their two years at ACS Headquarters

completed the program, the residents

patient safety. It analyzes the human

in Chicago, IL. The goal of this aspect

have demonstrated great dedication to

factors, systems, and processes that

of the program is to educate clini-

outcomes research and the improve-

affect surgical patient safety, and

cians to become effective health

ment of the quality of surgical care in

also outlines broad error-prevention

services and outcomes researchers.

line with the goals of the ACS.

methods such as the use of surgical

The health services and outcomes

The ACS Clinical Scholars have

simulation, educational interventions,

research curriculum focuses on these

presented their ﬁndings at numerous

and quality improvement initiatives.

issues within institutional and health

national meeting presentations and in

care delivery systems, as well as in

high-impact, peer-reviewed publica-

the external environment that shapes

tions, in addition to having contributed

ACS Clinical Scholars Program

health policy centered on quality and

a great deal to the ACS quality improve-

Since 2006, the ACS has had a

safety issues. The program takes

ment programs. Furthermore, scholars

Clinical Scholar in Residence. The

approximately two years to complete.

have gone on to gain prestigious fellow-

program is designed for surgical

In addition to the master’s degree, the

ships in several ﬁelds, including surgical

residents to pursue a two-year on-site

program also offers a variety of educa-

oncology and pediatric surgery.

fellowship in surgical outcomes,

tional programs from which Clinical

health services, and health care policy

Scholars may beneﬁt, including an

research. The program is intended

Outcomes Research Course, the Young

to advance the College’s quality

Surgical Investigators Course, and the

improvement initiatives and to offer

Clinical Trials Course.

Summary The ACS mission of quality evaluation and improvement in surgical

opportunities for residents to work on

The Clinical Scholars program offers

care and outcomes continues to

ACS quality improvement programs.

a team of mentors who meet regularly

expand and mature. The College’s

More speci f ica l ly, t he C l i n ica l

with each Clinical Scholar. Scholars

continual advances and reﬁnements to

Scholars perform research relevant

also have opportunities to interact

programs such as ACS NSQIP ensure

to ongoing projects in the ACS Division

with various surgeons who are afﬁli-

that it remains a leader in evaluation

of Research and Optimal Patient

ated with the ACS and the Division of

and improvement of surgical care,

Care. The ACS Clinical Scholars in

Research and Optimal Patient Care.

outcomes, and reducing costs. Q

Residence Program is intended to

Whereas mentorship is one of the

prepare surgical residents to become

most important aspects of the fellow-

successful surgeon scientists. The

ship, having guidance from multiple

At the American College of Surgeons,

program is a unique practical experi-

individuals from diverse backgrounds

Clifford Y. Ko, MD, FACS, is the Director

ence in surgical research.

will provide the best opportunity for

of the Division of Research and Optimal

The primary objective of the fellow-

success. In addition, a core of ACS staff

Patient Care, which houses the ACS

ship is to address issues in health care

statisticians and project analysts serve

Quality Improvement P rograms

quality, health policy, and patient

as invaluable resources to the Clinical

including ACS NSQIP, Trauma, Cancer,

safety, with the goal of helping the

Scholars in Residence.

and Bariatrics. He remains clinically

Clinical Scholar in Residence prepare

Since its inception, surgical resi-

active at UCLA, where he is Professor

for a research career in academic

dents from throughout the U.S.,

of Surgery and Public Health/Health

surgery. The ACS Clinical Scholars

including California, Connecticut,

Services. He is internationally recog-

have worked on projects and research

Colorado, Illinois, Louisiana, and

nized for his work in surgical quality

within the ACS NSQIP, the NCDB, the

Ohio, have participated in the Clinical

and has published over 250 articles.

The American College of Surgeons’ Contributions to International Surgery by FABRIZIO MICHELASSI, MD, FACS

Over the past half-century, the American College of Surgeons (ACS) has developed educational, research, and clinical offerings for surgeons outside of North America. Many ACS divisions have contributed to this effort by producing programs and products for international Fellows and surgeons. This chapter summarizes, and puts into perspective, some of the College’s most noteworthy contributions to international surgery. Division of Membership Services

Hawley became the ﬁrst director of

the Director of the ACS, which he led

medical services for the U.S. Veterans

from 1950 to 1961.

Administration (1946–1947) and chief

Dr. Hawley’s experience abroad led

International Relations Committee

executive officer of the Blue Cross

him to encourage international collab-

(IRC). The IRC was developed under

and Blue Shield insurance associa-

orations. He realized that funding the

the leadership of former ACS Director

tions (1947–1948) before becoming

travel of surgeons from abroad to the

Paul R. Hawley, MD, FACS (Hon). During World War II, Gen. Hawley was stationed in Europe as chief surgeon of the European theater of operations. Dr. Hawley was an acclaimed surgeon Distinguished Service Medal, the Legion of Merit, the Bronze Star, and the Lasker Award. He was also a global traveler whose achievements were recognized in France (the Croix de Guerre with Palm); Great Britain (Order of St. John of Jerusalem in the grade of Knight); Belgium (Order of the Crown in the grade of Commander); Norway (Order of St. Olav in the grade of Commander); and Nicaragua (Presidential Medal of Merit). After leaving the military, Dr.

Gen. Paul R. Hawley

PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES

and administrator who received the

annual ACS Clinical Congress would

Subcommittee, which, from its incep-

In 2011, this fellowship became a

encourage the international exchange

tion, has been extraordinarily selec-

two-way exchange, with the ANZ trav-

of ideas and information about surgical

tive. The IGS provides each scholar

eling surgeon sponsored by the ANZ

practice and education and the estab-

with an opportunity to attend the

Chapter and the Royal Australasian

lishment of professional and academic

annual Clinical Congress, where he

College of Surgeons. North American

collaborations and friendships. In the

or she is publicly recognized and

ANZ Fellows are expected to spend

end, this activity would beneﬁt not only

receives free admission to all lectures,

a minimum of two to three weeks in

the selected international surgeons,

demonstrations, and exhibits associ-

Australia and New Zealand, where

but also the ACS and the American

ated with the conference, as well as

they attend and participate in the

surgical programs these traveling

selected postgraduate courses. After

Annual Scientiﬁc Congress of the Royal

scholars would visit. The seed for

the Clinical Congress, scholars are

Australasian College of Surgeons; they

the IRC was planted during these

offered assistance in arranging visits

also visit at least two medical centers

exchanges. For the past 45 years, the

to various surgery clinics and depart-

in Australia and New Zealand. Spouses

ACS has built on this concept through

ments of their choice. IGS scholars are

are permitted to accompany successful

the international scholarship programs

expected to provide a detailed written

applicants in their travels. Likewise,

administered by the IRC.

report of their experiences upon

the ANZ ACS Chapter, in partnership

International Guest Scholarships

completion of the program in an effort

with the Royal Australasian College,

(IGS). The IRC’s ﬂagship scholarship

to disseminate their acquired know-

supports a young surgeon from

program, the International Guest

ledge to the greater ACS community.

Australia or New Zealand to attend

Scholarship, was established in

In 2011, two additional scholar-

the Clinical Congress, and then to tour

1968, three years after Dr. Hawley’s

ships—one focusing on evaluation and

North American institutions in which

death. The ﬁrst scholarship—funded

adoption of new technologies and the

they are interested.

directly through a bequest from Dr.

other on innovative surgical educa-

The ANZ Traveling Fellowship has

Hawley—supported the travel of

tion and training—were launched in

become the prototype for two other

Enrique Muyshondt-Contreras, MD,

collaboration with the ACS Division of

traveling fellowships co-sponsored by

of El Salvador to the Clinical Congress

Education. One scholar was accepted

the College, with the participation of

and, afterward, to several U.S. surgical

from the United Kingdom and the other

national ACS chapters and national soci-

centers. For its first 12 years, the

from India. These young international

eties in Japan and Germany. The Japan

program focused on promising surgical

faculty members attended the Clinical

program was established in 2003, and

scholars from Latin America and grad-

Congress, participated in the post-

the Germany program in 2005. Similar

ually increased the number of fellow-

graduate course Surgical Education:

to the ANZ Traveling Fellowship, fellows

ships. The program was expanded in

Principles and Practice, and attended a

are required to spend a minimum of

1980 to include travelers from Europe,

variety of sessions that addressed educa-

two weeks in the host country, part of

and then again in 1981 to welcome

tion and training. Following the Clinical

which is spent attending and partici-

surgeons from anywhere in the world.

Congress, each scholar visited a leading

pating in the annual meeting of the

Over the past decade, these scholar-

institution with recognized expertise in

Japan Surgical Society or the German

ships have been awarded to anywhere

surgical education and training.

Surgical Society, respectively. Travelers

from eight to 10 surgeons annually. In

ACS Traveling Fellowships. In 1982,

are also required to visit at least two

2011, the number of scholarships was

the ACS established its ﬁrst Traveling

medical centers outside the host city

increased to 12 each year.

Fellowship, which would allow a North

and share clinical and scientiﬁc exper-

Today, IGSs in the amount of $10,000

American surgeon to travel to Australia

tise with local surgeons. The Japan and

are offered to young (35- to 45-year-

and New Zealand (ANZ) with the ﬁnan-

German surgical societies, likewise,

old) surgeons from outside the U.S.

cial and organizational assistance of

each select a scholar annually to visit

and Canada who have demonstrated

the ANZ ACS Chapter. After existing

the annual ACS Clinical Congress and

a strong interest in surgical educa-

on a sporadic basis for several years,

academic surgical centers.

tion and research. Candidates are

the ANZ Traveling Fellowship became

The Value of ACS International

selected by the IRC’s Scholar Selection

a permanent annual award in 1989.

Fellowships. Since 1968, more than

We do what no other medical liability insurer does. We reward loyalty at a level that is entirely unmatched. We honor years spent practicing good medicine with the Tribute® Plan. We salute a great career with an unrivaled monetary award. We give a standing ovation. We are your biggest fans. We are The Doctors Company.

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We created the Tribute Plan to provide doctors with more than just a little gratitude for a career spent practicing good medicine. Now, the Tribute Plan has reached its ﬁve-year anniversary, and over 22,700 member physicians have qualiﬁed for a monetary award when they retire from the practice of medicine. More than 1,300 Tribute awards have already been distributed. So if you want an insurer that’s just as committed to honoring your career as it is to relentlessly defending your reputation, request more information today. The ACS has sponsored our medical professional liability program since 2002. To learn more about our program for ACS members, including the Tribute Plan, call (800) 352-0320 or visit us at www.thedoctors.com/tribute.

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250 surgeons, from six continents and 65 different nations, have partici-

ACS Honorary Fellows Who Were International Guest Scholars

pated in the international scholarship programs of the ACS. Most have been general surgeons, but as surgeons around the world have become more specialized, more subspecialties have been represented. Of all the international scholars over the past 45 years, half of them hold by now a professorial rank at their home institution, onethird are division heads and 21 are department chairs, two are presidents of foreign surgical societies, and four have been recognized as Honorary Fellows of the ACS. In an effort to estimate the effect Olajide Ajayi

Attila Csendes

Juan M. Acosta

Dario Birolini

in their own practice, research, and

selection committees or to host visiting

all with skill and ﬁdelity,” through its

education activities. One of the greatest

scholars, as well as the generosity of

mission to facilitate surgical humani-

validations of the IGS program is that

donors who have steadily increased the

tarian outreach. OGB is an informa-

86 percent of respondents to the IRC’s

endowment over the years.

tion resource that connects surgeons

of these scholarships, in 2003 the IRC distributed a survey to the 161 International Guest Scholars who had participated in the program. Half of the participants responded, and virtually all felt the IGS had a positive effect on their careers. In addition, many respondents felt they had made excellent contacts with North American surgeons, and some felt they had made friends for life. Many reported that their visit resulted in an ongoing exchange program. IGS visits, the survey revealed, affected clinical care, with many scholars reporting that they had learned new techniques. In addition, scholars uniformly agreed that their contact with

PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS

leading surgeons led to improvements

survey said they had encouraged others to apply for the scholarship.

Operation Giving Back (OGB).

with opportunities to volunteer their

Recognizing the dedication of its

talents—in patient care, training, or

Originally endowed through Dr.

Fellows to meeting the needs of the

education—or to donate equipment and

Hawley’s legacy, the IRC’s scholarship

underserved in communities domesti-

supplies to underserved communities

program has grown steadily over the

cally and around the world, the ACS

around the world. OGB helps to focus

years. Its continued success relies on

established OGB in 2004. OGB serves

these talents on critical public health

the support of the College’s senior

to perpetuate the ACS motto, Omnibus

issues related to the provision of safe,

surgeons, who donate time to serve on

per artem ﬁdemque prodesse, “To serve

timely, and necessary surgical care.

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✓ Comfort

The manifestations of surgical outreach

undertaken

ACS Division of Education

ACS

medical students from countries outside the U.S. and Canada.

members and supported through

The Division of Education has

The ACS Program for Accreditation

OGB encompass clinical care, educa-

developed a broad range of educa-

of Education Institutes (simulation

tional partnerships, and professional

tional programs and products that

centers) includes a number of insti-

exchange and collaboration toward

have been extremely well received

tutes that have been accredited by ACS

increasing surgical capacity, quality,

by international surgeons. Each year,

outside the U.S. and Canada. There are

and delivery. In addition, the OGB

the Clinical Congress attracts eminent

two ACS-accredited Education Institutes

community is committed to the

surgeons and surgeons-in-training from

in Sweden, and one each in the United

research and advocacy efforts needed

around the world. Their participation

Kingdom, France, Greece, Israel, and

to inform and address the unmet

in the Clinical Congress enriches the

China. Institutions from Italy and Saudi

burden of surgical disease and to

meeting immensely. Of special note is

Arabia have expressed interest in being

implement long-range solutions.

the Latin American Day session that

accredited, and their applications will

With its significant international

includes renowned surgeons from Latin

be reviewed once they are received.

membership and deep international

American countries. Speakers from

professional ties, there is a legacy

Mexico and Argentina are scheduled

of collaboration among surgeons in

to deliver presentations during this

different countries. Thousands of ACS

program at the 2012 Clinical Congress,

Fellows are involved in supporting

and much of the session is conducted in

After several Latin American ACS

surgical colleagues around the

Spanish, as well. In addition, abstracts

chapters established their own commit-

globe as well as in working to meet

are routinely submitted by international

tees on trauma in the late 1980s, the

the needs of surgical patients and

surgeons for the Poster Presentation

College established guidelines for the

strengthening the infrastructure and

and the Video-based Education sessions

formation of international committees

educational systems required for long-

at the Clinical Congress.

on trauma. Over time, these have been

ACS Committee on Trauma (COT)

term solutions. In doing so, they are

The renowned Surgical Education and

organized into several regional commit-

both educated and enriched by the

Self-Assessment Program™ (SESAP™)

tees: Latin and South America; Europe

opportunities and experiences.

remains popular with international

and Africa; Australia/New Zealand/

In times of disaster, as well as for

surgeons and surgical trainees. SESAP

Asia; the Middle East; and Canada.

everyday needs, OGB provides commu-

13™ has more than 100 subscribers

nity, coordination, collaboration,

from outside the U.S. and Canada.

Within these regions, the COT’s educational and professional develop-

information, inspiration, and needed

A number of international ACS

ment programs are in various stages

resources to surgeons engaged in this

members submitted applications for

of implementation. The committee’s

work. To date, OGB has worked with a

admission to the renowned annual

ﬂagship course, the Advanced Trauma

community of more than 100 interna-

Surgeons as Leaders course in May

Life Support® Course (ATLS®), estab-

tional partner organizations to facili-

2012, and surgeon leaders from

lished in 1980 to foster the develop-

tate the recruitment of surgeons for

Argentina and Pakistan participated in

ment of proper triage and treatment

more than 300 volunteer opportunities

the course.

techniques, has become the standard

in 74 countries. Online resources are

The division’s e-learning programs

that has transformed trauma care

supplemented by preparatory courses

have also generated considerable

around the world. In the late 1980s,

teaching skills on surgery in low

interest in the international surgical

ATLS materials were translated into

resource settings and different cultures

community. Furthermore, the popular

Spanish to facilitate the promulga-

or systems. The program is committed

Residents as Teachers and Leaders

tion of the course in Latin America.

to meeting disparate circumstances

course held in April 2012 included

To date, ATLS has trained more than

by understanding surgical needs and

two participants from the United Arab

1 million surgeons in 63 countries,

their contexts and with an ongoing

Emirates. Additionally, the Medical

including recent inaugural courses in

commitment to quality, collaboration,

Student Program offered at the Clinical

Iran (December 2011) and Rwanda

and humanitarian principles.

Congress has traditionally attracted

(October 2011).

The Advanced Trauma Operative

of Veterans Affairs program for moni-

Management® (ATOM®) course, devel-

toring and improving the quality of

oped in 2001 by Lenworth Jacobs, Jr.,

surgical care, ACS NSQIP is used today

In establishing the ACS one century

MD, FACS, is a surgical simulation

by the American University of Beirut

ago, Franklin Martin, MD, FACS, and

that has, to date, trained more than

Medical Center in Beirut, Lebanon;

his colleagues had the promotion of

2,300 surgeons worldwide. In 2005,

Shaikh Khalifa Medical City in Abu

the highest standards of surgical

a collaboration between the ACS and

Dhabi, the United Arab Emirates; and

care as their primary objective. Since

the West African College of Surgeons

the Imperial College Healthcare NHS

then, the College has provided more

resulted in the establishment of an

Trust of London, England. More broadly

than 250 international scholars from

ATOM course at the Korle Bu Teaching

focused efforts are under way to bring

around the world the opportunity to

Hospital in Accra, Ghana; ATOM has

ACS NSQIP to hospitals in Saudi Arabia

visit the annual Clinical Congress

since trained surgeons from 12 West

and Japan.

and selected surgical institutions; it has developed a volunteerism

African countries. Today, ATOM is available at 39 sites worldwide—in North

Conclusion

ACS Board of Governors (B/G)

platform for international outreach and has trained trauma surgeons all

America, West Africa, Europe, and the Middle East. In November 2011, an

International Fellows have been

over the world. The College also has

inaugural ATOM course was delivered

members of the College’s Board of

helped in developing quality assur-

in Asunción, Paraguay.

Governors since 1925, representing

ance programs for medical centers

Two other Committee on Trauma

members in their respective countries.

in Beirut and Abu Dhabi, and it has

courses are now offered internation-

All Governors, domestic and interna-

produced educational prog rams

ally. The Disaster Management and

tional, have the same basic duties and

of interest to surgeons around the

Emergency Preparedness course, which

serve as the ofﬁcial communications

world. In fact, the ACS’ founders

trains surgeons and acute care profes-

link between the Fellows and the Board

might have expected as much from an

sionals in mass casualty response, was

of Regents. In addition, International

organization that has never imposed

held for the ﬁrst time in Jeddah, Saudi

Governors aid in the selection of the

any boundaries on its mission to

Arabia, May 27 to May 28, 2012. The

committees organized within their

promote the highest standards of

Rural Trauma Team Development

areas and aid in investigating special-

surgical care. Q

Course (RTTDC), designed to teach rural

case applicants for Fellowship. Once

receiving facilities the fundamental

an international country obtains a

elements of injury resuscitation, was

Governor, it is then that Governor’s

Fabrizio Michelassi, MD, FACS, is

held in Santa Cruz, Chile, in April 2012,

responsibility to form a chapter; once a

a board certified general surgeon

drawing students from throughout the

chapter has been formed, the Governor

with a strong expertise in the

country and faculty from all over South

becomes an ex ofﬁcio member of the

surgical treatment of gastrointes-

America. The course was conducted in

governing group of the chapter.

tinal and pancreatic cancers as well

Spanish, and a Latin American team

In 2002, the B/G established the

as inﬂammatory bowel disease. A

of physicians is in the process of trans-

International Activities Subcommittee,

clinician, researcher, and teacher,

lating the RTTDC manual.

which was added to the College’s

Dr. Michelassi is the Lewis Atterbury

Chapter Activities (now Chapter

Stimson Professor and Chairman,

Relations) Committee, with the purpose

Department of Surgery and Surgeon-

of examining strategies, programs, and

in-Chief at New York Presbyterian/

activities to enhance the College’s rela-

Weill-Cornell Medical Center.

ACS Division of Research and Optimal Patient Care (DROPC) In recent years, ACS’ highest proﬁle

tionship with its international chapters

quality assurance program, the ACS

and Fellows, identifying strategies

National Surgical Quality Improvement

for recruiting international surgeons

Program (ACS NSQIP ), has gone inter-

for Fellowship in the College, and

national. A standardized risk-adjust-

increasing educational opportunities

ment model adapted from a Department

for the College’s international members.

Acknowledgements The author is indebted to Kathleen M. Casey, MD, FACS, Yuman Fong, MD, FACS, and Ajit K. Sachdeva, MD, FACS, FRCSC, for their contributions to this chapter.

Progress in Cancer Surgery by MURRAY F. BRENNAN, MD, FACS

More than 100 years ago, in July 1907, William Stewart Halsted presented his paper on the results of radical operations for the cure of carcinoma of the breast.1 That dissertation, focused on the radical approach to carcinoma of the breast, described his results from resecting the breast, the pectoralis muscles, and removing the axillary and supraclavicular lymph nodes. Halsted concluded, “Fortunately, we no longer need the proof which our ﬁgures so unmistakably give that the slightest delay is dangerous” and “It is interesting to note how late the metastasis occurred in these cases with undetected axillary involvement; another argument for wide operating.” Despite his presumed familiarity

of growth and spread for individual

accompanied by a major reduction

with the lymph node drainage of the

cancers were deﬁned. It became clear

in the mortality of large and compli-

that there was no single, defined

cated procedures such as esophagec-

he also concluded that, “the liver

pattern that could be applied to all

tomy and pancreatectomy. Much of

may be invaded by way of the deep

cancers. Some cancers such as breast

this was driven by focused attempts

fascia, the linea alba, and round liga-

regularly metastasized to lymph

by individual surgeons and institu-

ment.” This aggressive and radical

nodes, whereas others such as soft

tions to improve quality of the opera-

approach to surgery was perpetuated

tissue sarcoma rarely did so. This

tion and to decrease morbidity and

by others including those at Memorial

disease-based knowledge allowed

mortality. This has been supported

Sloan-Kettering Cancer Center, where

us to modify surgery appropriately.

by a number of studies conﬁrming

radical treatments for gastric cancer

More importantly, with increasing

the relationship between institutional

and even more extensive operations

knowledge of the lesser need for

and surgical volume on operative

– such as internal mammary node

radicality, an overall focus on func-

mortality.4,5 Unfortunately, despite

removal for breast cancer3 – were

tion, as opposed to radical extirpative

t he i mprovement i n operat ive

advocated ﬁve decades later.

breast described by Sappey in 1874,

procedures, became the goal. This

mortality, survival for comparably

In the last f ive decades, such

has allowed us to avoid amputation,

staged solid tumors from surgery

radical procedures have been aban-

preserve limbs, preserve sphincters,

alone has only minimally improved.

doned or modified. The evolution

and aim for both improved quality of

Overall apparent improvements in

of less radical operations occurred

life without loss of surgical efﬁcacy

survival from surgery alone are

as knowledge and understanding

and cancer-speciﬁc survival.

predominantly due to earlier diag-

of cancer as a disease evolved.

This change from routine radi-

nosis and improved patient selection.

Initially, this was due to observa-

cality to more conservative but

The subsequent demise of patients

tions of natural history, and patterns

still complete resection has been

with localized disease at the time

We now enter a crucial time where the evaluation of outcome can be expected to be much more realistic. When “signiﬁcant and meaningful” differences in outcome have to be established, critical review of what justiﬁes a meaningful result and a willingness to selfcritique will become mandatory if we are to sustain the advances made in the last 100 years.

management. It is clear that appropriate juxtaposition of what were formally seen as adjuvant modalities of radiation and chemotherapy can, when placed proximal to a surgical procedure, provide improved outcome and a decrease in the necessity for radicality, without increasing operative mortality or morbidity.8 We now enter a crucial time where the evaluation of outcome can be expected to be much more realistic. When “signiﬁcant and meaningful” differences in outcome have to be established, critical review of what justif ies a meaningful result and a willingness to self-critique will become mandatory if we are to sustain the advances made in the last 100 years. We are now in a position to look at populations. Evaluations will depend not just on single patient outcome but on the quality of that outcome a nd t he persona l a nd

of initial operation results from

initially focused on the minimization

ﬁnancial cost of such outcome to

subsequent recog nition of meta-

of the morbidity of the perioperative

the individual and society. We look

static disease. While death from

period, mainly driven by decrease

beyond overall improvement for the

uncontrolled local progression does

in wound incision size, to further

individual patient to the impact on

occur, e.g., in retroperitoneal soft

studies validating that the mini-

cadres of patients, looking not only

tissue sarcoma, most deaths from

mally invasive approach provides

at those who beneﬁt from our cancer

solid tumors are due to metastatic

the same oncological procedure as

care but at the personal (and ﬁnan-

disease. Importantly, this aware-

an open approach. It should be no

cial) cost to those who do not beneﬁt.

ness has allowed focused attempts

surprise that if a surgical procedure

We look at the potential beneﬁts to

at resection of isolated or conﬁned

is identical whether by an open or

those that still fail, recur, or die, and

metastatic disease. This is most

minimally invasive approach, then

to those who do not beneﬁt because

dramatically seen in resection of

long-term outcome should be the

they were not going to recur or die

colorectal metastasis to liver, where,

same. This thinking has developed

following their initial procedure.

in selected cases, long-term (>10

to where randomized clinical trials

We are challenged to look not only

w ith minimally invasive surgery

at the end result but at the time

versus open surgery are progres-

point of initiating therapy to predict

years) cure has been obtainable.

Concom ita nt w it h t hese technical advances has been a focus

sively available for review.

who will and will not beneﬁt. There

on “data driven care.” No longer

With the advent of meaningful

are clear opportunities to do this:

are the opinions of the surgeon left

chemotherapy and the increased

Clinically based nomograms 9 and

to stand alone without support of

sophistication of radiation therapy,

molecular signatures that are both

data from thoughtfully constructed

we now have a synthesis of cancer

prognostic and predictive of response

prospective databases or random-

care that is focused on disease

are increasingly becoming available.

ized clinical trials. These studies

management rather than discipline

Where such cannot be predicted, we

will progressively move to surro-

After 21 years as Chairman of the Department of Surgery at Memorial

gate indicators of likely response by

Sloan-Kettering Cancer Center, Dr. Murray Brennan presently holds the Benno

predictive biomarkers or metabolic

C. Schmidt Chair in Clinical Oncology and is Vice President for International

(PET) responses.

Programs and Director of the Bobst International Center at the same institution.

Addressing the societal issues of operations performed in the latter years of life—where 32 percent have an operation in the last year, 18 percent in the last month, and 8 percent in the last week of life—challenges us to evaluate our intentions and the meaningfulness of surgical procedures within the context of cancer care.10 Su rgeons can be proud of the contributions they have made to cancer care in the last 100 years and now have the great opportunity, with constructive self-critique, to focus on societal as well as indiv idua l dema nds to ensu re sa fe, equal, and meaningful cancer care to all patients. Q

References 1. Halsted WS. The Results of Radical Operations for the Cure of Carcinoma of the Breast. Ann Surg 46:1-19, 1907. 2. Sappey MPC. Anatomie, Physiologie, Pathologie des vaisseaux Lymphatiques consideres chez L’homme at les Vertebres Paris, A. Delahaye and E. Lecrosnier, 1874. 3. Urban JA, Baker HW. Radical mastectomy in continuity with en bloc resection of the internal mammary lymph-node chain; a new procedure for primary operable cancer of the breast. Cancer 5:992-1008, 1952. 4. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128-37, 2002. 5. Begg CB, Cramer LD, Hoskins WJ, et al. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280:1747-51, 1998. 6. Tomlinson JS, Jarnagin WR, DeMatteo RP, et al. Actual 10-year survival after resection of colorectal liver metastases deﬁnes cure. J Clin Oncol 25:4575-80, 2007. 7. Nelson H, Sargent D, Wieand S, et al. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. N Eng J Med 350:2050-2059, 2004. 8. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 355:11-20, 2006. 9. Kattan MW, Leung DH, Brennan MF. Postoperative nomogram for 12-year sarcoma-speciﬁc death. J Clin Oncol 20:791-6, 2002. 10. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 378:1408-13, 201.

City of Hope salutes the world’s top doctors. And what a great bunch of Fellows. The American College of Surgeons has been teaching doctors the highest standards of practice and the latest advances in medicine for 100 years. This commitment means life-saving care for millions of patients – past, present and future. We appreciate all the Fellows, men and women alike, for helping to make the world a healthier place. cityofhope.org

I chose Guthrie

for the collaboration. Joseph Scopelliti, MD CEO, Guthrie Health

â&#x20AC;&#x153;

My very first day here, I sensed that Guthrie was a different place. Thirty-six years later, its core values of patient-centeredness, teamwork and excellence continue to help us achieve optimal outcomes for patients. Physicians who join Guthrie find an inclusive and rewarding

â&#x20AC;?

environment in which they thrive.

Where compassion and excellence come together to make a meaningful difference in the lives of those we serve. Every person. Every time. Our Vision Founded in 1910 by Dr. Donald Guthrie— who brought the Mayo Clinic model to Sayre, PA—Guthrie Health System is among the most respected systems in the country. More than 100 years later, we continue to honor Dr. Guthrie’s vision of service, stability and continuous improvement. With our integrated medical delivery system, connected by a robust electronic health record, we embody a model of strong patient care.

We are fiscally stable, with a robust A+ bond rating. Our capabilities continue to grow as we enhance our physical facilities—revitalizing and remodeling with new campuses for our Corning and Troy hospitals—and continue to pursue research, education and new technologies. We consistently rank among the best for quality.

Innovation has always been a cornerstone of our identity. In addition to providing the full spectrum of specialty and subspecialty care, we are focused on three predominant health concerns that affect humanity: cardiovascular disease, cancer and musculoskeletal disorders. This results in a comprehensive service that few others in the country have implemented.

Patient-centeredness drives all that we do. Our advanced technologies, rarely found in rural facilities, attract the highest-caliber physicians who also share our commitment to compassion. Our network of regional hospitals and offices provides unparalleled access to internal medicine, family medicine and specialty medicines across the southern tier of New York and the northern tier of Pennsylvania. Quite simply, Guthrie is an extraordinary healthcare system where physicians who value patient-centeredness, teamwork and excellence forge fulfilling medical careers.

The philosophical approach to patient care in a group practice is one of cooperation and collaboration centered on the best possible outcomes for patients. Guthrie physicians enjoy an environment where they regard other physicians as colleagues, not competitors.

Why Physicians Choose Guthrie

If your skills and values align with ours, you may be one of the uniquely qualified providers we seek to help us expand our scope of services to ensure the best possible care and access for all those we serve. Discover more about Guthrie and our career opportunities at www.ichoseguthrie.org/Careers/ACS or by calling 1-800-724-1295. Scan here to view his video.

Find Guthrie Physician Recruitment:

Historical Achievements in Cardiothoracic Surgery by JOHN E. CONNOLLY, MD, FACS

During the American College of Surgeons’ (ACS) century of existence, many surgical advances have been made. L ung resection for pulmonary tuberculosis was the starting point of modern thoracic surgery led by Richard Overholt and J. Maxwell Chamberlain in North A merica. During World War I, the management of open chest wounds was first established, and during World War II, the surgical treatment of empyema began. In 1933, Evarts Graham used a tourniquet to perform the first pneumonectomy for carcinoma of the lung. In 1939, Churchill and Belsey performed the first segmental lung resection. Finally, in 1950, Ivor Lewis first reported both an abdominal and a chest approach for esophagectomy. During the ACS century, many advances were also made in cardiac surgery by ACS Fellow surgeons. Of note was the first successful ligation of a patent ductus arteriosus by Robert Children’s Hospital in 1938, while his Chief, William Ladd, was out of town. We are all born with a patent ductus.

John Gibbon and his wife with the IBM heart-lung machine.

If it does not close by itself after birth, congestive heart failure and infective

Well, surgeons at that time were

1944. Gross did the same procedure

endarteritis may ensue. Three or four

simply not used to working around the

in 1945. In 1945, Alfred Blalock at the

surgeons had tried unsuccessfully to

great vessels just outside the heart!

Johns Hopkins Hospital performed the

close it. When you think about it now,

Next was the f irst successful

so-called “Blue Baby” operation. A blue

the procedure was just to pass a tie

resection of coarctation of the aorta

baby is one whose pulmonary artery

around a vessel outside the heart.

by Clarence Crafoord of Sweden in

is congenitally narrowed, limiting

100

PHOTO COURTESY OF THE UNIVERSITY OF MINNESOTA

Gross, Chief Resident at the Boston

adequate oxygen to the lungs. Dr. Helen Taussig, the “founder” of pediatric cardiology, had noted that blue babies who have an open ductus live longer than those without. Therefore, she suggested to Dr. Blalock to divide the left subclavian artery and anastomose it to the left pulmonary artery. Suddenly the very blue and squatting child became pink! These three operations between 1938 and 1954 were the beginning of closed cardiac surgery. In 1950 –51, Wilfred Bigelow of Toronto was studying the use of hypo-

Richard DeWall (left) and Vincent Gott, colleague, pictured with the DeWall Oxygenator.

PHOTO USED WITH PERMISSION OF DR. RICHARD DEWALL / UNIVERSITY OF MINNESOTA ARCHIVES USED WITH PERMISSION FROM DR. JAMES V. MALONEY

thermia in cardiovascular surgery. His experiment was to anesthetize

cardiac surgeon at the University

collaborated with the Chairman

a dog and pack it in ice until its

of Minnesota, reported performing

and CEO of IBM®, Thomas Watson,

temperature fell from 36˚F to 30˚F.

Bigelow’s hypothermic technique

and ﬁve IBM engineers to develop a

Next, the sternum was opened and

on a 5-year-old child in 1952. This

sophisticated heart-lung machine.

both superior and inferior cavae were

was the ﬁrst direct vision open heart

The ﬁrst few patients that he used it

clamped, causing asystole. Then the

operation in the world!

with were unsuccessful. In 1953, he

right atrium was opened, while in a

John Gibbon, Professor of Surgery

performed the world’s ﬁrst successful

dry ﬁeld an atrial septal defect was

at Jefferson Medical College in

open heart operation, using the IBM

closed with a running suture. At

Philadelphia, PA, and his wife had

extracorporeal circulation machine

that time, Bigelow was looking for

been working for 10 years to develop

for 26 minutes to close a congenital

a suitable patient on whom to try

a heart-lung machine so that open

atrial septal defect. Dr. Gibbon did a

his hypothermic procedure. But to

heart operations could be performed

few more cases with the IBM machine

his surprise, F. John Lewis, a young

under direct vision. He eventually

unsuccessfully, and then gave up open heart surgery altogether. At that time, a young surgeon named Walt Lillehei, who was the Chief of Cardiac Surgery at the University of Minnesota, did not think much of the complicated IBM machine. He proposed that a patient’s father or mother be used as the “oxygenator.” In spite of the danger to both the patient and parent, Chief Surgeon Owen Wangensteen said, “go ahead, I have great conﬁdence in you.” Dr. Lillehei proceeded to perform 45 such cross-circulation operations to close ventricular septal defects, losing only a few patients and no parents. At the same time, Lillehei instructed a young surgical assistant, Richard DeWall, to devise a much simpler oxygenator than

Walt Lillehei’s Cross Circulation.

the IBM machine. What he produced

101

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was called a Bubble Oxygenator. It was simple to construct in the research laboratory. With the Bubble Oxygenator, Lillehei then proceeded to successfully perform every type of congenital open heart operation. His experience with the DeWall Oxygenator did more to promote cardiac surgery than any other surgeon did at that time or even later. A discovery that really revolutionized cardiac surgery occurred in 1958. Mason Sones of the Cleveland Clinic was a pediatric cardiologist by René Favaloro and Donald Efﬂer

training, but was working in the X-ray

PHOTO COURTESY OF DR. JOHN E. CONNOLLY

Department. At that time, cardiologists believed that coronary artery occlu-

may not occur. Subsequently, William

back together.” Shumway said, “Let’s

sive disease was generalized and as

Gay and Paul Ebert reintroduced

try it.” The next thing they did was to

such would not be surgically treatable.

low concentration potassium arrest,

transplant a dog’s heart, which, as

Also, they believed that if you intro-

which allowed surgeons to perform

expected, was rejected within ﬁve days

duced dye into a coronary artery, it

coronary artery bypass surgery in

because there were no antirejection

would kill the patient. Well, one day

a still, bloodless ﬁeld, an important

drugs available at that time. During

Sones was performing a left ventricu-

medical advance of the 20th century.

those ﬁve days, either Shumway, Stover

logram. As he pulled the catheter back

Two thousand such operations are

(the lab technician), or Lower stayed

into the aorta, unbeknownst to him it

performed every 24 hours worldwide.

day and night with the transplanted

slipped into the right coronary artery.

It is performed effortlessly with low

dogs. Five transplanted dogs lived for

When he injected 40 cc of dye, asys-

risk in all age groups.

two to six days with completely normal

tole occurred. It was corrected by the

The ﬁrst human lung transplant was

function! Death came with rejection.

patient’s cough. When Sones developed

performed by James Hardy on June 11,

Hearts appeared to function okay if

his picture, he surprisingly found that

1964, in Jackson, MS. The patient died

the immunologic mechanisms of the

his catheter had been in the right coro-

on the 18th day of renal failure. Only

host were prevented from destroying

nary artery, it did not kill the patient,

seven months later, Hardy attempted

the graft.

and he had a beautiful picture which

the ﬁrst heart transplant in a human

Su bseq uent ly, Shu mway wa s

showed that coronary artery disease

being, under what would be considered

looking for a human candidate for

was segmental. This eventually led to

to be disastrous conditions. The patient

transplantation when Dr. Christiaan

the development of the coronary artery

was in thermal shock and the donor

Barnard surprised the world in South

bypass operation, which was a tremen-

was a small chimpanzee heart, which,

Africa in 1967 with the ﬁrst human

dous development. Surgery consisted

unfortunately, gradually gave way.

heart transplant. Barnard’s donor was

of bypass of coronary artery disease

In 1961, my colleague Norman

a 25-year-old female who had been in

with a saphenous vein or internal

Shumway and I were working on

an auto accident and her heart was

mammary artery (Vasilii Kolesov in

different projects in the Stanford

transplanted into Louis Washkansky,

Leningrad) or by endarterectomy.

research lab, each with a full-time

a 53-year-old man with heart failure

René Favaloro and Donald Effler

resident. Shumway’s was Richard

who survived for 18 days. His second

were the leaders with the coronary

Lower, who was bright. One day while

transplant, Philip Blaiberg, survived

artery bypass procedure, performing

Shumway was cooling a dog’s heart,

almost two years. Many surgeons

1,573 cases in one year. In 1973, Denis

Lower said to Norm, “I wonder what

then tried transplantation with poor

Melrose induced cardiac arrest by high

would happen if we detached a dog’s

results. Eventually it was Shumway

potassium citrate, from which recovery

heart completely and then sewed it

who persisted and developed human

103

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At the Montefiore Einstein Center for Heart and Vascular Care in New York City, we develop innovative techniques and technologies to support our already excellent outcomes. In 1958, Montefiore implanted the world’s first transvenous cardiac pacemaker, and in 1960 our team performed the world’s first coronary artery bypass surgery. In 1982 we created a special technique to repair the mitral valve, and in 2011, Montefiore was among the first hospitals in the Northeast to be certified to implant a Total Artificial Heart, a lifesaving alternative that can serve as a bridge to a heart transplant. Most recently, Montefiore was among the first in the country selected to offer Transcatheter Aortic Valve Replacement (TAVR), a ground-breaking new therapy for the treatment of aortic valve disease. Awarded the prestigious three-star rating by the Society of Thoracic Surgeons, Montefiore’s heart surgeons are among the very best in the nation. The Montefiore Einstein Center for Heart and Vascular Care, pioneering cutting-edge medicine for more than 50 years.

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Norman Shumway

has g iven an enormous boost to

ment, began to catheterize dogs and

transplant medicine.

then he and Dickinson Richards, a

In the 1950s, a young cardiothoracic

Professor of Medicine at Columbia,

surgeon, Al Starr, was asked by engineer

worked together to develop human

M. Lowell Edwards to help him build

cardiac catheterization. Cournand,

an artiﬁcial heart. Starr suggested that

Richards, and Forssmann shared the

they start with an artiﬁcial heart valve.

Nobel Prize in 1956.

They then designed what is known as

In 1948, Sir Peter Medawar, a

the Starr-Edwards Ball Valve. It was

British zoologist, was investigating

ﬁrst successfully used in a human in

the use of skin grafting for extensive

1960. This was a major cardiac surgery

heart transplantation as we know

burns. He was unsuccessful until he

development. In 1971, Alain Carpentier

it today. After much trial and error,

tried grafting between littermates.

of France instituted plastic reconstruc-

lung transplantation became a reality

That discovery led Joseph Murray of

tion of the mitral valve. He and Starr

under Joel Cooper and F. Griffith

Boston to guess that kidney grafting

each received a Lasker Award in 1968

Pearson in Toronto in 1983, facili-

would be successful between iden-

for their valve advances.

tated by the use of cyclosporine and

tical twins. Thus, in 1954, he found

When the American College of

wrapping of the bronchial suture line

an identical twin brother with renal

Surgeons began in 1913, smoking

with a pedicle graft to reduce the inci-

failure who successfully accepted his

was not yet a widespread habit, but

dence of bronchial dehiscence. The

twin brother’s normal kidney. Both

it became so during World War I and

main problem with heart and lung

Medawar and Murray were awarded

has fostered much of our cardio-

transplantation now is shortage of

the Nobel Prize in Physiology or

vascular disease. It was between

organs. This has led to an increase in

Medicine—in 1960 and 1990, respec-

the ’40s and ’50s that Drs. Richard

the development of ventricular assist

tively—for discoveries that advanced

Overholt and Alton Ochsner began

devices and artiﬁcial hearts to employ

transplantation of organs.

to blow the antismoking alarm, and

until human hearts are available.

PHOTO COURTESY OF DR. JOHN E. CONNOLLY / PHOTO COURTESY OF AL STARR

Forssmann and his personal experi-

In 1970, the Swiss pharmaceu-

the Surgeon General began labeling

In 1929, a young German physician

tical company, Sandoz, discovered a

cigarette packages that “smoking may

named Werner Forssmann wanted

cyclosporine-producing fungus. The

be hazardous to your health.”

to catheterize a patient’s heart and

agent turned out to have a strong

In summary, cardiothoracic surgery

obtain pressures inside it, but his

immunosuppressive effect, and the

has made fantastic advances over the

superiors would not let him and said,

use of this substance was intro-

100 years of the American College

“You’ll kill the patient.” To prove the

duced in 1972 in humans, which

of Surgeons’ existence and future

point they were wrong, one weekend

expectations are even more unlimited.

he anesthetized his own forearm and

Hopefully, some ACS Fellows will also

passed a ureteral catheter all the

lead the ﬁght against obesity. Q

way into his right ventricle. He then walked down several ﬂights of stairs to the X-ray Department and had some

John E. Connolly, MD, FACS, is

dye injected into his right ventricle

the Founding Professor and Chair of

with no problem. On Monday when his

Surgery at the University of California,

Chiefs came back to town, they were

Irvine, 1965. He presently continues to

absolutely furious and said, “You will

teach there and is a researcher and

never do that again! If you do anything

author. Dr. Connolly has been very

that crazy again you’ll be out.”

active in the ACS since becoming a

In 1943, A nd ré Cou r na nd, a

Fellow in 1958, wearing numerous

pulmonary physiologist at Columbia Un iversit y

who

k new

a bout

hats including Past Chair of the Board Starr-Edwards Ball Valve.

of Regents and Vice-President.

105

Advances in the Twentieth Century: Colon and Rectal Surgery by HERAND ABCARIAN, MD, FACS

The twentieth century saw not only the birth and growth of the American College of Surgeons, but also an amazing transformation in all ﬁelds of surgical specialties including colon and rectal surgery (CRS). The following are brief highlights of a few of the accomplishments in the specialty of colon and rectal surgery during this period. 1. Colon and Rectal Cancer (CRC)

for presence of synchronous or meta-

disease. Now direct visualization of

chronous metastases without need for

the entire colon allows total examina-

unnecessary exploratory operations.

tion of the colon for mass lesions and

The two deﬁning landmarks in the

In 1982, Bill Heald described the tech-

inﬂammatory diseases. Colonoscopy is

early twentieth century were abdomi-

nique of total mesorectal excision (TME)

used for diagnosis, surveillance, and

noperineal resection of rectal cancer

to reduce the risk of pelvic recurrence,

follow-up of all patients, especially

by Ernest Miles and pathologic clas-

and he and Dr. Philip Quirke demon-

those at high risk of colon cancer

siﬁcation of rectal cancers by Cuthbert

strated the importance of mesorectal

including those with inﬂammatory

Dukes, who was instrumental in

lymph nodes and negative circumfer-

bowel disease, familial polyposis,

demonstrating the correlation of the

ential radial margins. TME has become

and/or cancer syndromes. In these

pathologic stage of rectal cancer with

the holy grail of rectal cancer surgery

latter cases, advances in genetics of

survival. Anterior resection and low

and has had a signiﬁcant impact in

CRC help to identify genetic markers

anterior resection became popular

reducing local recurrence, increasing

in familial adematous polyposis,

after World War II, but the manufac-

disease-free intervals and ultimately

Lynch syndrome, and other inherited

turing of mechanical stapling devices—

patient survival. With the advent

cancers especially in institutions

especially circular staplers—allowed

and widespread use of radiation and

utilizing inherited cancer registries.

for much lower anastomoses and

chemotherapy, preoperative treatment

Chemotherapy of colorectal cancer

avoidance of permanent colostomies

of locally advanced or bulky rectal

was originally recommended by Warren

by drastically reducing the incidence

cancers allows for resectability and

H. Cole, MD, FACS, but effective drugs

of abdominoperineal resections.

potential curability of these tumors.

were slow to develop. Formulation of

Advances in imaging technology—

Currently there are protocols studying

5-ﬂuorouracil in the ’50s was a ﬁrst

particularly computerized tomography,

the policy of close observation without

step, and the subsequent addition of

endorectal ultrasonography, and

radical surgery in cases of complete

leucovorin, inrinotecan, oxaliplatin,

magnetic resonance of the pelvis—

response to neoadjuvant therapy.

and “biologic monoclonal antibiotics”

allow for much better preoperative

In addition to advances in imaging

and antiangiogenic drugs have had a

evaluation and staging of colonic and

techniques, the invention of ﬁber-optic

deﬁnite impact in patients’ prognoses

especially rectal cancers. These tech-

colonoscopy in the early 1970s added

when used preoperatively or following

niques as well as PET scans make it

an invaluable addition to the diag-

resection of hepatic or pulmonary

possible to evaluate cancer patients

nostic armamentarium in colorectal

metastases from CRC. Preoperative

106

finding nearly coincided with the invention and marketing of ﬁber-optic colonoscopes and led to surveillance colonoscopy and target biopsies to diagnose dysplasia and offer prophylactic colectomy to patients when indicated, preventing colitis cancers. The next remarkable innovation was restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) proposed in 1978 by Sir Alan Parks Dr. Burrill Crohn (center) pictured with surgeons Gordon Oppenheimer (left) and Leon Ginzburg (right), with whom he published on regional ileitis.

and perfected by Joji Utsunomiya from Japan. This operation provides the patients with CUC an operation that would allow them to retain their

staging and individual stage directed

caused extensive morbidity and many

sphincter mechanism and avoid perma-

therapy involving neoadjuvant therapy

deaths until Bryan Brooke in the U.K.

nent ileostomy. Since the advent of IPAA

and surgery have made a real improve-

devised a simple eversion of the ileum

the patients are more amenable to

ment in prognosis of patients with CRC.

covering the serosa and exposing the

this operation, resulting in signiﬁcant

It i s i mpor t a nt to note t he

normal mucosa (Brooke ileostomy).

reduction in incidence of colitis cancers.

landmark original work of Norman

Two decades later, the efforts of Rupert

Advances in the medical treatment

D. Nigro, MD, FACS, in designing a

Turnbull, MD, FACS, and Norma Gill,

of inﬂammatory bowel disease have

“multimodality treatment” for anal

RN, ET, at the Cleveland Clinic gave

evolved from adrenocorticotropic

squamous cell cancers. This radically

enterostomal therapy formal recogni-

hormone (ACTH) and steroids to biologic

altered the care of such patients,

tion and changed the quality of life for

immune modulators. These agents have

reduced the need for proctectomy and

millions of ostomates in the U.S. and

helped improve the prognosis of anal

permanent colostomy by 85 percent,

the world.

CD and delay or prevent the need for

and increased the ﬁve-year survival

Basil C. Morson and Lillian S. C. Pang

diversion or protectomy. Popularization

rate from 50 percent with surgery

in the U.K. described the pathology of

of small bowel strictereplasty in the ’70s

alone to more than 80 percent with

“dysplasia” in CUC and its relation-

has led to bowel conservation surgery

chemoradiation therapy.

ship to “colitis cancers” in 1967. This

in an attempt to prevent short bowel syndrome in small bowel CD.

2. Inﬂammatory Bowel Disease 3. Diverticular Disease THE MOUNT SINAI ARCHIVES / NIH NATIONAL LIBRARY OF MEDICINE

While chronic ulcerative colitis (CUC) had been diagnosed and differentiated

Traditionally, acute sigmoid diver-

from speciﬁc colitides, it was not until

ticulitis resulting in a phlegmon or

the 1930s that Burrill Crohn, MD, and

perforation was treated by a three-

his associates published on “Regional

stage procedure of diverting colostomy

Ileitis.” Subsequently it was recognized

and drainage, resection, and closure

that the disease may involve the entire

of colostomy. Eugene Salvati, MD, and

gastrointestinal tract and was ofﬁcially

his colleagues reintroduced Hartmann’s

named Crohn’s disease (CD), with

procedure in the early ’80s as the

its own deﬁned pathologic ﬁndings.

preferred first stage in a two-stage

Patients with CUC were treated with

operation. Later, colonic lavage was introduced in an attempt to cleanse the

proctocolectomy and end ileostomy, but serositis at the site of the ileostomy

Rupert Turnbull

colon intraoperatively, allowing primary

107

anastomosis in obstructing diverticulitis

circular stapler to excise a donut of

or cancer. Primary resection, colorectal

rectal mucosa and submucosa at the

anastomosis, and proximal diverting

apex of the hemorrhoids and elevates

ileostomy introduced by Malcolm C.

and ﬁxes the hemorrhoidal tissue at

Veidenheimer, MD, resulted in reduced

the level of anorectal ring. This opera-

hospital and sick days and an easier

tion, when used judiciously and for

second-stage operation, i.e. closure

the correct indication (circumferential

of diverting ileostomy vs. Hartmann’s

third-degree hemorrhoids), results Bill Heald

reversal. CT-guided drainage of diver-

in comparably effective results with

ticular abscess since the early ’80s

Ferguson’s hemorrhoidectomy without

allows for subsequent single-stage

have been reported from a few centers

the signiﬁcant early postoperative pain

operation and avoidance of colostomy.

in the U.S., Korea, and the U.K., cost

and disability. Other minimally inva-

Abdominal washout, drainage, and

considerations are currently seen

sive procedures such as THD (trans-

intravenous antibiotics are currently

as the major impediment in expan-

anal hemorrhoidal dearterialization)

being studied in select cases of perfo-

sion of robotic rectal cancer surgery.

have since been introduced. Sutured

rated diverticulitis aiming for subse-

Randomized trials sponsored by

hemorrhoidopexy techniques may also

quent resection without colostomy.

the American College of Surgeons

accomplish the same results in eleva-

Oncology Group (ACSOG) will go a long

tion and fixation of prolapsing and

way to yield meaningful and cred-

bleeding hemorrhoids wherever stapler

ible level I evidence in rectal cancer

and new technologies are unavailable.

surgery analogous to the COST trial

b. Anal ﬁssure

4. Minimally Invasive Colon and Rectal Surgery The first report of laparoscopic

Anal ﬁssure was described by Joseph-

in colon cancer resection.

colon resection was published by

Newer techniques including single-

Claude-Anthelme Récamier in 1829.

Morris Franklin, MD, in the early ’90s.

port colectomy and NOTES (natural

Efforts to overcome the associated anal

Since then, the procedure has been

orif ice translum inal endoscopic

stenosis included anal dilation and

expanded to all benign disorders, and

surgery), etc., will need further evalu-

excision of anal ﬁssure with or without

after the publication of the Clinical

ation in randomized controlled trials

sphincterotomy. The landmark work of

Outcomes of Surgical Therapy (COST)

before attaining universal acceptance.

Dr. Stephen Eisenhammer from South

trial demonstrating equivalency of the oncologic results of laparoscopic

Africa in the 1950s documented the role of the internal sphincter in the patho-

5. Anorectal Surgery

colectomy to traditional open techAnorectal surgery has evolved into

1971, Dr. Mitchell J. Notaras described

surgery has become more popular and

an outpatient operation in recent years.

the technique of lateral internal sphinc-

used around the world in the treat-

a. Hemorrhoidectomy

terotomy, which revolutionized the as

surgical treatment of anal ﬁssure by

less early morbidity (e.g. pulmonary

performed by William Allingham in

avoiding a midline sphincterotomy that

complications and wound infections),

the 1850s, has remained popular in

causes “keyhole deformity” and variable

fewer sick days, and earlier return

the U.K. and European countries. In

degrees of incontinence to gas and stool.

to work are some of the parameters

the U.S., closed hemorrhoidectomy,

Since the early 1990s, a succession

favoring the laparoscopic technique.

popularized by James A. Ferguson,

of chemicals has been introduced

ment of CRC. Shorter hospital stays,

PHOTO COURTESY OF THE PELICAN CANCER FOUNDATION

genesis of chronic anal ﬁssure (CAF). In

nique, minimally invasive colorectal

Open

hemorrhoidectomy,

Laparoscopy is suitable for all

MD, in Grand Rapids, MI, has remained

to induce relaxation of the internal

colectomies, but mobilization of a

the procedure of choice. In the early

sphincter in order to avoid sphincter-

bulky rectal tumor in an obese man

’90s, Dr. Antonio Longo introduced a

otomy and possible postoperative fecal

can be truly challenging. The use

novel and revolutionary procedure,

incontinence. Nitroglycerine ointment,

of the robot facilitates proctectomy

i.e., stapled hemorrhoidopexy or PPH

calcium channel blockers, injection of

for cancer and proctopexy for rectal

(procedure for prolapse and hemor-

botulinum toxin, sildenaﬁl, and minox-

prolapse. Although excellent results

rhoids). This procedure uses a special

idil, among others, have been tried, but

109

the incidence of persistence of pain and

or biofeedback has been helpful in

recurrence of CAF after initial relief of

management of difﬁcult defecation

symptoms has been shown repeatedly

disorders, especially in patients

in Cochrane Reviews to be much higher

unsuitable for surgical correction.

in “medical sphincterotomy” rather

E. Anal incontinence

than lateral internal sphincterotomy,

For too long, patients with anal incon-

which remains the gold standard in treatment of CAF to this day.

tinence were condemned to a lifetime Joseph M. Mathews

NIH NATIONAL LIBRARY OF MEDICINE

c. Anorectal ﬁstula

use of constipating agents, diapers, and, at last resort, a colostomy. Newer

The standard treatment of anorectal

recent promising entry in the ﬁeld of

advances in the treatment of fecal

ﬁstulas was and is anal ﬁstulotomy,

sphincter sparing procedures is the

incontinence include pulsed gracilis

and St. Mark’s Hospital in London

LIFT (ligation of intersphincteric

muscle transfer (not available in the

became the mecca for treatment of

ﬁstula tract) procedure, which has

U.S.) and artificial bowel sphincter,

ﬁstulas in the late 1840s. Traditional

yielded excellent short-term results,

which has a modest success rate but is

treatment modalities of hemorrhoids

but awaits a larger number of cohorts

beset by mechanical failures and septic

and ﬁstulas were imported to the U.S.

with longer follow-up periods to gain

complications. Injection of various

by Joseph M. Mathews, the father of

universal acceptance.

microspheres in the submucosa of the

colon and rectal surgery in the U.S.,

d. Anorectal physiology

anorectum has been tried, and as soon

who chaired the first department

Anorectal physiology has enhanced

as one is abandoned, another surfaces

of proctology in the country at the

the ﬁeld of anorectal surgery in the

in the market. Sacral nerve stimulation

University of Kentucky and who served

last three decades. Anorectal manom-

(SNS) has shown real promise in the

as the ﬁrst president of the American

etry allows measurement of sphincter

treatment of fecal incontinence and

Proctologic Society in 1899. The land-

function at rest and at squeeze

for inexplicable physiologic reason for

mark classiﬁcation of Parks et al. in

in the evaluation of rest and urge

chronic constipation. The complexity of

the mid-1970s allows the surgeon to

fecal incontinence. Pudendal nerve

the procedure and the high cost of pulse

classify not only the complexity of the

terminal motor latency is a surrogate

generators mandate that this procedure

ﬁstula but also to assess the likeli-

for electromyography of the sphincter

be done in high-volume centers.

hood of cure vs. possibility of fecal

mechanism and is used to evaluate the

The preceding is a mere snap-

incontinence. Because ﬁstulotomy in

innervation of the external sphincter.

shot of some, but certainly not all,

transsphincteric and suprasphinc-

Endorectal ultrasonography provides

of the advances in the ﬁeld of colon

teric ﬁstulas will deﬁnitely result in

visualization of the sphincter mecha-

and rectal surgery in the twentieth

varying degrees of fecal incontinence,

nism in its entirety. Injection of

century. Human imagination and tech-

since the early ’90s multiple proce-

hydrogen peroxide into the external

nological innovations will undoubtedly

dures and techniques have been tried

opening of the ﬁstula during ultra-

continue this phenomenal progress in

in treatment of these “high” ﬁstulas.

sonography aids in visualization of

the twenty-ﬁrst century. Q

Fibrin sealant, ﬁrst autologous and

the ﬁstulae tract and identiﬁcation of

later in commercially prepared form,

the internal opening. Measurement

has had varying success rates of 30

of colonic transit time using radio

to 50 percent. This was followed by

opaque markers helps diagnose slow

Professor of Surgery at the University

introduction of a porcine intestinal

transit constipation and identify an

of Illinois at Chicago and Chairman

submucosal plug and more recently a

occasional patient who might beneﬁt

of the Division of Colon and Rectal

polytetraﬂuoroethylene (PTFE) plug to

from abdominal colectomy for intran-

Surgery at the John Stroger Hospital

close the internal opening of a ﬁstula.

sigent constipation. Defecography,

of Cook County. He is a Past President

There are also two ﬂaps, endorectal

or dynamic proctography, permits

of the American Society of Colon and

advancement and dermal island

the accurate evaluation of the rectal

Rectal Surgeons and a Past Executive

anoplasty, utilized to obliterate the

outlet in cases of outlet obstruction

Director and President of the American

internal opening of ﬁstulas. The most

or animus. Neuromuscular retraining

Board of Colon and Rectal Surgery.

Herand Abcarian, MD, FACS, is a

111

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Degrees of Freedom Advances in Gynecological and Obstetrical Surgery by KARL C. PODRATZ, MD, PHD, FACS

The development of gynecological and obstetric surgical procedure has not taken place in a void. As in every other ﬁeld of medicine, parallel developments in the understanding of human physiology, pharmacology, nutrition, intensive care, instrumentation—even electricity—have provided the synergy to make advances possible. Nothing, however, has been more important than the imagination and determination of individual surgeons who pioneered new techniques and created new tools. Their dedication has given modern women and the specialists entrusted with their gynecological and obstetrical care greater degrees of freedom than ever before. Laparoscopy

During the 1920s and ’30s, advances

position to maximize v isualiza-

in laparoscopy were chieﬂy centered

tion of pelvic structures. He began

Laparoscopy (more broadly endos-

on the development of equipment

performing laparoscopic operative

copy) has its origins in the quest for

including wider angle lenses, trocars

procedures for infertility diagnoses

an efﬁcient, minimally invasive way to

for port introduction of instruments,

in German-occupied Paris during

inspect the abdominal cavity. In 1910,

and insufﬂation devices. As crude as

World War II, further developing

not long before the founding of the

they were, these devices facilitated

it through the 1940s. Through his

American College of Surgeons (ACS)

the progress that would be made over

efforts, and following publication of

in 1913, Hans Christian Jacobaeus, a

the next 40 years.

his work in 1947, gynecologists began

Swedish internist, performed the ﬁrst

For example, in the 1930s, a

routinely using laparoscopy for tubal

laparoscopic procedures. His paper

Hungarian internist by the name of

sterilization, lysis of adhesions in the

reported his ﬁndings in the abdominal

Janos Veress developed and improved

abdomen, aspirations of ovarian cysts,

cavities of 19 patients using an endo-

the insufﬂation needle invented by

and retrieval of ova from the ovaries.

scopic approach, which he subse-

Otto Goetze in 1921 by means of

In the 1950s, the simple improvement

quently termed “laparothorakoscopie.”

adding a spring that enabled safe

of illumination expanded laparoscopy.

Bertram M. Bernheim, MD, of the

insertion and insufﬂation (inﬂation) of

Palmer introduced a safer light source

Johns Hopkins Hospital, was the

the peritoneal cavity. It could also be

by placing a small quartz-electric light

ﬁrst to introduce laparoscopy in the

used for draining ascites and evacu-

bulb at the tip of a laparoscope, which

United States, performing the proce-

ating ﬂuid and air from the chest and

increased brightness and decreased the

dure at Hopkins in 1911. He actually

remains an essential tool today.

chance of burns. Fiber-optic lighting

published his experiences prior to

Perhaps the most important pioneer

technology was a natural follow-on.

learning of Jacobaeus’ work, terming

in gynecologic laparoscopy was Raoul

A wider range of gynecologic opera-

the procedure “organoscopy.” Dr.

Palmer, a French gynecologist. He

tive laparoscopic procedures were

Bernheim’s work, and his reporting

was instrumental in emphasizing

performed in Europe than in the U.S.

of a high diagnostic success rate,

the importance of monitoring intra-

in the 1960s, including the ﬁrst lapa-

helped catalyze American interest

abdominal pressure during the proce-

roscopic appendectomy, performed by

in laparoscopy.

dure and used the Trendelenburg

German gynecologist Kurt Semm.

113

Semm’s laparoscopic appendectomy met with a signiﬁcant amount of criticism and even disbelief from fellow surgeons, but he was undeterred. He designed an improved automatic insufﬂator and thermocoagulator (preventing tissue from burning during laparoscopic sterilization), further demonstrating that gynecologists were at the forefront of laparoscopy development. The treatment of ectopic pregnancies via laparoscope began in the 1970s and early ’80s, abetted by the introduction of new television, video, camera, and light-source technologies. Technological development in turn inspired new techniques, and

With the da Vinci Surgical System, a surgeon controls robotic arms from a console to perform complex and delicate procedures through very small incisions with increased vision, precision, dexterity, and control.

in 1981, the A merican Board of Obstetrics and Gynecology required laparoscopic training to be a compo-

procedures including radical hyster-

Thus the procedure wasn’t attempted

nent of residency training.

ectomy and exenteration.

until Alexander Brunschwig, MD,

The ﬁrst video-laparoscopic chole-

embarked on a phase I trial.

Pelvic Exenteration

Dr. Philippe Mouret in Lyons, France.

Born in Texas and trained in Boston, France, and Chicago, Dr. Brunschwig

Five years later, Camran Nezhart

Cancer of the cervix accounted for

performed the ﬁrst total pelvic exenter-

reported the ﬁrst laparoscopic radical

a signiﬁcant percentage of the gyne-

ation in New York in 1947. He sympa-

hysterectomy and lymphadenectomy.

cological cancers during the ﬁrst half

thetically performed the procedure,

Considered the “father” of operative

of the twentieth century. Most were

considered by some at the time to be

video laparoscopy, Nezhart’s advances

treated with radiotherapy but recur-

an abusive, mutilating operation, on 22

were bolstered by use of the ﬁrst robotic

rence was all too common. Typically,

terminal patients with disease conﬁned

arm in laparoscopy to hold a camera/

the recurrent cancer invaded locally

to the pelvis. Still, Dr. Brunschwig’s

instruments in 1994. Subsequently,

adjacent organs including the rectum,

pelvic exenterations for patients

several generations of robot systems

bladder, and vagina. Chemotherapy was

with cervical and reproductive-tract

have been developed. The fully articu-

essentially unavailable and additional

cancers realized a modest salvage rate

lating instruments simulate the full

radiotherapy was ineffective. As such,

(12 percent) when other options did not

range of motion of the surgeon’s wrists

the only reasonable option was surgery.

exist. That did not prevent the surgical

and hands, and offer the advantage

The potential for survival existed if

community from criticizing him due to

of three-dimensional, high-deﬁnition

these central pelvic tumors could be

a surgical mortality rate of 23 percent.

imaging and magniﬁcation.

removed with wide margins of tissue

The initial keys to successful pelvic

The degrees of freedom now possible

clearance including surrounding

exenteration lay ﬁrst in determining

inside the abdomen with robotic

organs, a procedure called pelvic

which target lesions were appro-

instruments have made a marked

exenteration. Unfortunately, it was

priate for surgery and second, in

difference in approach. Robotic

recognized that with limited contem-

ﬁnding a method of substitution for

laparoscopy now facilitates hyster-

porary antibiotics, blood replace-

urinary bladder function following

ectomy, myomectomy, ectopic preg-

ment, and intensive care, rates of

the removal of the bladder, uterus,

nancy, oophorectomy, and oncologic

survival would be prohibitively low.

vagina, and rectum.

114

cystectomy was performed in 1987 by

Along with others, Dr. Brunschwig

These pioneering advances have been

new cases of ovarian cancer will be

helped identify lesions suitable for

complimented by further advances

diagnosed in 2012 and approximately

surgery and sought solutions suitable

in bladder substitution (the Kock and

15,500 deaths are anticipated. While

for urinary diversion. Eugene Bricker,

Miami pouches), better diagnostic

chemotherapy and some biological

MD, who had been involved with pelvic

techniques, and the employment of

agents are important treatments,

exenterations at Barnes Hospital in St.

robotics. Though pelvic exenteration

surgery remains central in the diag-

Louis, MO, in the 1940s, reported his

remains a very extensive procedure for

nosis, staging, and primary treatment

success with the construction of an

women undergoing it, there has been

of this disease. Fallopian tube and

ileal conduit that afforded low-pres-

a substantial improvement in longevity

primary peritoneal cancers present

sure drainage of urine into an appli-

with ﬁve-year survival rates approxi-

in similar fashion and are likewise

ance attached to the abdominal wall.

mating 55 to 60 percent. There has like-

managed with cytoreductive surgery.

In 1950, an ileostomy patient by the

wise been a dramatic improvement in

These cancers spread in a similar

name of Herman W. Rutzen constructed

the quality of life for those undergoing

manner, primarily through exfo-

a prototype of a rubber bag that could

the procedure, with new techniques

liation. Cells exfoliated from the

effectively form a watertight seal with

in pelvic ﬂoor reconstruction, colonic

surface of these cancers are carried

the skin. Dr. Bricker tried the so-called

reanastomosis, neovaginal reconstruc-

throughout the peritoneal cavity

“Rutzen bag” on two patients at the

tion, and continent urostomy.

by the abdominal f luid. The cells

Veterans Administration Hospital in St. Louis with results so promising

com mon ly seed the d iaph rag m,

Cytoreductive Surgery

that he suspended his own work on

omentum, and multiple other organs as well as the peritoneum and serosal

a bladder substitute. Ruzten’s device

Epithelial ovarian cancer accounts

surfaces of the bowel. As tumors

and Dr. Bricker’s application of it had

for the majority of deaths from cancers

grow, more cells are progressively

a major, positive impact on morbidity

of the female reproductive tract in the

shed, expanding the tumor burden

with pelvic exenteration.

U.S. According to estimates, 22,280

within the abdominal cavity. Patients

The College of American Pathologists is honored to partner with the American College of Surgeons to achieve optimal cancer care for patients. The CAP congratulates ACS on 100 years of

Congratulations improving quality in surgery, trauma, and cancer care.

cap.org

Thank you

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Physician Relations:

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henrymayo.com

frequently present with malignant

successful procedure was pioneered

ascites and pleural effusions.

in 1900 by Howard Kelly, MD, a uro-

Cytoreductive surgery refers to the

gynecologist at Johns Hopkins. Dr. Kelly

surgical excision of tumor and tumor-

performed a plication (folding) of the

involved organs with the intent of

bladder neck and proximal urethra by

minimizing the amount of residual

means of a deep mattress suture and

disease remaining at the completion

anterior colporrhaphy (repair of the

of the operative procedure. Optimal

anterior vagina after plication). In 1914,

cytoreduction is removal of all visible disease. At a minimum for women

Dr. Kelly presented a detailed analysis Howard Kelly

having completed childbearing, this

plication” remained the standard of

requires removal of the ovaries,

veriﬁed. Combined with more effective

uterus, fallopian tubes, omentum, and

chemotherapy, the procedure currently

The next significant advance

regional lymph nodes. With advanced

results in survival rates approaching

emerged in 1949 when Drs. Victor

disease, excision of the peritoneum,

100 months if all macroscopic disease

Marshall, Andrew Marchetti, and

spleen, bowel, and other adjoining

can be removed. As before, the larger

Kermit Krantz introduced the cysto-

organs may be necessary.

care for more than 50 years thereafter.

the remaining tumor mass, the lower

urethropexy and colposuspension

Prior to the 1970s, cytoreductive

the survival interval. But today, gyne-

procedure, also referred to as the MMK

surgery was not considered a viable

cological oncologists approach ovarian

procedure. The MMK procedure (in

procedure. Because of the limits of

cancer much more aggressively,

simple terms, bladder neck suspension/

contemporary chemotherapy, patients

resulting in survival rates improved by

support surgery) was subsequently

who presented with advanced ovarian

a factor of three to four over the 1970s.

modiﬁed in 1961 by Vanderbilt Medical

cancer (typically 70 percent) were not considered curable. For women who demonstrated extensive disease

School professor John C. Burch, MD.

Surgery for Stress Urinary Incontinence

throughout the abdominal cavity, surgery was generally limited to removal of the primary tumor site.

NIH NATIONAL LIBRARY OF MEDICINE

of outcomes for 20 patients. The “Kelly

Dr. Burch’s modification involved placing surgical sutures at the bladder neck and anchoring them to the Cooper

C hronic ailments have benefited

ligament. Gynecological surgeons used

from the development of gynecolog-

both the MMK and Burch procedures

But in the early 1970s, C. Thomas

ical surgical procedures, too. Stress

in the decades that followed, with SUI

Grifﬁths, MD, studied the effect of

Urinary Incontinence (SUI) has long

cures nearing 85 percent.

tumor “debulking” on survival in

been a source of physical, emotional,

More recently, “sling” procedures

102 patients with advanced ovarian

and social distress for women that

have become the surgical interventions

cancer. He reported that surgical cyto-

surgery has sought to alleviate. SUI

of choice for SUI. The sling is basi-

reductive procedures were associated

is essentially the loss of varying

cally a narrow ribbon, typically made

with improved survival rates. Despite

amounts of urine from movements

of synthetic material, which is placed

skepticism, Dr. Grifﬁths demonstrated

that increase pressure within the

beneath the urethra in minimally inva-

that if all tumor tissue in the abdomen

abdomen and on the bladder, such

sive fashion with minute incisions and

could be removed, patients had a

as coughing, sneezing, or exercising.

inserted via a trocar. The sling place-

survival rate of 39 months. If the

Technically, it stems from the loss of

ment augments deﬁcient pelvic ﬂoor

tumor could be reduced to 5 milli-

support of the urethra and bladder

muscles by providing a hammock of

meters or less, patients survived 29

neck. It is generally caused by changes

support under the urethra.

months on average. If the remaining

commonly associated with pregnancy,

A variety of slings, including the

tumor was between 5 and 15 millime-

childbirth, strenuous work-related

tension-free transvaginal tape (TVT)

ters, the survival rate was 18 months.

activities, and loss of estrogen support.

and transobturator tape (TOT) types,

As a result of Dr. Grifﬁths’ work, the

Surgical techniques for the cure of

are currently in use, and studies have

value of cytoreductive surgery was

SUI were not introduced until the late

shown them to be approximately

recognized and, over the years, further

nineteenth century. The first truly

85 percent effective. More recent

117

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SKILL We are training the next generation of surgeon-scientists to be lifelong learners and always seek inventive solutions to clinical problems. In fact, our general surgery residents spend additional years of training focused on research.

COMMITMENT Progressing education, furthering discovery, translating ﬁndings, and providing innovative quality surgical care…this is our mission, our commitment, as an academic surgery department.

5NIVERSITY OF &LORIDA $EPARTMENT OF 3URGERY s surgery.med.uﬂ.edu/acs

developments aim to minimize the

by interrupting blood supply in fetal

lower urinary tract obstruction, lesions

operative procedure as much as

puppies. The experiment established

of the thorax) met the criteria for fetal

possible to reduce complications.

the pathogeneses of neonatal intestinal

surgery that were set by consensus

atresia and, as importantly, demon-

during this period and endorsed by

strated the feasibility of simulating

the International Fetal Medicine and

human birth defects by appropriate

Surgery Society. As a result, very few

fetal manipulation.

open fetal procedures were attempted

Fetal Surgery The delicacy and complexity of childbearing have meant that obstetrical

The 1960s and ’70s saw experi-

in the following decades, and by the

surgical practices have historically

mental fetal surgery used to simulate

1990s, a shift to in utero endoscopy

been limited to post-birth procedures.

human congenital anomalies and for

was under way, particularly in Europe.

With the advent of fetal surgery or

the study of normal developmental

Minimally invasive endoscopic fetal

fetus-in-utero intervention, a funda-

physiology and the pathophysiology

surgery poses less risk to the fetal

mentally new (still nascent) channel of

of congenital defects. Experimental

patient and mother. The ﬁrst clinical

obstetrical surgery has opened.

fetal surgery in primates proved more

fetoscopic surgeries were interventions

The practical drivers of such change

difﬁcult as uterine contractility and

on the umbilical cord and placenta.

have been technological. The devel-

preterm labor were more difﬁcult to

Clinical trials also demonstrated

opment of safe, non-invasive fetal

control. However, advances in surgical

the potential of fetoscopic therapy

imaging, monitoring, and sampling

and anesthetic techniques and in the

for twin-twin transfusion syndrome

techniques has led to an increasing

pharmacologic control of labor made

(disproportionate blood supply).

number of fetal anomalies diagnosed

experimental manipulations of the

Future fetal interventions are likely to

prior to birth. While some of these

primate fetus possible, setting the

remain minimally invasive and center

anomalies were understood before

stage for human fetal procedures.

on prenatal gene therapy and stem cell

the application of these technolo-

The procedure that inaugurated

treatments. Recent trials in the prenatal

gies, acceptance of the potential of

hu ma n fet a l i nter vent ion wa s

treatment of open spina biﬁda (myelo-

fetal su rg ical and /or fetoscopic

performed by New Zealand surgeon

meningocele) at the Children’s Hospital

interventions accelerated after such

Sir William Liley, who attempted to

of Philadelphia, Vanderbilt, and UCSF

approaches became more adaptable.

transfuse the fetus in utero in 1963.

have shown promise as well.

Physiologic observation of the

His successful intra-abdominal infu-

The advancement of the surgical arts

mammalian fetus began with the

sion of blood ameliorated Rh disease

and their compliments in the century

examination of animal (guinea pig)

in a fetus expected to die before birth.

since the founding of the ACS have

fetuses in the nineteenth century. By

In 1981, the ﬁrst open fetal surgery

not only improved the mortality of

1920, the ﬁrst scientiﬁcally successful

was undertaken at the University of

patients but raised their quality of life

nonhuman fetal procedures had been

California, San Francisco (UCSF) by

as well. New technologies, techniques,

performed, studying aspects of fetal

a team including Michael Harrison,

and clinical philosophies have given

movements and experimental in utero

MD. In the operation, a vesicostomy

modern gynecological and obstetrical

manipulation. In the 1930s and ’40s,

was placed in a fetus with a urinary

surgeons greater degrees of freedom

observation of and operations on the

obstruction. Though the fetus did not

than their predecessors envisioned. Q

lamb fetus gained momentum, proving

survive, the procedure was a technical

the most productive fetal experimental

success and was complimented by the

model for decades thereafter.

ﬁrst successful sonographically guided

Karl C. Podratz, MD, PhD, FACS, a

In the 1950s, South African

placement of a fetal urinary catheter at

gynecologic oncologist, is the Joseph

surgeons Dr. Christiaan Barnard (who

UCSF the same year. The fetus survived

I. and Barbara Ashkins Professor of

performed the ﬁrst successful human

this less extensive intervention and the

Surgery Emeritus at Mayo Clinic in

heart transplant) and Dr. J. H. Louw

adult continues to communicate with

Rochester, MN. He served three terms

produced intestinal atresia (narrowing

the university team today.

as a member of the Board of Regents

or absence of portions of the intestine)

Despite these successes, few condi-

similar to that seen in human fetuses

tions (congenital diaphragmatic hernia,

of the American College of Surgeons (2003–2012).

119

Neurosurgery and the American College of Surgeons by EDWARD R. LAWS, JR., MD, FACS, DMEDCH NAPLES (HON), FRCSED (HON), FRCPSG (HON)

In 1913, the year that the American College of Surgeons (ACS) was founded, Harvey Williams Cushing (1869-1939), the pioneer of the “Special Field of Neurological Surgery,” was recruited to the newly opened Peter Bent Brigham Hospital as Moseley Professor of Surgery at Harvard. In those days, most of the very few surgeons who performed neurosurgical procedures were general surgeons who had agreed to take on the occasional neurosurgical case. Some specialization in surgery had

problems. Their expertise in this area

to Johns Hopkins for surgical training,

already occurred before World War I,

was recognized by membership in

Cushing took along a Roentgen tube

and there were surgeons who concen-

the Society of Neurological Surgeons,

and made the first X rays there,

trated their surgical practices in the

founded by Cushing in 1920. These indi-

including an image of a bullet lodged

areas of head, eyes, ear, nose, and throat

viduals included Edward W. Archibald of

in the spine. After spending a year

(HEENT), orthopaedics, gynecology and

Montreal, Charles Bagley of Baltimore,

abroad, he came back to Baltimore

obstetrics, and urology. Other surgical

Charles A. Elsberg of New York City,

and introduced intraoperative blood

specialties developed over time as

Charles H. Frazier of Philadelphia,

pressure monitoring and the concepts

surgical practice expanded and tech-

Albert E. Halstead of Chicago, Allen B.

of the Cushing reflex (bradycardia

nology and surgical science advanced.

Kanavel of Chicago, George Heuer of

and respiratory depression related to

Neurosurgery was one of these.

Baltimore, Dean Lewis of Chicago, and

increased intracranial pressure), and

Howard C. Taylor, Jr., of New York City.

the Cushing ulcer (gastric ulcer related

served in World War I had developed

Drs. Kanavel and Halstead deserve

to stress). By 1909 he had established

major experience in the treatment of

special mention. They had become

basic principles of pituitary physiology,

neurological injuries, and the imme-

experts, like Cushing, in transsphe-

and began his large series of successful

diate postwar years were character-

noidal pituitary surgery. Drs. Elsberg

operations for pituitary adenomas.

ized by many changes in medicine

and Taylor were pioneewrs in spinal

and technology. This surely provided

neurosurgery.

Many of the surgeons who had

Cushing’s experience in World War I established the principles of manage-

an impetus for surgical innovation and

Dr. Cushing, President of the

ment of head wounds, which have

specialization, and for the central posi-

American College of Surgeons in

been reﬁned during subsequent armed

tion of the ACS as an effective voice

1920–1921, contributed in many

conﬂicts. He actively worked on intraop-

and source of education and ethical

ways to the advance of surgery and

erative ﬂuid replacement, methods and

practice for all surgeons.

neurosurgery over the past century

principles of hemostasis, and the possi-

Among the Founders of the American

and more. As a medical student at

bilities of blood transfusion. Along with

College of Surgeons were a number

Harvard, he and a classmate, E. Amory

other surgeons, he had developed an

of prominent general surgeons who

Codman, introduced the ﬁrst anaes-

operation on the Gasserian ganglion for

also operated on some neurosurgical

thesia record. When he decided to go

the treatment of trigeminal neuralgia,

121

AHEAD.

Science moves forward. Fields evolve. And careers are not static. If youâ&#x20AC;&#x2122;re interested in putting your leadership skills to work, the Congress of Neurological Surgeons is interested in you. The CNS offers the insight, innovation and information that pave the way to your future. Hone your leadership skills, advance your education and further your career by joining the one organization focused on fresh ideas and the future of neurosurgery.

Think ahead. We are. For more information about member beneďŹ ts or to apply today, visit www.CNS.org.

Congratulations ACS on 100 years of improving the care of the surgical patient!

Phone: 847-240-2500 Toll Free: 1-877-517-1CNS info@1cns.org www.cns.org

From the more than 8,100 members of the American Association of Neurological Surgeons (AANS) to our colleagues at the American College of Surgeons (ACS), we congratulate you on your 100th anniversary. Best wishes for your continued success.

Figure 1. Neurosurgeon Presidents of the American College of Surgeons. Top row, from left: Harvey Williams Cushing, Howard Christian Naffziger, and Loyal Davis. Bottom row, from left: Charles George Drake and Edward Raymond Laws, Jr.

and pursued operations for the treat-

active in the College, helping to develop

The introduction of antibiotics in

ment of epilepsy and brain tumors.

surgical specialty representation and

the late 1930s was important for all

involvement, which continues to the

of surgery, as was the discovery and

present day (Table 1).

synthesis of cortisone.

Cushing’s pupil and coworker at

PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES

Johns Hopkins, Walter E. Dandy (1889–1948), was responsible for a

There are many milestones in the

In the 1950s, dexamethasone was

major advance in neurosurgery. With

evolution of contemporary neurosur-

introduced as a means of decreasing

his colleagues in the experimental

gery. Cushing and W. T. Bovie intro-

intracranial pressure. At the same

surgical laboratory, he discovered the

duced electrocautery in 1927. That

time, new principles of neuroan-

physiology of the cerebrospinal ﬂuid

same year, Cushing published his

aesthesia were developed, making

(CSF) circulation. In 1919, based on the

authoritative book on meningiomas,

intracranial surgery safer and more

observation of the ability to image free

classifying these benign tumors and

effective. That decade saw the intro-

air in the peritoneal cavity on X ray,

establishing the principles of their

duction of CSF shunting procedures,

Dandy introduced ventriculography,

surgical management.

wh ich revolut ion i zed ped iat r ic

replacing the CSF with air and thereby

In 1927, Egas Moniz of Portugal

neurosurgery. It also included the

visualizing intracranial structures and

introduced arteriography, setting the

application of stereotactic surgery to

their distortion by intracranial lesions.

foundation for the diagnosis and treat-

the treatment of tremor. Stereotactic

With the impetus from these early

ment of cerebrovascular disease. Over

surgery, now based on sophisticated

advances, neurosurgery has progressed

the subsequent years, endovascular

imaging, has evolved to deep brain

steadily over the past 100 years. Dr.

surgery has evolved and angiography-

stimulation (DBS) with indications

Cushing, as the ﬁrst neurosurgeon to

based interventions continue to be

not only for movement disorders, but

be President of the ACS, and many of

more and more effective and more

also for epilepsy and some psycho-

his trainees and colleagues remained

frequently employed.

logical conditions.

123

TABLE I

Other leaders in this paradigm

Neurosurgeon Leaders of the American College of Surgeons

shift for neurosurgery were R. M. Peardon Donaghy of Burlington, VT, Leonard Malis of New York City, Gazi

Presidents Harvey Williams Cushing, MD, FACS, Boston, MA

Yasargil, then of Zurich, Switzerland, 1921–22

Robert Rand and Theodore Kurze of Los Angeles, and Albert Rhoton of

Howard Christian Naffziger, MD, FACS, San Francisco, CA

1938–39

Gainesville, FL.

1962–63

the CT scan (1970s) and the MRI scan

Subsequently, the introduction of Loyal Davis, MD, FACS, Chicago, IL

(1980s) revolutionized neurosurgical Charles George Drake, MD, FACS, London, Ontario

1984–85

Edward Raymond Laws, Jr., MD, FACS, Charlottesville, VA

2004–05

diagnosis and treatment. Computerbased image guidance and the introduction of the operating endoscope (another collaborative phenomenon

Neurosurgeon Regents of the ACS (All of the above, and:) William Feland Meacham, MD, FACS, Nashville, TN Edward Louis Seljeskog, MD, FACS, Rapid City, SD Martin B. Camins, MD, FACS, New York City, NY

Neurosurgeon Secretary of the ACS

with otorhinolaryngology) have further advanced the ﬁeld, and have opened up new areas of endeavor. The collaborative nature of the adoption of microneurosurgery and minimally invasive endoscopic anterior skull base surgery emphasize the fact that so many of our subsequent advances result from multidisciplinary collaboration, an integral

W. Eugene Stern, Jr., MD, FACS, Los Angeles, CA

aspect of the educational programs of the ACS, and of its role in keeping

Neurosurgeon Vice-Presidents of the ACS

the “House of Surgery” together. Presently, neurosurgery collaborates with many of the other surgical disci-

John E. Raaf, MD, FACS, Portland, OR

plines on a regular basis. These include: Henry Gerard Schwartz, MD, FACS, St. Louis, MO

UÊ Neurotrauma and critical care – acute care surgery, ortho-

Eben Alexander, Jr., MD, FACS, Winston-Salem, OR

paedic surgery, ophthalmologic surgery, maxillofacial surgery;

Richard Lee Rovit, MD, FACS, New York City, NY

UÊ Cerebrovascular surgery – vascular surgery, interventional/

Julian Theodore Hoff, MD, FACS, Ann Arbor, MI

endovascular surgery; UÊ Brain tumor surgery – surgical neuro-oncology, neuropa-

The introduction of microneuro-

using and improving the operating

thology, radiation oncology;

surgery in the late 1960s marked a

microscope, neurosurgeons rapidly

UÊ Skull base surgery – otorhi-

major paradigm change. Spurred on by

adopted microneurosurgery, techni-

nolaryngology–head and neck

surgical pioneers like Julius Jacobson,

cally and conceptually. The almost

surgery, plastic surgery;

who introduced neurosurgeons to

simultaneous introduction of precise

microsurgical technique, and by otolo-

bipolar cautery was a signiﬁcant part

surgery, physiatry, rehabilitation

gists and ophthalmologists who were

of the success of microsurgery.

medicine, spinal instrumentation;

124

UÊ Spine surgery – orthopaedic

Edward R. Laws, Jr., MD, FACS,

is a member of the American Surgical

i ÌÊ` Ã À`iÀÊ iÕÀ }Þ]Êi« i«-

DMedCh Naples (Hon), FRCSEd (Hon),

Association, and is a member of the

Ì }Þ]Ê«ÃÞV >ÌÀÞ]Ê iÕÀ À>` }ÞÆ

UÊ Õ VÌ > Ê iÕÀ ÃÕÀ}iÀÞÊqÊ Ûi-

FRCPSG (Hon), is a graduate of Princeton

Institute of Medicine of the National

UÊ *iÀ « iÀ> Ê iÀÛiÊÃÕÀ}iÀÞÊqÊ

University and the Johns Hopkins

Academy of Science.

ÀÌ «>i` VÊÃÕÀ}iÀÞ]Ê > `Ê

Medical School and its neurosurgical

ÃÕÀ}iÀÞ]Ê« >ÃÌ VÊÃÕÀ}iÀÞÆ

training program. He has held endowed

UÊ *i` >ÌÀ VÊ iÕÀ ÃÕÀ}iÀÞÊqÊ«i` >ÌÀ VÊ

chairs at the Mayo Clinic and the

ÃÕÀ}iÀÞ]ÊVÀ> v>V > ÊÃÕÀ}iÀÞÆÊ> `

University of Virginia, Charlottesville,

UÊ -ÌiÀi Ì>VÌ VÊÀ>` ÃÕÀ}iÀÞÊqÊ

was Chair of Neurosurgery at George

À>` >Ì Ê« ÞÃ VÃ]ÊÀ>` >Ì Ê

Washington University, Washington,

V }Þ]Ê iÕÀ À>` }Þ°

DC, and currently is Professor of

/ iÀiÊ >ÛiÊLii ÊwÛiÊ iÕÀ ÃÕÀ}i ÃÊ

Surgery at Harvard Medical School and

Ü Ê >ÛiÊ ÃiÀÛi`Ê >ÃÊ > ÀÃÊ vÊ Ì iÊ

Brigham and Women’s Hospital, where

>À`Ê vÊ,i}i ÌÃÊ> `Ê>ÃÊ*ÀiÃ `i ÌÃÊ vÊ

he directs the Pituitary/Neuroendocrine

Ì iÊ -°Ê/ i ÀÊ*ÀiÃ `i Ì > Ê ``ÀiÃÃiÃÊ

Center. During his surgical career he

> iÊ} `ÊÀi>` }ÊÃiiÊ,iviÀi ViÃ®°Ê

has operated upon more than 7,800

"Ì iÀÃÊ >ÛiÊLii Ê"vwViÀÃÊ> `ÊivviV-

brain tumors, of which 5,500 have been

Ì ÛiÊ i>`iÀÃÊ vÊÌ iÊ i}i°Ê }ÕÀiÊ£]Ê

pituitary lesions.

/>L iÊ£®°

Dr. Laws has served as President of

-ÕÀ}iÀÞÊ > `Ê Ì iÊ ÃÕÀ} V> Ê Ã«iV > -

the American College of Surgeons, the

Ì iÃÊ >ÀiÊ > ÛiÊ > `Ê Üi ]Ê y ÕÀ Ã }Ê

Congress of Neurological Surgeons, the

Õ `iÀÊ Ì iÊ >i} ÃÊ vÊ Ì iÊ iÀ V> Ê

American Association of Neurological

i}iÊ vÊ-ÕÀ}i Ã°ÊQ

Surgeons, and the Pituitary Society. He

References Cushing H. The physician and surgeon. SGO. 1922;35:701-710. Cushing H. Surgical and end results in general. SGO. 1923;36:303-308. Davis L. Credo. Bull Amer Coll Surg. 1963;36:25-28;52. Drake CG. Fellowship: the benchmark for American Surgery. Bull Amer Coll Surg. 1984 Dec;69(12):6-10. Greenberg SH, ed. A History of Neurosurgery. Park Ridge, IL: AANS; 1997: 626pp. Laws, ER. Harvey Cushing and the unity of surgery. Bull Amer Coll Surg. 2004 Dec;89(12):8-12. Naffziger, HC. Metamorphosis of the surgeon. SGO. 1940;70:374-378. Scarff, JE. Fifty years of neurosurgery 19051955. In: Davis L, ed. Fifty Years of Surgical Progress 1905-1955 as reprinted from Surgery, Gynecology and Obstetrics. Chicago, IL: Franklin Martin Memorial Foundation; 1955: 303-399.

Through the Lens: A Century of Innovation in Ophthalmic Surgery by BARRETT G. HAIK, MD, FACS

A century ago, ophthalmic surgeries would not have been popular topics for casual conversation. Procedures involved large incisions and long recuperation periods that often involved immobilization in devices for several days. Complication rates were high and visual rehabilitation limited. However, due to the determination of innovative ophthalmic pioneers, the past 100 years have witnessed tremendous advancements in intraocular surgery. The first surgical procedures to

Herein, I shall discuss ﬁve key areas

cure blindness were devised more

of innovation that have most dramati-

than 2,000 years ago. The opera-

cally revolutionized ophthalmic surgery

tions to remove cataracts from the

over the past century.

visual axis utilized thorns and forged needles, and were surrounded by great

Intraocular Lens

mystique. Despite a very high rate of failure, successes were so dramatic

For eyesight to be possible, light

that early surgeons were treated with

entering the human eye must ﬁrst be

the greatest respect and honored

refracted at the air-tear interface of the

throughout the land. Over the ensuing

cornea and then focused by the crystal-

20 centuries, cataract surgery has

line lens onto our retinas. Next, photo-

undergone extraordinary advances,

receptors within the retina convert that

later devised methods for removing

especially in the past 100 years.

light into electrical impulses of infor-

the cataractous lens, but there was a

The nineteenth century set the stage

mation, which are transmitted through

problem: What would take the place

for modern surgery with the introduc-

the optic nerve to our brains, where the

of the lens? Removing an opaque lens

tion of germ theory and sterile surgery

perception of vision is created. When

meant condemning a patient to half-

by German physician Robert Koch and

we are born, the lens is clear as glass.

inch-thick glasses that did a poor job

British surgeon Baron Joseph Lister,

But, as the lens ages, it begins to lose

of replacing the lens’ ability to bend

after whom Listerine® was named. These

its ﬂexibility and undergoes natural

light. Innovation was needed, and it

discoveries dramatically improved the

changes to its structure that cause

took one brilliant man to change the

safety of surgical outcomes, and, coupled

yellowing and opaciﬁcation, ultimately

course of ophthalmology.

with major improvements in anesthesi-

leading to a decreased ability to see.

During World War II, ophthalmolo-

ology and the reﬁnement of vital surgical

For a long time, the only way to deal

gist Harold Ridley, MD, was treating

instruments such as the lancet blade,

with a visually signiﬁcant cataract

eye injuries in Royal Air Force pilots.

have resulted in much safer and less

was for a surgeon to stick a needle

He noted that when fragments of

invasive procedures that can treat a

into the eye and displace the lens out

acrylic plastic from cockpit canopies

wider variety of diseases and yield better

of the visual axis. With the advance

were embedded in patients’ eyes, they

outcomes for surgery patients.

of ophthalmic surgery, physicians

were tolerated without inﬂammation,

126

NIH NATIONAL LIBRARY OF MEDICINE

Robert Koch

rejection, or any apparent toxicity. He wondered, what if he made a lens from this acrylic to insert in the eye? It was a bold idea with limited acceptance from his colleagues. He pressed on, however, and introduced the ﬁrst intraocular lens (IOL) at the end of 1949. “In doing so, he changed the practice of ophthalmology,” note Drs. David J. Apple and John Sims in their biography of Ridley for Survey of Ophthalmology. “Not only [did] Ridley’s invention

Steve Charles, MD, FACS, uses an operating microscope for retinal surgery.

PHOTO BY STEVE MOSER, OPHTHALMIC PHOTOGRAPHER, UNIVERSITY OF TENNESSEE MEDICAL GROUP

provide superior visual rehabilitation to cataract patients for generations to

few key advances highlight the path

come, but also, without his having real-

to where we are today.

Each incremental improvement in microsurgical tools and techniques is

ized it, the IOL has been a major factor

In 1956, José I. Barraquer, MD, of

built upon its predecessors, allowing

in changing the way ophthalmology is

Buenos Aires, Argentina, pioneered

for the implementation of new tech-

practiced.” For his remarkable accom-

the idea of adapting surgical micro-

niques and reﬁnement of old ones.

plishments in ophthalmic medicine, Dr.

scopes for suspension from the

As a result of the past 100 years of

Ridley was knighted Sir Harold Ridley

ceiling, an approach ophthalmolo-

progress, most major eye surgery in

by Queen Elizabeth II in February 2000.

gists needed in order to keep their

developed nations around the globe

Initially, a patient had to be close to

patients lying in a supine position.

is done with operating microscopes,

legally blind before a surgeon would

This enabled proper stabilization and

facilitating new surgical techniques

perform cataract surgery because

positioning of patients, which was a

and improving patient outcomes.

early IOLs were associated with higher

key prerequisite to numerous future

complication rates. There were also

innovations in ophthalmic surgery.

Phacoemulsiﬁcation

concerns over their long-term effects

In the 1960s, Richard C. Troutman,

on eye health. Over the years, however,

MD, of New York approached German

In the 1960s, Charles Kelman, MD,

continued reﬁnement in IOL materials,

manufacturer Zeiss Oberkochen to

couldn’t turn off his brilliant mind

shape, and surgical method led to their

develop a zoom microscope with vari-

even while in the dentist’s chair. He

widespread acceptance with signiﬁcantly

able ranges for use in his practice and

was fascinated with the ultrasonic

better outcomes than leaving patients

at New York Hospital. When he demon-

device that cleaned his teeth and

aphakic. Following the introduction of

strated it at an American Academy of

began asking himself, if sound waves

foldable IOLs, the age of small-incision

Ophthalmology meeting in 1965, the

can break up plaque, why couldn’t

cataract surgery was born, and today’s

implications of what he had achieved

they do the same to a cataract? At

ophthalmic surgeons are able to operate

were obvious and he was met with

that time, cataract surgery involved

on patients as soon as they feel limited by

immediate acceptance and praise.

cutting 180 degrees around the eye

their vision. What was once a risky and

Subsequent advances have included

before removing the lens with a

imperfect procedure has thus evolved

variable wavelengths of illumination,

freezing cryoprobe. Recovery was

into a low-risk and highly satisfying

integrated laser capabilities, voice-

lengthy and postoperative complica-

surgery for both patient and surgeon.

activated adjustments, improved depth

tions were borderline routine.

Microsurgery

of focus, high-deﬁnition and 3-D video

In 1967, Dr. Kelman introduced

recording, and conferencing. These

phacoemulsiﬁcation, using ultrasonic

advances facilitate the creation of online

energy to emulsify the lens and then

The introduction of microscopy

surgical libraries, real-time education

aspirate it through a tiny vacuum. It

created the ﬁeld of microsurgery and

in adjacent or distant viewing sites, and

was a very crude procedure in the

revolutionized ophthalmic surgery. A

innovative telesurgical applications.

beginning with limited support from

127

100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to

2012 2 100 years 1912 to 2012 2 100 yearss 1912 to 20 012 10 00 years 1912 to 2012

MedStar Health celebrates the yearss 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years American College of Surgeons’ 1912 2 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 2 1Centennial 00 years 1912 to 2012Anniversary. 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100

100 years 1912 to 2012 100 years 1912 to 2012 2 100 years 1912 to 2012 100 yearss 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 191 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1 years 1912 to 2012 100 years 1912 to 2012 100 yea 1912 to 2012 100 years 1912 to 2012 100 y

2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 Years of Quality Care Since the College’s founding by Dr. Franklin H. Martin, you have partnered with healthcare institutions across the United States to enhance and ensure the safe care of surgical patients, while improving quality in surgery, trauma and cancer care.

We join you in celebrating this milestone of contributions to millions of people through the years, and we salute all of our surgical fellows. With knowledge and compassionate care, MedStar Health looks ahead with the American College of Surgeons to create further healthcare breakthoughs— all centered on the patient.

medstarhealth.org

PHOTOS BY JOE MASTELLONE, OPHTHALMIC PHOTOGRAPHER, UNIVERSITY OF TENNESSEE MEDICAL GROUP

Fundus photo showing scatter laser surgery for treatment of diabetic retinopathy.

separates from the retina. It was once

The foot-pedal-controlled aspiration

believed that touching the vitreous of

system was developed by Drs. Conor

the eye risked retinal detachment and

O’Malley and Ralph Heintz in 1971.

total loss of vision. Because of this,

Then, in the early 1980s, Steve Charles,

surgically removing the vitreous was

MD, FACS, introduced xenon endopho-

always considered dangerous and

tocoagulation, in which a ﬁber-optic

foolhardy. But then, in 1968, David

probe is positioned near the retina after

Kasner, MD, reported successful

a vitrectomy to treat retinal breaks, stop

extraction of diseased vitreous in a

retinal bleeding, coagulate neovascu-

his colleagues. That he was able to

case of amyloidosis, becoming the

larization, or manage a number of other

pioneer such a radical new approach

first surgeon to demonstrate that

complications, dramatically improving

is nothing short of amazing. It is said

removal of diseased or prolapsed

surgical outcomes. Numerous innova-

that he secretly performed his ﬁrst

vitreous is tolerated by the eye.

tive vitreoretinal surgeons have contin-

phacoemulsiﬁcation test on a blind

However, it was Robert Machemer,

ually improved the designs of these

man behind a closed door with a sign

MD, at Bascom Palmer Eye Institute

tools to include variable ﬂow control,

that read, “Contaminated Room—Do

who buried the erroneous notion once

disposability, reﬁned ergonomics, and

Not Enter.”

and for all. In 1969, he invented a

other remarkable advancements that

Today’s cataract patients have

miniaturized, motor-driven cutter

have paved the way to modern vitreo-

Dr. Kelman to thank for his persis-

and, working with Jean-Marie Parel,

retinal surgery.

tence. Like me, my father was an

PhD, a year later, a suction cutter that

Again, what was deemed impossible

ophthalmologist, and I remember as

would ﬁt into a small hole and act as

a century ago has become routine.

a child rounding on his postopera-

a guillotine to aspirate the vitreous

These pioneers have established

tive patients in the hospital where he

jelly. Coupled with continuous infu-

removal of vitreous as a safe and reli-

worked and seeing dozens of cataract

sion of solution, th is tech n ique

able procedure, leading to hope for

patients whose heads were immo-

marked the beginning of a revolution

millions of patients suffering from

bilized by sandbags for four or ﬁve

in vitreous microsurgery.

vitreoretinal diseases. Although it is

days. Dr. Kelman changed all that. By

impossible to quantify exactly how

contrast, today’s cataract surgery is

many patients have had their vision

an outpatient procedure with a short

saved or restored by vitrectomy, the

recovery period and rare complica-

enormity of its impact is unmistakable.

tions. Modern phacoemulsiﬁcation devices and our surgical techniques

Lasers

are extremely sophisticated, shunning the 4-pound hand pieces of the

More than a dozen types of lasers are

late 1960s and 1970s for a constantly

used in modern ophthalmic surgery

evolving set of tools that will continue

for different types of procedures. The

to be modiﬁed to yield even better

precursor to the ophthalmic laser was

outcomes for our patients.

the photocoagulator, invented in 1949 by Gerhard R. E. Meyer-Schwickerath of West Germany, whose experiments

Vitrectomy

resembled those of Dr. Frankenstein. Most of t he eye’s volu me i s

He observed numerous patients who

composed of a substance termed the vitreous. Like the lens, vitreous changes with age. When we are born, it is gelatinous and ﬂexible, but as we age it liqueﬁes and eventually

were blinded by staring at the sun, Hamilton Eye Institute vitreoretinal disease specialist Edward Chaum, MD, PhD, uses a laser to repair damage caused by diabetic retinopathy.

and he hypothesized that this power, if carefully harnessed, could be used to destroy diseased tissue. He would bring patients to a room on the top

129

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ﬂoor of his clinic, where the ceiling

to LASIK and photorefractive kera-

opened. On sunny days, he would

tectomy (PRK), which remain tremen-

use a series of mirrors to direct and

dously popular elective surgeries for

magnify the sun’s rays to treat—

those patients wishing to do away

and burn—areas of the retina. The

with corrective lenses.

technique proved very effective for

The femtosecond laser marks the

diabetes complications and was useful

next major advancement driven by new

for certain aneurysms and tumors

laser technology. As this safer and more

in the eye. Today, ophthalmologists

effective transpupillary laser system

use a variety of laser wavelengths to

is perfected and fully integrated into

treat retinal diseases such as diabetic retinopathy. Hundreds of thousands of diabetic patients have had their vision saved by retinal photocoagulation. In the 1950s, xenon lamps began to

Aaron N. Waite, MD, a skilled ophthalmic surgeon, uses an Nd:YAG laser to perform a peripheral iridotomy for angle closure glaucoma.

be used as the light source for photo-

cataract surgery, we will see postoperative outcomes improve beyond even the excellent results currently achieved by modern vitreoretinal surgeons.

Conclusions

PHOTO COURTESY OF THE HAMILTON EYE INSTITUTE

coagulation, eliminating the need for a hole in the roof. When the ruby laser

her laser beam precisely cut or vapor-

Thanks to the creativity and perse-

was invented at the end of that decade,

ized without damaging surrounding

verance of innovative ophthalmic

it was found effective in producing

tissue, solving a difﬁcult complication

surgeons, the past 100 years have seen

adhesive chorioretinitis, but was not

of modern cataract surgery: following

remarkable developments in technology

useful in treating vascular diseases.

cataract removal and intraocular lens

and technique that have led to reduced

However, as laser science rapidly devel-

placement, the capsular bag containing

recovery times and improved outcomes

oped, so did its ophthalmic surgery

the new man-made lens may grow

for patients. World-changing advances

applications. Francis L’Esperance, MD,

gradually opaque. Before the YAG

have been made in the areas of intra-

conducted the ﬁrst photocoagulation

laser, ophthalmic surgeons did not

ocular lenses, microsurgery, phaco-

with an argon ion laser at the Edward

have a safe, non-incisional treatment

emulsiﬁcation, vitrectomy, and laser

S. Harkness Eye Institute in 1968,

to restore vision lost as a result of this

surgery. Modern surgery is performed

which was highly successful and led

secondary posterior capsular opaciﬁca-

in ways unimaginable a century ago. As

to widespread applications for treating

tion. Now, a 5-minute YAG procedure

we train the next generation of ophthal-

an array of vitreoretinal diseases. In

restores this lost vision without a

mologists to lead us into the future, one

1971, the krypton laser was found to

surgical incision in the eye.

wonders what new developments may unfold over the next 100 years. Q

be even more effectively absorbed by

Another wave of innovation began

pigments of the eye, but producing the

with the excimer laser, patented by

beam was technologically difﬁcult and

Steven L. Trokel, MD. This laser is

cost prohibitive.

capable of reshaping corneas to

For the past 17 years, Dr. Haik

The development of the yttrium-

correct nearsightedness and farsight-

has served as Hamilton Professor

aluminum-garnet (YAG) laser in 1978

edness. It was originally used by IBM®

and Chair of Ophthalmology at the

was the next revolutionary step in

to cut silicone chips at its New York

University of Tennessee Health Science

the development of laser eye surgery.

facility in the 1970s. Rangaswamy

Center. He is the Founding Director

When Danièle S. Aron Rosa, MD, ﬁrst

Srinivasan, PhD, James Wynne, PhD,

of the world renowned Hamilton Eye

presented her results, she was widely

and Samuel Blum, PhD, who worked

Institute, a comprehensive, verti-

criticized and rejected by colleagues.

in the IBM research labs in 1982,

cally integrated center of ophthalmic

Over a decade, however, her work

recognized its potential in medical

excellence. He is also Director of the

was ﬁnally accepted and she became

applications, but it was Dr. Trokel

Division of Ophthalmology in the

an internationally renowned figure

who ﬁrst applied the excimer laser

Department of Surgery at St. Jude

in ophthalmology. Instead of burning,

to cornea surgery. This paved the way

Children’s Research Hospital.

131

Orthopaedic Surgery 1913 to 2012 100 Years of Evolution, Invention, and Innovation By DAVID G. MURRAY, MD, FACS

Orthopaedic surgery was well organized as a specialty by 1913, but in the latter years of the nineteenth century it was largely associated with “splints, straps, and buckles.” Most surgical procedures fell into the realm of the general surgeons, with orthopaedists providing supporting dressings or braces as well as setting fractures or caring for infections or lacerations. With the advent of the twentieth century, this began to change. One of the prominent orthopaedic

wounds, irrigating with iodine, and

continued to involve plaster cast immo-

entrepreneurs was Fred H. Albee, MD,

packing with Vaseline gauze. After

bilization after reduction, but the hip

who introduced bone grafting in 1915.

dressing, a plaster cast was applied

began to attract the attention of the

In addition, his several inventions at the

and the patient triaged back to the

more aggressive surgeons.

time included a bone mill and a unique

U.S. The cast was not to be windowed

fracture table. He pioneered the stabili-

or changed for several weeks unless

zation of tuberculous spines by means

absolutely necessary for sepsis. Most of

of inserting tibial bone grafts into the

the time the underlying wounds were

split spinous processes of the affected

clean and healing when the cast and

spine to achieve a solid fusion. He had

dressings were eventually removed.

a lengthy career with major involve-

Many limbs were saved by the “Orr

ment in World War I, where it was said

Method,” which continued to be used

(perhaps by him) that he performed half

for the treatment of osteomyelitis

of the bone graft operations required in

several decades after the war. The ’20s saw orthopaedic surgeons

Massive injuries to the extremi-

becoming more aggressive in the

ties during World War I presented a

surgical management of disabilities

major challenge for the medical staff.

and deformities. The residuals of

Amputations were frequently required

polio epidemics demanded a variety

and serious infections were almost

of surgical approaches to improve the

the rule rather than the exception. An

usefulness of involved extremities as

orthopaedic surgeon from Nebraska,

well as the spine. Techniques for tendon

H. Winnett Orr, promoted a treatment

transfers, joint fusions, limb length-

protocol that involved immediate

ening or shortening, etc., dominated

cleansing and debridement of the

the literature. Fracture management

132

Smith-Petersen-type acetabular cup for hip replacement surgery.

SCIENCE MUSEUM/SCIENCE & SOCIETY PICTURE LIBRARY

treating injured soldiers.

arthroplasty” procedure, which he developed, became the standard for treating arthritis of the hip for the next three decades. Willis Campbell, MD, of the ﬂedgling Campbell Clinic in Memphis, TN, created a metallic prosthesis to cover the femoral side of the arthritic knee, drawing inspiration from Dr. Smith-Petersen’s success with the hip. Unfortunately, the knee is a more complex joint than the hip and the Campbell attempt at arthroplasty was unsuccessful. Other concepts, including hinges, also failed. Further attempts at imaginative solutions Sterling Bunnell

were put on hold by the advent of

PHOTO COURTESY OF STERLING BUNNELL MEMORIAL HOSPITAL, PETER CARTER, MD, COLLECTION AND TEXAS SCOTTISH RITE HOSPITAL FOR CHILDREN

World War II, when orthopaedic In 1925, Marius Smith-Petersen, MD,

driving force behind the formation

of Boston devised a three-ﬂanged nail

of a new organization, the American

The war years were not without

for ﬁxing a fracture of the femoral neck.

Academy of Orthopaedic Surgeons

advances that affected orthopaedic

A slender guide wire was inserted into

(AAOS). The AAOS was created to be

practice. Streptomycin drastically

the femoral head with X-ray control

inclusive of all board-certiﬁed ortho-

changed the course of treatment for

and the nail, which had a longitudinal

paedic surgeons, with a commitment to

tuberculosis of the spine, historically

hole down the center, was driven in

promoting continuing education across

a condition creating major difﬁculties

over the wire, which was then removed.

the specialty. The new organization was

for the orthopaedic surgeon. Likewise,

Fred Knowles, MD, in Fort Dodge, IA,

spectacularly successful, eventually

penicillin profoundly altered both the

designed a pin that was threaded at

maturing into the largest association

incidence and management of osteo-

the end, with a hub halfway down the

of orthopaedic surgeons in the world.

myelitis. Otherwise, trauma manage-

surgeons were called up in droves.

shaft. A groove in the pin just beyond

The 1930s turned out to be a

ment occupied the surgical skills of the

the hub provided a weak point so that

watershed decade for the specialty.

large number of orthopaedic surgeons

when the pin was inserted to the hub

In 1936, Charles Venable, MD, and

serving in the various theaters of

against the bone, and the fractured hip

Walter Stuck, MD, introduced the

World War II. The novelty of creating

stabilized, a little stress on the rest of

use of a cobalt, chromium, and

new inventions or procedures tempo-

the pin would break it off, leaving only

molybdenum alloy called Vitallium

rarily took a back seat to the everyday

a tiny slit in the skin to be closed. It

in surgery. Vitallium turned out to

challenges of battlefront surgery.

was a very early example of “mini-

be not only strong and durable but,

During this time, Sterling Bunnell,

mally invasive surgery.” A number of

most importantly, completely inert

MD, devoted his talents to supervising

designs, modiﬁcations, or adaptations

in the physiologic environment of the

and organizing the treatment of inju-

emerged relatively quickly in the next

human body. This metal immediately

ries and other problems involving

few years and the fracture of the hip,

became the springboard to opening

the hand. In 1944, he authored

which previously was a catastrophic

up the entire field of orthopaedic

the classic textbook Surgery of the

injury in the elderly person, became

implants. Dr. Smith-Petersen, who

Hand. His enthusiasm for the ﬁeld

a manageable event with predictable

had been searching for a material

attracted others, and in 1946, the

restoration of function.

that could be interposed in the hip

American Society for Surgery of the

In 1933, the venerable American

to form a new joint surface, suddenly

Hand (ASSH) was inaugurated. This

Orthopaedic Association became the

found one in Vitallium. The “cup

was the ﬁrst subspecialty, or special

133

The Department of Surgery

We share with the American College of Surgeons the commitment to teach medical students, residents, fellows and surgeons in a manner which inspires quality, promotes the highest standards and strives for the best outcomes for our patients. We seek to create new knowledge to the benefit of all while at the same time train the surgical leaders of tomorrow.

The Alpert Medical School of Brown University Department of Surgery congratulates the American College of Surgeons on their 100th Anniversary

interest, society to be formed within the overall fabric of the AAOS. (A number of others emerged, eventually leading to the formation of the Council of Musculoskeletal Specialty Societies [COMSS] in 1984, as advisory to the Board of the AAOS.) Hand surgeons quickly grew in numbers and diversity of interests. Alfred Swanson, MD, of Grand Rapids, MI, was one of several concentrating on the development of replacements for damaged ﬁnger joints. Silastic spacers proved to be the most durable and well tolerated. His devices, Swanson prostheses, became the standard for the time and are still the choice for many hand surgeons. James Urbaniak, MD, of Duke University pursued the replantation of digits after an early experience

Ignacio Ponseti

with salvaging a severed thumb. He subsequently reported a number of

his patient’s knee. The operation was a

orthopaedists were able to direct

successful replants. This led to his

success! The ultimate MacIntosh knee

their attention toward other prob-

development of educational courses

prosthesis, originally manufactured

lems. At the time, congenital disloca-

to acquaint a large number of ortho-

in acrylic, was subsequently made

tion or subluxation of the hip was a

paedic surgeons with the techniques

of Vitallium and became one of the

known entity but was often missed

for repairing tiny vessels. His example

common devices for treating arthritis

in the nursery, precluding effective

has been responsible for the presence

of the knee well into the ’60s.

closed reduction at a later age. Dr.

of an operating microscope in the oper-

PHOTO COURTESY OF THE UNIVERSITY OF IOWA

ating room of every hand surgeon.

Mark Coventry, MD, of the Mayo

Robert Salter of Toronto devised an

Clinic pursued a different tack.

osteotomy of the pelvis just above the

The 1950s brought back the quest

Eschewing prostheses and taking

acetabulum, which allowed the socket

for a solution for the arthritic knee.

advantage of the fact that usually

to be reoriented to cover the femoral

Perhaps apocryphal, but quite possibly

one compartment of the knee was

head. When done early enough, it

factual considering the times, is the

more arthritic than the other, he

allowed the socket to remodel around

story of the MacIntosh device. As it is

created a wedge-shaped osteotomy

the head, creating a normal joint. He

told, Dr. David MacIntosh of Toronto

of the tibia just below the weight-

reported successes in patients up to

was taking a break from a very difﬁ-

bearing surface which, when closed,

the age of 12. The Salter osteotomy

cult case involving a large defect in the

realigned the knee so that the major

remains the treatment of choice for

lateral plateau of an arthritic knee. As

weight bearing was transferred to the

missed congenital hip dislocations to

he was tapping out his cigarette, he

better-preserved side. His theory was

the present time. Fortunately, careful

noticed that the acrylic ashtray was

that the operation would “buy time”

exam in the nursery has made this

oval in shape with two shallow depres-

before a more deﬁnitive operation was

procedure much less common.

sions, much like the surface of a tibial

necessary. Still, he was committed to

Another condition encountered in

plateau. Energized, he appropriated

pursuing a more permanent solution.

the nursery is the congenital club foot.

the ashtray, cleaned and sterilized it,

The Salk vaccine closed the door

Descriptions of the deformity date back

sawed it in half, and ﬁlled the defect in

on polio in 1955 and pediatric

to antiquity, but effective methods

135

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who had devised an arthroscope for inspecting the interior of the knee. Impressed with the potential of this instrument, Dr. Jackson came back to Toronto, bringing the ﬁrst arthroscope to the North American continent. He promptly began extoling its possibilities and inviting anyone interested to visit him. The problem with the instrument was a tiny light bulb on the end for illumination that had a propensity for bending out of position or breaking off entirely, necessitating an open operation to search for an elusive bulb. At that point, industrial engineers took over and very soon a ﬁber-optic arthroscope was on the market, along with instruments for operating through tiny nicks in the skin. Arthroscopic surgery took off like a rocket. The Arthroscopy Association of North America was formed in 1981, and by 1992 had more than 1,000 members. The use of the arthroscope expanded to include Robert Jackson

procedures on the shoulder, hip, ankle,

PHOTO COURTESY OF THE AMERICAN ORTHOPAEDIC SOCIETY FOR SPORTS MEDICINE

and the small joints of the wrist. for treating the problem with splints,

streptomycin, but spinal problems

In 1974, a Los Angeles Dodgers

manipulations, and braces were never

in the form of scoliosis still plagued

pitcher blew out his elbow, a career-

very effective. In the ’60s, Dr. Ignacio

teens and preteens. Casting, fusions,

ending injury. He came under the

Ponseti in Iowa City, IA, developed a

and braces at best stabilized the

care of Fran k Jobe, MD, of the

serial cast system concluding with

deformity but did little to correct

Kerlan-Jobe Orthopaedic Clinic in

cutting the Achilles tendon through

it. In the late ’50s, Paul Harrington,

Los Angeles. As an expert in surgery

a tiny slit. At this point, the foot was

MD, in Houston, TX, devised a system

of the upper extremity, Dr. Jobe was

corrected and maintained in that

involving a rod and hooks that could

not aware of any standard repair for

position with a brace or shoes until

be implanted in the curved spine and

this injury. Accordingly he devised

stable. Almost simultaneously, several

”jacked” out to straighten the curve.

a complex reconstruction involving

pediatric surgeons were working on

A fusion could be done at the same

ligament grafting. His patient recov-

procedures to correct the foot in a

time so the devices could be removed

ered, and with intensive physical

single operation. Comparisons of the

eventually and the correction main-

t herapy, ret u r ned to t he Major

two approaches over time led to the

tained. This innovation stimulated

Leagues in 1976 to win 164 more

conclusion that the Ponseti method

a ﬂurry of approaches for straight-

games. Dr. Jobe, whose exceptional

produced better results with fewer

ening or stabilizing the spine, but

surgical talents may be exceeded

complications. Working into his 90s,

Harrington rods remain the work-

only by his modesty, insisted that his

Dr. Ponseti was teaching his method

horse for treating the scoliotic curve.

operation be known by the name of

to surgeons from all over the world.

In 1964, Dr. Robert Jackson of

his patient, Tommy John. During the

Pott’s disease of the spine was

Toronto was doing a fellowship in

preparation of this manuscript, Phil

a th i ng of the past, than ks to

Japan with Dr. Masaki Watanabe,

Humber of the Chicago White Sox

137

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Geisinger Congratulates the American College of Surgeons “ I am proud of this great organization. I am proud of its distinguished traditions, of its meritorious accomplishments, of what it clearly promises for the future as a momentous force in American surgery. ” - Harold L. Foss, MD, speech to Clinical Congress, 1953 Surgeon-in-Chief and Superintendent, Geisinger, 1915-1958 President, American College of Surgeons, 1952-1953

Expert medicine. Leading-edge options.

threw only the 23rd perfect game

British surgeon Sir John Charnley

implanted with cement. Dr. Gunston’s

in the history of baseball. Humber

was responsible for one of the most

publication in 1971 was the ﬁrst to open

had had his career resurrected by

innovative and most widely productive

the door to the potential for cemented

Tommy John surgery in 2005.

advances in the history of orthopaedic

knee prostheses. Immediately, possi-

Not all proposals, innovations, and

surgery. With intensive background

bilities began to be explored in the

inventions turned out to be successful.

research and the introduction of two

U.S. The initial hypothesis was that if

The concept of dissolving the inter-

new materials (bone cement and high-

the total knee was being replaced, the

vertebral disc by enzymatic activity

density polyethylene) into the system,

replacement didn’t have to look like a

originated with Lyman Smith, MD, in

he perfected the total hip replacement

knee. Designs were bold, unique, and

1964. Using chymopapain, he demon-

in 1958. In the early ’60s, the world

imaginative. As it turned out, the closer

strated its effectiveness in vitro and in

of orthopaedic surgery was beating a

the prosthesis resembled the actual

animals. In the 1970s, experimental

path to his doorstep in Wrightington,

knee, the better it worked. Among

work began with humans. Initial

England. Orthopaedic surgeons from

the ﬁrst to concede this point were

results were encouraging. By the

the U.S. arrived in droves to observe

Dr. John Insall and Dr. Chit Ranawat

1980s, pressure was mounting from

and take notes to bring back home. At

of the Hospital for Special Surgery in

the orthopaedic community to release

this point, the FDA entered the picture,

New York. Their ﬁnal “Total Condylar”

this material for clinical use. In a

declaring the procedure “experimental,”

prosthesis design became the template

combined effort by the AAOS and the

based largely on the introduction of

for successful knee replacement.

American Association of Neurological

bone cement. Prior to approval, the

The success with hips and knees

Surgeons, a series of comprehensive

FDA required two years of closely docu-

opened the door for joint replacement

courses, including didactic material

mented experience with the operation,

surgery to include shoulders, elbows,

and hands-on practice with models,

including the cement, at 50 selected

and ankles. Results have varied, of

was organized. (This was not the ﬁrst

sites. This process only conﬁrmed the

course, but improvements in design,

time the two specialties had worked

safety and efﬁcacy of the procedure.

ﬁxation, and techniques have continued

together on the spine. In 1934, neuro-

Subsequently, total hip replacement has

to the present time.

surgeon William Mixter and ortho-

become the most common and the most

As the Clinical Congress of the ACS

paedic surgeon Joseph Barr together

consistently successful operation in the

approaches, an assessment of the

per for med t he f i rst successf u l

history of the specialty.

coincident century in the history of

removal of a ruptured lumbar disc.)

As large numbers of these cases

orthopaedic surgery would suggest

In November 1982, the FDA ﬁnally

were accumulating, it appeared that

that the pure excitement, and some-

released chymopapain for clinical

the bone cement was the weakest

times turbulence, associated with

use. The immediate reaction of both

link in the system. It occasionally

innovation and invention has subsided

orthopaedic surgeons and neurosur-

failed and was difﬁcult to remove. In

to a more reﬁned effort biased toward

geons was explosive. Strict indica-

the ’80s, the development of porous

modiﬁcation and adjustment, in the

tions promulgated by the educational

coating of the prostheses to permit

continuing pursuit of the ever elusive

courses were exceeded and the results

fixation by boney ingrowth helped

goal of perfection. Q

were understandably mixed. After

solve the problem. The development

the initial enthusiasm abated, usage

could be attributed to a coordinated

moderated and eventually became

effort by industry and orthopaedic

David G. Murray, MD, FACS,

limited to symptomatic demonstrable

surgeons, including William Harris of

was Professor and Chairman of the

disc herniations. A few years later, the

Boston and Jorge Galante of Chicago.

Department of Orthopedic Surgery at

procedure was rarely used. In 2003,

Charnley did not include the knee

Upstate Medical University in Syracuse,

the FDA placed chymopapain on the

in his arthroplasty efforts. A Canadian

NY, from 1966 to 2000. He is a Past

“Discontinued Drug Product List,”

orthopedic surgeon, Frank Gunston,

President of the American Academy

adding that it was “discontinued from

working in England with Charnley

of Orthopaedic Surgeons (1982–1983),

marketing for reasons other than

seized the opportunity to create a total

and a Past President of the American

safety or effectiveness.”

knee prosthetic design, which could be

College of Surgeons (1997–1998).

139

Milestones in Otolaryngology–Head and Neck Surgery From leaders to lasers, the ﬁeld of otolaryngology–head and neck surgery has impacted surgery in more ways than most patients— and fellow surgeons—would guess. by GERALD B. HEALY, MD, FACS, FRCSENG (HON), FRCSI (HON)

The history of otolaryngology–head and neck surgery probably begins with the Egyptians in 1550 B.C., with a suggestion of treatment for deafness and aural discharge. Practically, however, Americans owe today’s advances to the Civil War. Surgeons returning from the battlefields realized the war wounds of various body parts—limbs, eyes, ears, head and neck structures, etc.—were more than one surgeon could master. The medical community began to value the concentration by surgeons on specific anatomical areas, and modern specialization was born in the United States. The first otolaryngology specialty

required to have a vision and hearing

different training than an understudy

organization began in 1868 with the

test. By 1912, this Academy was the

in Berlin working with a different

founding of the American Otological

largest specialty society in the country.

professor in the same ﬁeld. However,

Society, followed in 1879 by the

The American College of Surgeons

as Europe headed toward World War

American Laryngological Association.

(ACS) was founded just a year later,

I, the physical danger to travel elimi-

In 1896, the American Academy of

and almost immediately it began to

nated these training opportunities for

Ophthalmology and Otolaryngology

shift the national focus to the local-

American surgeons.

(AAOO), a joint specialty organiza-

level surgeon. This approach greatly

tion devoted to surgery of structures

inﬂuenced AAOO decisions as well.

above the clavicle, excluding the brain, was founded.

A History of Firsts

Within the United States at that time, standards were even looser: You could

In the early 20th century, training was

call yourself whatever specialist you

an informal affair. A famous European

wanted as our country had no speciﬁc

surgeon would label himself a guru—

license or certiﬁcation structure. The

likely gaining know-ledge by dabbling

“Flexner Report” commissioned by the

with corpses and dissecting cadavers—

Carnegie Foundation in 1910 at the

AAOO was a true pioneer. In 1909, it

and an aspiring surgeon would ask if he

urging of Theodore Roosevelt would

began to push hard for vision, hearing,

could spend time learning, one-on-one,

become the template of academic

and nasal breathing examinations for

from the surgeon in London, Paris, or

teaching centers. This led to the stan-

children in schools. Today, of course,

Vienna. However, those who went to the

dardization of medical education and

every school-age child in America is

professor in London might get totally

residency training.

140

A s these t wo perfect stor ms produced a formalized education system, the AAOO was founding the first two certifying boards in all of medicine: ophthalmology in 1916, with otolaryngology following in 1924. Historically, this was not a popular direction; physicians grumbled and complained. However, otolaryngology leadership discussions centered on visionary people saying, “We must make sure our surgeons are qualified to do what they claim.” Thus the certification process began and all of medicine was enlisted to participate. Education has remained an important cornerstone of the specialty. Otolaryngology was the first specialty to start what’s known as “lifelong education” among residents and practitioners through a home study course. The A AOO collaborated with the ACS in 1940 to launch this program for residents and practitioners to augment what they were learning in the hospital setting. Educators felt

Chevalier Jackson

NIH NATIONAL LIBRARY OF MEDICINE

it was critical to teach more basic science that was applicable to the

otolaryngology was one of the ﬁrst

beneﬁted patients and their care-

areas being focused on in patient care.

two pathology registries at the Armed

givers in both specialties.

By 1970, otolaryngology was the ﬁrst

Forces Institute of Pathology (AFIP).

specialty to start a comprehensive,

Facial plastic surgery in the head

annual self-assessment exam (now

and neck region also gained interest

the cornerstone of the maintenance

as patients returning from World

The father of modern endoscopy

of certiﬁcation process): This was a

War II w ith signif icant cosmetic

was Chevalier Jackson, MD, an

voluntary program to evaluate how

defects began to seek treatment from

otolaryngologist from Philadelphia.

you compared with peers in relation

surgeons skilled in head and neck

Between the turn of the century and

to procedures and treatments. Today,

surgery. As these areas of interest

the late 1940s, he was the premier

lifelong learning/continuous profes-

grew and ophthalmology expanded,

instructor in teaching techniques for

sional development is a requirement

it became apparent the two special-

the removal of foreign objects from

of all surgical certifying boards.

ties had very divergent interests in

the air and food passages of children

Surgical Gifts

After World War II, otolaryngology

modern medicine. The specialty of

and adults. In addition, he pioneered

became heavily involved in addressing

eye care became very sophisticated

the treatment of caustic ingestion

head and neck cancer surgery; today,

and complex, as did the care of the

and forced government agencies

with our colleagues in general and

remaining structures of the head

to mandate the labeling of caustic

plastic surgery, we care for a majority

and neck. Thus the specialties split

products. Dr. Jackson also standard-

of these cancer patients in America.

into two separate organizations in

ized tracheotomy as a safe surgical

In support of this anatomical region,

the 1960s. This decision g reatly

procedure for airway obstruction. His

141

innovations became the precursor of

endoscopes to access the sinuses and

modern treatment of air and food

thus create options for surgical inter-

passage diseases by otolaryngologists,

vention. David W. Kennedy, MD, popu-

thoracic surgeons, pulmonologists,

larized the technique in the United

and gastroenterologists.

States soon thereafter, and today

Other specialty accomplishments

external sinus surgery is rarely done

include preservation /conservation

unless there is a rare complication of

surgery of the larynx. Previously,

the endoscopic approach.

laryngeal cancer led surgeons to

Access to the skull base has evolved

remove the entire organ and the art

with innovative surgical techniques.

of verbal communication was lost. But

Today, otolaryngologists, together

in the late ’60s, Joseph Ogura, MD,

with colleagues in neurosurgery and

of St. Louis pioneered partial resec-

plastic surgery, give new hope to

tion surgery to prevent this drastic

patients with tumors in this complex

outcome, and today this procedure is

anatomical region.

the standard worldwide. Surgical lasers have also become

Strides in Otology

an important surgical development of the modern era. Otolaryngology

Surgeons began working in the

was in the forefront in the ﬁrst use of

ear and mastoid in Europe in the

surgical lasers, thanks to the Boston

David W. Kennedy

and M. Stuart Strong. Their publication, Laser Surgery of the Vocal Cords:

Advancements in Nasal and Sinus Surgery

attempted. In the pre-antibiotic era, ear infections often progressed to mastoiditis and frequently to intra-

An Experimental Study With Carbon

COURTESY OF THE AMERICAN ACADEMY OF OTOLARYNGOLOGY–HEAD AND NECK SURGERY

mid-1800s—very crude operations usually done to relieve infection were

University team of Drs. Geza Jako

Dioxide Lasers on Dogs, detailed a

Nasal surgery certainly was the

cranial infection. Drainage was the

methodology to use a microscope and

purview of otolaryngologists from the

only treatment, and crude methods

laser attachment to visualize and treat

beginning of the specialty. It included

(by today’s standards) using hammer

lesions of the larynx transorally. This

reconstructive surgery, surgery for

and chisel were used to open the ear

was a major breakthrough because it

chronic infection, and surgery to

and mastoid.

magniﬁed structures and provided a

remove tumors. In the era before

Major developments changed this

laser delivery system, making trans-

antibiotics, sinus infections—thanks

approach. First came the evolution

oral endoscopic surgery of the larynx

to their proximity to the brain—were

of more reﬁned instruments. Otologic

possible. Jako and Strong opened the

potentially very lethal problems.

surgeons soon learned that the dental

airway to micro-minimally invasive

Intracranial infection secondary to

drill powered by electricity could

surgery so that patients didn’t have to

sinus pathology was potentially fatal.

be useful in opening the ear and

suffer invasive neck operations.

Methods to clear sinus pathology

mastoid. Next came the operating

More recently, the National Institute

evolved from the late 1800s through

microscope in the 1920s, which

of Deafness and Other Communication

the late 1970s, with most operations

otologists used to magnify the middle

Disorders was established as a result

taking an external approach. The

ear and the tiny ossicles behind the

of the urging and efforts of the otolar-

surgeon would make an incision

eardrum, thus allowing reconstruc-

yngology–head and neck surgery

somewhere on the patient’s face and

tion of the hearing system. This led to

community; it became a full institute

enter the sinuses by that route.

stapedectomy in 1956, an operation

at the National Institutes of Health

I n t he 1970 s, D r. Hei n z R.

that revolutionized the treatment

during the Reagan Administration,

Stammberger (an Honorary Fellow

of deafness. Otolaryngologists truly

bringing hope to millions of hearing-

of the ACS), an Austrian otolaryn-

became the ﬁrst micro surgeons with

and speech-impaired patients.

gologist, revolutionized the use of

this evolution.

143

Life Works Here THE DEPARTMENT OF SURGERY AT DARTMOUTH-HITCHCOCK MEDICAL CENTER is a vibrant, growing and dynamic academic surgical program built on a long-standing tradition of clinical excellence, teaching and research. We are actively involved in transforming surgical care by constantly striving to maximize value for our patients, our students and trainees, and to the overall population that we serve. As the only academic medical center and tertiary referral center for the State of New Hampshire, the Department of Surgery at Dartmouth-Hitchcock Medical Center provides an extensive variety of surgical services. Our Department has twelve highlyproductive surgical sections. Additionally, we have seven post-graduate training programs and fellowships in Vascular and Minimally-Invasive Surgery that consistently attract top candidates from around the country. Every one of our 100 faculty is actively involved in teaching at the undergraduate or graduate medical level and our Department serves as the focus for surgical education for the Dartmouth academic community and the Geisel School of Medicine at Dartmouth. The Geisel School of Medicine is the country’s 4th oldest medical school and has an established reputation as one of the greatest. Our faculty is increasingly attracting funding for clinical and basic research, and there are several exciting areas within our Department where new techniques and processes are evolving. We offer many exciting patient care, learning and research opportunities in every major surgical discipline, and encourage you to ﬁnd out more. Send a CV to: surgery@dhphysicians.org

Dartmouth-Hitchcock Clinic is an afﬁrmative action, equal opportunity employer. Women and minorities are encouraged to apply.

dartmouth-hitchcock.org

THE

BEST AND BRIGHTEST THE

At Sanford Health, every day we honor our own commitment to health and healing so that we can improve the human condition. Today, Sanford Health honors The American College of Surgeons’ commitment to the best quality and brightest outcomes. From the surgeons at Sanford Health, congratulations to The American College of Surgeons for 100 years of service. 100-11395-4596 8/12

Antibiotics obviously played a major role in reducing the need for surgery in the ﬁrst place, and so did the insertion of ear tubes. Ear tubes were actually developed by Dr. Adam Politzer in Austria in 1861. But—as is common with new ideas—the public at that time thought Politzer’s idea of inserting a tube into the eardrum to equalize pressure on either side was too radical. However, after World War II, otolaryngolog ists asked whether tubes could be used to prevent children from suffering ear infections. Beverly A rmstrong, MD, thought about using Politzer’s idea to see if we could turn that process around.

Capt. David Thompson performs an ear tube surgery on a young hospital patient.

The rest is history. Tube insertion in children is one of the most frequent

certainly our specialty, too, crossed

offers both medical and surgical oppor-

operations in the world. However,

lines with many other disciplines. But

tunities, enjoying a wide diversity.

w ith the emergence of resistant

the idea that only one group should

This need to be ambidextrous on

bacteria, the original problem of the

hold the answers is archaic, selﬁsh,

both sides of patient care has created

pre-antibiotic era is beginning to

and not good for patients. We have

a proud number of leaders in medi-

rear its ugly head again. There are

thankfully resolved that attitude

cine—from deans of medical schools to

more mastoid operations being done

today. We’re working together to

presidents of societies and academies

now than 20 years ago. It could very

make everyone a better surgeon to

like the ACS. But no matter the acco-

well be the next surgical challenge

help all patients.

lades and honors on the wall, otolar-

for our profession to tackle.

yngologists continue to search for the

Modern otology’s major break-

that approximately 40 to 50 percent

next surgical breakthrough to share

through, of course, is the cochlear

of otolaryngology involves treating

with our colleagues. Otolaryngology–

implant for the deaf. Robert K. Jackler,

patients medically without doing

head and neck surgery and its deep

MD, at the Stanford University School

surgery, and that’s an important

heritage is a proud member of the

of Medicine has tracked the origin to

distinction to some other surgical

House of Surgery. Q

American otolaryngologists working

disciplines. For students who are only

in California.

interested in technical intervention,

Standing Out, Standing Apart U.S. NAVY PHOTO BY JOURNALIST SEAMAN ERICA MATER

Still, it’s important to point out

otolaryngology is not appropriate. For

Gerald B. Healy, MD, FACS,

instance, a patient with a history of

FRCSEng (Hon), FRCSI (Hon), is the

nasal obstruction may visit an otolar-

emeritus Gerald B. Healy Chair

Otolaryngolog y–head and neck

yngologist. Many times the problem

in Otolaryngology and emeritus

surgery has become an integral part

is secondary to allergy, and if you

Surgeon-in- Chief at Children’s

of “the House of Surgery”—all the

treat the allergy effectively, surgery

Hospital Boston. He is a Professor of

surgical disciplines coming together

is unnecessary. A child with an ear

Otology and Laryngology at Harvard

under one virtual roof: the American

infection doesn’t receive ear tubes as

Medical School. He was Executive

College of Surgeons—collaborating

the ﬁrst treatment. We don’t resort

Director of the American Board of

for the common goal of trying to make

to surgery until the patient has had

Otolaryngology (1998–2004) and

life better for our patients. The past

medical treatment that may include a

President of the American College of

saw many turf wars in surgery, and

course of antibiotics. Thus the specialty

Surgeons (2007–2008).

145

The Large and the Small of It Advances in Pediatric Surgery by THOMAS V. WHALEN, MD, MMM, FACS

Looking back on his career, former U.S. Surgeon General C. Everett Koop, MD, FACS, reﬂected that prior to the 1960s, children “did not get a fair shake in surgery.” The reasons were many but chieﬂy because surgeons, Dr. Koop remembered, were frightened of children. “They distrusted the ability of

children injured in the fateful Halifax

coup. Nevertheless, the operation set

anesthetists to wake children up after

Explosion of 1917 inspired him to

a precedent for surgical correction of

putting them to sleep, a position not

focus on pediatrics and keep accurate

congenital cardiac malformations and

far from that of many anesthetists.

medical records of symptoms, surgical

pediatric surgery in general.

The younger and smaller the patient,

procedures, and outcomes. In 1927, he

The clinical material that Dr. Ladd

the more signiﬁcant the hazard.”

became surgeon-in-chief at Children’s

and others had been recording for years

The hazards were signiﬁcant to be

Hospital in Boston. There he estab-

at Children’s was compiled by Dr. Gross,

sure. Before the 1940s, the survival

lished the first pediatric surgical

and in 1941 a book was published,

rate for infants born with defects

training program, which produced

Abdominal Surgery of Infancy and

like esophageal atresia and tracheo-

the man many regard as the father of

Childhood, by Ladd and Gross.

esophageal ﬁstula (incomplete forma-

American pediatric surgery.

It was the ﬁrst pediatric surgery

tion of the trachea and esophagus in

Robert E. Gross, MD, was born in

text, and while it featured material

the womb) was zero percent. There

Baltimore, MD, and graduated from

on infants and children, the prevailing

was no curative surgery for common

Harvard Medical School in 1931 before

contemporary surgical emphasis was

congenital problems like patent ductus

residency at Peter Bent Brigham

on the period from birth to infancy.

arteriosus (PDA—the failed closing

Hospital and later Children’s Hospital

Venturing into small humans to

of a blood passage from the right to

in Boston under Dr. Ladd. Despite

operate was daunting given the tech-

the left side of the heart). Congenital

having vision in only one eye, he was

nology of the time, but a handful of

diaphragmatic hernia (through the

a talented and bold surgeon. Both

surgeons were willing to try.

foramen of Bochdalek) had 85 percent

qualities were demonstrated when

Cameron Haight, a California-born,

mortality within 24 hours of birth and

he successfully ligated (tied together/

Harvard-educated surgeon at the

8 percent overall survival from birth.

closed) a patent ductus arteriosis in a

University of Michigan was one. In

7-year-old girl in August 1938.

1941, he performed the ﬁrst successful

As serious as these defects were, a number of surgeons like Dr. Koop real-

Dr. Gross had carefully planned this

staged repair of esophageal atresia

ized they were potentially correctable

operation by practicing it in the post-

and tracheoesophageal ﬁstula (TEF).

operative conditions and that the quality

mortem room and animal laboratory

The implications of the successful

of surgical care available to infants and

but famously did it when his mentor,

procedure were huge.

children was simply not good enough.

Dr. Ladd, was on summer vacation. Dr.

Esophageal atresia, TEF, and intes-

The first to really act to create

Ladd surely would not have permitted

tinal atresia essentially created respi-

a pediatric surgical specialty was

Dr. Gross to undertake the proce-

ratory complications resulting in death.

William E. Ladd, MD, a Boston, MA,

dure, and, though it was a success, he

Typically, the proximal blind end of the

surgeon whose experience treating

never forgave Gross for the surgical

esophagus would quickly and always

147

experience gained during World War II, suggested a need for recognition of the pediatric surgical ﬁeld. This became a reality at the 1948 annual meeting of the American Academy of Pediatrics (which had itself formed in 1930) in Atlantic City, NJ. There, pediatric surgeons came together to form the Surgical Section of the Academy recognized by the AAP in 1949. Dr. Gross and Dr. Koop along with others from the “Boston School” of pediatric surgery were a driving force in formation of the Surgical Section, which facilitated both collegiality and peer discussion at a time when pediatric surgeons were spread across a handful of locations from Boston and Philadelphia to San Francisco. Annual gatherings had increased importance in an era when simple transcontinental phone calls were expensive and not universally available. The Surgical Section was also a forum—though an imperfect one— from which to gain recognition as a viable surgical sub-specialty apart C. Everett Koop examines an infant.

from general surgery or pediatrics.

In 1948, the ﬁrst successful surgical

an article for the journal Annals of

the trachea and the lungs. Worse yet,

repair of a fetal abdominal wall defect

Surgery, the inclusion of the Surgical

the distal end would bring stomach

was accomplished when Dr. Gross

Section within the AAP was a difﬁcult

acid up into the trachea and the lungs.

reported successfully excising the

marriage, the result of which was

That would set up an intense chemical

omphalocele sac and covering it with

that “for the next 20 years the estab-

pneumonitis followed by bacterial

skin grafts. An omphalocele (rupture)

lished surgical fraternity considered

pneumonitis from the saliva.

is a birth defect in which the infant's

pediatric surgeons to be the technical

Adding to these complications, there

intestine or other abdominal organs

operative arm of the pediatricians,

was no way to feed affected babies

fail to retract into the abdominal cavity

not real surgeons!”

because intravenous parenteral nutri-

in utero and stick out of the umbilicus

An illustration of prevailing attitudes

tion was not developed (by Stanley

(navel). In babies with an omphalocele,

was that through the 1960s, pediatric

Dudrick, MD, FACS, and associates

the intestines are covered only by a

surgeons were not allowed to have inde-

in Philadelphia) until 1968. Following

thin layer of tissue and can be easily

pendent admitting privileges for children

Dr. Haight, Dr. Gross subsequently

seen. Prior to this surgical procedure,

at a majority of children’s hospitals.

performed the ﬁrst single-stage repair.

little could be done for newborns with

These patients had to be admitted by a

As a result, the survival rate for full-

this and other associated birth defects.

pediatrician. A pediatric surgeon could

term babies with these conditions has

These adva nces a nd out side

participate and operate but only when

climbed to nearly 100 percent.

148

developments, some stemming from

asked by the attending pediatrician.

NIH NATIONAL LIBRARY OF MEDICINE

As J. Alex Haller, MD, recounted in overﬁll with saliva that would spill into

But surgeons with pediatric training

Section of the AAP that formed in 1966

the work of established pediatric

were coming into positions of respon-

and was headed by William Clatworthy,

surgeons and a second generation of

sibility throughout the United States.

MD, of Columbus Children’s Hospital.

surgeons developing new techniques.

Through the 1950s and ’60s, Dr. Gross

Under Dr. Clatworthy’s leadership, the

One of these was Dr. Dudrick, a

trained 69 pediatric surgeons, many of

directors of approximately 20 unregu-

University of Pennsylvania School of

whom founded training programs in

lated training programs for pediatric

Medicine graduate and general surgeon

medical centers around the country,

surgery in the U.S. and Canada estab-

who, in 1964, pioneered research into

joining others from the broader Boston

lished criteria for training that included

a specialized central venous feeding

School. Dr. Gross deﬁned the format

board certiﬁcation in general surgery

technique known as intravenous hyper-

of training to be a three-year pyramid

and two additional years of specialized

alimentation (IVH), or total parenteral

for residents with previous training. To

training in children’s surgery.

nutrition (TPN). The development and

assure continuity, Dr. Gross staggered

Meanwhile, the ﬁrst issue of the

subsequent clinical application of TPN

the start of the residents’ training,

only publication dedicated to pedi-

in pediatric surgery were conﬁrmed

which included a ﬁrst-year junior resi-

atric surgery—the Journal of Pediatric

when an infant with malrotation and

dency, a second-year senior residency,

Surgery—appeared in February 1966.

midgut volvulus (rotation of the gut and

and a following year as chief resident.

Before its publication, pediatric

its constituents—small bowel, cecum,

As a result, an increasing number

surgeons had to review either non-

ligament of Treitz—and twisting of

of pediatric surgery training programs

surgical pediatric literature or general

abdominal blood vessels) survived

“self-declared” in hospitals across the

surgical literature for relevant infor-

corrective surgery despite severe short

country. Oversight was provided by a

mation. The Journal’s editor-in-chief

bowel syndrome with the use of TPN at

voluntary committee of the Surgical

was Dr. Koop and it brought together

the Children’s Hospital of Philadelphia.

Children’s Hospital of Wisconsin congratulates the American College of Surgeons for providing a century of support in advancing and improving children’s surgical care and standards. The Pediatric Surgical Program at Children’s Hospital of Wisconsin in Milwaukee is one of the largest in the nation and includes all pediatric surgical specialties. We have expertise in traditional and minimally invasive general and thoracic procedures. Our program has achieved national recognition in surgical outcomes and

Visit chw.org/surgery.

120681

training pediatric surgeons.

Department of

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Another advance in the surgical treatment of congenital abdominal wall defects was achieved in 1967 when S. R. Schuster, MD, reported the ﬁrst staged closure of gastroschisis at Boston Children’s Hospital. Gastroschisis is a small, abnormal opening adjacent to the umbilicus from which the fetal bowel hangs out uncovered in the amniotic ﬂuid. The defect was untreatable until Dr. Schuster described a method involving plastic IV bags sewn to the abdominal

The 1948 annual meeting of the American Academy of Pediatrics.

NIH NATIONAL LIBRARY OF MEDICINE

wall and then together into a silo covering the exposed bowel. Each day

of general surgical residency. They

produce the latest in instrumentation

thereafter, the silo would be squeezed

would then become board eligible

in a timely fashion. Such is the case

progressively tighter, putting more

and certiﬁed in the general surgical

with robotics. While robotic pediatric

bowel back into the abdominal cavity

ﬁeld whereupon they were required

procedures have been tried, they have

while expanding the cavity to accom-

to do an additional two years of

not caught on widely because acqui-

modate it. This progressive staged

pediatric surgery residency to be

sition and maintenance costs are

closure was subsequently modiﬁed

eligible for pediatric surgery boards.

high and the single-source provider

and today the use of manufactured

Today, the ABS has separate certiﬁ-

of surgical robotics lacks sufﬁcient

pre-formed, sterilized silos has

cates numbering only four; pediatric

market incentive to produce special-

made a leap in the treatment of large

surgery was the ﬁrst, followed by

ized robotic instrumentation.

omphaloceles and gastroschisis, with

vascular surgery, surgical critical

By the early 1980s, the next pedi-

much reduced mortality rates.

care, and advanced surgical oncology.

atric surgical advance had been

The establishment of new pediatric

Though developments in pediatric

demonstrated and it represented a

surgery training programs nation-

surgical techniques and training

paradigm shift. Michael Harrison,

wide combined with the training of

progressed steadily, the development

MD, had only recently completed

more pediatric surgeons provided

of instruments and other specialized

his pediatric surgery residency at

impetus for the formation of an inde-

medical devices has lagged. This

Children's Hospital Los A ngeles

pendent American Pediatric Surgical

is chieﬂy because of the relatively

when in 1981, along with colleagues

Association in 1970 with Dr. Gross as

small commercial market for pedi-

from the University of California,

the ﬁrst president. With their own

atric surgical devices as opposed to

San Francisco (UCSF), he performed

specialty training requirements and

demand for adult surgical instrumen-

fetal surgery for hydronephrosis, a

an independent surgical organization,

tation. For example, the increasingly

condition in which a baby’s ureters

pediatric surgeons were in position to

commonplace laparoscopic removal

are blocked and urine is not made

ask the American Board of Surgery

of gallbladders in adults in the

effectively, leading to kidney damage.

(ABS) to recognize the discipline

1980s was not immediately adopted

Operating in utero, though concep-

with a special certiﬁcate. This it did

by pediatric surgeons because the

tually possible, was met with signiﬁ-

in 1972, further establishing the

instruments were simply too large

cant skepticism. Though the first

legitimacy and distinction of pediatric

to be effective in the small children

fetus did not survive, Dr. Harrison

surgery as a sub-specialty.

operated upon.

showed that the process was tech-

Finally, in 1973, the ABS delineated

The market dynamics of pediatric

nically feasible. The procedure was

the certification process for pedi-

surgery are such that there has not

complimented by the ﬁrst successful

atric surgeons who were required to

been enough proﬁt incentive for the

sonographically guided placement of

undertake a minimum of ﬁve years

medical device manufacturers to

a fetal urinary catheter at UCSF the

151

Department of Surgery YaleSurgery.org

Here’s to the next 100 years. Times change. But our shared commitment to high standards and better outcomes will always be the same. We’re proud of the partnership we’ve forged with the American College of Surgeons over the years. And no matter what the future holds, we will always be there supporting the vital role you have in improving the quality* of patient care. *Quality of care is a major focus for University of Utah Health Care, which recently ranked in the top 10 nationally by University HealthSystem Consortium.

laparoscopically, as is pediatric appendectomy. Though rare i n infants, appendicitis is prevalent enough in children to make it the second most frequently performed pediatric surgery. Despite trailing usage in adult surgery, robotics are beginning to become more accepted in the pediatric field; benefits (less scarring, greater precision, magnified vision) are being demonstrated in places like Seattle Children’s Hospital, where John Michael Harrison

Meehan, MD, and Thomas Lendvay,

PHOTO COURTESY OF UCSF FETAL TREATMENT CENTER

MD, are performing novel procedures same year. That fetus survived this

Around the same time Dr. Harrison

less extensive intervention and the

was pioneering fetal surgery in

As the ACS celebrates a century of

adult continues to communicate with

California, Alberto Peña, MD, laid

improving the vitality and quality

the university team today.

using the da Vinci Si Surgical System.

the foundation for greatly improved

of life of Americans, it’s fitting and

The focus of fetal intervention

surgical treatment of another congen-

personally gratifying to note that pedi-

shifted to congenital diaphragmatic

ital defect: imperforate anus. In these

atric surgeons represent the highest

hernia (CDH), a hole, usually in the

cases, the opening to the anus from

percentage of ACS Fellows of any disci-

left side of the diaphragm, such that

the rectum is missing or blocked. The

pline. Equally satisfying is the fact that

abdominal content is forced up into

rectum may end in a blind pouch or

the ﬁrst female president of the College,

the chest, squeezing the lungs, which

may have openings to the urethra,

Kathryn Anderson, MD, FACS (2005

don’t develop normally, resulting in

bladder, base of the penis or scrotum

through 2006), is a pediatric surgeon.

signiﬁcant difﬁculty breathing. By the

in boys, or vagina in girls.

Back in the early 2000s, the ACS

early 2000s fetal surgical emphasis

Though rare, the defect was only

recognized that among its 18-strong

had shifted to minimally invasive

partially treatable until Dr. Peña

Board of Regents, some disciplines

techniques including endoscopic and

undertook elegant anatomic studies to

were not represented. Wisely, they

image-guided manipulation.

delineate all of the different muscles of

added three additional Regents, one of

Recent trials in the prenatal treatment

the anal sphincters and improvised the

whom was to be a pediatric surgeon. It

of open spina biﬁda (myelomeningo-

posterior sagittal approach, an opera-

has been my pleasure to take on this

cele) are showing promise as well. More

tion using a muscle stimulator to, in

role since 2003, and when my term

broadly, it has only been over the past

an open fashion, bring the anus down

ﬁnishes in October of this year, the

10 to 15 years that minimally invasive

into the middle of the appropriate anal

College will draw a new Regent from

instrumentation has been sufﬁciently

sphincters. Though now in his 70s, Dr.

our ranks, reinvigorating the Board

perfected and commercially adopted as

Peña is still operating at Cincinnati

and advocating in all things—large

to allow widespread utilization.

Children’s Hospital. His work dramati-

and small—for pediatric surgeons. Q

A n interesting offshoot of Dr.

cally improved the potential for normal

Harrison’s pioneering work was the

bowel function and stool discharge in

ﬁnding that there was essentially no

babies with this defect.

Thomas V. Whalen, MD, MMM, FACS,

scarring left from incisions to the fetus

Today, the most common pedi-

completed his fellowship in Pediatric

once the baby was born. This has given

atric surgical procedure is inguinal

Surgery at the Children’s Hospital of

rise to a continuing scientiﬁc investiga-

hernia (IH) repair. IH affects from 0.5

Los Angeles in the early 1980s. He is

tion of fetal healing and the factors that

to 5 percent of all male infants. The

currently Chief Medical Ofﬁcer at Lehigh

allow for scar-less healing.

procedure is frequently performed

Valley Health Network, Allentown, PA.

153

Plastic Surgery A Story of Innovation BY MARY H. MCGRATH, MD, MPH, FACS

Entering the twentieth century in the U.S., there were no plastic surgeons as we now think of the specialty. Small ﬂaps for facial repair were done occasionally, full thickness skin grafts were used, and the renowned German surgeon Karl Ferdinand von Graefe performed the ﬁrst cleft palate repair and published Rhinoplastik in 1818. It is believed that the use of the word “plastic” as applied to this type of surgery dates from that time. The word “plastic” is derived from the Greek word “plastikos,” meaning “to mold.” At the outbreak of World War I

including tubed pedicle flaps to

By the time World War II broke

in 1914, there were a handful of

transfer soft tissue and maxillofacial

out, the scope of plastic surgery was

surgeons with modest experience

procedures that revolutionized the

ready to change. During this conﬂict,

with reconstructive techniques but

treatment of facial skeletal deformity.

treatment of complicated fractures of

no trained corps to treat the devas-

American casualties, initially treated

the extremities and facial skeleton,

tating maxillofacial wounds associ-

and stabilized on the Continent, were

nerve and tendon injuries, paraplegic

ated with trench warfare. Combat

transported home to military hospitals

pressure sores, frostbite, and severe

in Europe produced unprecedented

in the U.S., where the new specialty

burns fell to the plastic surgeon. The

numbers of appalling facial injuries,

was to take shape in North America.

specialty gained stature during the

and a hospital in Sidcup, England, was

The techniques and clinical experi-

war, and when the military plastic

taken over to treat such wounds. It

ence of the battleﬁeld entered civilian

surgeons returned to civilian life,

was in this crucible that the specialty

care, and surgeons began to treat

they brought the skills to deal with a

of plastic surgery was born.

previously irreparable defects and

changed civilian population. People

When the United States entered

expand the limits of care. Particularly

were no longer willing to accept

Europe’s trenches in 1917, a St. Louis,

notable were advancements in skin

congenital defects and facial scars

MO, surgeon, Vilray P. Blair, was sent

grafting, ﬂap construction and delay,

and were prepared to undergo elective

to England with orders to form a U.S.

and awareness of aesthetic outcomes.

surgery to correct these problems.1

military subsection for the treatment

With growing maturity and dispersion

Technical and scientific advances

of maxillofacial injuries. Working with

of the specialty during the 1920s and

soon followed with the introduction of

the English surgeons, Dr. Blair saw

1930s, plastic surgeons began profes-

successful human organ transplanta-

an advantage to partnering dental

sional organizations for the sharing of

tion by Joseph E. Murray, MD, in 1954

surgeons with their knowledge and

knowledge. By 1937, plastic surgery

for which he later received the Nobel

skills with general surgeons in the

had emerged as a distinct specialty,

Prize (Figure 1); the deltopectoral axial-

treatment of soldiers with facial inju-

and the American Board of Plastic

pattern ﬂap by Vahram Y. Bakamjian,

ries. Together, these teams made rapid

Surgery was founded in that year. The

MD, in 1965; craniofacial surgery by

advances and this war experience is

motto on the American Board of Plastic

Paul Louis Tessier in 1967; micro-

described in Harold Gillies’ classic book

Surgery certiﬁcate, Ad formam func-

surgical transfer by Harry J. Buncke,

Plastic Surgery of the Face, published

tionem felicitatemque restituendam,

Jr., MD, in 1972; and autologous ﬂap

in 1920. Remarkable surgical innova-

translates as “For restoring form, func-

breast reconstruction in 1978. The

tions arose from wartime devastation,

tion, and well-being.”

pace of innovation has never slowed.

154

a colleague in neurosurgery, devised an intracranial approach to the orbits to mobilize and relocate them medially without damaging either the eye or the brain. This was accomplished successfully in several patients, and when the work was reported at an international meeting in Rome in 1967, the enormity of what Dr. Tessier had done was recognized immediately.2 Over the ensuing years, his concepts led to the creation of the subspecialty of craniofacial surgery, which is now performed by multispecialty surgical teams at craniofacial centers around the world. Dr. Tessier was an honorary member of the American College of Surgeons (ACS) and was presented with the ACS’ Jacobson Innovation Award in 2000. Figure 1. Joseph E. Murray, MD, FACS, (left) of Boston receiving the 1990 Nobel Prize in Physiology or Medicine for his work on organ transplantation.

With the fundamental breakthrough of craniofacial surgery came a richness

JAN COLLSI/SCANPIX

of techniques, ideas, and concepts that With growing sophistication, plastic

impairment and has to face serious

continued to expand as plastic surgery

surgery has matured into areas of

social prejudice when navigating

evolved over subsequent years. The

specialization, of which some are:

through everyday life. Effective

treatment of facial trauma was forever

congenital, maxillofacial, breast

techniques for repair of cleft lip and

changed with the use of extensive

surgery, hand surgery, head and neck

palate had evolved by 1960 when the

subperiosteal dissection through

surgery, skin and soft tissue, aesthetic

Parisian plastic surgeon, Dr. Tessier,

coronal and intraoral approaches,

surgery, body contouring, wound care,

was consulted by a patient with a

direct interosseous osteosynthesis

microsurgery, and burn care. As a rela-

facial deformity unlike any that had

of fractured bones through these

tively small specialty, plastic surgeons

ever been treated. He described it

exposures, and extensive primary

quickly learn about innovations in each

as “prodigious exorbitism with a

bone grafting. Early efforts to correct

of these areas and readily adapt for

monstrous aspect” with severe maxil-

craniofacial asymmetry or deﬁciency

their own practices the new ideas devel-

lary hypoplasia, exposed eyes, and

relied on a variety of skeletal onlay

oped through the clinical and research

respiratory obstruction. Drawing on

grafts stabilized with wires. Later, the

experience of fellow plastic surgeons.

his experience with facial fractures

development of rigid skeletal ﬁxation

With the breadth of exposure that this

and anomalies, Dr. Tessier worked on

devices and plating systems helped to

collaboration brings, the momentum of

dry skulls and cadavers to delineate

stabilize osteotomy segments more

innovation is not surprising. New solu-

approaches to the problem, and when

accurately and permit more exten-

tions for perplexing clinical problems

he was ready, successfully operated

sive bone grafts. To avoid the need to

are constantly evolving.

on his patient, completely freeing the

remove some of these ﬁxation devices,

facial skeleton from the cranium,

plating systems composed of resorb-

advancing it by 25 mm, and securing it

able biomaterials were constructed.

Craniofacial Surgery

by the novel use of bone grafts. At the

Distraction osteogenesis techniques

The indiv idual w ith craniofa-

same time, he was caring for patients

are used to actively move osteotomy

cial deformity may have functional

with orbital hypertelorism and, with

segments of the mandible or maxilla

155

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while bone induction gradually fills the gaps or lengthens the bone as would natural growth. The process of presurgical workup and procedural planning now takes advantage of advanced craniofacial imaging techniques with three-dimensional modeling and surgical simulation that permit better prediction of surgical outcomes and more accurate information for the patient about risks and benefits. Based on 30 years of experience in multidisciplinary North American trauma units, today the basic principle for managing facial injury is early, definitive treatment as soon as THE FIGURE IS THE FRONT-PLATE FROM VOLUME 4, PEDIATRIC PLASTIC SURGERY, IN PLASTIC SURGERY, 2ND EDITION. MATHES SJ (ED). SAUNDERS ELSEVIER: PHILADELPHIA, 2006

consistent with the patient’s general cond it ion. Ea rly recon st r uct ion improves the quality of the result and reduces the residual deformities that may affect function and appearance. One area of special interest is postnatal growth of the facial structures since children with facial injuries may have posttraumatic facial deformity as a result not only of displacement of bone structures caused by the fractures, but also of faulty or arrested development stemming from the injury. Ongoing inves-

Figure 2. This ﬁgure shows some of the surgical approaches and techniques used to treat cleft lip, cleft palate, craniofacial microsomia, velopharyngeal dysfunction, craniosynostosis, hypertelorism, and other facial anomalies.

tigation into the molecular biology of craniofacial bone may lead to an understanding of the etiopathogen-

Microsurgical Free Tissue Transfer

became two of the most important ﬂaps in plastic surgery at that time. As it happened, the design principle

esis of craniofacial deformity. There is a wide spectrum of cranio-

By the early 1970s, the design of tube

of these new ﬂaps was soon to fuse

facial deformity: soft tissue and

pedicle ﬂaps for soft tissue transfer

with another body of innovative work

bone, congenital and developmental,

had changed as plastic surgeons real-

to produce a momentous advance.

traumatic, and tumor resection. For

ized that the inclusion of an identiﬁ-

Simultaneously, Dr. Buncke was

each of these, complex aesthetic and

able artery to nourish the ﬂap would

working in California to develop tech-

functional problems call for individu-

enhance its survival. Flaps with a

niques for vascular reattachment of

alized surgical interventions based

known arterial, or axial, circulation

severed digits. Working with vessels

on fundamental concepts (Figure 2).

supplanted older random pattern

as small as 1 mm in size, he devel-

The volume of activity and the pace of

ﬂaps. The deltopectoral axial-pattern

oped minute metallicized tip sutures,

continuous improvement in this area

ﬂap described by Dr. Bakamjian in

modified delicate instruments for

are striking, and are likely to continue

1965 and the groin ﬂap based on the

use in his procedures, and in March

in the search for an anatomically

superficial circumf lex iliac artery

of 1964 reported the ﬁrst successful

perfect reconstruction.

described by Ian McGregor in 1972

rabbit ear replantation to the Plastic

157

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Surgical Research Council meeting.

thrombosis can occur when kinking

In 1966, he performed the ﬁrst great

or compression of vessels by hema-

toe-to-thumb transplant in the rhesus

toma or edema leads to decreased

monkey. Shigeo Komatsu, MD, and

inﬂow. Even with a technically perfect

Susumu Tamai, MD, did the first

anastomosis, there can be failure of

human digital replantation in 1968.

reperfusion in an ischemic organ after

Dr. Buncke perfected his techniques,

reestablishment of blood supply. This

and by 1969 he was ready to perform

is termed the no-reﬂow phenomenon

microsurgery in the human; he and

and the mechanism is thought to be

Donald McLean, MD, transferred the

due to endothelial injury, platelet

omentum by microvascular techniques

aggregation, and leakage of intravas-

to ﬁll a large scalp defect. From there,

cular ﬂuid; the severity of this effect

Dr. Buncke went on to many micro-

correlates with ischemia time.

vascular “ﬁrsts,” among them a great

Microvascular ﬂap transfer remains

toe-to-thumb transfer, serratus muscle

technically demanding, with re-explo-

transfer for facial paralysis, and

ration rates ranging from 6 to 25

tongue replant. In 2004, Dr. Buncke was presented with the ACS Jacobson

PHOTOGRAPH IS FROM THE ARTISTRY OF RECONSTRUCTIVE SURGERY: SELECTED CLASSIC CASE STUDIES. BRENT B (ED). CV MOSBY CO: ST. LOUIS, 1987, PAGE 726

Innovation Award for his pioneering work with microsurgery (Figure 3). The two streams of innovation

Figure 3. Harry J. Buncke, Jr., MD, FACS, has been called “the Father of Microsurgery” for his contributions in the history and development of reconstructive microsurgical procedures.

converged at this point. An under-

percent. The use of pharmacologic agents for postoperative anticoagulation is not a uniform practice for elective microvascular transfers since they can increase the chance of hematoma, and even a small collection near

standing of vascular territories and

the anastomotic site can obstruct the

axial ﬂap design existed at the same

and the donor site deformity that will

fragile vessels. Postoperative moni-

time that the frontier of successful

be created with regard to function and

toring is critical since rapid identiﬁ-

anastomosis of vessels with the small

aesthetic appearance.

cation of ischemia allows immediate

diameter of most axial flap vessels

Initially a technical feat of note,

intervention, and salvage rates vary

was reached. Now the door was open

microvascular surgery rapidly became

between 54 to 100 percent in different

for the transfer of skin ﬂaps that were

an integral part of plastic surgery,

series. A number of devices are

completely disconnected from their

an essential element in residency

used for ﬂap monitoring, including

circulatory sources. A microvascular

training programs, and a technology

temperature probes, pulse oximetry,

free tissue transfer, also called a free

that dispersed around the world and

photoplethysmography, handheld

ﬂap, brings distant tissue with a pedi-

into many surgical specialties. Over

pencil Doppler probes (low frequency

cled arterial and venous supply from

time, outcomes have improved to

continuous ultrasonography), and

another part of the body to be anasto-

the point where tissue survival rates

implantable Doppler probes.

mosed to vessels at the recipient site to

for free tissue transfers exceed 95

Microvascular tissue transfer has

reestablish blood ﬂow. The transferred

percent. Getting to this point required

made it possible to bring healthy tissue

tissue may be skin, fat, muscle, fascia,

years of incremental improvements.

to lower limb defects with exposed

bone, nerves, small bowel, large bowel,

Technical precision is required to

bone and orthopedic hardware,

or omentum as needed to reconstruct a

avoid anastomotic failure due to

vascularized ﬁbula to a mandible with

given defect. The goal is to transplant

faults such as narrowing of the lumen,

osteoradionecrosis, and innervated

tissue as similar as possible to replace

sutures tied too loosely so that media

muscle to reanimate the paralyzed

missing components. Selection of tissue

of the vessel is exposed in the gap and

face. Hundreds of surgical procedures

for transfer depends on the size, compo-

clot forms, sutures tied too tightly that

based on this technology have been

sition, and functional capabilities of the

tear through the vessel, or too many

described; it is truly the case that if

tissue needed, technical considerations

sutures with subendothelial expo-

it can be imagined, it can be done. In

such as vessel size and pedicle length,

sure and clot formation. Secondary

addition, the principles and techniques

159

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of microsurgery are under continual refinement. Areas of emphasis include identification of tissue transfers that better suit the needs of the recipient site and minimize donor site sequelae. The latter has led to minimally invasive and endoscopic techniques for harvesting flap tissue through smaller incisions. It has also led to the description of tissue transfers such as perforator flaps that preserve functional muscle and fascia at the donor site and suprafascial free flaps that require supermicrosurgery techniques. Supermicrosurgery is the anastomosis of smaller caliber vessels ranging from 0.3 to 0.8 mm in diameter and means that a flap can be elevated PHOTOGRAPH IS FROM MENICK FJ. DISCUSSION: SIMPLIFYING CHEEK RECONSTRUCTION: A REVIEW OF OVER 400 CASES. PLAST RECONSTR SURG. 2012 JUN;129(6):1300-3

anywhere on the body that a discrete tiny perforator vessel can be identified. With this “freestyle flap,” tissue can be harvested from better concealed parts of the body, but the use of 12-0 nylon sutures with 50- to 30-μm needles can make this “freestyle reconstruction” difficult to learn.3

Restoration Based on Aesthetic Principles Plastic surgery holds dear the belief that optimal reconstructive surgery has an aesthetic component. The dual goals of reconstructive surgery are preservation of life and limb AND restoration of form and function. Over the decades, the conviction that a superior reconstruction should be

Figure 4. (Above, left) This teenager’s nose, orbit, and right cheek were obliterated by a shotgun blast. (Above, right) A cheek flap with a triangular cervical extension is designed, (below, left) and the cheek skin component is advanced to resurface the anterior cheek. (Below, right) The result after facial and nasal repair. Surgical procedures included skin grafting of the right cheek and eyelids, a radial forearm microsurgical free tissue transfer for nasal lining, rib grafts to provide nasal skeletal structure, a three-stage pedicle forehead flap for total external nasal reconstruction, and two cheek skin flaps.

aesthetically correct has driven the search for better methods to reach

to treat speciﬁc defects (Figure 4). The

axis of blood supply. The option of

these goals. Merely replacing lost

evolution of muscle and musculocuta-

using muscle as a potential ﬂap was

tissue with a shapeless blob outlined

neous ﬂaps, fascia and fasciocutaneous

noted because muscles have inde-

by scar—viable though it may be—

ﬂaps, tissue expansion, and fat injec-

pendent, intrinsic blood supply. In

does not restore a patient’s identity or

tions have added new dimensions to

1972, Miguel Orticochea, MD, made

satisfy the wish to look normal. This

the plastic surgeon’s skills.4

an important additional observation

means that employing a single surgical

By the early 1970s, the plastic

when he described musculocuta-

approach to a problem is not enough; a

surgery community was familiar

neous perforating vessels supplying

spectrum of procedures may be needed

with the idea of moving tissue on its

a cutaneous territory on superﬁcial

161

Supporting the American College of Surgeons

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Congratulations to the American College of Surgeons on Your 100-Year Anniversary!

Commission on Accreditation

of Allied Health Education Programs

The Eastern Association for the Surgery of Trauma congratulates the American College of Surgeons on its

100 Anniversary! PROUD COLLABORATORS IN THE CARE OF THE INJURED PATIENT

t th

1987-2012

Eastern Association for the Surgery of Trauma

AMWA salutes the American College of Surgeons for their 100 years of achievement. Become a member of AMWA today to be a part of AMWA’s Countdown to a Century, 1915-2015!

ACS fellows receive a 20% discount. Use discount code ACS2012. Register at www.amwa-doc.org/join-renew. Eleni Tousimis, MD, FACS, ACS Member and AMWA Board Member Chief Breast Surgery Associate Professor of Clinical Surgery Director of Fellowship Program Georgetown University Hospital

Congratulations to the American College of Surgeons on their 100th Anniversary.

muscles. He designed a musculocuta-

f lap, the radial forearm f lap, and

temporary prosthesis that is gradually

neous ﬂap, which is a muscle ﬂap with

scapular ﬂap. One of the most useful

enlarged by adding ﬂuid; this expan-

an attached skin island. Appreciated

features of a fasciocutaneous ﬂap is

sion increases the surface area of

immediately, this was the impetus for

that it can be distally based. Unlike

the overlying soft tissue. Over time,

a vigorous 10-year period of contri-

a muscle ﬂap where the dominant

it is not just stretching but actual

butions, among them the deﬁnition of

pedicle is closest to the heart, the blood

growth of the skin ﬂap that creates

the cutaneous territories of superﬁ-

ﬂow in the fascial plexus is multidirec-

an increase in the surface area with

cial muscles, the anatomy of muscles

tional. This means that a ﬂap distally

accompanying increases in collagen

including each one’s arc of rotation,

based on the calf can be rotated to

and ground substance. Expanders

and the application of muscle and

cover the foot and ankle. This obvi-

should be placed under tissue that

musculocutaneous ﬂaps for breast,

ates the need for a free microvascular

best matches the lost tissue. Filling

chest, extremity, and head and neck

transfer and has become a standard

of the expander is initiated about two

reconstruction. Scores of ﬂaps were

for foot coverage. Another advantage

weeks after surgery and continued

described, and breadth of treatable

of the fasciocutaneous ﬂap is that it

at weekly or biweekly intervals. The

deformities increased exponentially.

can confer sensibility if a sensory

patient is ready for the second surgical

Compared with skin f laps, muscle

nerve is included.

procedure when the expanded tissue

ﬂaps are less bulky, less stiff, and

The latest addition to the armamen-

is adequate to produce the desired

more malleable to conform to wounds

tarium of ﬂaps is the perforator ﬂap

effect. At the second surgery, the

with irregular three-dimensional

ﬁrst described about 10 years ago.

skin is incised through the old scar,

contours. They have more robust blood

An improvement over the musculo-

the expander removed, and the

supply and demonstrate superiority in

cutaneous and fasciocutaneous ﬂaps,

expanded f lap advanced over the

wounds compromised by irradiation

it relies on evidence that neither a

defect. It is important to conﬁrm that

or infection. The vascular anatomy

muscle nor a fascial plexus of vessels

the expanded tissue will replace the

is predictable and easily identiﬁable,

is necessary for ﬂap survival provided

defect before excising the defect. If

and the muscle can be put into use as

the single muscu locutaneous or

it is not sufﬁcient, this is handled by

a functional unit for a dynamic tissue

fasciocutaneous vessel is care-

subtotal resection of the defect and

transfer. A major consideration with

fully dissected out and preserved.

leaving the expander in place for

muscle ﬂaps is whether the loss of

Advantages include preservation

a second round of expansion.5 The

function at the donor site is accept-

of functional muscle and fascia at

advantages of expansion are the

able. In an effort to limit the func-

the donor site and versatility of ﬂap

provision of matching tissue for recon-

tional loss associated with use of an

design with regard to including as

struction, normal sensibility of the

entire muscle, methods of functional

little or as much tissue as required.

transferred tissue, a donor defect that

preservation have been devised. If

The disadvantages are the difﬁcult

is negligible, and enhanced success

some portion of the muscle chosen as

dissection needed to isolate the perfo-

of pre-expanded traditional f laps

the ﬂap is left innervated and attached

rator vessels, anatomic variability

due to enhanced vascularity. Tissue

at its insertion and origin, function

of position and size of perforator

expansion also can be combined with

is preserved after transfer of the

vessels, short pedicle length avail-

other reconstructive techniques. For

remainder of the muscle.

able, and the fragile nature of these

example, expander placement in

small blood vessels.

either the subcutaneous or submus-

In the 1980s, the observation of

cular plane can facilitate later repair

septocutaneous perforating vessels

Even as work was ongoing to ﬁnd

to the overlying skin circulation led

flaps to fit specific needs with less

to the description of fasciocutaneous

bulk and less donor site morbidity,

Lipotransfer, or autologous fat

ﬂaps. By including the deep fascia and

another technique was maturing.

injection, is an area of current

its regional fascial vascular system,

Tissue expansion uses a mechanical

interest in plastic surgery. In the last

specif ic f laps could be designed

stimulus to induce tissue growth in

few years, autologous fat injections

and some have come into wide use,

order to create soft tissue for recon-

for volume restoration have shown

including the anterior lateral thigh

structive use. It involves implanting a

the surprising beneﬁt of appearing

of abdominal wall hernias.6

163

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to reverse atrophic skin changes and

The Future of the Specialty

Mary H. McGrath, MD, MPH, FACS, is Professor of Surgery in the Division

soften areas of scarring. Fat grafting is a technique-dependent procedure

Pla st ic su rger y cont i nues t o

of Plastic Surgery and Associate

where atraumatic handling and

evolve w ith new approaches for

Chair of the Department of Surgery

methodical layering of the autologous

the care of people with congenital

at the University of California, San

fat is emphasized for long-lasting

and acq u i red deform ities. With

Francisco. She is a member of the

results. An unexpected ﬁnding is that

therapeutic advances in medicine

Board of Commissioners for The

in addition to volume restoration, fat

and surgery, new problems emerge

Joint Commission and a member of

grafting seems to have a rejuvenative

that call for novel reconstructive

the Plastic Surgery Residency Review

effect on the skin itself. When fat is

techniques. Challenged by these

Committee. She was First Vice-

injected beneath depressed scars, not

difﬁcult problems, plastic surgery

President of the American College

only the indentation but the character

continues to look for ways to treat

of Surgeons in 2008 and is a former

of the skin itself appear to improve.

life- and limb-threatening problems

member of the ACS Board of Regents

With reports of the transforma-

and at the same time restore form,

and former Vice-Chair of the Board

tive power of fat grafted in areas of

function, and well-being. Chest wall,

of Regents.

radiation damage, chronic ulcers, and

abdominal wall, and perineal recon-

other defects, there is much interest

struction are progressing rapidly,

in documenting the extent and identi-

and defects that were incapacitating

a decade ago are now correctable.

With the ongoing advances in recon-

Lower extremity salvage after devas-

structive and aesthetic surgery, it is

tating injury is commonplace. With

no longer necessary to be limited to a

the advent of new specialties such

single surgical approach to a problem.

as bariatric surgery, entirely new

As illustrated by Frederick J. Menick,

needs for plastic surgery emerge.

MD, in Figure 4, procedures are

Old techniques, such as perforator

combined to effectively treat speciﬁc

ﬂaps, continue to evolve and supply

defects on an individualized basis.

more perfect ways to reconstruct

This integrated approach means

defects. Facial transplantation is

that an advanced technique such as

an option for a select number of

microvascular tissue transfer may be

severely d isf ig u red i nd iv idua ls,

feasible, but a simpler approach with

for whom it can provide a better

tissue expansion may produce a supe-

functional and aesthetic outcome

rior result for a defect where color,

than conventional reconstructive

thickness, and texture are important.

methods. From empiric observa-

A musculocutaneous ﬂap may restore

tions come new techniques such as

lost bulk, but fat injections can be

fat grafting, which may revolutionize

added to perfect the contour at the

clinical practice. From the research

margins of the ﬂap. Selecting the best

laboratory come tissue engineering,

treatment modality requires a system-

gene therapy, and stem cell work

atic approach to patient care through

that will change reconstruction in

the key phases of management. The

unforeseeable ways in the future.

steps in this surgical decision making

The search continues for the most

process are: defect analysis, assess-

reliable, durable, and aesthetic ways

ment of surgical options, identiﬁca-

to, as Gaspare Tagliacozzi wrote in

tion of surgical goals, execution of

1597, “restore, repair, and make

the operative procedure, and result

whole those parts ... which fortune

fying the mechanism of these effects.

analysis or outcome evaluation.

References 1. McCarthy JG. Introduction to Plastic Surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders Co; 1990:1-68. 2. Jones, BM. Paul Louis Tessier: Plastic surgeon who revolutionized the treatment of facial deformity. J Plast Reconstr Aesthetic Surgery. 2008;61(9):1005-1007. 3. Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg. 2009;123(1):230-235. 4. McGrath MH, Pomerantz J. Plastic surgery. In: CM Townsend, RD Beauchamp, BM Evers, KL Mattox, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia: Elsevier Saunders; 2012;1916-1951. 5. Argenta LC, Marks MW. Principles of tissue expansion. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Saunders Elsevier; 2006;539-567. 6. Tran NV, Petty PM, Bite U, Clay RP, Johnson CH, Arnold PG. Tissue expansion-assisted closure of massive ventral hernias. J Am Coll Surg. 2003;196(3):484-488. 7. Rigotti G, Marchi A, Galiè M, Baroni G, Banati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;119(5):1409-1422. 8. Mathes SJ, Nahai, R. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchhill Livingstone; 1997: 10-36. 9. Tagliacozzi G. De Curtorum chirurgia per Insitionem. Venice: Gaspare Bindoni; 1597.

has taken away.”9 Q

165

History of the Committee on Trauma “He who wishes to be a surgeon should go to war.”—Hippocrates by DONALD D. TRUNKEY, MD, FACS

The most widely read previous history on the Committee on Trauma (COT) was authored by George W. Stephenson, MD, FACS, and published in the Journal of the American College of Surgeons in 1979. It would be impudent and even crass for me to attempt a history as complete and well-written as Dr. Stephenson has presented. I have to comment, however, on his title, “The Committee on Trauma: Its Men and Its Mission.” In 2012, the appropriate title would be, “The Committee on Trauma: Its Men and Women and Its Mission.” My effort will be to give some background that begins in the late 1800s and introduces societal needs, and to trace the evolution of trauma care during this period of time through military conﬂicts to the present. In addition, I will conclude with comments on the committee’s efforts since Dr. Stephenson ended his history in 1980. Antiseptic Surgery: A Fundamental Difference in the Care of Fractures

each day that the number of such germs

healed. Lister used carbolic acid not

is insigniﬁcant compared to those in the

only in the wound but also sprayed the

dust on the surface of objects or in the

atmosphere around the operative ﬁeld

clearest of ordinary water.”

and table. Other antiseptics such as

In 1878, Louis Pasteur presented

It was a Scottish surgeon, Joseph

a paper on the theory of germs and

Lister (1827–1912), who introduced a

Ironically, Lister’s theories were most

its application to surgery before the

systematic, scientiﬁcally based anti-

strongly opposed in his own country but

Academy of Medicine in Paris. He stated,

sepsis in the treatment of wounds in the

were adopted by Continental surgeons

“If I had the honor of being a surgeon,

performance of surgical operations.

in Europe, especially those in Germany.

impressed as I am with the dangers of

He made Pasteur’s ﬁndings a prag-

In 1876, Lister traveled to the United

exposure to the germs and microbes

matic adjunct to all surgical sepsis.

States, where he spoke about his anti-

scattered on the surface of all objects,

Lister learned of Pasteur’s method of

septic dressings at the International

particularly in hospitals, not only would

destroying bacteria by excessive heat,

Medical Congress in Philadelphia, PA.

I use only perfectly clean instruments,

but he knew that would not be possible

The presentation lasted three hours,

but after washing my hands with the

in surgical procedures. He turned to

but post-meeting, American surgeons

greatest care and submitting them to

chemical antisepsis and experimented

remained unconvinced of the meth-

a rapid ﬂaming, which would cause no

with using chloride and sulﬁdes, but

od’s efﬁcacy. As late as 1883, at the

more discomfort than a smoker feels

ﬁnally decided to use carbolic acid.

ﬁrst ofﬁcial meeting of the American

in passing a burning coal from one

He instilled carbolic acid into wounds

Surgical Association (ASA), more

hand to the other. I would never use

but learned that it could be equally

speakers opposed Listerian practices

water which had not been submitted

effective in decreased concentration.

than supported them.

to a temperature of 110–120 degrees

In 1865, he successfully employed this

Another attempt was made by

[Celsius]. All this is practical. In this

process in the case of a compound

European surgeons to convince

way, I would have to fear only the germs

fracture in the tibia of an 11-year-old

the United States that operative

in suspension in the air around the

boy. He found that the fracture had

management of fractures was appro-

[patient’s] bed but observation shows us

united and that the sore was entirely

priate, particularly if conservative

166

Dakin’s solution were also used.

management failed. Sir Arbuthnot

non-operative methods of reposition

Lane, a British surgeon, visited the

used are entirely inadequate. 3) That

United States and advocated open

when proper, non-operative methods

treatment and internal ﬁxation of frac-

are used, good results are obtained.”

tures. This generated the same type

It took Scudder a signiﬁcant amount

of controversy that followed the ASA

of time to come to the conclusions

meeting in 1883. The ASA committee

that he presented in his Oration on

that heard this presentation demurred

Fractures. Operative management of

and asked to continue gathering infor-

fractures did not get total acceptance

mation using a report it had devised. Incredibly, an irony was in the

in the United States until the end of Charles Scudder

NIH NATIONAL LIBRARY OF MEDICINE

making. In May 1922, Charles Scudder,

World War II; German surgeons had treated U.S. prisoners of war by opera-

MD, appeared before the American

and of that amount, $20 million was

tive internal ﬁxation using Kuntscher

College of Surgeons (ACS) Board of

paid for the treatment of fractures.”

rods. All had successfully healed and

Regents and presented the problem

He articulated one other advance-

of traumatic surgery and fractures in

ment, which was direct and indirect

particular. This led to organization

research into the processes of repair,

of the Committee on Fractures. Dr.

involving physical, chemical, physi-

Scudder was appointed as the ﬁrst

ological, and pathologic studies. In

chairman and immediately organized

closing his oration, Scudder was terse:

his committee with appointment of 12

“Twenty years ago, at the time of the

There were several societal issues

of his members as area chairmen and

popularization and exploitation of the

that would impact the Committee

66 as local chairmen. Scudder did not

operative treatment of fractures, I said

on Fractures and subsequently the

embrace Listerian antisepsis and was

in Atlantic City, in opening the discus-

Committee on Trauma. In the 1880s,

lukewarm on open repair of fractures.

sion of Sir Arbuthnot Lane’s paper: ‘We

Otto von Bismarck, the minister presi-

Dr. Scudder delivered the first

are not ready for the popularization of

dent of the Kingdom of Prussia, insti-

Oration on Fractures (which evolved

the operative fracture treatment in the

tuted social legislation that included

into the annual Scudder Oration) in

country. We should advance fracture

the ﬁrst system of socialized medicine

October 1929. He prefaced his paper

treatment by developing non-operative

as well as accident insurance. The

by stating, “Many problems which

methods.’ Gentlemen, time has proved

health care system, which served as

arise in the treatment of fractures are

that opinion expressed in 1909.” He

a model for other countries, placed

yet unsolved. Let me enumerate a few:

then went on to say, “I believe the situ-

emphasis on trauma care (although

1) The securing of accurate records of

ation in this country is changed and is

a formalized statewide trauma care

clinical observations, which can serve

as follows: The operative treatment of

system in Germany would not come

as the basis for dependable conclu-

fractures has become a ﬁrmly estab-

into fruition until 1975).

sions. 2) The understanding of the

lished practice. It is based upon neces-

Prior to World War I, the No. 1

relation of fractures to industry. 3) The

sity, asepsis, and a clearer knowledge

cause of compound fractures (open)

necessity for sound, ethical practices.

of the pathology of repair. It is a safe

was industrial accidents. (Motor

4) The further development of new

and sound treatment. It is no longer

vehicle accidents did not contribute

methods of treatment. 5) The proper

a method of last resort. It is often the

to mortality and morbidity until much

treatment of the rapidly increasing

method of primary choice. The results

later. The ﬁrst mortality was in New

number of bizarre and complex types

of such operative treatment when safe-

York City on Sept. 13, 1899, when

of fractures, the results of railroad,

guarded and carried out by compe-

Henry Bliss was struck by an electric-

motor vehicle, and airplane accidents.

tent men are brilliant.” He closed

powered taxicab and killed.) Even

During 1928, about $41 million was

by saying, “My theses tonight are: 1)

after World War I, industrial accidents

spent by the railroads of the country

That surgeons must demand the early

were a leading cause of traumatic

for the treatment of personal injuries,

treatment of fractures. 2) That the

injury. In Stephenson’s history on the

internal ﬁxation plates and rods were ﬁnally accepted.

Accident Hospitals and Trauma Centers

167

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COT, he points out that Dr. Frederick

and Philadelphia General Hospital.

Besley was able to get information

Others including Charity Hospital in

from the National Board of Casualty

New Orleans, Parkland Hospital in

Insurance Underwriters that showed

Dallas, Los Angeles County Hospital,

that in 1927, there were 23,000 indus-

Cook County Hospital, San Francisco

trial accidental deaths out of a total

General Hospital and Harborview

of 95,500 accidental deaths. There

Hospita l i n Seat t le were early

were 3,250,000 non-fatal industrial

providers of this trauma care.

accidents; 115,000 employees with permanent partial disabilities; and

Otto von Bismarck

World Wars I and II

1,150 more totally disabled, at a total cost of $1 billion. This emphasizes

years earlier, was scheduled for

I believe it is safe to say that the

that the COT has had a need to docu-

closure, but Gissane made a powerful

United States military has always

ment injuries and to use this informa-

argument to keep it open and use it

had an inﬂuence on the treatment of

tion in developing strategies that can

as an accident hospital. Thus, the

civilian trauma, by virtue of medical

reduce disability and return workers

Birmingham Accident Hospital was

advances pioneered on battleﬁelds as

to gainful employment.

born and has arguably been labeled

well as through its efforts—force orga-

as the ﬁrst civilian trauma center.

nization and evacuation practices—to

LIBRARY OF CONGRESS

Such numbers suggested there was a need for hospitals or centers to treat

Dr. Freeark in modest fashion

decrease the time between injury and

traumatic injuries specifically. Bob

referred to the ﬁrst and only accident

treatment. Many of the members of

Freeark’s Scudder Oration gave an

hospital in North America as the

the ASA, the ACS, and speciﬁcally the

early example of an accident hospital,

Maryland Institute for Emergency

COT have served in the armed forces.

one founded by Lorenz Böhler, an

Medical Services, established in

It is noteworthy that in April 1917,

Austrian surgeon. During World War I,

Baltimore in 1968. Although this is

Sir Arthur Balfour and a British mili-

Böhler treated many wounded soldiers

true, Freeark and Bill Blaisdell, MD,

tary mission came to the United States

who had sustained at that time what

in San Francisco both established

to discuss the pressing needs of the

were considered uniformly disabling

trauma services in the county hospi-

allies. He pleaded, “Send us doctors.”

and even fatal gunshot fractures of

tals in which they worked and turned

Britain had too few physicians for its

the extremities. Following the war,

them into legitimate trauma centers.

civilian and military requirements

he endeavored to establish a hospital

In 1966, Cook County Hospital, under

and since the main battlefield was

to care for the victims of traumatic

Dr. Freeark, took care of thousands of

along the Somme River, the French

injury—now due to industrial accidents

patients. Similarly, Dr. Blaisdell over

physicians were overwhelmed. The

(in most cases) rather than combat—

a 12-year period made San Francisco

regular army hospital units at that

where prompt commencement of

General Hospital the only trauma

time could not answer the plea, but

treatment could better the chances for

center in the city of San Francisco.

fortunately, a number of 500-bed Red

positive outcomes. Working with the

The center exists to this day and treats

Cross base hospital units were trained

Workman’s Compensation Board, he

approximately 3,500 cases annually.

and ready for service. Six of these units

established after several years a ward

There is no question that the estab-

(base hospitals 2, 4, 5, 10, 12, and 21)

for the treatment of patients injured at

lishment of trauma centers and public

were ordered to France in May 1917

work. His results were so impressive

hospitals and ultimately university

to support the British Expeditionary

they developed other accident hospi-

hospitals was a stroke of genius since

Force (BEF). The ﬁrst unit to go was

tals throughout the whole of Austria.

they combined critical care with

George Criles’ base hospital number

Dr. Freeark also mentioned a

teaching and research. A number of

4 from Western Reserve in Lakeside

second pioneer, an Australian by the

these public hospitals included Boston

Hospital in Cleveland. It left New York

name of William Gissane. In 1941,

City Hospital, Bellevue Hospital in

on May 8, and on May 25 assumed

The Queen’s Hospital in Birmingham,

New York City, Shock Trauma in

responsibility for British General

England, which had been built 100

Baltimore, Grady Hospital in Atlanta,

Hospital number 9 at Rouen, France.

169

We’re practicing

BIG MEDICINE in a (pretty darn amazing) small town.

What makes the Department of Surgery at the University of Vermont and Fletcher Allen the ﬁrst choice for surgeons like James Hebert, Susan MacLennan and Bruce Tranmer? Some might say it’s being a part of a team of nearly 100 surgeons who make up our 13 surgical divisions. Others would say that it’s our focus on academic medicine; the way we strive to foster leading-edge research and innovation; and our strong commitment to putting our patients ﬁrst. But, the one thing we’d all agree on is that we work, and live, in one of the most amazing towns in the country. UVM.edu/Medicine/Surgery

Harvey Cushing’s base hospital number 5 (Harvard University) at BEF General Hospital number 11 suffered the ﬁrst U.S. military losses to hostile action. A German bombing raid on the night of Sept. 4, 1917, killed 1st Lt. William T. Fitzsimmons, MC and several enlisted men. Another eight hospitals—6, 8, 9, 15, 17, 18, 27, and 39—joined the British Expeditionary Force.

Walter B. Cannon

A World War II blood transfusion.

Soon after reaching Europe, the early hospitals doubled to 1,000-bed

Offensive of September to November

were utilized, studies were conducted

units. However, there were no accom-

1918 was the American Expeditionary

on primary suture and delayed primary

panying additional personnel. By July

Forces’ largest of the war. The

suture, X-ray machines were used in

1918, only eight of the required 52

Offensive reﬂected the magnitude of

combat, and increased importance

evacuation hospitals were in France

the medical department’s challenges,

was placed on orthopedic surgery and

to support the 26 combat divi-

but it also stretched an already

physical therapy and rehabilitation.

sions. Evacuation hospitals took the

badly extended medical force to the

Drugs including penicillin and

wounded from the ﬁeld hospitals for

breaking point. In the course of the

sulfa were introduced in the interwar

initial treatment, stabilization, resus-

operation, 69,832 American and 2,635

years and were a major advance in

citation, and life-saving surgery and

German wounded were treated along

treating infection. They would inﬂu-

passed them by hospital train to the

with 18,864 gas victims and 2,029

ence the care of the wounded both in

rear for more deﬁnitive care. Lacking

shell-shock cases for a total of 93,360

peacetime and in war. During World

evacuation hospitals, Merritte Ireland,

casualties. Another 68,760 medical

War II, sulfonamide, sulfathiazole,

MD, the chief surgeon, had to impro-

cases were admitted to hospitals,

sulfadiazine, and others continued as

vise from the existing base hospitals,

many of them with inﬂuenza.

drugs for infection. However, the real

NIH NATIONAL LIBRARY OF MEDICINE

often with negative consequences.

Another innovation to support the

revolution was in penicillin, which

In the summer of 1918, Ireland took

American Expeditionary Force was

entered large-scale military distribu-

personnel from the 46 base hospitals

the establishment of ﬁve Navy hospi-

tion in 1944. This wonder drug proved

and organized shock and surgical

tals in order to transport casualties

to be the most effective weapon in the

teams to augment the stressed evacua-

back to the U.S. Although hospital

military’s age-old battle against wound

tion hospitals. This solved one problem

ships were protected under the Geneva

infection. Even in the war in the Paciﬁc,

but created another by removing

Conventions, Navy ofﬁcials noted the

where there were multiple indigenous

surgical personnel when they were

German government did not abide by

diseases, advances were made in

most needed to care for wounded

these agreements, as evidenced by the

treating malaria with synthetic quinine

arriving from the front. Despite

fact that several British hospital ships

called Atabrine. Just as in World War I,

adverse conditions, it was the medical

were sunk by torpedo or shelling.

the frequent use of plasma and whole

and surgical personnel in the Red

Major medical advances came from

blood to maintain blood pressure was

Cross base hospitals—that came from

World War I. Oswald Hope Robertson

one of the most signiﬁcant treatments

some of the ﬁnest medical schools and

championed the first use of blood

of shock during World War II.

hospitals in the U.S. Academic medical

transfusion. The contributions of

During World War II, more than

centers to this day have supported our

Walter B. Cannon are probably the

231,000 seriously wounded and sick

armed forces when put in harm’s way.

most exhaustive and well-written

patients who would not serve again

Amazingly, the total bed capacity

concepts of shock to come out of this

were evacuated to the United States

increased from 30,890 in July 1918

war. His book, published in 1923, is

by hospital ship and airplane from the

to 163,368 in December 1918. It is

just as appropriate now as it was then.

United Kingdom and the Continent.

noteworthy that the Meuse-Argonne

Reconstructive and plastic surgery

Another change in the evacuation of the

171

Helicopters were used to evacuate injured soldiers during the Vietnam War.

injured was in the South Paciﬁc, where

in Japan and then on to Tripler Army

be effective whereas others were

helicopters were used—albeit rarely—

Medical Center and Brooke Army

dismissed because of too many prob-

to evacuate casualties from the remote

Medical Center for care of burn

lems. The most remarkable improve-

jungles to the hospitals in the rear. Of

wounds. Blood was readily available

ment in the care of the wounded was

393,987 South Paciﬁc battle casualties

at forward hospitals. For example,

the time from wounding to the ﬁrst

treated, 12,523 died for a rate of 3.2

in 1965, 100 units were brought into

surgery, which recently was shown to

percent, the lowest yet attained.

Vietnam; this increased to 38,000

be about 26 minutes. Furthermore, as

units in February 1969. Complex

the patient progressed back through

operat ion s

Later Conﬂicts

PHOTOS BY BEN EISEMAN

Surgery on a soldier in a ﬁeld operating room during the Vietnam War.

va sc u la r

the chain of command, it was not atyp-

surgery and neurosurgery routinely

i nclud i ng

ical to return a wounded soldier to the

Five years after the end of World

were performed far forward. The Air

continental United States within 48–72

War II, the war in Korea broke out

Force also acquired its ﬁrst specially

hours. This was particularly true for

and helicopters revolutionized the

designed air medical jet, the C9A

burn injuries.

chain of evacuation of the wounded.

Nightingale, in August 1968.

The problem of moving the surgeon

The next conflict of note was in

forward was solved by bringing

1990–1991 with the first Gulf War.

wounded back to the Mobile Army

Medical readiness proved to be infe-

Surgical Hospitals (MASHes) and

rior to previous conﬂicts, which has

From the very onset of the COT, the

even the evacuation hospitals. The

been documented in Government

members worked in a selﬂess and altru-

time from wounding to surgical care

Accountability Ofﬁce studies and more

istic approach to trauma care. John W.

was 65–70 minutes. Also for the ﬁrst

recently in the Excelsior Lecture of

Batdorf, MD, in his reﬂections for the

time, vascular surgery salvaged many

2011. This was also true for the conﬂict

75th anniversary, highlighted some of

limbs by repair of blood vessels. The

in Somalia in 1993. Fortunately, the

the early concerns of the Committee.

U.S. Navy hospital ships also served

military, particularly the Air Force,

They were interested in critical care

as ﬂoating hospitals off Korea rather

was ready for Iraq and Afghanistan.

area development and head injury

than as medical transports.

Once again, research was carried

priorities. Wound care and hand care

Thoughts on the Committee on Trauma Since 1980

Many advances were made in

out in theater and led to signiﬁcant

were high on the list. Deke Farrington,

Vietnam, particularly the use of

innovations. Use of tourniquets was

MD, focused in on pre-hospital care in

aircraft to take the patient from the

life-saving and, in some instances,

a paper called “Death in a Ditch.” They

combat area to the MASH hospitals.

limb-saving. Blood was shown to be

also pursued reducing the number of

For the first time, larger aircraft

life-saving, particularly if it was fresh,

funeral homes that owned the ambu-

such as the C-130 and the C-141 were

warm blood. The ratio of plasma,

lance systems. Hand care and burn

used to transport the wounded from

packed red blood cells, and platelets

care posters for emergency rooms

Vietnam to Clark Air Force Base in

was worked out. Local hemostatic

describing various injuries were devel-

the Philippines to Kishini Barracks

agents in injuries also proved to

oped. Dr. Batdorf, Cuth Owens, MD, and

173

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The AHPBA values and appreciates the work and advancements of the ACS

Dedicated to increasing awareness, improving education, training, innovation, research and patient care in the ﬁeld of HPB Surgery. For more information, please visit ahpba.org and ahpbaconference.org

Henry Cleveland, MD, started an annual trauma course in Las Vegas that was very successful from the beginning. It included nurses, particularly critical care nurses and emergency room nurses. Similar courses were developed in Kansas City and Atlantic City. Dr. Stephenson’s history ended in 1980. Four years before, the Committee came out with the ﬁrst Optimal Care booklet, which was a It is not uncommon for soldiers who sustain traumatic injuries to receive surgical care of their wounds within 30 minutes.

guideline for development of Level I, II, and III trauma centers. The ﬁrst document was contentious since it pitted the academic centers against

presented. I met with the Executive

Board of Regents. This included the

very good non-academic centers.

Director of the ACS in September

VIP program, veriﬁcation of trauma

These issues were addressed in the

1983 and articulated that we wanted

centers was approved, and ATLS

second Optimal Care document.

to translate Advanced Trauma Life

was eventually translated and is now

(ATLS ) into Spanish for

offered in multiple countries. One of the

of the COT, and I believe, as I stated

our Latin-American colleagues and

remarkable things accomplished was

in my reﬂections, this was character-

into French for the Quebec province

the National Trauma Database, which

ized as “stormy.” I did not believe it

in Canada. We also wanted to develop

now has more than 3 million patients

was a contentious tenure, just stormy.

a parallel track for our nursing

in the registry. It is an opportunity for

There were several issues facing the

colleagues so they could take ATLS.

research and a document that can be

Committee. It was very difficult to

Additionally, we had an embryonic

used to improve the COT’s programs.

get programs through the Board of

trauma registry run by Howard

Looking back on the Committee on

Regents. This was not the fault of the

Champion in Washington, DC, but this

Trauma in 1980, I have never worked

Regents because in fact, they were

was turning into a tremendous work-

with a more committed and dedicated

only given certain bits of information

load and we wanted to transfer it to

group of surgeons. The commitment

and what we put forward as poten-

the College. A proposal was sent to the

of the Committee to a public health

tial agenda items were not always

Robert Wood Johnson Foundation and

problem is truly remarkable. The COT

had been approved. Another conten-

works extremely hard and at times, even

tious issue was establishing rosters of

plays hard. One of the reasons that the

trauma centers within the U.S. that

Committee on Trauma is so successful is

might be used by the President’s ofﬁce

the support staff, which is outstanding. Q

In 1982, I assumed the chairmanship

PHOTO COURTESY OF DR. DONALD D. TRUNKEY / PHOTO COURTESY OF WWW.Z-MEDICA.COM

Support

or other VIPs when they traveled. I sent a follow-up letter to C. Rollins Hanlon, MD, which set off a ﬁrestorm of letters. Eventually in February of the following

Hemostatic agents, such as QuikClot Combat Gauze®, have proven effective in traumatic injury treatment on the battleﬁeld.

year,

the

Donald D. Trunkey, MD, FACS, a trauma surgeon, served as Chair of the

Executive

Oregon Health & Science University

Committee of the COT met with the

Department of Surgery from 1986 to

Board of Regents, Dr. Hanlon, and the

2001 and continues to be active on

President of the American College of

the trauma call schedule. He headed

Surgeons. The COT was not deterred by

the ACS Committee on Trauma from

the nature of this meeting. Eventually

1982 to 1986 and remains an advocate

we got almost every program that was

for improved trauma care throughout

perceived as contentious through the

Oregon and the United States.

175

A Look Inside Advancements in Urologic Surgery by JACK W. MCANINCH, MD, FACS, FRCSENG (HON)

Urology as we know it today describes the medical and surgical specialty that focuses on the urinary tracts of males and females, and on the reproductive system of males. Urological disorders affect organs including the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs. The origin of the word “urology,”

(from Greek, “lithos,” or stone, and

treat the organs and anatomy addressed

however, derives from uroscopy: the

“tomos,” or cut). Lithotomists, consid-

by the ﬁeld. That’s where the modern

ancient practice of the inspection of

ered surgeons not physicians, cut

specialty known as urology begins.

urine—its taste, smell, and gradations

bladder stones, employing different

of color—to draw conclusions about

types of incisions into the perineum.

The Cystoscope and the Endoscopic Revolution

the general state of health of the entire

Imperfect as uroscopy and lithotomy

body. From the time of Hippocrates

were, both are at the roots of urology.

(approximately 460 BC–370 BC), and

The two “blind” techniques evolved over

From the inception of medicine,

likely before, uroscopy was viewed as

centuries to deal with a range of geni-

physicians, and more particularly

a legitimate method for determining

tourinary disorders. What was missing

surgeons, desired a way to look inside

the progress or course of diseases

was a method to visualize and visually

the human anatomy to see and study

in general. Diagnosis of individual diseases was secondary. But in an era before rudimentary diagnostic tools, uroscopy was a simple, non-invasive technique whereby physicians might gain insight into urine-forming organs, the urinary tract, and, more generally, the human body’s internal organs. Flawed though violate the tenants of the famed physicians’ Hippocratic Oath—“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art”—may have also promoted its acceptance. The cutting of stones, or calculi, also dates back at least as far as ancient Greece; however, it was left to “specialists,” those who practiced lithotomy

176

The Lichtleiter developed by Phillip Bozzini.

PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS

it was, the fact that the practice did not

the inner workings of the body. That “look inside” is known as endoscopy. Endoscopy was thousands of years in the making. Over centuries, lithotomists developed various methods (lateral, perineal, and suprapubic lithotomy) and special instruments for crushing or removing calculi, and though they were initially shunned,

A Nitze female cystoscope. The platinum wire ﬁlament that provided illumination can be seen in the tip of the instrument. Also visible are the two water irrigation horns for cooling the wire.

ALL PHOTOS COURTESY OF THE WILLIAM P. DIDUSCH CENTER FOR UROLOGIC HISTORY UNLESS OTHERWISE NOTED

they eventurally gained greater public acceptance. Prior to the nineteenth

German physician. Maximilian Nitze’s

The ability for the first time to

century, however, even the most

“cystoscope” is perhaps the most

examine and diagnose intraure-

sophisticated of these techniques

significant contribution to modern

thral and intravesical diseases was

were blind.

urology and the wider landscape of

groundbreaking. But Dr. Nitze also

Surgeons could only insert tubular

medical technology. Designed to look

recognized that the cystoscope could

instruments into the bladder through

inside the bladder, the cystoscope was

be used operatively. Fitted with

which they passed blades, burrs, or

initially comprised of a thin metal tube

cautery cutting loops and knives, the

pincers to feel for, grasp, and crush or

with a water-cooled electric platinum

instrument could remove tumors and

remove stones. The few body cavities

ﬁlament lamp at the tip of the instru-

cauterize the tumor bed for the treat-

that could be examined could only be

ment and a lens system to allow a clear

ment of bladder cancer. The device

inspected with the use of specula.

view inside the urinary tract, allowing

gave rise to a large array of special-

It wasn’t until a German army surgeon

the inspection of the urethra. The ﬁrst

ized instruments or scopes that allow

named Philipp Bozzini conceived and

design was somewhat compromised

us to operate inside the human body.

demonstrated his “Lichtleiter,” or light

by the need for a cumbersome cooling

Among them was the resectoscope,

conductor” in 1806 for the inspection

system for the platinum wire at the tip.

introduced in 1926 by urologist

of the pharynx and the nasal cavities

The device was markedly improved

Maximilian Stern, MD, of New York.

that the ﬁrst endoscopic instrument

in 1888 when ﬁtted with a miniatur-

The resectoscope incorporated a

debuted. Bozzini’s primitive endo-

ized electric light bulb (the mignon

wide-angle telescope and an electri-

scope consisted of a tube with various

bulb), which eliminated the need for

cally activated wire loop for trans-

attachments that could be inserted

the cooling system and had the added

urethral removal or biopsy of lesions

into a body cavity. A candle and angled

benefit of making the instrument

of the bladder, prostate, or urethra.

mirrors inside the device enabled the

affordable. Thereafter, the cystoscope

Improved and reﬁned, many types of

physician to see inside the cavity.

was widely used and paved the way

resectoscope are in use today.

Though the usefu lness of the

for endoscopy and, later, laparoscopy.

More reﬁned cystoscopes, both rigid

Lichtleiter was initially dismissed it

and ﬂexible, were developed in the

inspired an array of European and

following decades, including examples

American nineteenth century physi-

with ﬁber-optic lens systems. These

cians and scientists to experiment

and other advances in technology

with the development of endoscopic

paved the way for the endoscopic revo-

dev ices. Pa ra l lel development s

lution in urology and other specialties.

in artificial lighting (from gas to

Laparoscopy was pioneered in 1901

electricity) and the development of

by German physician Georg Kelling.

optics (mirrors and lenses) were

But laparoscopic tools and techniques

incorporated by these pioneers for

advanced most signiﬁcantly from the

the improvement of early endoscopes.

1950s forward, leading to the modern

The ﬁrst breakthrough in endoscopy was pioneered in 1877 by another

video and digital/fiber-optic laparoMaximilian Stern

scopes used widely today in urology.

177

human kidney stones. Their successful Stern resectoscope

animal testing program led to a new prototype lithotripter, the HM1 (Human

So effective and popular with

During experiments with shock

Machine). The ﬁrst human patient was

patients were the minimally invasive

waves created by high-speed water

treated with the HM1 in February 1980.

laparoscopic procedures that they

droplets shot at a target, a Dornier

The first commercially available

quickly overtook American urology

engineer noted the effect on biological

lithotripter debuted in 1984, trans-

in the 1990s. Laparoscopic surgery

tissue (pain as from an electrical

forming urologists’ approach to renal

displaced open surgery in operations

shock) when in contact with the shock

calculi. Further developments led to a

including nephrectomy, cystectomy,

wave setup. The phenomenon led to a

wide range of ESWL devices, including

urinary diversion, radical prostatec-

project funded by the German Ministry

lithotripters utilizing electrohydraulic

tomy, and in transplantation.

of Defense to research the effect of

energy. These common lithotripters

Today, robot-assisted laparoscopy

shock waves on biological structures.

generate a shock wave in an ellipsoidal

allows urologists to perform very precise

Subsequent experiments with high-

reﬂector located below the patient.

minimally invasive procedures including

speed water droplets proved that it

The sedated or anesthetized patient

prostatectomy. Robots are also making

was possible to destroy kidney stones

lies down in the apparatus' bed, with

it possible for urologic surgeons to

within closed waveguides. Physicists at

the back supported by a water-ﬁlled

perform surgery remotely, operating

Dornier were able to fragment stones

coupling device placed at the level of

machines via robots at distant locations.

in an open water bath using shock

kidneys. A ﬂuoroscopic X-ray imaging

waves generated by a light-gas gun.

system or an ultrasound imaging

The shock wave source, located in an

system is used to locate the stone and

ellipsoid reﬂector, allowed shock wave

aim the treatment. Acoustic pulses of

concentration on a kidney stone.

varying power fragment the stones into

Extracorporeal Shock Wave Lithotripsy Extracorporeal shock wave litho-

The process was known as shock

smaller pieces that then can easily pass

tripsy (ESWL) is another endoscopic

wave lithotripsy, and by the early

through the ureters or the cystic duct.

procedure that revolutionized urologic

1970s, Dornier sought a clinical partner

Millions of ESWL treatments have

surgery. Created as a minimally inva-

to develop the application of ESWL

been successfully performed since the

sive means of treating kidney stones

in humans. Urologists Eisenberger,

1980s and the minimally invasive tech-

(renal calculi) and stones in the gall-

Chaussy, and Forssmann began devel-

nique remains popular. Open surgical

bladder and liver (biliary calculi), the

opment work on a “lithotripter,” experi-

removal of stones has largely disap-

ESWL technique attempts to break up

menting with dogs implanted with

peared from urology and has been

calculi with minimal collateral damage by using an externally applied, focused, high-intensity acoustic pulse. Research into the approach began in the 1970s at the University of Munich by doctors Ferdinand Eisenberger, Christian

Chaussy,

and

Bernd

Forssmann. The effort built on prior investigations done by German aerospace firm Dornier in the late 1960s to study the effects of shock waves produced in supersonic flight on metal fuselage structures. Shock waves such as those produced by raindrops or micrometeorites impacting a fuselage can cause significant metal fatigue.

Christian Chaussey, Ferdinand Eisenberger, and Bernd Forssmann conduct extracorporeal shock wave lithotripsy research.

179

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replaced by ESWL and endoscopic as

combined w ith chemotherapy in

well as percutaneous procedures, all

selected cases are used to treat many

of which represent great advacements.

urologic pelvic cancers. The advent of the prostate-speciﬁc antigen, or PSA, screening for prostate cancer in the

Urologic Cancer Treatment

1980s was also a signiﬁcant if someThe impact of urologic oncology

what controversial advancement. Hugh Young

on most forms of cancer has been

NIH NATIONAL LIBRARY OF MEDICINE

tremendous. Progress in treating

Erectile Dysfunction

testicular cancer in particular, the

most common cancer in males aged

Hospital), who worked to improve the

Impotency has always been a chal-

20 to 39 years, has been near mirac-

technique of transurethral bladder

lenge for urology. Largely untreatable

ulous. Combating testicular tumors

tumor resection using early resecto-

for millennia, erectile dysfunction

with a combined surgical and medical

scopes for basic surgery.

(ED) is also one of the prime complica-

(Sloan-Kettering

Memorial

tions of radical pelvic surgery.

(chemotherapy) approach has dramat-

In 1904, Hugh Young, MD, at Johns

ically improved chances for survival.

Hopkins Hospital, assisted by William

Early efforts for treatment included

As recently as 50 years ago, survival

Stewart Halsted, MD, performed a

home remedies and a considerable

rates were no more than 15 to 20

radical prostatectomy. A perineal

amount of quackery. By the begin-

percent among men. Today, in excess

incision was made, and the seminal

ning of the twentieth century, contem-

of 90 percent of patients treated via

vesicles were also removed. It was

porary therapy addressed lack of

urological surgery and chemotherapy

one of a number of early operations

testosterone primarily. Around 1900,

survive, giving testicular cancer one

to treat prostate cancer that met with

intramuscular injection of dog testic-

of the highest cure rates of all cancers.

limited success. Surgeons at Johns

ular extract was suggested and by the

Orchiectomy, the removal of a

Hopkins, led by Dr. Patrick Walsh,

end of World War I, testicular implan-

testicle aff licted with a cancerous

have continued the advancement of

tation was widely practiced in Europe.

tumor, often performed as robot-

treatment of prostate cancer, utilizing

Ligation of the dorsal vein of the penis

assisted laparoscopy, and retroperi-

the retropubic surgical approach with

was also tried in the 1920s and 1930s

toneal lymph node dissection (surgery

erectile nerve sparing. This has become

but results weren’t impressive.

executed on the retroperitoneal /

a standard accepted worldwide.

Penile implants were ﬁrst tried in

paraaortic lymph nodes to accurately

Dr. Jewett was one of the early inves-

the mid-1930s using rib cartilage, and

determine whether the cancer is in

tigators of intravesical chemotherapy

by the 1950s experiments with single

stage I or stage II and to reduce the

(treatment via injection of an antineo-

acrylic rod implants were under way.

risk that malignant testicular cancer

plastic drug or with a combination of

Wounds and infections were common.

cells may metastasize to lymph nodes

such drugs directly into the bladder

Silastic (a silicone and plastic combi-

in the lower abdomen) are the most

through a catheter rather than being

nation material) rods were proposed

common surgical procedures.

given by mouth or injected into a vein) in

in the 1960s, but again, perforations and infections were common.

Modern treatments for testicular

the treatment of bladder cancer during

cancer and other genitourinary tumors

the mid-twentieth century. In the late

The ﬁrst real advance took place

stem from work done early in the twen-

1960s, he reported on his experience of

in 1972 with the introduction of the

tieth century in the treatment of bladder

preoperative radiation therapy followed

inﬂatable prosthesis by Texas-based

and prostate cancer by several noted

by radical cystectomy. He concluded

urologist Brantley Scott, MD. Dr. Scott’s

urologists. Austrian physician Joseph

that external beam radiation rarely

initial implant was cumbersome and

Grünfeld was a pioneer in transurethral

eradicated all bladder cancer.

plagued by technical drawbacks, but

therapy of bladder cancer, preceding

Today, laparoscopic and robotic

it began modern penile prosthesis, a

urologists including Lawrence Green,

procedures including robotic pros-

technique that advanced through the

MD (Mayo Clinic), Hugh J. Jewett, MD

t at ec t omy, c y s t opro s t at ec t omy,

1980s and 1990s but which became

(Johns Hopkins), and Willet Whitmore,

and anterior pelvic exenteration

secondary by the current century.

181

ClinicalKey congratulates the American College of Surgeons on 100 years of advancing surgical patient care!

ClinicalKey invites you to booth #2722 at the Annual ACS Clinical Conference to experience its breakthrough search capabilities.

Erectile dysfunction treatments

researchers developed the drug, ﬁnally

epididymal sperm aspiration, percuta-

introducing it as Viagra in 1998.

neous biopsy of the testis, and micro-

All ED therapies have made a great

surgical epididymal sperm aspiration.

difference to the lives of men, none

Advances in sperm preservation,

more so than modern drugs. Procedures

including cryopreservation or sperm

such as nerve-sparing prostatectomy,

freezing, have helped make possible ex

Development of pharmacological

ﬁrst introduced in 1982, and minimally

vivo fertilization, or the fertilization of

treatments for ED began in the late

invasive laparoscopic surgery have also

human eggs outside the living organism.

1980s. In 1992, the use of intracaver-

contributed to a decrease in impotency

nosal vassal active agents was demon-

associated with urologic treatments.

strated. The intracavernous injection therapy technique involved the injec-

ART and other developments in reproductive urology are rapidly transforming treatments for infertility,

Reproductive Urology

tion of vasodilator medicine into the

positively impacting the lives of childless couples. In fact, this is one of the

part of the penis having the least

Understanding of the human repro-

sensation. Three principal medica-

ductive process and reproductive

tions—prostaglandin E1, papaverine,

disorders such as infertility has been

and phentolamine—or a mixture of

and continues to be one of the great

two or three of these agents can be

challenges for urology. Advancements

Space permitting, other advance-

self-injected by ED patients.

fastest-advancing ﬁelds of urology.

Conclusion

have been many over time, however,

ments including those in treating

The revolutionary development

beginning with the first recorded

urinary incontinence, percutaneous

that overtook other ED treatments

artiﬁcial insemination with donor

lithotripsy and nephrostomy for kidney

came in the late 1990s with the ﬁrst

sperm by Philadelphia physician

stone removal, and the development

pharmacological approach using an

William Pancoast in 1884.

of ureteral stents could be mentioned.

oral agent. The result was the blue ®

Through the 1930s, research into

But I’ll close with this thought:

pill now famously known as Viagra .

reproductive endocrinology and human

Urologic surgery has made its most

The genesis of the drug began with

sexuality laid the groundwork for the

impressive progress over the last two

research into the chemical compound

ﬁrst experiments in in-vitro fertilization,

to three decades. By way of illustra-

sildenaﬁl for the treatment of angina

undertaken in 1934 by Harvard scientist

tion, I started as a urology resident

at pharmaceutical giant Pﬁzer.

Gregory Pincus in rabbits. By the 1970s,

in 1964. I probably do less than 20

During clinical trials, the drug was

efforts to fertilize human eggs in the

percent now of what I learned in

found to have little effect on angina

laboratory were successful but artiﬁcial

my training. I use many of the same

but researchers noticed an unex-

insemination remained highly contro-

principles that I learned at the begin-

pected side effect. Sildenafil could

versial. Nevertheless, in 1978, the ﬁrst

ning of my career, but the actual

improve and sustain a man’s penile

“test-tube baby” was born in England.

procedures that I do today are vastly

erection by increasing blood ﬂow to

The success and slow acceptance

different. What we can see and what

the region. Pﬁzer then stopped the

of in vitro fertilization as a means of

we can do now is amazing. Every day

research on sildenaﬁl as heart medi-

dealing with infertility set the stage for

I go to work I learn something new. Q

cation and initiated investigation on it

the development of a range of male and

for penile erection.

female infertility therapies in the 1980s

Sildenafil was found to increase the muscle relaxing effects of nitric

and 1990s, giving rise to assisted reproductive technology, or ART.

Jack W. McAninch, MD, FACS, FRCSEng (Hon), is Professor of Urology

oxide, a chemical that is released

The field, embraced by urolo-

at the University of California, San

when a person is sexually stimulated.

gists, has resulted in modern treat-

Francisco, and Chief of Urology at

The relaxation of smooth muscle in

ments including sperm harvesting

San Francisco General Hospital. He

the penis facilitates higher rate of

via surgical sperm techniques such

has served as a Regent and as a

blood ﬂow and helps in producing an

as electroejaculation, testicular ﬁne

First Vice-President of the American

erection. Through the 1990s, Pﬁzer

needle aspiration, percutaneous

College of Surgeons.

183

No Roadblocks Advancements in Vascular Surgery by MAHMOUD MALAS, MD, MHS, FACS, AND JULIE FREISCHLAG, MD, FACS

The story of modern vascular surgery is an international tale. Born in the late 19th century, the field was at first an outgrowth of conflict as doctors in Europe attempted to treat battlefield injuries during the Napoleonic Wars via ligation. Reconstruction or restoration-of-circulation were not truly considerations. Still, it was clear that

Recognition of aneurysmal disease

In simple terms, it’s a surgical proce-

invaginated the proximal end into

f irst surfaced a century earlier.

dure to join together two hollow

the distal vessel, and held it in place

Brothers William and John Hunter,

organs such as blood vessels. Most

with sutures.

Scottish physicians, and English

vascular procedures, including all

But it was another French-born

doctor Astley Cooper brought the

arterial bypass operations, aneurys-

surgeon, Alexis Carrel, who would

treatment of vascular diseases other

mectomies, and solid organ trans-

revolutionize surgery of the vascular

than bleeding associated with trauma

plants, require anastomosis.

system. Dr. Carrel, who emigrated

to the attention of contemporary clini-

Two French physicians, Mathieu

cians. But as in the following century,

Jaboulay and Eugene Briau, made the

ligature was the only method known

initial breakthrough in performing

to deal with such conditions.

what would become anastomosis.

It wasn’t until the late 1800s in

Together, they published a paper in

the wake of the century’s many wars

1896 on an experimental surgery they

that a small group of surgeons began

had performed in dogs in Lyon, France.

to visualize and pioneer the repair

The publication described a technique

and treatment of the circulatory

that consisted of suturing a carotid

system. Since then, the evolution

artery end to end, literally connecting

of vascular surgery—the specialty

two ends of the vessel together using

for the treatment of non-cardiac

an inverted U-shaped suture.

vascular disease—has been a process

The idea took hold in the U.S. at about

of clearing roadblocks, both in the

the same time. Just after Dr. Jaboulay

circulatory system itself and to gain

and Dr. Briau’s work appeared, J. B.

acceptance of the discipline as an

Murphy, MD, an American doctor who

independent specialty.

had experimented with arterial and venous repair in animals, performed

The First Vascular Anastomosis

the ﬁrst successful circular suture in a human. On October 7, 1896, the Chicago-based physician united

Vascular surgery as we know it in

the ends of a femoral artery injured

the twenty-ﬁrst century begins with

by a gunshot wound. He excised

the technique known as anastomosis.

the damaged section of the artery,

184

An illustration by J. B. Murphy depicting a suture technique for repairing severed arteries and veins.

NIH NATIONAL LIBRARY OF MEDICINE

amputation, the most frequent outcome of wartime ligation, was less than satisfactory.

hemodialysis. Dr. Carrel’s techniques for anastomosis are considered the foundation of vascular surgery.

The First Aortic Reconstruction and First Bypass to the Lower Extremity The next great step in vascular surgery took place almost a half century after anastomosis was established as the fundamental technique in treating arterial insufﬁciency. A raft of early advancements from surgical specialists including Rudolph Matas, MD (pioneered endoaneurysmorrhaphy in 1888, the treatment of aneurysms without graft placement), Jay McLean, MD (discovered heparin in 1916, an anticoagulant allowing vascular occlusion without distal thrombosis), Dr. Reynaldo Dos Santos, Alexis Carrel

and Dr. Egas Moniz (developed angi-

NIH NATIONAL LIBRARY OF MEDICINE

ography in 1920, the ﬁrst diagnostic to America in 1904, worked at both

Interestingly, Dr. Carrel also collab-

roadmap for vascular surgeons), and

the University of Chicago (along

orated with famed pilot and friend,

breakthroughs during World War I

with Charles Guthrie, MD) and the

Charles Lindbergh. Attempting to

and World War II in anesthesia and

Rockefeller Institute for Medical

devise a pump for organ perfusion (the

the transfusion of blood for the treat-

Research in New York City. He built

injection of ﬂuid into a blood vessel

ment of shock set the stage for a huge

upon the early work of Dr. Jaboulay,

in order to reach an organ or tissues,

advancement in the late 1940s.

Dr. Briau, and Dr. Murphy with a

usually to supply nutrients and

The ﬁrst successful aortic recon-

technique in which he triangulated

oxygen), Carrel enlisted Lindbergh

struction also originated in France.

arteries and sutured them end to end

to aid in engineering such a device.

Three French surgeons, Dr. Jean

with ﬁne needles and suture mate-

Lindbergh came up with a pump

Kunlin, Dr. Charles Dubost, and Dr.

rials. He also devised a side-to-side

that was used for many years at the

Jacques Oudot, undertook the ﬁrst

anastomosis. From end-to-end and

Rockefeller Institute for preserving

successful reconstructions of the

side-to-side anastomosis, he went on

organs. The device could be consid-

aortoiliac segment for both aneu-

to graft arteries using a vein, then

ered the ﬁrst pump oxygenator, or

rysmal and occlusive disease.

proceeded to transplant organs from

mechanical heart.

In 1948, Dr. Kunlin, who was a

animal to animal. The work led to Dr.

In 1912, Dr. Carrel received a

trainee and later an assistant to Dr.

Carrel’s development of the “patch-

Nobel Prize for his milestone work in

René Leriche (a student of Dr. Jaboulay

graft” technique of reconstruction. In

anastomosis. It’s the basic technique

who authored more than 1,000 papers

addition, he pioneered the preserva-

vascular surgeons still use today to

on surgery and physiology), performed

tion of blood vessels in cold storage so

bypass blockages in arteries and to

the ﬁrst successful femoral popliteal

that preserved arteries could be used

create arteriovenous ﬁstulas—doing a

bypass with saphenous vein. He

for days or weeks after harvesting

bypass with a conduit, connecting an

referred to it as “long vein transplan-

from donor animals.

artery to a vein or to a plastic graft for

tation in treatment of ischemia caused

185

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by arteritis [inﬂammation of the walls

The First Carotid Endarterectomy

of arteries, commonly the result of infection or auto-immune response]” in a 1951 paper on the technique.

The signiﬁcance of the ﬁrst carotid

Dr. Kunlin subsequently presented

endarterectomy, the removal of material

eight similar cases the same year,

on the inside of an artery, was its impact

transforming the surgical approach

in lowering the incidence of stroke. The carotid arteries on either side

to profound lower extremity ischemia. Dr. Kunlin’s technique evolved

Rudolph Matas

the beginning of a separation of

for treating AAA. Operating on a

and cholesterol deposits) to form in the

vascular surgery from general and

very famous patient to remove intes-

arteries as humans age. The plaque

cardiac surgery. Today, bypass for limb

tinal cysts at the Jewish Hospital in

can build up on the inner surface of

salvage—relieving arterial blockages

Brooklyn, NY, Dr. Nissen discovered

the artery, narrowing or constricting

that can lead to tissue loss, gangrene,

another problem. Albert Einstein had

it. Small pieces of plaque called emboli

and ultimately the loss of a limb—

a large intact AAA. A brand-new tech-

can break off, traveling up the carotid

accounts for as much as half of the

nique developed over the preceding

artery to the brain where they may

procedures vascular surgeons perform.

decade, which involved wrapping the

block a major cerebral vessel, causing

aorta with polyethene cellophane to

the death of brain tissue and stroke.

The First Open Aortic Aneurysm Repair with Homograft Graft

induce ﬁbrosis (the formation of excess

Dr. DeBakey performed the first

ﬁbrous connective tissue in an organ

carotid endarterectomy in August 1953

or tissue in a reparative or reactive

on a 53-year-old school bus driver.

process) and restricting the growth

Over a two-year period, the patient

Abdominal aortic aneurysms (AAA)

of the aneurysm, was worth a try. Dr.

was having minor strokes in the form

occur when the large blood vessel that

Nissen pulled off the tricky procedure,

of transient ischemic attacks (TIA),

supplies blood to the abdomen, pelvis,

resulting in another seven years of life

losing vision in his eyes temporarily

and legs becomes abnormally large or

for the famed physicist, who died in

or having weakness in his arm or leg.

balloons (dilates) outward. The condi-

1955 when the aneurysm ruptured.

On a hunch, Dr. DeBakey listened to

tion is most often seen in males older

Progress in the development of

than 60 who have one or more risk

homografts and end-to-end anasto-

factors. AAA rupture is a true medical

mosis of the aorta through the 1940s

That sound he heard with his stetho-

emergency and is the 13th leading

paved the way for the ﬁrst successful

scope indicated that there was an

cause of death in the U.S.

resection of an abdominal aortic

abnormal blood ﬂow through the left

aneurysm with graft replacement.

carotid artery, suggesting a narrowing.

Early attempts to treat A A A via

NIH NATIONAL LIBRARY OF MEDICINE

of the neck supply blood to the brain. Atherosclerosis causes plaque (calcium

dramatically in the U.S. and marked

his neck. He heard a whishing sound referred to as a “bruit.”

ligation were unsuccessful until

On March 29, 1951, Dr. Dubost used

He was able to convince the patient that,

1923, when Dr. Matas successfully

a thoracic aorta, taken three weeks

even though it had not been conﬁrmed

ligated the abdominal aorta (he

earlier from a 20-year-old female, as

medically, the reason for the driver’s

tied the aorta before and after the

a graft. The landmark accomplish-

TIA was a blockage in the carotid artery.

aneurysm) in the treatment of an

ment rapidly changed the perception

Further, Dr. DeBakey persuaded the bus

abdominal aneurysm. The success

of vascular surgery’s potential, and

driver that he could open the artery

was only temporary, however, as the

other successful operations using Dr.

surgically and carve out the plaque to

patient died 18 months later when the

Dubost’s technique were reported by a

ﬁx the problem. Amazingly, the patient

aneurysm eventually ruptured. By

selection of noted surgeons, including

agreed to the untested procedure.

1940, there were only ﬁve recorded

the legendary American surgeon

During the surgery, Dr. DeBakey

cases in which ligation had worked.

Michael E. DeBakey, who used his

conﬁrmed his suspicion, discovering

In December 1948, Rudolph Nissen,

wife’s sewing machine to create the

severly stenotic atherosclerotic plaque

ﬁrst Dacron graft to treat AAA.

with a fresh clot completely occluding

MD, pursued an alternate strategy

187

American College of Surgeons 100th Anniversary

The Society for Vascular Surgery congratulates the American College of Surgeons on its

100th Anniversary. ACS continues to inspire specialty surgical societies to maintain

high standards and improve patient outcomes.

VascularWeb.org

the left artery. He successfully carried out an endarterectomy, restoring circulation. The patient made a full recovery and lived for another 19 years without any further strokes. Doubts lingered about carotid endarterectomy, even decades after Dr. DeBakey’s initial success. Some specialists including neurologists Michael E. DeBakey

disputed its long-term effectiveness. The North American Symptomatic Carotid Endarterectomy Trial (1987–

enabled in three ways—via a cath-

extremity bypass is the creation of

1990) showed clearly that the surgery

eter, an arteriovenous graft, or an

an AV ﬁstula for dialysis.

was more effective than other courses,

arteriovenous (AV) ﬁstula. A ﬁstula

such as taking aspirin. Patients under-

is a surgically created connection of

going endarterectomy experienced

an artery directly to a vein without

less than one-third the rate of recur-

the need for a graft.

ring strokes as those taking aspirin.

AV fistula is the preferred type

The most signiﬁcant advancement

The techniques introduced in the

of access because when the ﬁstula

in the modern era of vascular surgery

1950s including aortic aneurysm

properly matures, strengthens, and

is the move away from invasive or

repair and carotid endarterectomy

enlarges, it provides vascular access

open vascular surgery to non-invasive

represented breakthroughs for open

with good blood ﬂow that can last for

endovascular surgery.

arterial surgery. The following two

decades. Thereafter, a patient can go

Beginning in the mid-1960s with

decades would see the growth of

two or three times a week for dialysis,

advances such as interventional radi-

operative procedures with advances

puncturing into their own vein to

ology and transluminal angioplasty,

such as the introduction of the cath-

connect to the dialyzer.

the movement toward treatment of vascular disease without the scalpel

eter selective arteriogram, reﬁnement

The ﬁrst AV ﬁstula for hemodialysis

of prosthetic grafts, revasculariza-

was invented and developed by Kenneth

tion procedures extended to all parts

C. Appell, MD, at Bronx Veterans

The ﬁrst angioplasty in the leg was

of the body, and the emergence of

Administration Hospital in 1963. Dr.

performed in 1964 by Charles Dotter,

new imaging techniques such as

Appell’s original procedure was a type

MD, and his assistant, Melvin Judkins,

ultrasound, computed tomography

of AV ﬁstula known as a radial-cephalic

MD. Dr. Dotter, who had been instru-

(CT) scan, and magnetic resonance

ﬁstula, between the radial artery and

mental in the development of interven-

imaging (MRI).

the cephalic vein near the wrist.

tional radiology, treated an 82-year-old

The Creation of the First Arteriovenous Fistula for Dialysis

AP PHOTO

The First Endovascular Repair for Aortic Aneurysm

gathered momentum.

Prior to Dr. Appell’s creation of

woman with a blockage of the superﬁcial

the AV or “native ﬁstula” (so called

femoral artery in her left leg with a proce-

because it uses the patient’s own blood

dure he called transluminal angioplasty.

vessels), dialysis was chieﬂy admin-

The non-invasive technique employed a

istered using tubing and a catheter.

percutaneous dilating catheter.

Dialysis is an artiﬁcial replacement

The painful procedure also was prone

A balloon attached to the long tube

for lost kidney function in people with

to problems including bleeding, infec-

catheter was guided by X-ray images

renal failure. The process, performed

tion, erosion, clotting, and the need for

from the femoral artery in the groin to

with the aid of a dialysis machine

the patient to have a bulky dressing in

the blockage and then inﬂated, thereby

or “dialyzer,” removes wastes and

order to maintain sterility.

opening the artery. The procedure

excess water from the blood normally

Today, the procedure performed

went well and the patient’s blockage

ﬁltered by the kidneys. Hemodialysis,

most often by the average American

was relieved without open surgery.

one of three types of dialysis, can be

vascular surgeon along with lower

However, Dr. Dotter’s philosophy of

189

MERCY HOSPITAL & MEDICAL CENTER SALUTES THE AMERICAN COLLEGE OF SURGEONS AND ITS FELLOWS FOR 100 YEARS OF INSPIRATION, LEADERSHIP AND UNWAVERING COMMITMENT TO EXCELLENCE IN SURGICAL CARE.

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C I T Y

non-invasive surgery and his technique

surgery was formally recognized as

were resisted for a number of years by

an independent specialty. Q

many in the medical community. Endovascular surgery didn’t become a reality until almost three decades

Mahmoud Malas, MD, MHS, FACS,

later with the ﬁrst endovascular repair

is an Associate Professor of Surgery

for aortic aneurysm (EVAR). The non-

at Johns Hopkins University and the

invasive counterpart to invasive open

Director of Endovascular Surgery and of

surgery for AAA, the ﬁrst EVAR was

The Vascular and Endovascular Clinical

performed in the Soviet Union in 1987

Research Center at Johns Hopkins

by Russian physician Nicholas Volodos.

Illustration of AV ﬁstula for dialysis.

NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES, NATIONAL INSTITUTES OF HEALTH

The procedure, described in a 1988

Bayview Medical Center. Dr. Malas is the Johns Hopkins principal investi-

publication, was relatively rudimen-

and refining existing procedures.

gator for 14 clinical trials, including

tary. The real breakthrough came in

Despite skepticism from specialists in

six trials involving prevention of stroke

1990 when Argentinian surgeon Dr.

other ﬁelds, vascular surgeons became

and carotid artery disease treatment

Juan Carlos Parodi implanted the ﬁrst

global leaders, performing angioplas-

comparing endarterectomy to stenting

stent graft to treat AAA in a friend of

ties and an array of different endovas-

with several cerebral protection

Carlos Menem, Argentina’s president

cular techniques, such as angioplasties

methods, endovascular treatment of

at the time. Instead of making a cut

of vessels in the legs or carotid stenting.

abdominal aortic aneurysm and periph-

in the abdomen to perform open

Frank J. Veith, MD, one of the early

eral arterial disease. He is the national

surgery and sewing a graft to recon-

proponents of endovascular surgery,

principal investigator for the ROBUST

struct the aorta, Dr. Parodi inserted

was among those who argued for the

randomized trial comparing bypass to

an endovascular stent graft through

recognition of vascular surgery as a

stenting of the lower extremities.

the femoral artery in the groin to line

deﬁned specialty based on ﬁve pillars:

up the aorta from inside and relieve

an understanding of the natural

Dr. Freischlag is The William

the pressure of the aneurysm sac.

history of vascular disease; mastery

Stewart Halsted Professor, Chair of the

Parodi’s success with EVAR literally

of non-interventional or medical treat-

Department of Surgery and Surgeon-in-

changed vascular surgery. Patients

ment of vascular disease; knowledge

Chief at The Johns Hopkins Hospital in

who might not otherwise be candidates

and understanding of invasive and

Baltimore, MD. Dr. Freischlag has served

for open surgery (most commonly due

non-invasive diagnostics; mastery

as a Governor of the American College

to age and other complications) could

of open surgical techniques; and

of Surgeons (2000–2006) and is pres-

now be treated with a non-invasive,

mastery of endovascular techniques.

ently a Regent of the American College

less surgically risky technique. This

“In the late 1990s, it became obvious

of Surgeons. She is the national prin-

made vascular repair practical for a

to many of us that vascular surgery

cipal investigator of the VA OVER trial

much wider variety of people. Without

could no longer be restricted to a few

(Open Versus Endovascular Repair) of

invasive surgery, patients could walk

operations done as a sideline of either

abdominal aortic aneurysms. The study

the next day, eat the same night, and

cardiac or general surgery,” said Dr.

is a prospective randomized trial, which

leave the hospital within 24 hours

Veith. “I and others felt that we had

has randomized over 800 patients from

versus having to stay at least a week.

to modify our training paradigms so

34 medical centers across the country.

Shortly after this initial EVAR,

that a vascular surgeon could devote

She is presently serving President-elect

American interventional radiologist

the bulk of his postgraduate training

of the Society of Vascular Surgery. She

Michael Dake performed the same

to this specialty.”

is the Editor of the Archives of Surgery,

operation with similar results.

Today, minimally invasive tech-

which is one of the major surgical jour-

Through the 1990s, vascular surgeons

niques are the standard for repairing

nals. She also serves on several other

improved and adapted the technique of

a neu r ysms —popu la r w it h bot h

editorial boards. She has published over

endovascular repair, developing new

vascular surgeons and the public—

200 manuscripts, numerous abstracts,

technology (stents and stented-grafts)

and in the early 2000s, vascular

and book chapters.

191

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