General surgery is a specialty of medicine that deals with operating on the human body and being responsible for the preoperative, operative, and postoperative management of patients with a variety of diseases. Although there are other more highly specialized field of surgery such as neurosurgery and cardiothoracic surgery, general surgeons need to have the skills to diagnose and treat a variety of diseases.
Scope of general surgery
General surgeons deal with diseases that involve the breast, endocrine system, upper and lower GIT, and transplants. They may also be competent enough to perform vascular, pediatric, thoracic surgeries, and to deal with burns. Preferably, however, doctors who specialize in these latter few topics should be the ones to deal with them as they’re better trained in these areas.
Breast disease is fairly common. In fact 1 of every 9 women in the United States will develop breast cancer. Those may seem like meager numbers, a little over 10% prevalence among females is a high figure. Breast cancer and other diseases such as lactational mastitis are dealt with by general surgeons and not gynecologists or anyone else. They decide the next step and the best treatment options and present them to the patient so she can choose what she would like to do. Lots of breast diseases don’t require surgery. Surgeons won’t always rush to surgery and if there’s a possibility to wait and see what happens next or prescribe the patient medical treatment then they’ll definitely offer this to the patient. Fibroadenosis for instance is very common among young women but its treatment is almost always conservative without surgery.
On the other hand if a patient has breast cancer then she’s going to need surgery. The surgeon will classify the tumor and accordingly formulate a treatment plan. If the cancer is still in its early stages then conservative surgery such as a lumpectomy or quadrantectomy might be options instead of having to remove the entire breast. Radiotherapy has also made this possible as combining it with surgery provides excellent results.
The endocrine system is another that falls under the jurisdiction of general surgery. It should be noted, however, that there are doctors who specialize in endocrinology so you’re probably going to see an internist with a subspecialty in endocrinology before you go visit a general surgeon. If the endocrinologist believes that surgery is needed then he or she will refer you to a surgeon who will then deal accordingly. One of the commonest endocrine pathologies that require surgery is thyroid cancer. You might also need surgery in some cases of non-malignant hyperthyroidism such as multinodular goiter where the thyroid is enlarged and hyperfunctioning. A close relative of the thyroid is the parathyroid gland which may also cause an adenoma that requires removal as it results in hypercalcemia and bone weakness as it takes the calcium out of the bone and leaves it in the blood. Other endocrine pathologies may arise from the adrenal gland which is located above the kidney.
The gastrointestinal tract is entirely the responsibility of a general surgeon. No other surgery specialty will deal with a disease in a person’s stomach or colon for example. Again, if you don’t present with an acute abdomen that will result in you being admitted to a hospital and emergency surgery being performed on you then you have probably had a disease for a long time in which case you were following with your gastroenterologist. If your gastroenterologist sees that your disease can’t be controlled by medical treatment or that a complicated is beginning to develop so that surgery is required then you’ll be referred to a general surgeon. An example of this would be a resistant peptic ulcer. If you have a peptic ulcer that’s resistant to medical treatment and might even be growing then there’s a possibility of cancer. You would then need surgery.
Of course you might present with an acute abdomen from the start. A person who develops acute appendicitis has no time to go to a doctor’s office. The same goes for someone with a perforated peptic ulcer or acute pancreatitis. These patients will most likely arrive at the hospital via an ambulance and urgent surgery will be performed in order to treat them. Appendicitis and acute abdomens in general are the most encountered diseases that general surgeons face. A patient with an acute abdomen will have abdominal pain so severe that they will try to restrict their breathing. This is because breathing involves a moving diaphragm which increases the pain during inspiration as it pushes on the contents of the abdomen.
Hernias are very common nowadays and surgeons will often know how to perform hernia operations with their eyes shut. Hernias have been around for hundreds of years and in the old days before the advancements of medicine people would correct hernias by pushing the hernia back into the abdomen and burning the skin on top of the hernia so that it becomes scarred and tough. A third of these patients would die, a third would have recurrence of the hernia, and a third would be completely cured. These are fairly good results considering the circumstances. Of course hernia procedures are much more advanced right now and people very rarely die from hernia complications, although some people still get recurrences after the operation.
Colon cancer is something general surgeons see often as it is the third most common cancer in both men and females. In men the three most common cancers in order are prostate, lung, and colorectal. In females the three most common cancers are breast, lung, and colorectal. As you can see, general surgeons deal with almost half of these in the form of breast and colorectal cancer. Lung cancer is often inoperable while prostate cancer is for urologists to deal with.
Finally we have organ transplants. General surgeons are responsible for transplanting organs such as kidneys, liver, and pancreas. There are indications for each of course that are too complex to be discussed here, but if you’re receiving a transplant or donating one then the person performing the procedure will be a general surgeon. It should be noted that not all general surgeons perform transplants as these procedures are a little more complicated and often require additional training so you’ll find particular surgeons who are more adept at performing transplants than others.
Surgeons are not just responsible for what happens in the operating room. They’re responsible for preparing the patient before the procedure and making sure they’re okay after the procedure. Before the operation they’ll check that the patient’s general condition is stable and that if it isn’t then they’ll make special preparations for that during surgery. They’ll also know to prepare blood bags if necessary. After the operation it’s their job to check the patient’s condition, make sure the wound is healing properly and that no complications have happened.
There are other kinds of procedures that general surgeons might perform although it’s preferred that they’re left to those who are specialized in them. Vascular surgeons are better trained at dealing with vascular pathologies and pediatric surgeons are the best people to operate on children and infants. In a given situation a general surgeon will be able to do the job, but it’s always better to have someone with more experience and training to do it.
History of general surgery
Surgery has been around forever. There’s evidence that Neandertals made holes in their skulls in order to relieve high pressure inside them. This is a procedure we still perform to this day although now we have a name for it “creating a burr hole.” There’s also the difference in tools and sterilization obviously. It’s easy to believe that surgery has been around for as long as people have lived. Sometimes it’s instinctual. If you have a growing mass on your arm and you remove it then that’s surgery. If you have an abscess that’s causing severe pain and you cut it open then that’s also surgery.
There was a lag during medieval times and a little bit after that in medicine because the church in Europe codified the works of Galen and Aristotle as the basis for medicine and prevented the study and research of human anatomy and physiology otherwise. The problem wasn’t just that medical knowledge stalled because people couldn’t perform further studies, but the existing work of Galen and Aristotle wasn’t entirely correct. Galen for instance wasn’t allowed to dissect humans and most of the anatomy he described was based on that of animals. Things took a turn for the better when Leonardo Da Vinci and Vesalius came along. These two were able to describe the human anatomy more accurately as they started dissecting actual dead people (mostly illegally). Their work formed the basis for modern anatomy and showed that Galen’s work was often incorrect.
Moving along to the 1700s John Hunter came along and after studying human anatomy and performing his own dissections, he was able to start operating and was able to successfully surgically treat popliteal artery aneurysms. Aneurysms are dilated parts of an artery and popliteal artery aneurysms are those that arise from the popliteal artery which is located in the posterior aspect of the knee between the thigh and the leg. Surgery on the arms and legs is quite simple compared to surgery on the abdomen and GIT. Limb amputations in the 1840s would take seconds and there are still operating tables from that time present in museums that show saw marks from the amputation procedures.
Basically in a limb you’re operating in a much more confined space and there’s not much depth to it. In a limb you only have bones muscles, nerves, and blood vessels. In the abdomen there’s much more to worry about. Overall our abdomen is a much larger space than any space found in our limbs. Abdomens also have muscles, nerves, and blood vessels like arms and legs, but they have a multitude of organs in addition such as the stomach, spleen, liver, pancreas, small intestine, large intestine, kidneys, adrenal glands, and the ureter. Now if you injure a nerve or a blood vessel in the knee the area below the knee might die or become paralyzed. If you injure a nerve or a blood vessel in the abdomen then it could have several consequences because it could be supplying several organs. There’s also the difficulty of operating without injuring adjacent organs.
These are anatomical difficulties that surgeons face while operating on the abdomen, but let’s remember that a couple of hundred years ago we didn’t have painkillers and anesthesia while operating. Abdominal surgeries take time and the muscles of the abdomen are there to protect it. If you incise someone’s abdomen and operate for a while the pain will keep getting worse and the muscles will progressively contract until they close the incision and shut you out. This problem wasn’t present in limb surgery as it only took a few minutes.
For all these reasons the first successful surgery was only performed in 1809, on Christmas morning to be precise. Dr. Ephraim McDowell was able to remove a 22 pound ovarian mass from Jane Sarah Crawford. It is reported that she sang hymns to herself in order to take her mind off the pain while the surgery went on. Dr. McDowell died 21 years later in 1830 of a ruptured appendix after he had performed 12 additional abdominal surgeries. Soon afterwards we discovered anesthesia and surgery became easier to perform.
In 1865 another breakthrough was made that is now considered one of the cornerstones of not just surgery, but all medical procedures in general. In 1865 Joseph Lister developed antiseptic surgery. Surgical instruments from this point forwards would be sterilized before an operation rather than simply washed.
Famous general surgeons
Dr. Theodore Kocher is a man who conquered the thyroid gland and won a Nobel Prize for it in 1909. He was able to identify what the gland did, the importance of thyroid hormones, and how to perform surgery on the gland. His career wasn’t without trouble as many of his patients died after removal of the thyroid gland from hypothyroidism. This almost drove him to suicide following severe depression. He then discovered that giving these patients thyroid hormones was able to correct the problem and the patients survived. His removal of the thyroid gland is the first true solid organ removal in surgery and his “Kocher collar incision” is still performed in thyroid surgeries to this day. He demonstrated that it’s important for surgeons to understand the physiology (how something works) in addition to the anatomy and that simply knowing the anatomy alone wasn’t enough to be a great surgeon.
Dr. Alexis Carrell is a famous French surgeon who isn’t very popular because of his support for Nazi Germany and eugenics, but he left his mark on medicine without a doubt. He was awarded the Nobel Prize in 1912 for inventing vascular surgery as he was the first person to invent techniques to allow successful suturing of vessels.
In 1990 Dr. Joseph Murray won the Nobel Prize in medicine becoming the first American to do so. He’s considered the father of transplantation. The first transplant was performed by him in 1954 when he successfully transplanted a kidney. He went on working in the transplantation field and worked on developing anti-rejection drugs which have helped make transplants successful.
Dr. Hiroma Shinya brought himself to the forefront of medicine and surgery in the 1960s when he invented the laparoscope. Laparoscopes are tubes with cameras that allow doctors to see the inside of the abdominal cavity without making a large incision that’ll leave a scar. Through a simple incision a laparoscope can be inserted through the skin and into the abdomen to allow doctors to observe pathologies in the abdomen and even treat them through inserting a couple of other probes. This is revolutionary and is considered minimally invasive surgery as it barely leaves a scar.
It wasn’t until 1980 that people started using laparoscopes to treat as well. This was done by Dr. Patrick Steptoe. By making 2 more small incisions besides that of the laparoscope doctors can now treat abdominal lesions without having to cut large incisions. Dr. Patrick Steptoe also used the technology to harvest ova from a woman performing the first in vitro fertilization procedure.
Up until this point surgeons who used laparoscopes had to use the eye piece in order to see inside. In 1987 video technology revolutionized the process. By attaching a camera to the scope the video would then be transmitted on a monitor so that the surgeon and everyone else in the room can observe the video on the monitor without having to lean to view the eyepiece. The first laparoscopic cholecystectomy was done in 1987 in France by Dr. Phillipe Mouret.
The future of general surgery
There’s a general direction towards minimally invasive procedures throughout medical field and surgery is no exception. There’s no reason to make a large incision when you can make an incision that’s 2 cms long and perform through inserting smaller instruments through it and using a laparoscope. There are many scopes right now used in multiple other fields such as obstetrics and gynecology. There are also cardiac catheterization procedures which have replaced many cardiothoracic surgery operations. Why would you cut open someone’s chest when you can insert a small catheter through their femoral or radial artery and perform what you need to perform through it with minimal complications and scarring?
Now we have laparoscopes, but who knows what we might have in a few more years. Laparoscopes were invested about 50 years ago which is a very short time in the world of medicine. In 20 more years we might have something much smaller that renders laparoscopes obsolete.
Becoming a general surgeon
The road to becoming a general surgeon is pretty straightforward. You get a general surgery residency after medical school for 4 years and you’re now a surgeon. You could choose to pursue further specialties such as vascular surgery for example. You could also become more specialized in a certain field of general surgery such as becoming a specialist in breast cancer. This would open up the path to performing more research on the topic you specialize in and ultimately becoming one of the leaders of that particular field.
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