The surgical team is a unit providing the continuum of care beginning with preoperative care , and extending through perioperative (during the surgery) procedures, and postoperative recovery. Each specialist on the team, whether surgeon, anesthesiologist or nurse, has advanced training for his or her role before, during, and after surgery.
Surgery, whether elective, required or emergency, is done for a variety of conditions that include:
- cosmetic procedures
- diagnostic and exploratory procedures
- treatment of acute, chronic, and infectious diseases of tissue or organs
- transplantation of organs
- resposition and enhancement of bone, ligaments, tendons, or organ conduits
- replacement or implantation of artificial or electronic devices
The crucial elements of surgery—surgical and operative procedures, pain control, patient safety, and blood and wound control—require individual expertise and high levels of concentration and coordination. Through a team effort, the patient is treated and monitored as he or she undergoes significant acts of bodily invasion and pain control that make up the surgical experience. These surgical acts are true for the most benign and superficial operations, as well as the most intense.
According to the Centers for Disease Control and Prevention and the National Center for Health Statistics, 40 million inpatient surgical procedures were performed in the United States in 2000, followed closely by 31.5 million outpatient surgeries. Leading surgeries included:
- digestive system surgeries: 12 million
- musculoskeletal system surgeries: 7.4 million
- cardiovascular system surgeries: 6.8 million
- eye surgeries: 5.4 million
The makeup of the surgical team depends upon the type of surgery, the precise procedures, and the location and the type of anesthesia utilized. The team may include surgeons, anesthesiologists, and nursing and technical staff who are trained in general surgery or in a particular surgical specialty. Intense surgeries require larger teams and more comprehensive recovery care. Even though minimally invasive procedures (e.g., laparoscopy or endoscopy) are conducted with small instruments and a video camera probe, they require specialized expertise and high technology knowledge. These procedures utilize smaller teams, create less extensive wounds, and yield quicker healing, but often require more operating time and may result in operative injuries.
Types of surgery
Many surgeries are categorized as general surgery, and are associated primarily with accidents, emergencies, and trauma care. Hospitals have general surgeons that staff their emergency rooms or trauma centers. As surgical technology and knowledge have advanced, other surgical specialties have developed for each function and organ of the body. They involve special surgical techniques and anesthesiology requirements, and sometimes require subspecialtists with in-depth knowledge of organ function, operative techniques, complex anesthesiology procedures, and specialized nursing care.
The basic surgical specialties include:
- General surgery—General surgeons manage a broad spectrum of surgical conditions that involve almost any part of the body. They confirm the diagnoses provided by primary care or emergency physicians and radiologists, and perform procedures necessary to correct or alleviate the problem.
- Cardiothoracic surgery—A major surgical specialty with very high demands. The cardiothoracic surgical team oversees the preoperative, operative, and critical care of patients with pathologic conditions within the chest, including the heart and its valves, cancers of the lung, esophagus, and chest wall, and chest vessels.
- Neurosurgery—Neurosurgical teams specialize in surgery of the nervous system, including the brain, spine, and peripheral nervous system, and their supporting structures.
- Oral and maxillofacial surgery—Head and neck surgical teams provide treatment for problems of the ears, sinuses, mouth, pharynx, jaw, and other structures of the head and neck.
- Reconstructive and plastic surgery—Reconstructive surgery is performed on abnormal structures of the body due to injury, birth defects, infection, tumors, or disease. Cosmetic surgery is performed to improve a patient's appearance.
- Transplantation—Transplant surgical teams specialize in specific organ transplant techniques, such as heart and heart-lung transplants, liver transplants, and kidney/pancreas transplants. These highly intricate surgeries require very advanced training and technological support.
- Urology and renal transplantation—Also known as gastrointestinal surgery. The team specializes in problems of the digestive tract (stomach, bowels, liver, and gallbladder) with intensive use of or coordination with transplant team members.
- Vascular surgery—Vascular surgery offers diagnosis and treatment of such arterial and venous disorders as aneurysms, lower extremity revascularization, and other problems.
- Pediatric surgery—Pediatric surgical teams are specially trained to treat a broad range of conditions affecting infants and children. They work closely with specially trained anesthesiologists, and are experts in childhood diseases of the head, neck, chest, and abdomen, with training in birth defects and injuries. Many pediatric surgeons work to increase the use of minimally invasive techniques with children.
Open surgeries requiring invasive procedures within the abdominal cavity, brain or extensive limb areas require a hospital stay overnight or up to two weeks. Hospitalization allows the clinical staff to monitor patient recovery (and provide medical attention in the case of a complication), while allowing patients to regain organ functions.
Surgery has been revolutionized by new technology. Ambulatory or outpatient surgeries account for an increasing percentage of surgeries in the United States. Imagery with miniature videoscopes that pass into the patient via tiny incisions is an example of how minimally invasive procedures are replacing open surgeries. Minimally invasive surgeries reduce recovery time and increase the speed of healing. Outpatient or ambulatory surgery environments often allow patients to recover and go home the same day. In such specialty surgery centers, as those designed for ophthalmology, surgery is performed as part of a physician's office practice. These centers contain their own operating rooms and recovery areas.
Minimally invasive procedures that involve the use of a video scope as an exploratory as well as viewing instrument, include the following:
- Arthroscopy—allows viewing of the interior of joints, especially the knee joint.
- Cystoscopy—used to examine the urethra and bladder.
- Endoscopy—much like the laparascope, the endoscope is used in gastrointestinal surgeries of the esophagus, stomach, and colon.
- Laparoscopy—an illuminated tube with a video camera inserted in small incisions in the abdomen.
- Sigmoidoscopy—used for examining the rectum and sigmoid colon.
Types of anesthesia
Surgical procedures and the surgical setting may be associated with different types of anesthesia:
- General anesthesia renders the patient unconscious during surgery. The anesthesia is either inhaled or given intravenously. A breathing tube may be inserted into the windpipe (trachea) to facilitate breathing. The patient is carefully monitored and wakes up in the recovery room .
- Regional anesthesia numbs the surgical section of the body. This is usually accomplished via injection through the spinal canal (spinal anesthesia) or through a catheter to the lower part of the back (epidural). Regional anesthetics numb the area of the nerves that provide feeling to the designated part of the body.
- Local anesthesia medicates only the direct operative site, and is administered through injection. The patient remains conscious during the operation.
The basic surgical team consists of experts in operative procedure, pain management , and overall or specific patient care. Team members include the surgeon, anesthesiologist, and operating room nurse. In teaching hospitals attached to medical schools, the team may be enlarged by those in training, such as interns, residents, and nursing students.
SURGEON. The surgeon performs the operation, and leads the surgical team. Surgeons have medical degrees, specialized surgical training of up to seven years, and in most cases have passed national board certification exams. Board certification means that the surgeon has passed written and oral examinations of academic competence. The American Board of Surgery, a professional organization that strives to improve the quality of care by surgeons, is the certifying board for surgeons. As a peer review organization, the College has advanced standards to certify surgical competence by allowing examined surgeons to become a fellow of the organization. Fellows of the American College of Surgeons (FACS) are the elite members of the profession. An FACS designation after a physician's name and degree denotes attainment of the profession's highest training and expertise. Surgeons' credentials may be explored through the Official American Board of Medical Specialties, available at libraries or online.
ANESTHESIOLOGIST. Anesthesiologists are physicians with at least four years of advanced training in anesthesia. They may attain further specialization in surgical procedures, such as neurosurgery or pediatric surgery . They are directly or indirectly involved in all three stages of surgery (preoperative, operative, and postoperative) due to their focus on pain management and patient safety.
CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA). The certified nurse anesthetist supports the anesthesiologists, and in an increasing number of hospitals, takes full control of the anesthesia for the operation. Registered nurses must graduate from an approved nursing program and pass a licensing examination. They may be licensed in more than one state. While states determine the training and certification requirements of nurses, the work setting determines their daily responsibilities. Certified registered nurse anesthetists must have advance education and clinical practice experience in anesthesiology.
OPERATING NURSE. The general nursing staff is a critical feature of the surgical team. The nursing staff performs comprehensive care, assistance, and pain management during each surgical phase. He or she is usually the team member providing the most continuity between the stages of care. The operating nurse is the general assistant to the surgeon during the actual operation phase, and usually has advanced training.
The surgical team admits the patient to the hospital or surgery center. Many surgeons and anesthesiologists have privileges at more than one hospital and may admit the patient to a center of the patient's choosing. Surgical preparation is the preoperative phase of surgery, and involves special team activities that include monitoring vital signs , and administering medications and tests needed immediately before the procedure. In preparation for surgery, the patient meets with the surgeon, anesthesiologist, and surgical nurse. Each team member discusses his or her role in the surgery, and obtains from the patient pertinent information.
After the surgical procedure has been performed, the patient is brought to a recovery room where post-anesthesia staff take over from the surgical team under the guidance of the surgeon and anesthesiologist. The staff carefully monitors the patient by checking vital signs, the surgical wound and its dressings, IV medications, swallowing ability, level of consciousness, and any tubes or drains. Clinical staff also manage the patient's pain and body positioning.
Because of its risks, surgery should be the option chosen when the benefit includes the removal of life-threatening conditions or improvement in quality of daily life. Radical surgeries for some types of cancer may offer less than a 20% chance of cure, and the operation may pose the same percentage of mortality risk. A failed operation may shorten time with loved ones and friends, or a successful operation may lead to major positive changes in daily life.
Surgery often brings quicker relief from many conditions than other medical treatment. The risks of surgery depend upon a number of factors, including the experience of the surgical team. A recent New England Journal of Medicine article reported the findings of a national Medicare study that examined 25 million procedures performed between 1994 and 1999 in the United States. Seeking to determine the mortality associated with a number of cardiovascular and cancer surgeries, the researchers found that mortality decreased as patient volume in a surgical setting increased. The variance was dramatic for both pancreatic and esophageal surgeries. The study's messages were that Medicare patients should choose surgical centers where a large number of the type of surgery they need is performed, and that physicians working in low-volume hospitals should find ways to increase volume and reduce their morbidity and mortality rates.
Mortality rates are lower and the care more extensive in teaching hospitals with a "house staff" made up of interns and residents in training.
Health care facilities keep records of the procedures they perform. By contacting the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a center's success with surgical care, mortality and morbidity rates, and surgical complications can be determined.
The Institute of Medicine estimates that today's anesthesia care is nearly 50 times safer than it was 20 years ago, with one anesthesia-related death per 200,000–300,000 cases. Despite this record of progress, many questions remain about anesthetic safety. Certified registered nurse anesthetists administer over 65 percent of anesthesia in the United States, and are often the primary anesthetists for rural communities and delivery rooms.
Independent of surgical team expertise and experience, patient status, and the level of technological advancement in surgical procedures, cardiac events, blood clots, and infection pose surgical risks. These risks accompany all surgeries and, while great progress has been achieved, they remain factors that are part of any surgical invasion and any use of anesthesia.
Alternatives to surgery should be investigated with the referring physician or primary care physician. Many medical conditions benefit from changes in lifestyle, such as losing weight, increasing exercise , and undergoing physical rehabilitation. This is especially true for chronic conditions of the gastrointestinal tract, cardiovascular system, urologic system, and bone and joint issues. Research and other resources offer alternatives to surgery including pharmaceutical and medical remedies.
Patients should obtain a second opinion before undergoing most major surgeries. It is very important that patients understand that a second opinion offers them the ability to obtain a confirming or differing diagnosis as well as new treatment options. A study of New York City employees and retirees who sought second opinions found that 30% of the second opinions differed from the first. Many health plans have mandatory second opinion clauses. Second opinions should involve physicians in other facilities or even other cities. A change in surgeon will mean a change in the surgical team.
McLanahan, S.A., and D.J. McLanahan. Surgery and Its Alternatives: How to Make the Right Choices for Your Health. Twin Streams: Kensington Books, 2002.
Birkmeyer, J.D., E.V. Finlayson, and C.M. Birkmeyer. "Volume Standards for High-risk Surgical Procedures: Potential Benefits of the Leapfrog Initiative." Surgery (130) (September 2001): 415-22.
Finlayson, E.V., and J.D. Birkmeyer. "Operative Mortality with Elective Surgery in Older Adults." Effective Clinical Practice 4 (July 2001): 172-7.
American Board of Medical Specialties. 1007 Church Street, Suite 404, Evanston, IL 60201. (847) 491-9091. http://www.abms.org/
American Board of Surgery. 1617 John F. Kennedy Boulevard, Suite 860, Philadelphia, PA 19103. (215) 568-4000. Fax: 215-563-5718.
American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-32311. (312) 202-5000. Fax: (312) 02-5001. http://www.facs.org/ .
American Society of Anesthesiologists. 520 N. Northwest Highway Park Ridge, IL 60068-2573. (847) 825-5586. Fax: (847) 825-1692. http://www.asahq.org .
Joint Commission on Accreditation of Healthcare Organizations. One Renaissance Blvd., Oakbrook Terrace, IL 60181. (630) 792-5000. http://www.jcaho.org/ ,
Nancy McKenzie, Ph.D.