A PLASTIC APPROACH TO SURGERY

A PLASTIC APPROACH TO SURGERY

94 Points of View The gentle handling of tissues is essential; this rule be broken. Avoid lethal surgery, whether it is cell or the patient that d...

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94

Points of View

The

gentle handling of tissues is essential; this rule

be broken. Avoid lethal surgery, whether it is cell or the patient that dies. The more dead or dying cells left in an operation site, the slower the recovery. The heavy-handed surgeon who mauls tissues, often with the aid of fierce instruments and retractors, is the one who complicates already elaborate techniques in a vain attempt to reduce the incidence of postoperative sepsis. There must be no tension, either in the surgeon or in the tissues. Healing is quickest when the tissues lie adjacent to one another without tension or compression. Both these states, which are associated with tight stitching, upset the blood-supply to the healing edge. Sutures should be inserted in such a way that the blood-vessels in the loop of the stitch are not compressed, either at the time of stitching or later when the tissues swell from postoperative oedema : otherwise more trauma is caused, with more oedema and more compression. Whereas a ligature is for haEmostasis, a suture is to approximate tissues until they heal, and a stitch that is inserted to perform both these functions is essentially bad. The stitch that sutures the transverse mesocolon to the stomach in the posterior Polya gastrectomy should be tied so loosely that even if the middle colic vessels are contained in its loop, they are not obstructed. The stitch that sews the peritoneal layer but inadvertently pierces the gut lumen will not slough out. Often the leakage of intestinal contents results from a stitch obliterating the blood-supply to the suture line. I remember a surgeon who, his muscles bulging as he tied his sutures, said : " I can never understand why my colporrhaphies break down-I tie my stitches tight

must not a

A PLASTIC APPROACH TO SURGERY CHARLES HEANLEY T.D., M.A., M.B. Cantab., F.R.C.S., M.R.C.P. CONSULTANT PLASTIC

SURGEON,

THE LONDON

HOSPITAL, E. 1

THERE is no such thing as a " lucky " surgeon-" the wind and the waves are on the side of the ablest navigator ". To be lucky is to know the rules and to know when to break them. The first rule is that diagnosis should precede treatment, and to disregard this rule is " worse than a crime, it is a mistake ". The word " diagnosis " is merely a verbal symbol to represent a living and changing phenomenon; diagnosis in its fullest sense is an understanding of the pathological process present. The making of a diagnosis is a continuous process which does not cease with the start of the operation, but should always be one step ahead of the treatment. It is fatal to cling to an incorrect diagnosis; so, having made a diagnosis, do not stick to it. A plastic outlook is essential. Each case should be treated on its own merits, since no two cases are the same. The man with a rigid method and technique is dangerous: if he says that something is always so, he is either teaching or no surgeon. Since pathological processes change, what was a correct diagnosis at one time may be wrong later. One should start an operation with a working diagnosis, together with a clear conception of the known facts and an open mind. One learns quickly from one’s own mistakes, sometimes It is nicer to learn from the mistakes of too quickly. others. However, it is essential to be able to recognise a mistake, and it may be hard to realise that the result might have been better. Inquisitiveness is an essential attribute of a good surgeon, because inquisitiveness leads to an increase of knowledge; and to know all about a condition is to know its complications, and thus avoid them. Do not ignore the opinion of the uninstructed; for rude minds sometimes contain pearls of wisdom, and discussion is always helpful, because what is dark when unspoken may become clear when discussed. Although the diagnosis is correct, it may be difficult to decide on the treatment, because this so much depends on the prognosis. The knowledge of the prognosis of a disease and the assessment of the prognosis in the particular case is essential in deciding the treatment, especially in carcinoma. So often the problem is not how to do the operation, but what operation to do, since it is the duty of the surgeon to prolong living in comfort, rather than to prolong the discomfort of dying. A clear conception of why one is operating at all, and why the particular operation has been decided upon, should always be kept in mind. You should not do today in an ill patient what can be done tomorrow or later in a fit patient. Emergency operations should be avoided, if possible: the acute abdomen, for instance, is a Pandora’s box of mischief. To an already ill patient do not add the insult of a big operation; he needs a life-saving operation, and no more. Do not try to paint the lily, for a live weed is better than ,

a

dead lily. *

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enough." Each stitch must be inserted andtied as if it were the important one. Since a successful operation depends on its weakest stitch, each one should have meticulous care. As is seen in skin suture, a badly placed stitch cannot be corrected by any number of rightly placed stitches, so it should be removed at once. If the stitches are loose and soon removed, only the incision will be visible, and not the stitch marks. But stitches can be removed early only if there is no tension and a good bloodsupply. On the face, for instance, stitches can be removed in three days, but where the blood-supply is bad, as on the back, they may have to be left in for fourteen days. By your scars will you be judged-the patient honours the surgeon if the scar is neat, for if the internal malady is cured, what is left save the scar by which to judge the result ? A neat suture line may cover a multitude of sins. Incisions should be made in the direction of Lange’s lines, which for the most part lie in the flexion creases. If a circle is drawn on the skin, and the circle of tissue is removed, the resultant bare area is larger than the area removed, and is oval in shape, showing that tension, and unequal tension, exists in the skin. Therefore, if the incision is made at right angles to direction of the least tension a good scar results ; if it is made in another direction there may be a contracture. " I shall excise the scar, the whole scar, and nothing but the scar, so help me Hippocrates ", is the initiate oath of the plastic surgeon. The resulting defect is sometimes surprisingly large-one removes a pennyworth of scar and gets a shillingsworth of bare area. This is due to the fact that, where the skin is supple, skin defects heal by the contracture of the scar tissue drawing the edges together, rather than by epithelial growth.

most

:):

*

*

95

Nature abhors

a

vacuum, and fills it with

a

blood-

clot ; and, as hxmatomata are almost synonymous with wound infection, subcutaneous dead spaces can be obliterated by end-on mattress sutures of non-absorbSome able material with the loops tied over packs. sites are more prone to the formation of haematomata than others. Whereas blood-vessels in the face usually stop bleeding naturally, those in the lower abdomen do not; so every miserable bleeding blood-vessel must be ligated. In plastic surgery, pressure dressings are used to press the graft against the recipient area and so prevent haematomata. The introduction of the crepe bandage has been the greatest advance in skin-grafting in the 20th century. To control haemorrhages, pressure dressings should be left for four days. Six days shall you labour and the seventh is for the evacuation of hasmatomata. Raw surfaces should not be left exposed, because they granulate and form scar tissue. Scar tissue is feminine in gender, being perverse at all times : it contracts when it should relax, as in strictures, and stretches when it should contract, as in hernia repairs. To say that a wound is granulating well is a contradiction in terms. If, in transplanting a ureter into the colon, it is allowed to prolapse into the lumen, so that the epithelium where the ureter is cut is not in contact with the epithelium of the colon, the outer surface of the ureter will granulate, forming a circular scar which contracts around the ureter and causes urinary obstruction, sepsis, and death ; even if the ureter is put into a defunctioned loop of bowel there will still be stricture leading to urinary sepsis. Whitehead’s operation for haemorrhoids fell into disrepute because tension and sepsis led to the separation of the bowel mucous membrane from the skin, and the circular scar led to stricture formation. Some surgeons wonder why their colostomies stenose when they do not suture the mucous membrane to the skin, but the wonder is that stricture is not commoner. *

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The best dressing for any raw surface is a skin graft, and the thicker the graft the less the contracture. Repeated dilatations are the signposts of surgical failure, and pull-through methods of anastomosis are bad. The failures of prostatectomy, immediate and delayed, are failures to get immediate epithelial cover. Hippocrates said, " Do not operate on growths-it makes them worst " the same rule holds today. One should operate on the normal tissues away from the growth, and not cut across carcinomatous tissue. For the surgeon, the way to hell is paved with short incisions ; for the patient the way to heaven is paved with small excisions, particularly in carcinoma surgery. Carcinomata are seldom removed completely, but the growth of those cells that are left behind is held in check by many factors. As the radiotherapist depends on the tissue reaction of the healthy patient for the treatment of carcinoma, so does the general surgeon. The cynic says that in every case of carcinoma of the breast, recurrences will develop provided the patient lives long enough. But the early recurrence appears in the patient who has made a slow postoperative recovery. Therefore she should be kept as fit as possible before, during, and after the operation. Large operations should be avoided wherever possible, because they lessen the general health of the patient and so upset the hormonal control. At the site of successfully treated carcinomata, plastic operations should be

avoided lest tissue.

they

liberate carcinoma cells from the *

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scar

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quick operator is good, but speed must never gained by the sacrifice of any principles. Thou shalt not worship speed for its own sake, for it is a false god. A quick surgeon never hurries, for speed is not made by overhaste : when you drive a car, a high average speed depends not on how fast you go, but on how slowly you don’t go. Delay is due to indecision, which results from incorrect diagnosis, faulty planning, and lack of experience. The repetitive, unproductive movement should be avoided, as in time-and-motion study : the hand that puts down the scalpel picks up the artery clip-in one movement. Time is saved by attention to many details, such as the position of lights, trolleys, and assistants, and by teamwork. Time is saved, therefore, by performing slow, deliberate, economical movements, never unnecessarily repeated. Thus, speed becomes the To be

a

be

handmaiden of the surgeon and

not

his mistress.

Public Health INFLUENZA IN LIVERPOOL ANDREW B. SEMPLE V.R.D., M.D. Glasg., D.P.H. MEDICAL OFFICER OF HEALTH

J. B.

MEREDITH DAVIES Lond., D.P.H.

M.D.

DEPUTY MEDICAL OFFICER OF HEALTH

P. J.

DISLEY

M.B. Glasg., D.P.H. ASSISTANT MEDICAL OFFICER OF HEALTH

CITY OF LIVERPOOL

spread of influenza from North China and Hong Kong spring has been reported from many areas (Mulder 1957, Fawdry 1957, Guthrie et al. 1957, Lim et al. 1957). We describe here its arrival and spread in Liverpool, and compare its course and effects with those of the last sharp outbreak, which attacked Merseyside in January, 1951 (Semple 1951). THE

last

Influenza in 1957

The first influenza patient to reach Liverpool arrived in the s.s. Clan Chattan from Calcutta on June 27. 4 more cases were reported in another ship from India on July 1. There was then a break of seven weeks until August 19, when 27 patients arrived in the s.s. Hellenes from South Africa. From then until the end of October, 35 ships docked carrying a total of 455 people with The most heavily infected ship was an influenza. Indian naval vessel which docked on Aug. 27, with 252 cases of influenza aboard. The outbreak in Liverpool started early in September. It seemed to be at its height on Sept. 27 and 28. Incidence The spread of the epidemic was studied day by day by collecting information from as many sources as possible, including the first sickness-claim forms, school absences, and sickness returns from industrial firms in the city and from the

Liverpool Passenger Transport Department. The school absence figures rose quickly to a peak on Sept. 27 when the average sickness-rate was 39-6% for infant schools, 40-2% for junior schools, and 50% for senior schools. The