Surgical innovation

The Oxford English Dictionary defines innovation as ‘ . . . the introduction of a new thing; the alteration of something established . . . ’1 and there can be no doubt that the past century has been a time of great innovation. Just as society has witnessed the introduction of air travel, digital electronics, computers and robotics, surgical innovations have been equally transformative. Some of the innovations have come as changes in surgical practice necessitated by alterations in other aspects of healthcare, such as the declining importance of infectious diseases and rising importance of neoplastic diseases, whereas others have been truly novel surgical innovations, such as the introduction of vascular anastomoses and transplant surgery. It exceeds the bounds of this article to review all surgical advances over the past century or to credit all worthy surgeon innovators; there are so many. Instead, this article describes key changes in practice, illustrated using a few examples of fields that have evolved dramatically, and ends with a summary of the Nobel Laureate surgeons and their unique contributions to surgical innovations. Major transformations of surgery over the past century followed sharply on the heels of three critical discoveries of the preceding century, namely anaesthesia, antisepsis and anatomical pathology2. To consider the magnitude of the impact of these discoveries, one must only recall a statement made by Sir John Erichsen, Surgeon Extraordinaire to Queen Victoria in 1837, who stated that ‘ . . . the chest, and the abdomen will forever be shut from the intrusion of the wise and humane surgeon . . . ’. It is within this context that the surgical procedure for appendicitis, appendicectomy, was thought to be aggressive by the people of 1880. Anaesthesia, antisepsis and anatomical knowledge revolutionized the practice of surgery, not only expanding its scope but also increasing surgical safety and efficacy. From this start it can be seen how much the established practice of surgery shifted to a new normal through the past 100 years. For example, A Manual of Modern Surgery, General and Operative (1895) is dominated by the description of bacteriology, the management of infectious, inflammatory and injurious diseases and wounds, with only 33 of the 785 text pages devoted to ‘tumors or morbid growths’3. By 1906, Operative Surgery, For Students and Practitioners illustrated an abundance of procedures within diverse body cavities4 and, by 1913, Surgery: Its Principles and Practice required numerous volumes to cover all the many and diverse surgical diseases and procedures5. Life expectancy increased as infectious diseases came under better control with antibiotics and modern forms of hygiene, and with it conditions of advanced age such as heart disease, organ failure and cancer became dominant, prompting the development of new procedures and entirely new fields of surgery. The management of rectal cancer illustrates how a field of surgery, essentially defined by a single procedure, came to be transformed by innovations in surgical tools, including stapling devices, endoscopes, laparoscopes and robots. At the turn of the last century the Miles abdominoperineal resection (APR) was described as a desperate measure for managing the debilitating and life-threatening complications resulting from progressive, obstructing rectal cancer6. Based on anatomical considerations, oncological principles and lymphatic mapping studies, the APR procedure became the standard of care. Today the APR remains relevant, but is no longer the preferred procedure, nor is it even the most common operation performed for rectal cancer. Within a few decades surgeons found that they could safely hand sew an anastomosis in the upper rectum (anterior resection), patients had an alternative to a permanent colostomy, and data confirmed that cancer outcomes were equivalent. So the new procedure was adopted and new oncological standards for bowel margins were established7. Almost immediately, even more sophisticated procedures (low anterior resection and coloanal anastomosis) were facilitated by the introduction of linear and circular staplers. The concept of mechanical stapling is credited to Humer Hutle of Budapest, who developed the mechanical suture around 1908, and Russian surgeons appear to be the first to have employed linear and circular staplers8,9. By the 1970s and 1980s, technical innovations in fibreoptic endoscopy and computed tomography enabled early detection and accurate staging of rectal cancer, ushering in local excision and transluminal endoscopic microsurgery as alternative approaches to early-stage disease. Indeed, by 2003 nearly half of patients in the USA with T1 N0 M0 disease were managed in this way10.