Kemerovo State Medical Academy,

Kemerovo, Russia

 

“One should remember that many medical books contain errors”

Claudius Galen

 

The scientific technical progress of the last decades resulted in appearance of multiple new words, tokens and definitions. It influenced on the medical terminology related to the surgical operation. This word has a lot of meanings: war operation, industrial, financial etc.

An operation (from Latin – operatio) means an action. Until the recent years the surgical operation was considered as an intervention for medical purpose with using cutting tools. The term “surgery” is described in the surgery manual [5] as following: “An operation is a mechanic influence on patient’s tissues and organs for diagnostic and treatment purposes”. In the general surgery textbooks [2] an operation is defined as “performing the special mechanic influence on organs and tissues with treatment or diagnostic aim”.

Meanwhile, during the last decades the operations are performed with physical, chemical, biologic or other types of influence on tissues. So, there are messages about a possibility of pathologic focus destruction by means of high energy ultrasound impact without skin injury (bloodless operation), as well as about a possibility of myocardial tunneling with laser beam. Also there are messages about chemical impact on neural structures and pathologic focus. In one word, it emerged that the definition of surgical operation is behind the reality, although it should be conversely – the definition has to include the significant amount of real possibilities and to be ahead of time. If the definition does not include all positions relating to the surgery term, then the time has come to make its correction. Obsolescent definitions, terms, classifications and different understanding of the terms have negative influence on communication of specialists, analysis of materials and young specialist training.

According to our opinion the following definition of an operation can satisfy the present realia. An operation is an impact on the body using mechanic, physical, chemical, biological or combined methods with preventive, diagnostic, curative or cosmetic purposes. The analysis of the used terms relating to definition of surgical operation showed the significant confusion, which is to be discussed.

Presurgical period. The traditional definition of presurgical period (from hospital admission to starting surgery) is considered as obsolete at the present time, because significant amount of operations is performed in outpatient conditions. However, the volume of this operations is equivalent to inhospital ones (herniotomy, venectomy). Therefore, the criterion for initiating presurgical period should comply with any operation regardless of the conditions. Because of phsycological preparation is the earliest element for operation preparation, then the moment of making decision about surgery is the beginning of presurgical period. Immediately after physician’s message about operation necessity the process of internal psychological self-preparation for this important surgical act begins in a patient. Therefore, presurgical period is the time point from the moment of decision making about surgery till its initiating. The duration depends on several factors: disease characteristics, physician’s qualification, rational organization of diagnostic process and patient’s state.

During presurgical period the assessment of general state of patients is performed. A physician does it at presurgical stage in the reception ward or during patient’s diagram filling, without results of laboratory or other examinations. Unfortunately, in examination of histories of patients admitted in a surgical clinic, one may observe different estimates of state severity performed by different doctors and consultants for one time point. Our investigations showed that assessment range could vary from satisfactory state to high severity. In most cases doctors do not differentiate state between middle and severe, severe and very severe degrees. This fact testifies the absence of clear criteria for assessing state severity in patients. At the present time the terminology of severity degrees is not uniform. As the example, the terms from three Russian sources are given:

-          good – normal – normal;

-          satisfactory – mild – stress-compensated;

-          middle severity – middle severity – alarm;

-          severe – middle and severe degrees – critical;

-          very severe – severe – critical;

-          agonal – terminal – catastrophic.

During the first look onto three approaches for assessing state severity the necessity of uniform terminology for each severity degree appears. We are impressed by the names of severity degrees in the classification of operation and anesthesiology risk recommended by Moscow Scientific Society of Anesthesiologists-Resuscitators in 1988. According to the classification the estimation of general state of patients is performed in 5 degrees:

-          satisfactory - somatically healthy patients with localized surgical diseases without systemic disorders;

-          middle severity – patients with mild or moderate systemic disorders associated or not associated with main disease;

-          severe – patients with expressed systemic disorders which are conditioned (or not) by surgical disease;

-          extremely severe – patients with extremely severe systemic disorders with/without relation to surgical disease and with threat for patient’s life without surgery or during surgery;

-          terminal – patients in terminal state with evident events of decompensated functions of the vital organs and systems, when death is expected during operation or the following hours after it.

This classification is similar with the classification from American Society of Anesthesiologists. It includes 5 classes based on the degree of systemic disorders. However, there are no clear boundaries between the degrees of the disorders in both classifications (mild, expressed, extremely severe, incapacitating, life threatening). Also they do not allow giving firm estimate for patient’s state. Furthermore, only 5 degrees are separated, whereas six in other classifications.

There is no doubt that the classification should be uniform, interdisciplinary and without dependence on disease characteristics. The difficulties of development of such classification are associated with distribution of diseases into acute, rapidly progressing and chronical. In chronic diseases the state of patients is constant during long time period. For them disease progression is assessed with development of multiple organ dysfunction (compensation, subcompensation, decompensation). Because of this fact the individual classifications are given for acute and chronic ischemic of limbs, but it is not exactly correct.

For acute diseases the community of physicians accepted the classification based on systemic inflammatory response syndrome (SIRS) for sepsis which is offered by the consensus conference of American College of Pulmonologists and Society of Critical Care Medicine Specialists (1992). The syndrome develops as a response to an infection, trauma, operation and other factors. It is naturally that estimation of body state is started with the criteria for almost healthy individual and finished with terminal state.

Considering the above mentioned positions our vision of the uniform estimation of patients’ state is presented in six levels as the following:

1. Quite satisfactory (normal) – the state of a healthy person with non-acute local diseases without systemic disorders (for example, lipoma, small hernia, primary varicose veins of lower extremities).

2. Satisfactory – the body state with acute local disease, systemic disorders with bordering laboratory values, compensated state of the vital organs (for example, malleolar fracture, whitlow, furunculus).

3. Middle severity – the state corresponding with SIRS and shock reaction of degree 1, compensated state of vital organs. SIRS is characterized with >1 of the following signs: body temperature > 38 or < 36° C, HR > 90/min., RR >20/min., blood leukocytes > 12,000 or < 4,000, or > 10 % of immature forms.

4. Severe – the state corresponding with sepsis, shock reaction of degree 2, subcompensated state of vital organs.

5. Extremely severe – the state corresponding with severe sepsis (organ dysfunction), shock reaction of degree 3, decompensated vital organs.

6. Terminal – preagony, agony – the state corresponding with septic shock (shock reaction of degree 1U), decompensated state of vital organs.

Surgery indications and contraindications. Time and rate of disease development with possible life threat are two interrelating factors, which define indications for surgery. It is common practice to differentiate absolute and relative indications. The absolute indications include health states that are associated with unfavorable outcomes (before natural death) in case of surgery absence. Therefore, an operation is essential, but depending on disease characteristics it can be urgent (immediate, emergent). Bleeding is a typical example. Most cases are related to delayed surgery. Delay time is used for realization of treatment tactics: trial conservative treatment, efficiency of which is related to making decision about surgery (acute cholecystitis), or radial treatment of malignant disease before surgery. In case of stunted negative influence of pathologic process on the body of a patient with chronic disease planned operations are performed. Such states can include arterial hypertension, obliterating atherosclerosis of different locations, hernial disease, with threat in view of stroke, myocardial infarction and impaction. Some authors emphasize “vital” indications, but it is not appropriate, because the definition of absolute indication for urgent surgery is duplicated.

The relative indications for surgery are diseases without threat for patient’s life neither during the nearest nor in long term period. These diseases include superficial benign tumors (lipoma), primary varicose veins of lower extremities, hallus valgus.

The contraindications for surgery, like indications, are absolute and relative. The absolute contraindications for surgery are: 1) a patient gives not consent for surgery; 2) terminal state of a patient with long period of its initiation. Without consent, operations are performed according to the vital signs in children with absent relatives or foster parents, in irresponsive patients and in unconscious patients. In such cases the necessity of surgery is formalized by council of physicians. The relative contraindications for surgery are concurrent or background diseases of vital organs. But these contraindications are neglected if an operation is necessary according to absolute indications. In this case an operation is performed with consideration of patient’s body characteristics.

Surgical operation. Every day thousands of different operations are performed – from abdominal wall centesis to surgery of heart with artificial blood circulation. There are many classifications, which characterize operations from different aspects. The following operations are distinguished: 1) blood and bloodless; 2) one stage and multiple stage operations; 3) organ saving and with organ removal; 4) radical – with recovery, palliative – for alleviation; 5) plastic, restorative – for restoration of shape and function of tissues and organs; 6) reconstructive – for creation of new situation; 7) combined - in conjunction with main surgery, simultaneously; 8) according to technique – microsurgical and endoscopic operations; 9) according to prescription – medical, preventive, medical diagnostic, cosmetic; 10) trial – impossibility of surgery is assessed during intervention.

Because of increasing popularity of concurrent interventions the classification of these operations appeared: 1) monolocular, two-cavity, extramonocular; 2) mild, middle, severe; 3) unexpected, assumed, planned. The classification of low invasive and endoscopic operations with different signs was offered. The dissatisfaction in terms of surgery classification depending on time of conduction resulted in discussion in the Journal of Surgery (1985), where we participated [5]. Particularly, the issues of different interpretation of the terms “urgent”, “immediate” and “emergency” surgery were discussed. There was an offer to consider these terms as equivalent.

According to our opinion the sources of the confusion are non-compliance of the main principles of classification development. It is known that classification is presented in view of distribution of concepts into classes depending on the common features. On the basis of this prerequisite it is easy to find the failure in surgery classifications according to timing of operations. For designation of time stages the terms from different languages are used. It resulted in the fact that two terms which are equivalent in regard to meaning and shade – immediate and urgent – are used for different time stages. It is evident that “immediate” is related to the Russian “срочный” – done quickly, in short time. The grouping of the used terms according to language and base belonging allows considering three types of independent use: 1) immediate – delayed; 2) urgent – delayed – non-urgent (planned); 3) emergency – planned. It is natural that the classification should cover the general starting point for performed operations. It is acceptable to talk about early and late surgeries from beginning of disease, and it is logically to differentiate between urgent, delayed and planned operations after hospital admission. At that, planned operation is an operation which is performed in chronic disease or at the background of acute process remission.                              Therefore, according to our opinion, the surgery classification in regard to time from admission can be as indicated below. Urgent surgery – an operation which is performed immediately, because of necessity, according to medical indications. The time interval from a few minutes to several hours is needed for organization of operation and preparation of a patient. Delayed surgery is an operation which is performed after unsuccessful trial conservative treatment, diagnosis confirmation (delay in regard to medical indications) or in case of late consent from a patient (delay in regard to non-medical indications). Non-urgent (planned) surgery is an operation which is performed at the background of remission of acute disease or in chronic disease.

In the last years the term “simultaneous surgery” is implemented into surgical practice. It is an operation which is performed simultaneously with main operation. In French language “simultaneous” means simultaneity, in Latin – cooperative, performed together. In Russia “simultaneous” means performed together or combined. A comparison suggests itself for the term “concomitant”. This case demonstrates abnormal inclination towards misuse of foreign words. Therefore, operations, which are performed simultaneously with an intervention for main disease, should be called concomitant, not simultaneous, not even combined (Latin – combination – conjunction, connection in a certain order). For concomitant operations it is unacceptable to use the term “hybrid”. Hybridos (Greek) – an organism which resulted from sexual or vegetative breeding, incest.

         Rapid development of transplantology and prosthetics required improving terminology in these surgery chapters. The process of implementation of new terms was accompanied by displacement of transplantation and prosthetics conceptions that resulted in significant terminology confusion, which is observed in academic activity, scientific works and practical work. In 1967 during the international symposium in Vein the new classification of terms for transplantology was accepted instead of the old one. Unfortunately, this classification is associated with inaccuracy, displaced terms of transplantation and prosthetics. Besides, at the present time it is incomplete and is to be updated and completed.

Before presentation of comparative terminology for the old and new classifications (1967), we will indicate description of terms in transplantology and prosthetics.

Transplantology is a medical biological science, which looks into the questions of preparation, conservation and transplantation of cells, tissues and organs with possibility of long term acceptance and functioning.

Prosthetics is use of artificial materials and non-viable biologic substrates which replace a missing body part or hide presence of a defect. These materials do not endure, but incapsulate themselves in the body or degrade and resorb themselves.

Here we indicate the names of operations for transplantation of cells, organs and tissues (depending on graft characteristics) in the new (1967) and old (in brackets) classifications [3]:

Autotransplantation (autotransplantation) – in one body.

Isotransplantation (isotransplantation) – between genetically identical bodies.

Allotransplantation (homotransplantations) – between bodies of one species.

Xenografting (heterotrasplantation) – between bodies of different species.

Explantation (allotransplantation) – transplantation of non-biological substrate.

Combined plastics (combined transplantation) – transplantation of tissue and non-biological substrate.

According to the new classification the grafts are named in concordance with origin: autologous (Greek Autos – itself), isogenous (Greek isos – identical), allogenic (Greek allos – other), xenogenic (Greek – xenos – alien). There was an inaccuracy in the classification. It is associated with the fact that placement of non-biological substrates into the body (prosthetics) was named as explantation. Explantation (Latin ex – outside + plantation – planting) – transplantation and growing outside the body (for example, cell culture). It is possible to transplant an explant (for example, epidermal cells in case of burns) to donor organism. Therefore, the term “explantation” is related to transplantation of biologic materials, which are able to endure.

Combined plastics is an appropriate term for two simultaneous operations – transplantation of biologic and non-biologic substrates. In case of presence of biologic and non-biologic substrates in one construction (prosthesis) it is appropriate to use the term “combined prosthesis”.

The names of operations in terms of graft origin should be supplemented with syngenesiotransplantation (Greek – syn – together) – transplantation from first degree relative – from fraternal twin. It is different from isotransplantation – from cosmobion. Correspondingly, according to the origin, the graft is called as syngeneic in this case.

According to the operating techniques for transplantation of organs and tissues the operations are named:

-          transplantation – transfer to other part of the same or other body;

-          implantation – introduction into other place or into the body;

-          replantation – transfer to previous place;

-          explantation – transfer and growing outside the body;

-          split transplantation – organ (liver) splitting into two grafts for 2 recipients.      

Correspondingly, tissues and organs are named as graft, implant, replant, explant, split graft.

According to location grafts are separated into: orthotopic graft with natural location and heterotopic – with location of graft in other place (location of grafted kidney in natural bed or in the iliac fossa).

In contrast to the grafts, prosthesis (Greek prosthesis – addition, attachment) – is a device for compensation or fulfillment of cosmetic or functional defects of different organs and living body parts after trauma, disease or congenital abnormality. This definition allows quite wide understanding actions of prosthesis use – prosthetics. Prosthetics is performed not only for extremities, but also for eye ball, heart valves, joints, bones, abdominal wall soft tissues in herniotomy, as well as for many other organs and tissues.

Depending on the origin, prostheses are divided into:

-          biological – biological tissues without ability for acceptance,

-          non-biological – artificial, including synthetic,

-          combined – consisting of dissimilar materials.

There are types of prosthetics:

-          endoprosthetics – prosthesis location inside the body;

-          exoprosthetics – outside location;

-          combined prosthetics - the part of prosthesis is inside, the other part is outside;

-          unpermanent, for example, artificial heart for the period before donor cardiac transplantation, metal osteosynthesis;

-          permanent.

Therefore, the above mentioned facts demonstrate that, besides the indicated moments, the stumbling stone is naming operations according to placement of non-biological materials. With this purpose the transplantology terms are used: explantation, implantation, and the materials are named as explants, implants. One should avoid this concept shift. It is appropriate to use acceptable terms and tokens that one could understand that prosthetics was performed, not transplantation: “implantation of corresponding prosthesis”, hip joint endoprosthetics, osteosynthesis with rod endoprosthesis for femoral bone, external endoprosthetics with plate etc., with saving sense of prosthetics in each individual case.

As an example of concept shift in prosthetics and transplantation we indicate the quotation from the vascular surgery monograph: “However, for most patients replacement (prosthetics) of resected arterial segment with autovenous or autoarterial graft (black type used by us) is used”. As one can see, the operation with using vascular prosthesis or graft is interpreted by vascular surgeons as the specific type of surgery with displacement of vascular segment – prosthetics, but it is not correct. The solution is adherence to the classification sign. In this case this sign is blood flow restoration. The blood flow direction into other way in parallel to the main one is bypassing with prosthesis or grafts. But the direction of blood flow into the main way should be logically named as reconstruction (restoration, reorganization) with using prostheses or grafts. Therefore, operations are named as aorto-femoral bypassing, and instead of prosthetics, aorto-femoral reconstruction with indication a type of prosthesis or graft.

Postsurgical period. After an operation the postsurgical period begins. It is the interval between operation end and recovery or accept of disability. In the surgery literature the different terms are used, with different concept content of time intervals of the postsurgical period. One can meet the terms “short term” or “long term”, “early” – the first 2-3 days after surgery, or “early” before hospital discharge; “late” versus “long term” – the time from discharge to recovery or disability acknowledgment.

The above mentioned facts demonstrate the absence of the criteria for separation of the postsurgical period into time intervals. It is not exactly correct to consider hospital discharge as a criterion, because at the present time after laparoscopic cholecystectomy the patients are discharged 4-5 days after the operation, but in the past such cases were associated with discharge after 12-14 days for traditional surgical approach. The time intervals are defined by traumatic degree of an operation. There is no concept of hospital discharge in outpatient surgery. Therefore, hospital discharge is not considered as the sign of differentiation between the early and late postsurgical periods. Such criterion may be postagressive metabolic processes in the patient’s body, which are already generally accepted. According to our opinion, the concepts of early and late postsurgical periods correspond closely with periods of catabolism and anabolism, which are the parts of any stress impact, including surgical operation.

Therefore, according to the time of operation completing the classification of the postsurgical period can be described in the following way: early – catabolism period, late – anabolism period, long term – period of consequences. According to the dictionary by S.I. Ozhegov and S.Y. Shvedova (2000) “early” – relating to initial period of something, in this case – to beginning of postsurgical period. “Late” – relating to the last, final stage of something, leading up to the end (to recovery in this case). “Long term” – in great distance according to the time. It is naturally that for each disease the duration of early and late periods is different. It was already different in the previous conception of early postsurgical period in context of hospital discharge.

 

CONCLUSION

The information about surgical operation is quite extensive and is unlikely presented in short message. Therefore, the analysis included the most common terms associated with surgical operation, but other issues are shortly described, sometimes in the order of citation. The terminological boom is inevitable, because it is associated with progress in surgery and in other scientific fields. The development of endoscopic and mini-approach surgery resulted in creation of “technological” classification of low invasive operations [1]. In the nearest future operation rooms with automatic work positions for surgeons will become available. The surgeons’ action will be tracked with ultrasound and magnetic resonance imaging. Magnetic resonance operation rooms will allow performing very precise tissue biopsy and will simplify conduction of operations and performing laser, radio frequency, ultrasound, thermal, cold and chemical destruction of pathologic formations through blood free way. At the present time the robot manipulators and teleoperational systems are implemented. In the long view the new types of surgical rooms for tissue engineering operations, biotechnological, biochemical and genetic interventions will appear.

It is naturally that surgery development will be associated with new terms and classifications. At this stage we would like to observe orderliness of the terminology for traditional operations and to wish sense of moderation and common sense in issues of implementation of new terms into the practical work.