Surgery (medicine)

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Operation scene re-enacted in a museum exhibition
Appendix surgery
Eye muscle surgery

An operation (abbreviation: OP ) is an instrumental surgical intervention on or in the body of a patient for the purpose of therapy or diagnostics . The procedure is generally performed under anesthesia . The doctor performing the operation is called the surgeon.

The main focus of such interventions is surgery with its sub-areas (e.g. trauma surgery ). But other medical specialties also use surgery as a healing method and count among the so-called operative subjects , including gynecology and obstetrics , urology , ear, nose and throat medicine and ophthalmology .

history

Phases of the operation

Basically, one can define three time phases for an operation according to western medical standards:

  1. The preoperative phase: This is where the indication is made (in Germany “specialist standard”), patient risks are recorded (e.g. through questionnaires, blood samples, ECG, X-rays, etc.), patient information and consent is provided (except in emergencies) and the The patient himself is prepared (shaving or hair trimming of certain parts of the body, removing piercings, marking the side to be operated on, removing clothing and “wearing a surgical shirt”, etc.).
  2. The intraoperative phase: it is the period around the procedure itself with anesthesia, sterile or disinfecting drape, surgery, etc.
  3. The postoperative phase: In this case, direct monitoring after general anesthesia is the rule, followed by a check of the surgical result by the surgeon at appropriate intervals, although there are large differences between the individual procedures.

The procedure itself can be divided into the following three phases:

  • Access,
  • Surgery in the strict sense,
  • Closure of access.

Minimally invasive operations reduce the extent of tissue damage through the access and thereby the operative and postoperative pain alone. A distinction must be made between the various forms of minimally invasive surgery: NOTES (access via natural body openings such as transvaginal, transrectal, etc.), laparoscopic (insertion of instruments into the abdominal cavity) or video-assisted, for example. Strictly speaking, even a particularly small incision in an otherwise “classic” operation can mean minimally invasive surgery.

In some surgical disciplines, access, such as opening the skull in neurosurgical operations, takes up a not inconsiderable amount of time.

urgency

Depending on the urgency of such an intervention, one can differentiate:

  • Emergency operations : operations that must be carried out within two hours;
  • Urgent operations : conservative interventions that should be carried out as soon as possible, but which can be postponed for a short time (hours);
  • Early selective operations : planned, indispensable interventions that are partially urgent, but can also be postponed (days)
  • Elective operations : Elective interventions that are not urgent and can be postponed. The time can be determined by the patient.

A distinction is made here according to strictly medical indications, i.e. whether a patient has a significantly higher level of damage if the urgency is assessed to be lower. This can sometimes lead to negative psychological effects if a "cancer operation" is carried out as an "elective procedure", but the patient suffers from the feeling of a malignant foreign body within himself, from which he would like to be freed as quickly as possible.

anesthesia

To ensure freedom from pain, the operation is performed under anesthesia in the form of general anesthesia , regional anesthesia ( spinal anesthesia , epidural anesthesia , plexus anesthesia ) or local anesthesia . The anesthetist present during the operation or, in the case of pure local anesthesia or central anesthesia, the surgeon is responsible for this .

operating room

With the exception of minor interventions, the operation is carried out in a special operating room . There, the patient usually lies on an operating table for the procedure or sits (in exceptional cases) in an operating chair. The surgical positioning is of crucial importance in order to meet the requirements of the patient (prevention of pressure damage) and the surgeon's requirements (good "access route", freedom of movement, possibility of intraoperative diagnostics such as X-rays).

Frequent surgeries

Penis circumcision ( circumcision )

The most common operation worldwide is the circumcision of the male foreskin, also known as circumcision . 33% of the world's male population are circumcised by the age of 15 or more. This is done according to medical indication, e.g. B. with foreskin constriction ( phimosis ), or with Muslims and Jews for ritual reasons. The next step is the operation for a cataract (of cataracts) with around 600,000 operations per year in Germany. Another common operation is a caesarean section . A typical emergency operation is the removal of the appendix appendix ( appendectomy ) in the case of appendicitis .

Around 12.6 million operations were performed in Germany in 2006. The front runner among the surgeries performed in Germany in 2006 were those on the locomotor organs (3.3 million), followed by operations on the digestive tract (2 million) and on the skin and subcutaneous tissue (900,000). In 2012 around 15.7 million operations were carried out in Germany, almost 300,000 more than in 2011. 41.9% of the operations were performed on people over 65 years of age.

Complications

Around seven million patients worldwide suffer complications from surgery every year. Half of these cases would be preventable according to a US study for the WHO , which for the first time determined the total number of all surgical interventions worldwide. According to this, there are 234.2 million operations worldwide every year. On a global average, one in 28 people is operated on every year. While 0.4 to 0.8 percent of interventions in industrialized countries die, the death rate in developing countries is 5 to 10 percent. The evaluation also makes it clear: the richest third of the world's population receives almost three quarters of all interventions, the poorest third only 3.5 percent. For the study, surgical data from 56 of the 192 WHO member countries from 2004 were evaluated and then extrapolated. All incisions that were performed in the operating room and for which at least one local anesthetic was necessary were taken into account .

Patients with coronary artery disease, for example, have an increased operative risk (if the coronary blood flow reserve is reduced, there is an up to ten-fold higher perioperative risk of heart attack (as part of the operation) compared to healthy persons), with kidney failure or with diabetes mellitus .

Perioperative antibiotic prophylaxis

In order to avoid postoperative infections (occurring after the operation), a perioperative antimicrobial prophylaxis ( PAP ) is repeated half an hour to a full hour before the intervention and for longer operations after about three to five hours . Such a risk exists in the case of immune deficiencies, endocarditis , implants and an increased intraoperative (during the operation) entry of germs ( contamination during interventions in the oropharynx , gastrointestinal operations and during surgery in the genital area and on the airways). In exceptional cases, perioperative prophylaxis is extended to 24 to 48 hours (in the case of high-risk patients, even longer) in the case of long-standing bone fractures, intestinal part removal in the event of necrosis, intestinal lesions due to trauma, gastric duodenal perforation, appendectomy or gallbladder removal duration in the case of gangrenous inflammation, longer periods of inflammation , relevant blood thinning and liquor shunt operations. The antibiotics used for prophylaxis are selected depending on the type of surgical intervention. For example, cefuroxime is used in combination with metronidazole in abdominal and vascular surgery, cefotaxime in eye surgery , cefazolin in cardiac and thoracic surgery and orthopedic surgery , imipenem in kidney transplants , and ampicillin-sulbactam , amoxicillin , in other therapeutic or diagnostic procedures, depending on the patient population -Clavulanic acid , ceftriaxone , vancomycin , clindamycin or levofloxacin are used. If multi-resistant bacteria are to be detected in prophylaxis, vancomycin (against MRSA), linezolid and tigecycline (against vancomycin-resistant enterococci (VRE) ) as well as against ESBL- positive enterobacteria, ertapenem , imipenem and meropenem, come into question.

Risk factors for post-operative infections:

  • Preoperative (existing before the operation):
    • Emergency interventions
    • contaminated wounds
    • High risk interventions
    • Foreign body implantation
    • Pre-operative stay over three weeks
    • Operation within four weeks of acute admission
    • Stones or repeated interventions in / on the biliary tract
  • Perioperative:
    • little experience of the surgical team
    • Operation time over two hours
    • extensive bleeding
    • Need for blood transfusions
    • Surgical complications
    • several surgical interventions
    • extensive diathermy
    • Oxygen drop
    • Hypothermia
  • Postoperative:
  • Patient-specific risk factors

Legal position

According to the current legal situation in Germany, an operation constitutes a criminal offense of bodily harm . It is therefore only lawful if there is also a reason for justification. Usually this consists of the patient's consent after he has been informed about the planned procedure. In order to avoid a criminal offense, the information provided and the patient's consent is usually documented with a declaration of consent . Later legal disputes regarding a surgical error like to use this fact by questioning the detailed clarification. If the patient is incorrectly informed, the burden of proof is reversed to the disadvantage of the attending physician.

In case law and literature, the “back door” of the declaration of consent is assessed as unfounded if the patient has been fraudulently deceived . This can be the case with an operation that is not medically necessary. Here the doctor commits a bodily harm. According to the BGH, signs of deception are insufficient information about the type, scope, danger, consequences, goals . The literature, on the other hand, assumes that a deception is only present if the type, extent and danger of not being properly informed. A pure deception about the reasons for the operation is to be interpreted as bodily harm, despite the declaration of consent.

In the course of the health reform , according to some doctors and health insurance companies, the wrong incentives were set. This fact is favored by the economic framework, since hospitals are not paid for treatments based on time, but per treatment case . At the beginning of 2013, the federal government therefore decided to change the law, which has been in force since April 2013: In the law on the further development of cancer early detection and quality assurance through clinical cancer registries , more transparency was called for in a passage. It is stipulated that the German Medical Association and the German Hospital Association should develop guidelines to prevent inappropriate bonus payments. The law passed the Federal Council on March 1, 2013 .

See also

literature

  • Margret Liehn, Brigitte Lengersdorf, Lutz Steinmüller and Rüdiger Döhler : OP manual. Basics, instruments, operating procedures , 6th, updated and expanded edition. Springer, Berlin Heidelberg New York 2016, ISBN 978-3-662-49280-2 .

Web links

Commons : Medical Operations  - Collection of Images, Videos and Audio Files

Individual evidence

  1. ↑ Duden online: OP, die
  2. ↑ Volker Kittlas: emergency surgery. In: Chirurgie-Portal.de. June 5, 2019, accessed June 22, 2019 .
  3. ^ Male circumcision: global trends and determinants of prevalence, safety and acceptability. World Health Organization and Joint United Nations Program on HIV / AIDS, 2007, pp. 7–8.
  4. ↑ Deutsches Ärzteblatt
  5. ↑ Federal Statistical Office and Doctor & Economy, 10/2007, p. 13.
  6. ↑ 15.7 million operations in Germany
  7. ↑ According to: A quarter of a billion operations worldwide per year. In: Doctors newspaper . June 24, 2008, p. 5. (online)
  8. ↑ Thomas G. Weiser, Scott E. Regenbogen, Katherine D. Thompson, Alex B. Haynes, and others. a .: An estimation of the global volume of surgery: a modeling strategy based on available data. June 25, 2008, DOI: 10.1016 / S0140-6736 (08) 60878-8 .
  9. ↑ Wolfgang Eichler, Anja Voß: Operative Intensive Care Medicine. In: Jörg Braun, Roland Preuss (Ed.): Clinic Guide Intensive Care Medicine. 9th edition. Elsevier, Munich 2016, ISBN 978-3-437-23763-8 , pp. 619-672, here: pp. 630 f. ( Operative risk patients ).
  10. ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , pp. 311-317.
  11. ↑ Marianne Abele-Horn (2009), p. 317.
  12. ↑ See §§ 223 ff. StGB .
  13. ↑ BGH 1 StR 319/03
  14. ↑ Christian Jäger , Examination Repetitorium Criminal Law General Part , 6th Edition, Heidelberg 2013, p. 131 .
  15. ↑ Sch / Sch / Eser, § 211, Rn 29; Rengier, Deputy 86, 406 f.
  16. ↑ BGHSt 38, 353 m. Note Rengier, JZ 1993, 364.
  17. ↑ Law to prevent superfluous operations , Potsdam Latest News of March 21, 2013.