Facets of Surgery: From Basics to Robots

INTRODUCTION

The word ‘veterinarian’ derives from the Latin verb ‘veheri’, meaning “to draw” or “pull’ and refers to an animal doctor. It was originally used to describe people who cared for yoke-worked animals like cattle and horses in ancient Rome. Due to the association between “veterinary medicine” and Rome, discussions of its history often begin with Galen (129-216 CE), Hippocrates (460-379 BCE), or Vegetius. However, veterinary medicine was well established before their time (Mark, 2020). Whereas, the word surgery derives from the Latin word “chirurgia” and the Greek word “kheirourgia”, where “kheir” means “hand” and “ergon” means “work”. It involves diagnosing and treating animal diseases, injuries and deformities using manual or operative methods. Veterinarians perform surgery to improve animal health (Soutis, 2006).

ANCIENT SURGICAL PRACTICE

Ancient people believed that surgery was a mystical mix of medicine and spirituality. Ancient surgeons used primitive tools and techniques and had little anatomy and infection control knowledge. Despite obstacles, ancient civilizations advanced surgical knowledge and innovation, laying the groundwork for modern surgery (Mark, 2020).

Stone-Age and Bronze-Age

Trepanation of the skull

The healers of stone-age used to treat patients probably suffering from epilepsy or seizures, as evidenced by the trepenated skull found at different archeological sites. Trepanation is an ancient surgical procedure that drills or cuts skull holes. Lifelong trepanation removes cranial vault sections (Brothwell, 1967). Early cranial surgery (trepanation) dates to the Mesolithic. Champ-Durant is the earliest evidence of veterinary surgery, dating back to 3400-3000 BC, as the cow underwent trepanation to save it. The Champ-Durand cow would be the earliest evidence of a surgical procedure on an animal if trepanation was used (Rozzi & Froment, 2018). After craniotomy, reactive processes fail and long-term survival is possible if primary bone healing occurs and hemorrhage, brain damage, wound infection, and meningitis do not occur.

Wound healing techniques

The historical development of wound suturing closely parallels the advancements of surgical practices over time, signifying its crucial role in medical treatment. The historical development in wound healing closely parallels the advancements of surgical practices over time, signifying its crucial role in medical treatment. The history of wound healing dates back thousands of years, with the protection of wounds covered by mud, clay, or leaves to prevent dirt and the use of natural substances such as saliva and herbs. After that, people used bear and wine to wash wounds. Ancient Egyptian in 1600 to 1200 BC used honey, grease, Bandages and suture material to cure wounds. Ancient Indians in 600 BC performed debridement (removing dead tissue), suturing and used herbal remedies such as turmeric, aloe vera and other plant-based ingredients. Ancient people of Greece and Rome introduced wine and vinegar to clean wounds and identified the cardinal signs of inflammation (heat, redness, swelling, pain) and removing pus (Kuijjer, 1998). They used copper-based pigments, such as astringents and antiseptics. In the era of the Middle Ages and the Renaissance, the wounds remained open and allowed to “rot a bit,” A practice believed to prevent infection from spreading. In the 16th century, wounds were cauterized with boiling oil and used oil of roses and turpentine. They also introduce to ligate blood vessels instead of cauterization. After germ theory and antiseptic concepts in the 19th century, Joseph Lister (1860) introduced carbolic acid (phenol) to sterilize surgical instruments, hand washing, and wound dressings. Robert Wood Johnson in 1890, improved the methods of sterilization and pre-packed dressings for the cure of wounds (Abedellaah et al., 2019). In the 20th century, Researches show that moist wounds recover faster than dry once then start the idea of modern occlusive dressings. Nowadays, different types of hydrogels, foams, alginates, and hydrocolloids are used to treat wounds and maintain a moist environment. Recently, some biological and technical therapies such as maggot therapy, negative pressure wound therapy, hyperbaric oxygen, and engineered skin substitute have been used to treat wounds (Schiappa & Van Hee, 2012).

Traditional wound closure uses vegetable thorns or animal spikes. These thorns or spikes were placed across both wound gap edges and secured with vegetable fibres or a figure-of-eight pattern. This technique was developed in Africa around the 10th century BC, and was later refined by the Greeks and Mycenaeans using “fibulae,” metal devices. Fibulae held tissued together like safety pins. Galon also treated gladiator’s cut tendons with thread-like animal viscera. Late Middle Ages surgery used gold wires. Hernia surgery uses the “golden thread suture” to prevent recurrence after sac reduction. Sutures have been made from gold threads, kangaroo tendons, horse hair, linen, wire, catgut, cotton, silk, tantalum, and others (Schiappa & Van Hee, 2012).

Fracture management

The Edwin Smith Papyrus (Smith, 1930), shows that ancient Egyptians used simple splints to support fractured bones. Early splints were made of reeds and wood. Egyptian burial sites contain splints from 5000 years ago, indicating early use. Bark and linen were used to make these ancient splints. In ancient times, vegetable fibers were dressed in various ways. Wet leather strips and linen soaked in lime and egg white stiffened. Hippocrates described resin-coated bandages. Later, Shoshone Indians used rawhide strips to immobilize broken bones. Material availability, ease of application, and effectiveness in aligning fractured bones during healing made this technique appealing (Ellis, 2011).

Dental surgery

Addressing dental and jaw issues has a long and varied history. Toothaches were once considered a divine curse. Dentistry has advanced to become one of the most advanced and forward-thinking fields of science. The ancient Egyptian 'Phostophori' healed the sick (Coppa et al., 2006). 'Hesy Re,' the first dentist, was described as 'the greatest of those who deal with teeth, and of physicians'. His tomb shows early dental practice. This is the first dental practitioner recognition. Ancient Egyptian dentists used bow drills, copper chisels, and linen thread to treat oral issues. Bow drills removed decay and copper chisels extracted teeth. A dental floss made of linen thread. A 5000 BC Sumerian text blamed "tooth worms" for dental decay (Majumdar, 2002). Greek literature credits Esculapius with inventing purgatives and tooth extractions in the twelfth century BC. Later, Celius Aurelianus mentioned a leaden 'plumbeumodontagogoon' for tooth extraction. Hippocrates and Aristotle wrote about tooth eruption patterns, decay, and gum disease treatment, forceps tooth extraction, and wire stabilization of loose teeth and fractured jaws between 500 and 300 BC. Celsus, a Roman physician, wrote extensively about oral hygiene, loose tooth stabilization, toothaches, teething pain, and jaw fractures in 100 BC. Etruscans tried tooth-wrapped gold bands. The golden bands would cover damaged and replaced human and animal teeth. Dental practice was documented in the Indus Valley Civilization in 7000 BC (Majumdar, 2002).

Caesarean section

Cesarean sections were once considered extreme, often killing the mother, and were only performed as a last resort when the mother was dead or beyond medical help. Different cultures have recorded the practice since ancient times. Luzhong, a relative of the Yellow Emperor, had six sons by cesarean section in China (Qian & Watson, 1993). In the early 1st millennium CE, the Sanskrit medical treatise Sushruta Samhita mentions post-mortem cesarean sections. The first non-mythical cesarean section in India occurred in 320 BC when Bindusara, the second Mauryan emperor, was born (Lurie, 2005). An accidental poisoning killed his mother, prompting the procedure. Ancient texts from Persia and Ireland describe cesarean sections. Jewish religious texts, specifically the Babylonian Talmud, texts called the procedure "yotzei dofen" which means “one who emerges from the side wall (of the abdomen)”. Roman historian Pliny the Elder believed Julius Caesar's name came from a cesarean-sectioned ancestor. The first successful cesarean section with a live mother and child occurred in Prague in 1337. The procedure became more common, such as veterinarian Jakob Nufer's 1580s Swiss cesarean section, which saved his wife and produced several more children (Jauniaux & Grobman, 2016). The first caesarean section in cattle was documented in 1930 AD (Dhindsa et al., 2013).

MEDIEVAL ERA

In Mediaeval monasteries, monks provided medical care and refuge for the sick. Each monastery had an infirmary, bookstore, and medicinal garden, where monks learned surgery. Monks needed barbers to maintain their tonsures, which symbolized their devotion to God. A compromise allowed monks to keep Saint Paul's haircut despite biblical prohibitions. Barbers changed from hair care to minor surgeries and amputations in monasteries. While lacking medical degrees, these barber surgeons learned surgery through apprenticeships and experience. Doctors studied medical theory and diagnosis, but barber-surgeons performed bloodletting, wound care, and minor surgeries (Hernigou et al., 2021).

Era of Barber Surgeons

Barber surgeons treated fractures, amputations, wounds, and bloodletting (Mäntylä & Ylikahri, 1984). Since they used sharp tools, barbers also did dental work. People with toothaches often had their teeth pulled. They filled cavities occasionally, but it hurt and there was no anesthesia except for alcohol. Alcohol was often used instead of anesthesia. Patients reported severe pain during many operations performed without anesthesia. Ergotism amputations were performed only by barbers after 1215. Barbers also did phlebotomies and scarifications. Circumcision, abscess drainage, and leech bloodletting were common medical procedures (Hernigou et al., 2021).

Major Contributors

Throughout history, numerous scientists and intellectuals have made invaluable contributions, directly or indirectly, through their groundbreaking innovations and discoveries to the advancement of surgery. The following section highlights the seminal work of some of the pioneers whose exceptional work accelerated surgery toward modern methodologies and established the fundamentals of present-day surgical practices. Leonardo da Vinci (1452-1519) was a mathematician, engineer, and historian. He contributed to anatomy, astronomy, botany, geology, optics, and hydrodynamics. Da Vinci was a topographic anatomy expert who studied muscles, tendons and other anatomy. Da Vinci used to create drawings of different organs. To that end, he created more than 240 drawings of the heart, vascular system, and other internal organs, which also includes a depiction of a fetus in the uterus. He also made drawings of innovative machines, like a helicopter. These skills demonstrate his skills in engineering also (Catani & Mazarello, 2019). Among the major contributors to modern surgery, we cannot deny the name of Ambroise Pare (1510-1590). He was a French surgeon and also considered a pioneer of modern medicine and surgery. Among his groundbreaking fields, forensic pathology and anatomy are other achievements. His skills led to the inventions of modern surgical instruments and prostheses. He was the first who invented hemostats and other hemorrhage control techniques (Asimopoulos & Asimopoulos, 2016). There was another scientist who helped modern surgery through contributing to the development of modern human anatomy, namely Andreas Vesalius (1514-1564). He was a Flemish anatomist and also a physician. He wrote a book on human anatomy when he was 28 years old, named “On the Fabric of the Human Body”. He is the founder of the skeletal, muscular, circulatory and nervous systems. Vesalius was the first to disprove the myth that men had one rib less than women (Benini & Bonar, 1996).

A Scottish surgeon named John Hunter (1728-1793) is well known for medical innovations. He was considered an expert of venereal diseases and was the pioneer of small pox vaccine. The first artificial insemination was performed by the Hunter. His findings of mechanism of the development of surgical diseases are well established. Hunter established his legacy in fracture management and the management of gunshot wounds (Stevenson, 1964). Dominique Larrey (1766-1842) was a military doctor and a French Surgeon. He was well known as Napoleon’s Surgeon-in-Chief. His contributions to writing the medical and surgical practices are well accepted in the modern era. He also established the modern protocols of military medicine and surgery (Skandalakis et al., 2006). Modern anesthesiology is indebted to Sir Humphry Davy (1778-1829), a Cornish chemist. He is the inventor of the Davy lamp and the arc lamp. He discovered the anesthetic abilities of nitrous oxide for the first time and named it “Laughing gas” in 1799. This was a great breakthrough in the field of modern surgery, which allowed the surgeon to operate deeper into the body without inflicting pain on the patient (Knight, 1998). The concept of aseptic surgery was introduced by Joseph Lister (1827-1912). Lister studied wound infections after surgery, despite not being a great surgeon. He pioneered sterile surgery with carbolic acid and phenol antiseptics. Lister's groundbreaking work reduced post-operative infections, improving patient safety and surgical practices worldwide. His famous quote, "It is as important to wash your hands before surgery as it is afterward," underpins modern surgery (Jessney, 2012). William Halsted (1852-1922) was popularly known as the Father of Modern Surgery. He promoted new anesthesia and surgical techniques. As one of the "Big Four" in US medicine, his operating room was known as the "Place of Miracles." Halsted invented the Radical Mastectomy and taught Harvey Cushing and Walter Dandy. Hernia repair, biliary duct surgery, thyroidectomy, and suture techniques were also developed. His eight surgical principles are still taught today.

Advancements in Concepts of Anesthesia and Sterilization

The Alexandrians used mandrake plant juice for anesthesia in 300 B.C., starting veterinary anesthesiology. Egyptians used opium and atropine-like plants and compressed carotid arteries to induce unconsciousness. Paracelsus gave chickens ether in the 16th century, starting aesthetic research. In the 19th century, Joseph Priestley discovered dephlogisticated air, oxygen, and nitrous oxide in 1771, and Von Liebig, Souberian, and Guthrie discovered chloroform in 1831. William Thomas Green Morton's 1846 demonstration of ether's use as an anesthetic for tumor removal in humans was crucial to its patenting as "Letheon." In 1846, Flourens used chloroform on animals, and in 1857, John Snow gave Queen Victoria chloroform during childbirth, popularising its use. Sir William Macewen and William Stewart Halsted advanced veterinary anesthesia by developing oral and nasopharyngeal intubation for diphtheria patients and cocaine nerve block techniques in 1886 (Sneader, 2005).

MODERN SURGERY

The mid-20th century was a boom for modern surgery. How and what was made for surgery changed drastically. Doctors began organ transplants around this time. They even tried implanting animal organs in humans, which was novel. Body movement engineers collaborated with surgeons. They created innovative surgical instruments and methods. Machines helped diagnose and operate on patients. The use of MRI, CT scan, and ultrasound changed how doctors took internal images. Surgeons can clearly see organs and health issues with these images. This improved patient safety and precision during surgery (Payne et al., 2021).

Advancements in Surgery from the 18th to the 20th Century

Human blood transfusions began in 1818. In 1843, England had its first hysterectomy and recognized ether as an anesthetic. During tumor removal surgery in 1846, ether was first used publicly. In 1867, Joseph Lister published surgical antiseptic principles (Payne et al., 2021). The first successful pericardial surgery was performed in Chicago in 1893. In 1896, Germany successfully repaired a right ventricular stab wound, a milestone in cardiac surgery. Roentgen discovered X-rays in 1896, revolutionizing medical imaging (Payne et al., 2021). The first corneal transplant occurred in 1905 (Crawford et al., 2013). Plastic surgery was introduced in 1917 (Tolhurst, 2015). Penicillin was discovered in 1928 (Ayres & Ayres, 2021).Germany pioneered surgical sex change in 1930 (Hausman, 1995). The first hospital blood bank was founded by Bernard Fantus at Cook County Hospital in 1937. He created a “blood bank” to store blood for safe transfusions and enable more surgeries (Gammon et al., 2024).

In 1940, the first metal hip replacement surgery established the foundation for future joint replacements (Gomez & Morcuende, 2005). The first successful kidney transplant was performed in 1950, but the recipient rejected it after 8 months due to compatibility issues. The first living donor kidney transplant between twin brothers led to an 8-year survival rate. The successful transplantation of a pancreas in 1966 opened new doors for pancreatic disease treatment. The first successful liver transplant occurred in 1967, a surgical milestone. In the same year, the first heart transplant was performed. The heart transplant recipient died of pneumonia after 18 days. The 1950s introduced LASIK eye surgery, a revolutionary vision correction method (Apple et al., 2011).

Mechanical Era

In this mechanical era, machines helped ease human life in every field. Likewise, the bioengineers and biomedical engineers are playing their central and key role in making the medical field modernize and helping in revolutionizing the disease diagnosis, treatment and surgical intervention by making them more precise and effective (Hanna et al., 2024). The surgeons, in collaboration with biomedical engineers, not only developed new instruments but also new machines that help them in the development of mechanical methods of surgery so that they would be able to perform the surgery more precisely.

Minimum invasive surgery

The long incisions always gave the opportunity to the surgeons to think over their replacements with the small incisions. This led to the development of laparoscopic surgery in 1980, which gave a breakthrough and introduced the minimally invasive surgical procedures. The minimally invasive procedures helped the surgeons to perform the surgeries with less blood loss, scaring and shorter recovery time (Singh & Shinde, 2023). Originally, laparoscopy was used for biopsies and gallbladder surgeries. Now the surgeons are performing surgeries of liver and intestines (Davies et al., 1991). Laparoscopy was introduced for soft tissue surgery in 1975. Philippe Mouret pioneered laparoscopic gallbladder removal in 1987, transforming surgery. Rigid surgical tools limit surgical skills. Surgeons use elongated instruments to stay away from the surgery. With technology increasingly used in clinical settings, computer and robotic surgery have sought new solutions to these limitations. Computers simplify preoperative planning and instrument positioning, while robotic surgical arms improve precision (Davies et al., 1991).

Laser surgery: Laser surgery has many advantages over stainless steel scalpels. These include less pain, bleeding, tissue healing, and inflammation. Lasers were first used in larynx surgeries on dogs and horses. Lasers are now used in general surgery, targeted liver lobe resection in small animals, partial kidney excision, and tumor removal or resection. These early studies laid the groundwork for their use. Few studies have used photodynamic therapy to treat veterinary cancers. Dogs can develop esophageal, oral, prostate, skin, and brain tumors (Jacobs & Rosen, 2000). It has also treated farm animal skin and dental diseases (Ogata, 1990) and small animal chronic otitis externa, plantar bursitis, tendinitis, granulomas, small wounds, and ulcers. Recently, lasers have been used in nearly all aspects of veterinary medicine, not just surgery. The widespread use in veterinary practice opens new avenues for treating soft and hard tissues. Laser therapy is non-invasive, non-toxic, and cost-effective, giving patients treatment options.

First artificial heart (JARVIK-7)

Dr. William DeVries replaced Dr. Clark's diseased heart with the Jarvik-7, the first permanent artificial heart, on December 2, 1982. The 7-hour procedure involved implanting an aluminum-polyurethane artificial heart with an air compressor. Like landing a man on the moon, this accomplishment was monumental. After surgery, Dr. Clark died of circulatory collapse on March 23, 1983 (DeVries, 1988).

Baboon heart transplant

Xenotransplantation, the transplantation of organs from one animal to another, achieved a milestone on October 26, 1984, when Dr. Bailey, along with his team, replaced the heart of Stephanie Fae, a 12-day-old baby suffered with hypoplastic heart syndrome, with the heart of a baboon. This was a groundbreaking procedure in the history of surgery when a human was transplanted with an animal’s organ. Fae survived three weeks after transplantation of a baboon heart (Rodger et al., 2023).

Genetically modified pig’s heart transplantation

In 2022, another milestone was achieved in the field of modern surgery when 57-year-old David Bennet was transplanted with a genetically modified pig’s heart. In this, four genes of the pig were deleted with the help of CRISPR technology, and six human genes were added. These alterations aimed to enhance compatibility between pig organs and human recipients. Authorized by the Food and Drug Administration (FDA) under a "compassionate use" designation, the procedure marked a significant advancement in xenotransplantation. Despite the pioneering nature of the surgery, the patient survived for 61 days following the transplant (Griffith et al., 2022). In 2023, another attempt was made in Mr. Lawrence Faucette. Both of these recipients survived beyond 2 months and the death in both cases was preceded by the antibody-mediated rejection. However, anticipation of such disappointments arises in the process of pioneering a new form of therapy (Mohiuddin et al., 2023). Recently, a 10-gene edited porcine heart was transplanted into brain-dead human recipients to analyze xenograft function under physiological stress and to detect hyperacute rejection. They found no evidence of cellular or antibody-mediated rejection using histology, flow cytometry and a cytotoxic crossmatch assay. Their results indicated that pig-to-human heart xenotransplantation can be performed successfully without hyperacute rejection or zoonosis (Moazami et al., 2023).

Robotic Surgery

For 3000 years, humans have dreamed of creating mechanical robots to replicate themselves, but robots have only been used in medicine for 39 years. This shift was driven by the need for telepresence and precise, repetitive tasks. The PUMA 200 was the first "robot surgeon" to operate on a human in 1985. By the 1990s, scientists created "master-slave" robots that allowed surgeons to control remote manipulators from a surgical workstation. Although robotic surgery lacks force feedback, its 3D vision, stable imaging, specialized instruments, tremor filtering, and motion scaling have helped overcome many laparoscopic surgery challenges (Leal Ghezzi & Campos Corleta 2016).

Precision in neurosurgical biopsies marked a surgical breakthrough. Following this, cholecystectomy was pioneered. The FDA's 1990 approval of endoscopic robotic surgery sparked innovation. In 2000, the da Vinci Surgery System introduced surgical robots. This comprehensive robotic system’s FDA approved assist in a new era of surgical techniques and capabilities (Oliveira et al., 2012). Robotic surgery is the pinnacle of medical precision. This advanced method uses robots for neurological, urological, gynecological, and cardiothoracic surgeries. Robotics helps surgeons achieve unmatched accuracy and precision, improving patient outcomes and recovery times (Shah et al., 2014). Various surgical disciplines are using this innovative technology. The da Vinci system has been used for closed-chest internal mammary artery harvesting, coronary artery bypass grafts, and mitral valve repair (Stephenson et al., 1998). Urologists have successfully performed radical prostatectomies and nephrectomies with the robot (Bentas et al., 2003) General surgeons use it for minimally invasive cholecystectomy, Nissen fundoplication, gastric bypass, and adrenalectomy (Ayav et al., 2004).

Robotic surgery in animals

Sofie, a veterinary robot, was designed to help practitioners make quick decisions while learning (Fraiwan & Abutarbush, 2020). Researchers created an operating room-specific robotic total hip replacement system for dogs. This second-generation system is for hip implant clinical trials on dogs. The da Vinci Surgical Robot-assisted in a supraglottic partial laryngectomy on a mongrel dog under general anesthesia (Weinstein et al., 2005). The short-term outcome of a dog treated for prostatic cancer with da Vinci Si Surgical System robot-assisted radical prostatectomy (RARP) is reported (Schlake et al., 2020). Animal models are used for robotic surgery training. Robot-assisted implantation of patient-specific orthopedic implants using additive manufacturing was tested in sheep. This was the first attempt to use surgical robotics and custom implants to remove bone tumors (Williamson et al., 2023). Dogs and sheep have been used for surgical training, but pigs are preferred. Their human-like anatomy and physiology make them preferable (Ganpule et al., 2015).

CONCLUSION

The veterinary surgery has evolved from the basic traditional surgical practices of ancient times to a new era of incorporating robotic technology, leading to improved outcomes for patients and recovery. The field of surgery has witnessed significant progress, from ancient procedures like skull trepanation to organ transplantation. This chapter highlights the evolution of surgical practices from the Stone Age, the era of barber surgeons, the significant progress made in surgical techniques, tools, and practices during the period of the 18th to 20th century, to the modern era of robotics. With the help of robotic assistance, veterinarians can now perform more complex procedures with enhanced precision, less time consumption, increased accuracy, and minimal invasiveness. Furthermore, the evolution of robotic surgeries is expected, which can lead to more improvements and treatment options.