INTRODUCTION TO SURGERY

BASIC SURGICAL PRINCIPLES

History of Surgery
Surgical process
Surgical history
Clinical examination
Imaging
Diagnostic process

Prof. DR. Paul Tahalele, FCTS

Chief of Surgical Department Airlangga University
School of Medicine/Dr. Soetomo Hospital Surabaya

PT/SK/2003/4
 DEFINITION
Surgery : Chirourgia (Greek),
consisting two words, cheir (hand)
and ergon (to work).
Chirurgia (Latin), is defined as the
treatment of disease, injury, or
deformity by manual or instrumental
operations, as the removal of
diseased parts of tissue by cutting.
Chirurgeon or Surgeon, known
since the 1300s (Rutkow IM, 1993)
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 Surgery Teamwork

Multidiscipline
Professional
Knowledge
Skill
Art
Ethic
Human

1894 - 1962 PT/SK/2

Ilmu Bedah merupakan bagian dari ilmu
kedokteran : Ketrampilan Tangan, Ilmu
Pengetahuan dan Seni (Handwerk, Wissenchaf
und Art, Theodore Billroth, 1829 1894) (Breiger GH,
1991)

Dokter termasuk Tenaga Kesehatan, Tenaga

Profesional dengan ciri-ciri :
1. Memegang teguh kode etik profesi
2. Menguasai Ilmu Pengetahuan
3. Mempunyai daya imaginasi atau inovasi
4.Mempunyai ketrampilan dibidangnya(Guilbert,
1977).

Dalam pendidikan, seorang dokter calon spesialis

bedah lebih ditegaskan kearah profesional. (Levin,
 Perilaku seorang Dokter Spesialis
Bedah :
1. Kognitif : menguasai ilmu kedokteran
dasar, ilmu penunjang klinik, ilmu bedah
dasar, ilmu bedah lanjutan.
2. Afektif : gentleness, courtesy, respect,
sense of confidence (assessment &
judgment).
3. Psikomotor : Ketrampilan memadai
(Ramsey, 1983)
Sikap cekatan seperti burung Turkey (Ellis,
1994)
Ilmu Pengetahuan yang dimiliki selain bidang
kedokteran, juga ilmu sosial, komunikasi,
filsafat, humaniora dan agama.
 Dokter Spesialis Bedah :
Dokter yang mampu menjaga mutu/kualitas
kesehatan penderita seutuhnya dengan
bekal ilmu pengetahuan dan ketrampilan
tangan melalui ropanasuri (the healing
knife) dalam upaya meningkatkan
mutu/kualitas hidup penderita secara
tepat guna, tuntas dan bertanggung
jawab dengan dilandasi etik-moral. (Tahalele P,
Seorang dokter spesialis bedah harus :
1996)
1. Berakhlak
2. Berilmu
3. Mempunyai tabiat yang baik berdasarkan
etik dan moral (Djamaloedin, 1978)
 Perbedaan :
Dokter (Umum) Vs Dokter Spesialis
Bedah
4 Kriteria Guilbert, 1977 4 Kriteria Guilbert,
1977

Kode Etik Kode Etik

Ilmu Pengetahuan Ilmu
Pengetahuan
Imaginasi/Inovatif
Imaginasi/Inovatif
Ketrampilan (terbatas)
Ketrampilan
Profesi pembedahan telah dikenal sejak
waktu yang lama, yaitu pada era
Hippocrates (460-370 BC), Bapak
Kedokteran. Pada jaman Yunani Kuno
para dokter dilatih di sekolah Cnidos &
Cos dalam melakukan pembedahan
serta mengikuti pelajaran dari
mahaguru Hippocrates (Whipple, 1956)
Aphorism I Hippocrates (460-370
BC) :
Life is short and the art long, the
occasion instant, experiment
perilous, decision difficult (Levine,
1960)
Sejak jaman itu, rambu-rambu
penjagaan mutu pelayanan kesehatan
bagi penderita telah dicanangkan dalam
sumpah dokter-dokter : Per Primum
Non Nocere, artinya pertama-tama
jangan merugikan penderita (Rutkow IM,
1993)
Pada abad ke-XVI, rambu-rambu etik dan
moral telah dipublikasi oleh Ambroise Pare
(1510 1590), seorang dokter spesialis
bedah bangsa Perancis, perintis bedah
vascular : I dressed him, God
healed him (Breiger, 1991). PT/SK/2
 THE HISTORY OF SURGERY
A. Pre-scientific & Primitive Surgery
1. Paleolithic (old Stone Age : e.g. : Cro-Magnon &
Neanderthal
2. Mesolithic (Middle Stone Age)
3. Neolithic (New Stone Age)
The magic & evil spirits
Including bandages, hemostatic plants,
pressure
tamponade, and cautery.
Various herbs and plant extracts that
would have
decreased pain.
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 TREPHINATION

The surgical achievement of prehistoric

& primitive humans are unquestionably
impressive in view of their lock of
knowledge of wound healing, anatomy,
physiology, and basic
instrumentation. PT/SK/2
B. The Classical Worlds
Greece

The founder of medical

school at croton : the
first scientific studies on
Treatment for a leg using anatomy and physiology
the Hippocratic bench PT/SK/2
 Alexandria (331 BC) in Egypt

Galen Galens works 1500-an

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C. The Byzantine Empire (Roman Empire, 395-1453)

Seven book of Paul of Aegina

(625)
The indication of opening of
Trachea
The ligature to arrest
traumatic
hemorrhage

Mandibula dislocation PT/SK/2

D. Arab And Jewish Surgery
Rhazes
(Persians)
Haly Abbas (930-
994)
Albucasis
Cauterization of
swollen lymph
nodes (scrofula)
Animal got for
suture
Ethical & Moral
standard PT/SK/2
E. The Far East
1. INDIA
Clearly surgery in
India : era of Sushruta.
The Buddhist (600 BC
to 600 AD) and a
consequent religious
authoritarianism,
dogma, and
mysticisms, a
stagnation of the
surgical progress and a PT/SK/2
2. CHINA
A definite hierarchy of physicians existed in
ancient China, including ulcer doctors.
Whether this were a specialized group of
individuals who may have been surgeons is
unknown. Ancient China also had
gynecologist and nose and throat experts.

3. JAPAN
During the Muromachi period (AD 1334-
1568) the so called Kinso-I, or wound
surgeon, came into social prominence

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F. The Middle Ages (500 1500)

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G. The Renaissance

Seven books on the structure of the human

body (Professor Anatomy & Surgery)
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Pada abad ke-XVI,
rambu-rambu etik
& moral telah
dipublikasi oleh
Ambroise Pare
(1510 1590),
seorang dokter
spesialis bedah
bangsa Perancis,
perintis bedah
vascular : I
dressed him,
God healedPT/SK/2
him
H. The Seventeenth Century

William Harvey
(1578) : Cains College
Cambridge
Discovery of the
lesson of the blood

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I. The Eighteenth Century

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J. The Nineteenth Century

Cellular
Pathology
Experiment
al
Physiology

1865, Process Fermentation

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 Anesthesia

Sir Humphrey Davy

first discovered of
Nitrous Oxide (Laughing
gas) 1799

Crawford W. Long
:
ETHER 1842 PT/SK/2
 Ferdinand
Sauerbruch (1875
1951)

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 Bacteriology and Surgical Antisepsis
and Asepsis

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 X Rays

A change discovery in 1895 led

to the development of X-rays
by the German physicist,
Wilhelm Konrad Roentgen.
The development of the
therapeutic uses of radium
paralleled that of X-rays whose
effects on tissues are similar.
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Wilhelm Conrad
Rntgen
(1875 1951)

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K. The Twentieth Century
General Surgery
Colorectal Surgery
Gynecological Surgery
Neurological Surgery
Ophthalmological Surgery
Orthopedic Surgery
Otorhinolaryngological Surgery
Plastic Surgery
Thoracic Surgery, Cardiac & Vascular
Surgery
Urological Surgery
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THE HISTORY OF SURGERY
IN INDONESIA
1. The first period : The period from
the end of the 1st World war till the
capitulation oh the Dutch.
2. The second period : The period of
the Japanese Occupation time and
the initial stage of the revolution of
the Republic of Indonesia.
3. The third period : The period of
Complete independence of the
Republic of Indonesia.
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1. The First
Period
In 1920 to the new Central
Hospital, the present, Cipto
Mangunkusumo Hospital. The 1st
head of the Department was
Prof. Lesk a native of Austria
and the first resident was the late
Professor Margono Soekarjo,
honorary member of this
association.
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The successor of Prof. Lesk
was Dr. Wieberdink and later
on Prof. Reddinguis about
1930 and Prof Oetama was
his last resident.
In this period there are only
about 10 Indonesia doctors
trained in Jakarta as well as in
Surabaya.
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2. The Second Period

In the Japanese occupation

time Indonesian heads of
Department were appointed,
in Jakarta dr. St. Assin and in
Surabaya dr. M. Soetojo and
on top of these Indonesian
heads, there were Japanese
doctors appointed to
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3. The Third Period (Complete
Independence)
As head of the Department in
Jakarta was appointed Prof.
M. Soekarjo and for
Surabaya Prof. M. Soetojo.
Both department were fairly
well staffed and the era of
institutional training begins.
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An Indonesian surgical association
was founded with Prof. M.
Soekarjo as Chairman and Prof.
Salim from the new Medical School
in Yogya as Vice Chairman. But this
association has achieved not much.
The during the Indonesian Medical
Association meeting in Semarang in
1955 some 9 surgeons and
anesthesiologist gathered at dr.
Heyder bin Heyders home and
reestablish a surgical association.
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(H.
Kepala Bagian
Bedah FK. Unair
Surabaya :
1.Prof. M. Soetojo
(1952/1954 1961)
2. dr. R. Soetojo
(1961 1970)
3. Prof. dr. Basuki
Wirjowidjojo
(1970 1987)
4. Prof. dr. Widjoseno
Gardjito
(1987 1994)
5. Prof. dr. Sajid Kamar Operasi Tempo Doloe,
Darmadipura 1948 RS Simpang Sekarang
(1994 2001) Plaza Surabaya (Prof. M.
Soetojo).
6. Prof. Dr. Dr. med Paul
Tahalele
(2001 2005)
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 BASIC SURGICAL PRINCIPLES
The patient is the center of the
medical universe around which all our
works revolve and towards which all
our efforts trend. JB. Murphy, 1857-1916, USA

Surgical diagnosis is based on a

sound knowledge of anatomy,
physiology and pathology, a
specific history and examination
with confirmation by imagingPT/SK/2
and
The actual operation in surgery
is but one part of :
1.The process of surgical
care
2.Diagnosis
3.Preoperative care
4.Postoperative
management being
of equal importancePT/SK/2
in
SURGICALPROCESS(1)
1.A careful history is taken.
2.A focused physical examination
3.The complete medical status

The likely diagnosis is considered on

the basis of this clinical assessment,
and confirmed by the appropriate test.
Continued observation over a limited
period of time remains a powerful tool for
achieving a diagnosis. PT/SK/2
SURGICALPROCESS(2)
Despite current concepts, many
patients with complaints requiring
surgical treatment present with a
simple history such as a lump or a
pain for which a specific algorithmic
approach will provide an answer.
So enabling full assessment of the
whole patient (holistic) on the basis
of a confirmed pathology, often in
co-operation with colleagues from
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SURGICALPROCESS(3)
Just as the stethoscope is helpful in
diagnosis, so also ultrasonography,
endoscopy and other forms of
imaging will lead to a rapid
confirmation of the clinical findings.
By avoiding this errors through
better and more exact diagnosis,
preoperative care and
postoperative management, the
surgical management of patients PT/SK/2
 SURGICALHISTORY(1)
The history of the complain is the key step
in surgical diagnosis. There are two
types of history in surgical practice.
(1) The first is the outpatient or
emergency room history in which the
specific complaint of the patient is
pinpointed; (2) The second is the clerking
of a patient admitted of elective
surgery.
The first history is to obtain a diagnosis
on which the treatment is ordered.
The second history is to asses that the
 SURGICALHISTORY(2)
a c
The
surgical
history is
dynamic
event
a. Lung Ca Dextra d
b
b. Lung Ca Sinistra
c. Pneumectomy S.
d. Fluido-Pnemoth. S.

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CLINICAL EXAMINATION
a
There are two aspects of the
examination :
1. That concentrating on the
specific complaint, the
lump or the pain.
b
2. That reviewing the whole
patient (holistic).
Examination of the whole
patient particularly before a.Hodentorsion
an operation b.Phimose
performed in a routine
medical examination. In
examining a specific
surgical feature, it is
important to follow an
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accurate clinical
 a
b

c d

a. Congenital elevation of the little toe c. Syndactyly

b. Hypoplasia of the toes d. Microdactyly of the hand
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Diagnosis of a
lump
1. First, determine in what anatomical
plane the lump is situated : the skin,
subcutaneous tissue, muscle, tendon,
nerve or bone, or it is attached to some
particular organ.
2. Second, determine the physical
characteristics of the lump: is it tender
or non-tender ? If not acutely tender,
determine: its size measure in
centimeters; shape round or flattened,
regular or irregular; and consistency
very soft (like a jelly), soft (as relaxed
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 Fig. Saccular aneurysm
of the radial artery

Important
specific signs
: Thrill, Sign of
compression,
Sign of
indentation,
Signofan
aneurysm

Fig. Gumma overlying the sternoclavicular joint.

A classic site. PT/SK/2
Ulcers

An ulcer is a loss of
epithelial lining; when
examining an ulcer,
attention should be
paid to the following
points:
Shape, Edge, Floor,
Base, Surrounding
tissues
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Ulcers are of five main
varieties :
The septic ulcer with
sloping varieties
The tuberculous ulcer
with undermined edges
The carcinomatous
ulcer * with averted
hard edges
The rodent ulcer with
barely visible pearly
edges
The syphilitic
punctuated
Fig. ulcer
Squamous carcinoma on the nose
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 Terminolog
y
In describing an
examination, terms
should be used
specifically and
correctly.
A fistula, A sinus,
Lyphangitis,
Phlebitis, Cellulites,
Inflammation,
Crepitus,
Translucency,
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HEAT REDNESS SWELLING PAIN LOSS OF
FUNCTION

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 IMAGING
Most physical signs can be confirmed
by ultrasonography, plain
radiography, computed tomography
or magnetic resonance imaging,
doppler imaging (aneurysm).
Magnetic resonance imaging will
define abnormalities in joints and within
the skull, whereas computed
tomography, particularly with contrast
enhancement, will outline solid
organs. PT/SK/2
AORTIC ANEURYSM

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a b

c
a. Hand-held Doppler Ultrasound
b. Doppler Scanner
c. Colour Duplex Scanner of
Carotid Vessels PT/SK/2
COLLES FRACTURE

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 DIAGNOSTIC PROCESS
The initial surgical process is complete
when a diagnosis has been obtained by
(1) history, (2) examination and (3)
imaging, supported by (4) pathology.
Experience enables correct weighting to
be placed on each aspect of this process
to define the correct treatment.
Surgical conditions trend to follow a
logic based on anatomy, physiology and
pathology; if that logic is transgressed,
mistakes are made, and the patientPT/SK/2
may
THANK YOU. PT/SK/2