The Evolution of Surgery – Dr. Prasant Pandey – Health & Wellness Seminar

The Evolution of Surgery – Dr. Prasant Pandey – Health & Wellness Seminar


(applause) – Thanks everyone. I’m a big buff of the History Channel. When I get bored at night,
I’m channel surfing. I just watch stuff
because I think the more you know about the past,
the more you can try to figure out where the future is going. And it’s interesting to see that surgery or attempts at trying
to cure maladies that human beings have goes back
many thousands of years. 9,000 years ago, 7000 B.C. In Ukraine, trepanation
was drilling, or making a burr hole in the head to
release the evil humors. Whether you had a
headache, maybe he gave you another headache or to cure maladies. I mean, that’s what was known back then. And the ancient Egyptians in
the building of the pyramids, they did this actually with
a high degree of proficiency in the embalming process,
they knew to remove the brain, they could do the entire
thing just through the nose. And neurosurgeons, as
some of you may know, can do certain surgeries
right through the nose, while the patient is
awake, while you’re awake. Because your brain actually doesn’t have sensory, just like your skin does. There’s a picture, I’ll
show you of what’s called the Edwin Smith Papyrus
that was discovered. It’s a hieroglyphics, but it was the first surgical manual text, kind of like a residency manual of teaching surgery and in many cultures, you
know in India 400 B.C. Sushruta was called The Father of Surgery. In ancient Greece, you
had Hippocrates and Galen and these are names of surgeons that we learn in medical
school as a history of medicine of who started to think about
the human body, dissection, knowing what the insides are
like, how you can fix problems. In the medieval times,
the dark ages obviously, there was a decline in surgery
because tools were limited. Often it was the barbers and monks. Barbers because they had
easy access to the blade and they did minor surgical procedures. Sometimes in times of war, they
would take the barber along with them in case there was
a problem with the soldier. Amputation with the blade. Physicians, at that point, slowly started to gain higher status
because of their knowledge of how to treat ailments and to operate. Rogerius Salernitanus in 1180 A.D. Published the Chirurgiae
surgery, the manual of surgery. Back then, it was really amputations. Draining abscesses,
removing or scarification. Blood-letting was felt to be curative so you could cut yourself to relieve blood or put leeches on to suck the blood out. These were felt to cure certain maladies with the theory of the evil humours. Because there were four humours. Bile and blood and things like that. Ambroise Pare in France,
John Hunter, Scotland. So evolution of surgical
techniques continue. Now you start to get to names
that may be more familiar. Louis Pasteur in France, as
you know from pasteurization, he really advanced the
field of microbiology. ‘Cause until then, we
didn’t understand that bugs that you could not see, bacteria were the cause of a lot of problems. That was the start of germ theory. And along the same
time, an Austrian German Ignaz Semmelweis showed
that just by washing hands, in a mother-baby ward, just
by washing hands with soap, reduced the number of
deaths of moms and babies. Just because of lowering the
germ burden on the patient. Joseph Lister took this to the next level. I’m sure that name’s familiar because, yes I just heard someone say Listerine and that’s probably why they picked that. He was called the Father
of Modern Antisepsis. Carbolic acid, also known as Phenol, he used that to sterilize wounds, and to clean the surgical tools and instruments before operating. That started the modern
era and he actually, in 1902, operated on King
Edward VII in England who had appendicitis and he survived. Because at that time,
even a simple surgery like appendix or gallbladder
often meant you didn’t die of the surgery, but you died
of the infection afterwards. So he survived and he said
that, “I know that if it had not been for you and your work, I would not have been sitting here today.” So he was thankful for that. A Boston dentist, Morton, first used ether to knock people out
and started anesthesia. William Halsted is regarded by many as kind of like the father of modern surgery. He was the first one to start a surgical residency
program at Johns Hopkins, that’s what made Hopkins so famous. Lots of inventions along the way of things that we take for granted. Sterile gloves, new surgery
based on anatomy and physiology, studying animals to see how we can benefit from dissecting pigs and monkeys. Modern operating room
theater which I don’t know if you’ve seen that episode of Seinfeld, where the candy pops out. What was it a milk dud
or something like that? – [Audience Member] M & M’s. – Oh, right and but he started the residency scheme of training surgeons. At that time in the late 1800s, you just have a bunch of surgeons now doing the first of many surgeries. Gastrectomy was the removal
of the stomach for cancer. Gallbladder and appendix. This is that Papyrus from 11 A.D. Well, it’s 1600 B.C. is the date, but it was purchased by somebody in 1850 and that’s the
name that they gave it to. These are not the surgical manuals that we have to read and study, but it’s interesting how far back just the training of surgeons go to. As a cardiologist, you may be wondering, well why am I talking about the history of medicine and the history of surgery? Because it’s important to know all the things that have come. There’s the operating
room theater which looked like this when they operated
with people watching. That was in Hopkins and
that’s what we have now today. That’s a common operating room in any hospital that you’ll see. With all the technology pieces
that we take for granted now. Like Dr. Mede and Dr. Luketty said, you just expect to get in and get out and not have any complications,
wake up from anesthesia. This is real, this is what
the future OR will look like, where it’s similar but
you get these fancy, kind of like a C-arm which
can do angiography and X-rays at the same time you’re doing surgery. This is the high-end, what they call the hybrid OR where you can do anything from a catheterization to a full
surgery if necessary. So modern surgery was founded on these four important legs of
anatomy, anesthesia, understanding how blood
clotting works to stop bleeding. And concepts of asepsis,
which is the Listerine concept of keeping things clean and germ free. This 20th century, the last 100
years things have taken off. It’s hard to keep up. It’s hard for a medical
student, a resident to learn all of what we have
done in the past 100 years, so therefore we have to specialize but understanding of shock, what happens when you lose too much blood,
what happens when you get too much infection in your body. Blood transfusion, how blood clots, antibiotics, analgesics for pain. Then you have electrically
powered surgical instruments. Stapling, surgical glues and
tapes, and X-rays and scans. Now many of you know it’s
gone to even more things. Cryogenic super-cooled probes using liquid nitrogen to
freeze or burn something. You can actually burn something by freezing it too cold because if you ever get liquid
nitrogen on your skin, it feels like you’re having a burn. Ultrasound devices, medical lasers, heart-lung bypass
machine, hypothermia gets your temperature down so you have less injury to the brain during
a surgery or procedure. Cementing substances,
bone joint replacements, micro, minimally invasive surgery, and then vascular imaging and angioplasty. Here’s the switch. That’s what the past hundred
or so years have given us, which is a tremendous advancement in medicine and surgical techniques. But now there’s a shift that’s occurring. Over the last 20 to 30
years, we’re realizing that not everything can just be
cut and removed or replaced. Because a lot of things happen
on a test tube biology level. Microbiology, biochemistry,
disorders of function that you can’t just replace, for example, just as easy as joint replacement. You could have inflammation if you have a rheumatological condition like lupus or rheumatoid arthritis or Crohn’s. Ischemia infarction can
be anywhere from a stroke to a heart attack to a leg amputation. Metabolic disorders are diabetes, that’s probably the
most common and biggest metabolic disorder that’s out there. Cancer, neoplasia, cysts, hypertrophy. So now you’re getting into test tube. It’s like back into the
microscopy of things. So what that’s leading healthcare and the future of healthcare is
back away from the OR again. It’s taking from the invasive
OR to the non-invasive. We’ve known that we can do with things without having to cut somebody open. I’m sure at some time back if
you had a large kidney stone you had to have surgery to remove it. Then they realized you can
break it up with ultrasound, which is lithotripsy and
you can just pee it out. Painful, but you can pee it out. Radiation, gamma-knife, without
even having to cut the skull you can use a gamma,
which is a radiation form, to cut actual tissue inside
the skull to do something to say, a brain tumor,
without having to even cut the person open or
to cut the skull open. Seed implants for prostate
cancer and other types of cancer. Minimal surgery with
minimally invasive techniques where you just make small port holes. Laparoscopy, VATS, video
assisted thoracoscopy techniques which you could just
go in and remove a lump or a mass with just small port holes. This has led to the endoscopy. Any place you can put a scope down, including inside a blood vessel, leading to cardiac
catheterization, arterial, venous, and we’ll look at some of
the venous things that we do. And then you can block off
abnormal blood vessels to try to kill tumors for
example or to close off varicose veins that are
problematic that you can’t fix. Super glue, some of you may know, has been used for a long
time actually, for decades. You can suture kids’ cuts with super glue because kids don’t tolerate
having a stitch there and they’re gonna play with it. A scalp incision is hard to stitch, it’s easier to just super glue it. They have super glued
aneurysms inside the brain, shut them down. They have super glued tumors inside livers of ovarian conditions and now we’re using it to close off varicose veins. Coils are another way
to do the same thing. Ablation is a term, it just
means to knock out, get rid of. And you can do it with any technique. Most common ablation is
with heat, so it’s thermal. Anything that’ll heat up a catheter, using laser or ultrasound. Radio frequency is the
fancy word for microwave. That’s why you don’t put a
spoon in the microwave oven because it’ll heat up and
it’ll start sparking on you. But we do that on purpose with
the catheter to take it up to about 250 degrees to
purposely burn a vein. But you can also burn
something by freezing it because once you get tissue under minus 40 degrees Celsius,
you create a ball of ice. The shards of ice inside the cells actually spike it to death, so you can actually kill tissue that way. There’s a trial in cardiology
called Fire and Ice meaning that you can
treat atrial fibrillation with either a hot probe or liquid C02, liquid nitrogen to try
to burn that same tissue. Just like Dr. Mede and Dr. Luketty said, what’s this all leading to? Well, it’s faster recovery
and decreased clots. There’s gonna be a tremendous
pressure on the whole country as we all age and try to
reduce the cost of everything. That’s a national mandate regardless of who’s in charge of
Congress or whatever. A dollar’s a dollar. So all of these same
things that we talked about get you out of the hospital faster, makes more things outpatient instead of inpatient and also reduces the cost. Getting into the molecular, back into the tiny again, things we can not see. The understanding of the more recent scientific advances is well
why is heart surgery less now? The second one, antiplatelets, we actually have less severe heart attacks because of use of drugs
like aspirin and Plavix. These are antiplatelets
because we’re learning that if you can make the blood slick, like putting WD-40 into a system, it doesn’t matter if you have a blockage as long as the blood
flows across the blockage. You just don’t want something
to get stuck in a pipe. That’s when you have a stroke or a heart attack, or some other problem. So you don’t necessarily
have to fix the blockage. You could live to 100 with the blockage. So it’s the quality of life
that’s becoming more important. So antiplatelets have shown
that you can do that with treat heart attacks, stents,
and strokes that way. Anticoagulants, the old
Warfarin, rat poison, Coumadin. Now there are newer drugs like Xarelto and Eliquis and Pradaxa. You’ve seen the TV ads
for atrial fibrillation. Even fancier things, statins… They’ve had a pro and con of people can have side effects, but statins have actually reduced the rates of heart attacks and stroke here in the country over the last 10 to 20 years. When I was training at the
University of Pittsburgh for my cardiology fellowship, we used to see the degree
and severity and frequency of heart attacks every
night, Friday night, Saturday night, it didn’t
matter if it was Christmas, Thanksgiving, or New Year. It was just like, non-stop,
we were just up all night. We just don’t see that
degree of cardiovascular type of stroke anymore, because I think the medical therapies have stabilized a lot of those conditions. And the immunobiologics, like the Humiras, treatment
of rheumatoid arthritis, treatment of Crohn’s, psoriasis, they’ve taken it to the next level, and that’s also another
reason why surgery’s down, because way back in the day or probably in other parts of the world, if your Crohn’s, bless you, if your Crohn’s went nuts on you, then you had to have
surgery in your intestine. The distal ileum. Now we just don’t see as much of that with these new therapies. Immunosuppressants for transplants, and of course the
antivirals and antibiotics. So, the theme of the history of medicine is that medical advances
are basically leading to less surgery because of
molecular and biologic advances. And whatever we do is
becoming more outpatient, which is all, has a positive
effect for all of us. It’s a faster recovery and lower cost. So, some of the things that we do here from a cardiovascular standpoint is, just to focus on the leg and vascular, a lot of parts go into
making your leg work properly from bones and muscles
and tendons and nerves and blood supplies. To focus on the blood supply, blood goes down to our
legs through arteries. That’s the high-pressure system. It’s just like an HVAC system, high-pressure system. And then the return is the low-pressure. The return are through healthy veins and you can see the picture
of a vein in the leg. (coughs) That healthy vein,
interestingly, has valves in it. It’s kinda neat to think that our body is engineered with valves in the veins, ’cause otherwise, all
the blood would fall down and all of our legs would be
swollen at the end of the day. When they’re working, the blood flows up, valve closes and does not fall down. That’s the arrow pointing up. Over time, veins can get dilated and develop reflux. The valves don’t check anymore, it’s like a one-way valve, and then the blood starts falling down. And what happens then? You start getting varicose veins. Your legs hurt. They’re restless at night. You get what’s called venous claudication, where you don’t feel
like walking in a mall because the moment you get up and start, you have to sit down on
the bench for a little bit ’cause your legs are heavy. If you wait long enough,
the skin starts to change because the circulation’s not good. And you can start to get ulcers, which can then threaten the limb. And so, here’s some of the pictures. And I’m sure that you’ve seen people or you know family or friends with legs that may look like this. Whether they have varicose veins. These are the people that I tell that wear the pants at the beach, ’cause they’re conscious about not wanting to expose their legs. But you get varicose veins from it, you can see that that
one patient’s left leg is swollen, it can be one-sided,
both-sided, either or. It doesn’t have to be
equally on both sides. And you can start to
get those skin changes. It’s like this tanning, kind of like a leather, sort of like a baseball glove. Because the circulation is poor and the skin thickens and
becomes more like parchment-like. And you get that dark coloration. And then if you bump your leg, you get a venous ulcer that
takes a long time to heal. Of course, a lot of
things happen with age. Women are a bit more at risk for this, probably because of
history of child-bearing, ’cause it puts pressure
on the pelvic veins. Family history is strong. If you’re overweight, if you have a profession
that you’re standing. That’s like, almost all of us. Whether you’re a physician or a nurse or a hairdresser or a cashier, or even a PennDOT worker. We’re standing all the time. And if you have history
of blood clots or DVTs, they can damage those veins
and cause the same problem. We diagnose it with an ultrasound. Once we see this abnormal
flow in the vein, in combination with the
history and physical, we can go into these veins, this is like a plumbing technique where we can snake the
vein with a catheter. And as we pull the catheter back, it’s done through the skin, what we call percutaneous, the same day, you’re
awake for the procedure, we numb up your leg with lidocaine. That’s the equipment. Either you could put that closure fast is the catheter on the right. It has a tip that’s about
seven centimeters long that heats up through microwave, that’s radio frequency. And that actually burns the vein closed. The picture on the bottom is showing you what looks like kind of like a glue gun. That’s exactly what it is. And what you’re doing is
you’re putting super glue through that glue gun. Think of how you put a bead of caulk on the bathroom sill or something like that. Except, you’re actually filling
the vein with that stuff and you’re closing the pipe up that way. It doesn’t matter how you close it, whether you burn it, damage it. For 50 plus years, surgeons
did stripping of the veins. And I’ve had ladies tell me that yeah, doc, I had that done in 1968 and I had my left leg done and never went back for the right leg because it took like, two weeks to heal, a lot of bruising, scars
left over from that. So, this is one of the reasons
why we’re doing less surgery, because we have minimally
invasive techniques to take care of the same thing. Just a couple more
slides to wrap up here is that almost anything
that was done surgically, triple A, which is an
abdominal aortic aneurism, that’s a big problem,
it’s a severe problem. It was one of the most challenging
and high-risk surgeries that were performed, because whenever you do a vascular surgery on the body’s largest
blood vessel, the aorta, the body does not like it, obviously. There was a high morbidity and mortality associated with these surgeries. But now you can do what’s
called a stent graft. You can go in through the
femoral arteries on both groins and deploy this thing
that looks like a sleeve. All you need to do is to
kind of line the inside like a can sleeve inside another can, and it will stop that
aneurism from expanding and reduce the risk of rupture. ‘Cause that’s the ultimate goal, if that thing ruptures,
you’re not gonna be around for more than about two minutes. Similar to that in cardiology, the cardiothoracic surgeons
at one point thought that they were gonna be
a dying breed because stents, cardiac catheterization, we can go into the heart, and that’s what a cardiac
catheterization looks like, that’s a normal left side of the heart. The shadow that you see here, this is the whole heart. Right there in the chest. And some of these lines coming across, like these bands, those are the ribs. So, when we put a catheter
up through the leg or in through the arm and you can see the catheter seated into the left main coronary, and when you inject the
dye and you take a picture, that’s what a normal
cardiac catheterization in coronaries look like. If you have a blockage or a pinch, it sort of looks like the
waist of an hourglass. You can see that, and then
they can deploy a stent. That reduced the need for
bypass surgery, big time. Now, we have techniques
where you can actually use the same technique to replace a valve. I’m sure you are aware that TAVR is there, it’s not a new thing any more. All the regional hospitals are doing it. At first it was only available
in New York or Philly. But TAVR is putting an aortic valve, we never thought it was possible to replace your aortic valve. It’s a technique where you
actually put something in, like say if a door is stuck. Imagine putting a skinny
umbrella into the door and popping it open and coming out, and now the door is open, and what you’ve left is a new valve that’s opening and closing. You kinda crushed the old door, but in elderly patients, particularly those that are 80 and older, they tolerate TAVR much better than having your chest cracked and going under anesthesia for six hours. So, that’s also cutting down
the need for cardiac surgery. You can get a cardiac
catheterization equivalent without even doing a
cardiac catheterization now. Insurance won’t always cover this, but this is a CAT scan, this is a really fancy high-end CAT scan. CAT scan is just X-ray. To get pictures like this, you have to take an X-ray
picture really fast, like a camera with a
very high shutter speed. If you’re taking a picture
of an athlete on a field, you gotta have a high shutter speed, otherwise the picture’s gonna be blurry and you won’t be able to
see these crisp details. The heart’s moving, every
second it’s doing this. So, you have to have a newer CAT scan that can take high shutter speed shots and line them up to actually, and you can tell if you have a blockage without having to go inside. And then on the far
left you have a PET scan is a type of nuclear scan. It’s not quite like your dog or cat pet, but it’s positron emission technology. So the nuclear goes into different cells and it kind of glows in a way, the camera can see it. You and I can’t see it with the naked eye. Then if you take a CAT scan, which is done with X-ray. So, this is physiology, blood flowing to different places. That’s anatomy, just like a picture, just like a snapshot. You can fuse the two to
create a PET CT image to do specialized surgery, find which, say if you have two lumps in your lungs. One is cancerous, one is not, you can tell which one
needs to be removed. If you just do a CAT scan, you can’t tell. But then if you fuse it with a PET scan, you can see which one is the bad one. And these are the technologies
that are actively here that have reduced the need for surgery. Where is this all going? Who knows, but this is
actually stuff that’s out here, so I just thought it would be kind of neat to wrap up with. Will this be the future where the dentist will be that robot? (audience laughs) They actually have these robots, you know? It sounds kind of funny, but we know that Honda’s
and Toyota’s spot welds are done by robot arms with much higher accuracy and reproducibility than a human being. And they work 24/7 without complaining. (audience laughs) So they’ve just, using that, right, and using that technology to, and now of course, there will always be an operator nearby to control things. Maybe that’ll be your
doctor of the future. (audience laughs) Yeah, you know, with
all this talk about AI and technology, where’s this going? You’ve seen TV ads for IBM, they have the system called Watson. Watson’s played Jeopardy and won Jeopardy. Watson’s played chess grand
masters and beat them. So, it’s only a matter of time. And they’re trying to actually use Watson to say well, Watson has
been shown to come up with a diagnosis in the emergency department better than most physicians. (audience members respond) Right, right. Right, if we’re all replaced
by Watson or this robot, we just have to figure
out what we’re gonna do in our spare time. (audience laughs) That’s actually the real challenge of how not to get bored and stay active. – [Audience Member] Stryker advertises remotes and robotics. Is anybody around here doing
robotic heart surgeries? – Yeah, there is a Da Vinci robot system that’s been in use for some time. – [Audience Member] Around here? – Yeah. St. Luke’s Lehigh Valley, for prostate and other types of surgery. The future could be that you’re gonna be operated on
by robotic arms like this. But what the real system
actually looks like this. So, there’s a patient draped
and that’s the abdomen. And there’s robots one, two, and three instead of surgical tech
one, two, and three. But these are much more accurate. And interestingly, these
universal joints that are here, they can move in seven degrees of freedom better than the human wrist can. Without the tremor. (audience murmurs) Because a neurosurgeon has to know, a neurosurgeon cannot operate on something that that’s big in a
critical part of your brain, if you have a shaky hand. These hands never shake. – [Audience Member] What
would it do for positions? – I have no idea. – [Audience Member] I mean, the ones that are being replaced? – That’s a good question,
that’s a good question. – [Audience Member] Maybe they
just walk around and watch, make sure– – Well, there would be a role, I think that obviously we’re not gonna be 100% replaced, but this
is actually around. So, these robotic arms
are being controlled by these two physicians with
special gloves and hands. – [Audience Member] You
shouldn’t be (mumbles) give up your day job and teach history. This is great stuff! – And it’s actually nice for me to do this because it also give me a sense of, from thousands of years ago to modern surgery to 1880s til now, and now things are changing
in a different kind of way. I thought it was like, five years ago. Time flies, it was 2001
actually, 17 years ago. That they used this kind of a system with a patient needed
a gallbladder removed. I think it was the appendix. Appendectomy or
cholecystectomy on a patient. The patient was lying in
New York City in a hospital. The surgeons were in France. (audience murmurs) You may have caught the news. And of course, next to the patient, there was a team standing by, should something break down, and jump in. But they were able to
do the entire surgery with operators in France
through fiber optic cables that gave very reliable
Wi-Fi or Internet connection. So, this has interesting implications of maybe you can give
surgeries to remote towns where people don’t get medical care, that you can have a standby team. Not that it’s necessarily going to replace the physicians here or at NYU or Penn. And also it has very
interesting applications in the military. In the war field, if somebody
is down and bleeding, you could send a robot out there. They actually have these things
that the army is working on, you could send a robot out there that just kind of grabs
that person’s legs, sucks them in, and then
the robot just starts doing stuff, and the
operators are somewhere else, safe, and can start operating, give Epi, tie off a blood clot, and start, just to save a life. So, there’s lots of neat things.

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