Asepsis, hemostasis, and gentleness to tissues are the bases of the surgeon’s art. Nevertheless, recent decades have shown a shift in emphasis from the attainment of technical skill to the search for new procedures. The advances in minimally invasive techniques have allowed the surgeon great flexibility in the choice of operative techniques. Nearly all operations may be performed by an open or a minimally invasive laparoscopic technique. The surgeon must decide which approach is in the best interest of the individual patient. In addition, application of robotic surgery has added a new dimension to the surgical armamentarium. Throughout the evolution of surgery it has been recognized that faulty technique rather than the procedure itself was the cause of failure. Consequently it is essential for the the young, as well as the experienced surgeon, to appreciate the important relationship between the art of performing an operation and its subsequent success. The growing recognition of this relationship should reemphasize the value of precise technique.

The technique described in this book emanates from the school of surgery inspired by William Stewart Halsted. This school, properly characterized as a “school for safety in surgery,” arose before surgeons in general recognized the great advantage of anesthesia. Before Halsted’s teaching, speed in operating was not only justified as necessary for the patient’s safety but also extolled as a mark of ability. Despite the fact that anesthesia afforded an opportunity for the development of a precise surgical technique that would ensure a minimum of injury to the patient, spectacular surgeons continued to emphasize speedy procedures that disregarded the patient’s welfare. Halsted first demonstrated that, with careful hemostasis and gentleness to tissues, an operative procedure lasting as long as 4 or 5 hours left the patient in better condition than a similar procedure performed in 30 minutes with the loss of blood and injury to tissues attendant on speed. The protection of each tissue with the exquisite care typical of Halsted is a difficult lesson for the young surgeon to learn. The preoperative preparation of the skin, the draping of the patient, the selection of instruments, and even the choice of suture material are not so essential as the manner in which details are executed. Gentleness is essential in the performance of any surgical procedure.

Young surgeons have difficulty in acquiring this point of view because they are usually taught anatomy, histology, and pathology by teachers using dead, chemically fixed tissues. Hence, students regard tissues as inanimate material that may be handled without concern. They must learn that living cells may be injured by unnecessary handling or dehydration. A review of anatomy, pathology, and associated basic sciences is essential in the daily preparation of young surgeons before they assume the responsibility of performing a major surgical procedure on a living person. The young surgeon is often impressed by the speed of the operator who is interested more in accomplishing a day’s work than in teaching the art of surgery. Under such conditions, there is little time for review of technique, discussion of wound healing, consideration of related basic scientific aspects of the surgical procedure, or the criticism of results. Wound complications become a distinct problem associated with the operative procedure. If the wound heals, that is enough. A little redness and swelling in and about wounds are taken as a natural course and not as a criticism of what took place in the operating room 3 to 5 days previously. Should a wound disrupt, it is a calamity; but how often is the suture material blamed, or the patient’s condition, and how seldom does the surgeon inquire into just where the operative technique went wrong?

The following detailed consideration of a common surgical procedure, appendectomy, will serve to illustrate the care necessary to ensure successful results. Prior to the procedure, the verified site of the incision is marked with the surgeon’s initials by the operating surgeon. Then the patient is transferred to the operating room and is anesthetized. The operating table must be placed where there is maximum illumination and adjusted to present the abdomen and right groin. The light must be focused with due regard for the position of the surgeon and assistants as well as for the type and depth of the wound. These details must be planned and directed before the skin is disinfected. A prophylactic antibiotic is administered within 1 hour of the skin incision and, in uncomplicated cases, is discontinued within 24 hours of the procedure.

The ever-present threat of sepsis requires constant vigilance on the part of the surgeon. Young surgeons must acquire an aseptic conscience and discipline themselves to carry out a meticulous hand-scrubbing technique. A knowledge of bacterial flora of the skin and of the proper method of preparing one’s hands before entering the operating room, along with a sustained adherence to a methodical scrub routine, are as much a part of the art of surgery as the many other facets that ensure proper wound healing. A cut, burn, or folliculitis on the surgeon’s hand is as hazardous as the infected scratch on the operative site.

The preoperative preparation of the skin is concerned chiefly with mechanical cleansing. It is important that the hair on the patient’s skin is removed with clippers immediately before operation; preferably in the operating suite after anesthetization. This eliminates discomfort to the patient, affords relaxation of the operative site, and is a bacteriologically sound technique. There should be as short a time-lapse as possible between hair removal and incision, thus preventing contamination of the site by a regrowth of organisms or the possibility of a nick or scratch presenting a source of infection. The skin is held taut to present an even, smooth surface, as the hair is removed with power-driven disposable clippers. The use of sharp razors to remove hair is discouraged.

Obviously, it is a useless gesture to scrub the skin the night before operation, and to send the patient to the operating room with the site of incision covered with a sterile towel. However, some surgeons prefer to carry out a preliminary preparation in elective operations on the joints, hands, feet, and abdominal wall. Historically, this would involve scrubbing the skin with a cleansing agent several times a day for 2 or 3 days before the surgery. Today the patient may be instructed to shower using a specialized cleansing agent, preferably chlorhexidine gluconate, the evening before and the day of the surgery. Intravenous antibiotics are ordered to be administered within 1 hour of the planned incision.

In the operating room, after the patient has been properly positioned, the lights adjusted, and the proper plane of anesthesia reached, the final preparation of the operative site is begun. An assistant, puts on sterile gloves, and completes the mechanical cleansing of the operative site with sponges saturated in the desired solution. Chlorhexidine gluconate is the ideal cleansing agent. The contemplated site of incision is treated first; the remainder of the field is cleansed with concentric strokes until all of the exposed area has been covered. As with all tinctures and alcohols used in skin preparation, caution must be observed to prevent skin blisters caused by puddling of solutions at the patient’s side or about skin creases. It is important to allow the prep solution to dry completely before draping in order to minimize a fire hazard. This usually requires 3 minutes with chlorhexidine gluconate. Similarly, electrocardiographic (ECG) and cautery pads should not be wetted. Some surgeons prefer to paint the skin with an iodine-containing solution or a similar preparation.