PROGRESS IN OB GYN 2019...PROGRESS IN OB GYN 2019 James W. Orr, Jr. M.D. FACOG, FACS Medical...
Transcript of PROGRESS IN OB GYN 2019...PROGRESS IN OB GYN 2019 James W. Orr, Jr. M.D. FACOG, FACS Medical...
2/25/2019
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James W. Orr, Jr. M.D. FACOG, FACSMedical Director
Florida Gynecologic Oncology
Regional Cancer Center
Past Chair, Florida Board of Medicine
Fort Myers
THE EVOLUTION OF SURGERY:A journey of opportunity,
invention and quality!
PROGRESS IN OB GYN2019
James W. Orr, Jr. M.D. FACOG, FACSMedical Director
Florida Gynecologic Oncology
Regional Cancer Center
Past Chair, Florida Board of Medicine
Fort Myers
Nothing to disclose!
PROGRESS IN OB GYN2019
ObjectivesA “whirlwind” tour of major historical events that shaped
surgery as we know it!
Fundamental prerequisites:1) Anatomy 2) Hemostasis3) Anesthesia/analgesia4) Antisepsis and aseptic technique5) “Instrumentation”
Evolution of Surgery
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41,000BC
1 BC
40,0000 BCNeanderthal cave drawings, stone figures
of the human body
37,000 BC1st depiction of
female genitalia
1800 BC
Kahun Papyrus:
Women’s diseases
3500 BC
The wheel :
Mesopotamia (Iraq)
2560 BCThe Great Pyramid at
Giza completed
Kahun Gynecological PapyrusEgypt 1800 BC
Discovered 1889
• Oldest known medical text.
• 34 sections, addressing specific problems.
• Addressed women's health:
fertility, pregnancy, contraception.
• Diagnosis and non-surgical treatment.
• Symptoms/Diagnosis/Treatment approach
• PROGNOSIS was not addressed!
• Egyptian written level of knowledge of medicine
surpassed that of Hippocrates (1,400 years later).
Page1&2
1800 BC
1700 BC
1750 BC
Code of Hammurabi:
Medical rules of operation
(Babylon)
1800 BCBronze metalworking: Europe
( Middle East -3000 B.C.)
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Code of HammurabiMedical laws and ethics of Babylon (1700 BC)
• 282 laws, dealing with all aspect of public life,
citizen's rights and limits the Babylon Kingdome's justice
system.
• Represents the initial INTERFACE BETWEEN MEDICINE AND LAW .
• In principle, the human body represents a forbidden existence in nature, saved and protected against violation which may endanger life.
• Allows violating the body integrity in treatment and surgery by CONSENT, on condition that this interference in the human body is limited specifically to those cases that would benefit HEALTH.
Code of HammurabiMedical laws and ethics of Babylon (1700 BC)
• 282 laws, dealing with all aspect of public life, citizen's
rights and limits and the Babylon Kingdome's justice
system.
• Described a SCALED FEE SCHEDULE for surgical services, LINKED TO THE OUTCOME* of the surgery with severe penalties if expectations not met!
• Required documentation of diseases and therapies, included PRESCRIPTION BENEFITS.
• The code fully explained PATIENT RIGHTS.• Surgical care was authoritarian; there were possibility of
LEGAL ACTIONS to insure justice and equity particular to each social class.
*3700 years prior to NSQIP
1650 BC1st reference to suture material;
Edwin Smith Papyrus (Egypt)1700 BC
1 BC
1500 BC1st reference to “adhesive” tape
(Egypt) [1960 1st micro pore tape]
1000 BCFirst “skin” staples: Decapitated Ants!
[Modern staple use 1960s]
250 BC
1st recorded references to nursing as a
profession (India)
400 BC
HIPPOCRATES: operative techniques
-PATIENT POSITIONING -LIGHTING
980 BCAlbucasis used hot iron to
stop bleeding [1854: Middeldorpf describes galvanocautery]
776 BC
753 BC Rome founded
50 BCPhoebe, (Romans 16:1),
1st “Christian” nurse
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Hippocrates (460-375 BC) *
• "Father of Western Medicine”• Under his influence medicine became a “profession”!• 1st to believe that diseases were caused naturally, not
related to superstition and gods.• Hippocratic medicine was humble and passive and the
therapeutic approach was based in "the healing power” of nature.
• CRISIS, a point in the progression of disease at which either the illness would progress and the patient would succumb to death, or the opposite would occur and natural processes would “allow” the patient to recover.
*2
30 1st reference to vessel ligation:
Soft and not over twisted (Aulus Cornelius Celsus: Rome)
1 AD
1200
33 AD Christianity
793Vikings raid
Ireland
550 Persians use windmills
to power irrigation pumps
1099The first crusade captures
Jerusalem
• Treatise On Medicine (De Medicina). • 1 – The History of Medicine (references 80 medical authors)
• 2 – General Pathology• 3 – Specific Diseases• 4 – Parts of the Body• 5 & 6 – Pharmacology• 7 – Surgery• 8 – Orthopedics
• Theory to medical practice and pros and cons of animal & human experimentation.
• Credited with recording the cardinal signs of inflammation: "Celsus tetrad": calor (warmth), dolor (pain), tumor (swelling) and rubor
(redness and hyperemia).
• Celsus who translated the Greek term CARCINOS (used by
Hippocrates meaning crab or crayfish, to refer to malignant tumors) into the Latin cancer, also meaning crab.
Aulus Cornelius Celsus* (25 BC – 50 AD)
*Roman encyclopedist? physician
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1 AD
200 AD
30 1st reference to vessel ligation: Soft and not
over twisted (Aulus Cornelius Celsus: Rome )
33 AD Christianity
100
Soranus: Described the uterus (human dissection):
- Packed the uterus for hemorrhage - Performed hysterectomy for prolapse
150
Anatomic detail vessel origin, incision placement
Galen (Greek in Rome) *14
175 Tendon repair with silk (Gladiators)
1st reference to catgut (Galen)
200SURGERY SEPARATES
FROM MEDICINE
200 AD
793Vikings raid
Ireland
1-500 ADNursing care palliative needs of persons
and families. Religious organizations were the care providers !
1175
Intestinal suturing over a hollow tube Warmed exposed intestine: covered with
the viscera of a dying animal. Primitive MURPHY BUTTON (1903) !
(Roger of Palermo)
1099The first crusade captures
Jerusalem
1200 AD
910
Rhazes (Persia)
- Urine analysis
- Identifies smallpox,
- Suggests blood as the cause of infectious disease
(900 years prior to Lister, Semmelweiss, Pasteur, Koch)
Murphy’s Anastomosis Button: 1903
two bowls inserted into the lumen of the intestine and clipped together, making an inverted anastomosis.
End to End anastomosis, EEA 1978
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1320
SEVEN BOOKS OF SURGERY Arterial vessel control;
Jehan Yperman (1st Flemish medical writer)
1200
1600
1215
England's King John signs Magna Carta No freeman shall be taken, imprisoned,...or in any other way destroyed...except by the lawful
judgment of his peers, or by the law of the land. To no one will we sell, to none will we deny or
delay, right or justice.
1300-
1600
Renaissance:
cultural bridge between the Middle Ages and modern history
1455Gutenberg
PRINTING PRESS
1348Bubonic Plague kills
75 million in Europe
Jehan Yperman (1260-1331 AD)
• Flemish surgeon and the first Dutch medical writer.
• Realized the “lowly” status of surgery during late medieval time.
• Advocated that surgeons know nature, philosophy and ethics and have “good behavior”. (Origin of Disruptive behavior)
• Raised the level of surgery based on reason and experience in an effort to take medicine out of the hands of barbers and “ignorant practitioners”.
1380 Arterial vessel control; SEVEN BOOKS OF SURGERY Jehan Yperman (1st Dutch medical writter)
1300
1600
1400
Honey & wound edge eversion
Chirugia Magna (Guy de Chaulic)
1530
Pare:
Control of hemorrhage (cautery renounced in favor of ligatures)
- Cervix amputation
1543
Andreas Vesalius: Detailed description of
anatomy. -Hands on education.
1348Bubonic Plague kills
75 million in Europe
1431Joan of Arc burned at
the stake
1455Gutenberg
PRINTING PRESS
1492 COLUMBUS
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Andreas Vesalius (1514-1564) *Father of human anatomy (Dutch)
• 1543: De humini corporus fabrica, a fully illustrated book on human anatomy body, based on observations from dissections (many animal), over turning misconceptions that had persisted for >1000 years (Galen).
• Book 1: The Bones and Cartilages*2: The Ligaments and Muscles3: The Veins and Arteries4: The Nerves*5: The Organs of Nutrition and Generation6: The Heart and Associated Organs*7: The Brain* *#6
1540
1600
1545 Pare: “clean” care of
traumatic wounds
1597A Discourse of the Whole Art of Chirurgery
1st English Surgical text (Peter Lowe)
1546
Verona theorized that small germs cause contagious
diseases (>300 years prior to
Semmelweis, Lister and Pasteur)
1592 Galileo: 1st thermometer
1541John Knox leads Reformation in
Scotland
1588 Defeat of the Spanish Armada
1628 William Harvey: Circulatory system
An Anatomical Study of the Motion of the Heart and of the Blood in Animals
1600
1750
1633Daughters of Charity of Saint
Vincent de Paul: Servants of the Sick Poor
1736 1st appendectomy: (Amyand’s
hernia [R inguinal hernia])
U.S. Population: 5,700
U.S. Population: 474,000
1730 1st small bowel resection for
gangrenous bowel (Ramdohr: 1 year survivor!!)
1607 Jamestown settlement
1743 Jefferson’s birthday
1645French nurse Jeanne Mance
established North America's 1st
hospital Hôtel-Dieu de Montréal.
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1750
1810
1807 Repair of enterotomy;
Samuel White
U.S. Population: 474,000
U.S. Population: 5.3 million
1809 REMOVAL OVARIAN CYST:
E. MCDOWELL
17941st successful Cesarean
section in U.S. (J. Bennett: section or craniotomy)
1750Benjamin Franklin:
Silver coil catheter (brother and himself)
1776Declaration of Independence
Ephraim McDowell (1771-1830)
• Father of abdominal surgery!• Studied in Scotland and Virginia:
never received a degree.• 1809: 1st successful removal of an ovarian tumor (Danville, Ky)
• Performed without anesthetic or antisepsis. • Tumor weighed 22.5 pounds (10.2 kg). • Operative time 25 mins!• His report: "scrupulously clean“ technique, removal of
blood from the peritoneal cavity and “bathing” the intestines with warm water.
• Uncomplicated recovery ……..Mrs. Crawford lived another 32 years.
1813 Phillip Physick (Penn) : “Father of American Surgery” demonstrates Nasogastric tube
1810
1825
1818 1st transfusion of human blood for post partum hemorrhage
(James Blundell; London)
1821
Ovariotomy: pedicle “dropped” back into the
abdomen (Nathan Smith: Yale)
1824 1st attempt to remove a
cancerous uterus via the vagina: unsuccessful!
1815 Napoleon Waterloo
1819UVA chartered
Alabama Statehood
U.S. Population: 12.3 million
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1826 1st U.S. Gynecologic Text: (William Dewees: U Penn)
1825
1842
1828 1st ligation of
internal iliac artery: (Samuel White)
1826
-1st Creation of colocutaneous fistula
(Physick)
-Lembert describes his serosal suture
technique (as a resident!)
1842 Anesthesia (Crawford Long)
U.S. Population: 17 million
1831Nat Turner’s
rebellion
Crawford Long (1815 – 1878)
• Cousin of famed gambler John Henry "Doc" Holliday!
• Performed his first surgical procedure using SULFURIC ETHER on March 30, 1842, removing a neck tumor from a young man. Later used it in his obstetrical practice.
• Never published his findings!!!• Six years later (1846), William Morton, unaware of
Long's prior work, administered ether anesthesia before a medical audience at MGH.
1842
1850
1843
1st hysterectomy: Clay (England)
1st successful BILATERAL oophorectomy in US
John Altee (Pennsylvania)
1847 AMA Founded
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1851 Puerperal Infection (Semmelweiss)
1850
1868
U.S. Population: 23 million
1863 Battle of Gettysburg
1865 Lincoln assassinated
1858 1st transatlantic cable
1851 Florence Nightingale
completes her nursing training
Ignaz Semmelweis (1818-1865 *)
• Hungarian physician:“SAVIOR OF MOTHERS”.• As an assistant (“Chief resident”) in the
maternity clinic in Vienna, he introduced HAND WASHING with chlorinated lime solutions for interns who had performed autopsies.
• Immediate reduction of the incidence of fatal puerperal fever from ~ 10 % (range 5–30%) to <2%.
• The concept of “cleanliness”, was considered extreme and was ignored, rejected and ridiculed, dismissed and harassed by the medical community in Vienna, which eventually forced him to move to Budapest. LATER COMMITTED!
*3
1851 Puerperal Infection
(Semmelweiss)
1850
1868
1852 Fistula repair
(J. Marion Sims)
U.S. Population: 23 million
1863 Battle of Gettysburg
1865 Lincoln assassinated
1858 1st transatlantic cable
1853 Florence Nightengale
Crimean War
1851
Florence Nightingale completes her nursing
training
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J Marion Sims (1813 – 1883)
• “Father of modern gynecology" • Repair of vesico-vaginal fistula,
"catastrophic complication of childbirth”!• Silver-wire sutures led to successful repair of a fistula,
after multiple procedures (30)!!!• He founded the Woman's Hospital (1855), later to be
named St. Luke's-Roosevelt Hospital Center and established America's first cancer institute, New York Cancer Hospital in 1871 (MSKCC).
• Hero or Villain?
1851 Puerperal Infection
(Semmelweiss)
1850
1868
1852 Fistula repair
(J. Marion Sims)
1863 1st American woman to
specialize in pelvic surgery (Mary Harris Thompson)
1858 Needle/Suture
wrapped “skewers” (Goffres)
U.S. Population: 23 million
1857
Pasteur: the growth of micro-organisms was responsible for spoiling beverages and cause disease!(900 years after Rhazes)
1853 1st successful TAH (Burnham)
1861-65American
Civil War
1854
Middeldorpf electrical current in surgical
operations ("galvanocautery")
(850 years after Albucasis)
1851
Florence Nightingale
completes her nursing training
U.S. Women in Medicine
• 1849: Elizabeth Blackwell: 1st woman to obtain a medical degree in the U.S..
(Geneva Medical College)
• 1855: Mary Edwards Walker: 1st U.S. female surgeon: Civil War, Medal of Honor. (Syracuse Medical College)
• 1863: Mary Harris Thompson: 1st American woman to specialize in pelvic surgery. Chicago Hospital for Women and Children!
(New England Female Medical College/Chicago)
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U.S. Women in Medicine
• 1864: Rebecca Lee Crumpler: 1st black woman to earn a medical degree (New England Female Medical College)
54,543 physicians in the United States, 300 of whom were women. None of them were African
American women!!
U.S. Women in Medicine
• 1889: Susan La Flesche Picotte MD: 1st Native American woman to become a physician in the U.S.(Women's Medical College of Pennsylvania)
• 1947: Gerti Cori MD: 1st woman to win Nobel peace prize in physiology and medicine.
U.S. Women in Medicine
Journal of Medical Regulation 2017
30%
47%
0.8%/year
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1851 Puerperal Infection
(Semmelweiss)
1850
1868
1852 Fistula repair
(J. Marion Sims)
1863
1st American woman to specialize in pelvic surgery (Mary Harris Thompson)
1858 Needle/Suture
wrapped “skewers” (Goffres)
U.S. Population: 23 million
1867 LISTER: Carbolic acid antisepsis
1857
Pasteur: the growth of micro-organisms was responsible for spoiling beverages and cause disease!
1853 1st successful TAH (Burnham)
1861-65American
Civil War
Joseph Lister: (1827 – 1912)
• British surgeon: “Father of antiseptic surgery"• Applied Pasteur's principles in microbiology,
introducing carbolic acid (phenol) to sterilize surgical instruments and clean wounds, reducing post-operative infections.
• Lister promoted the antiseptic system by stressing ‘principles’ and ‘professionalism’ and ‘performance’ (soaking surgical sponges and bandages in a solution of carbolic acid, spraying a
wound with an antiseptic solution during surgery, washing surgical instruments, rinsing hands before beginning an operation, and wearing appropriate surgical gowns).
• Procedural changes confusing, use of carbolic area was unpleasant, not easily reproduced and “germ theory” was certainly not accepted by all!
“Mister”*4(Orthopedic injuries)
1869Cesarean Hysterectomy: 3 day
survival!! (Horatio Storer)
1868
1881
1877 P. Bozzini: electro-cauterization
1879Gastrectomy for
cancer (Pean)U.S. Population: 50.1 million
1881 1st successful
gastrectomy for cancer (Billroth I)
1869Suture
antisepsis (Lister)
1881 Garfield assassinated
1881 Clara Barton becomes
the first president of the American Red Cross
1879
Mary Eliza Mahoney 1st African American
nurse in the U.S.
1868 14th Amendment
1871 Life expectance 43 years
1877 1st resection for rectal cancer (Von Volkman)
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1881
1890
1883
-1st successful operation for ectopic pregnancy:
mortality rate 90% to 4% (Tait)
- EDISON INVENTS LIGHTBULB
18881st HYSTERECTOMY
FOR FIBROIDS (Mary Jane Dixon)
1882
Koch's postulates
“microorganisms cause disease”
1886 Statue of Liberty is dedicated
Hysterectomy: Historical “Highlights”
HYSTERECTOMIES WERE PERFORMED SPORADICALLY AND ONLY FOR UTERINE PROLAPSE OR UTERINE INVERSION.
HOWEVER, URINARY INJURY WAS COMMON & PATIENTS RARELY SURVIVED.
120 ADSoranus (Greece) removed an inverted gangrenous uterus
50 BC1st reference to vaginal
hysterectomy Themison of Athens.
1000
Alsaharavius (Arabic physician) “if the uterus had
prolapsed externally and could not be reinserted, it should be
surgically excised”.
1507
1st authenticated vaginal hysterectomy performed by
the Italian anatomist Berengario da Carpi of
Bologna
Hysterectomy: Historical “Highlights”
• 1670: One of the first reported successful vaginal hysterectomies was self-performed.
Faith Haworth, a 46-year-old peasant suffered a complete uterine prolapse while carrying a heavy loadFrustrated by this frequent occurrence, she grabbed her uterus and amputated it with a short knife.
She survived for a decade, with a persistent vesico-vaginal fistula.
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Hysterectomy: Historical “Highlights”
1829
1st “successful” vaginal hysterectomy for cervical cancer.
(Joseph Récamier)
With deliberate ligature of the uterine arteries and broad ligaments. Operative time: 20 minutes.
Death due to recurrent disease!
1813
Conrad Lagenbeck of Gottingen performed the 1st
planned vaginal hysterectomy (reported 1817).
1843
Charles Clay performed the 1st
recorded abdominal (subtotal) hysterectomy in Manchester,
England. (postoperative hemorrhage and death)
Hysterectomy: Historical “highlights”
• 1853: Walter Burnham performed the 1st successful abdominal hysterectomy, in Lowell, Mass, by accident! (12/15 (80%) subsequent patients died)
• 1868: 1st Cesarean hysterectomy in US (Storer, Boston for “perfectly frightful” hemorrhage)
• 1872: Due to high mortality rate Abdominal hysterectomy was “formally condemned” by the Academy of Medicine in Paris.
• 1895: Clark and Rumpf performed “extended hysterectomy” and pelvic lymphadenectomy (Hopkins).
Hysterectomy: Historical “highlights”
1902Schauta performed radical
vaginal hysterectomy
1898Wertheim devised extended
hysterectomy and lymphadenectomy
1929
Richardson (U.S.) performed the 1st total abdominal
hysterectomy, recommended cervix excision, to avoid
cervical stump carcinoma.
1948Brunschwig reports “ultra radical” salvage surgery
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1890 Halsted1st to wear rubber gloves
1890
1896
U.S. Population: 62 million
1890Catgut
available
1891James Naismith invents
basketball.
1890
National American Woman Suffrage
Association (NAWSA) is founded,
“In the winter of 1889 and 1890—I cannot recall the month—the nurse in charge of my operating-room (Caroline Hampton) complained that the solutions of mercuric chloride produced a dermatitis of her arms and hands. As she was an unusually efficient woman, I gave the matter my consideration and one day in New York requested the Goodyear Rubber Company to make as an experiment two pair of thin rubber gloves with gauntlets.
On trial these proved to be so satisfactory that additional gloves were ordered. In the autumn, on my return to town, an assistant who passed the instruments and threaded the needles was also provided with rubber gloves to wear at the operations. At first the operator wore them only when exploratory incisions into joints were made.
After a time the assistants became so accustomed to working in gloves that they also wore them as operators and would remark that they seemed to be less expert with the bare hands than with the gloved hands”.
1890
1897
1891 Halsted: Radical mastectomy
1894 1st survival after
perforated appendix (Richard Hall)
1892 Silver wire readily available
U.S. Population: 62 million
1895
- Xrays discovered (Roentgen)
- 1st extended hysterectomy (Clark)
- Mackenrodt describes pelvic connective tissue
- Surgical mask – (Mikulicz-Radecki)
I Olympiad 1896
1890National American Woman
Suffrage Association (NAWSA) is founded,
1897The American Nurses
Association holds initial meeting
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1898 Operative Gynecology (Kelly)
1898
1912
1900 Pfannenstiel incision
19011st abdominal
“oscopy”
U.S. Population: 62 million
1900Uterine
hyperplasia (Cullen) 1902
Suture sterilization; Iodine
U.S. Population: 92 million
1903 Wright brothers 1st flight
1898 Spanish-American War: USS Maine
We have come a long way…….1901: Dimitri Ott, wore head mirrors to reflect light and
augment visualization and used a speculum in the a posterior fornix incision as access in a pregnant woman (Petrograd gynecologist)
1901: Kelling, described “coelioscopy,” filling the abdomen of a living dog with air and inserted a Nitze cystoscope to inspect the viscera using high pressure insufflation (German surgeon)
1910
1982
1910H.C. Jacobaeus: published description of peritoneal, pleural and pericardial cavity!
1911Bertram M. Bernheim (John Hopkins Hospital)
introduced diagnostic laparoscopic surgery in US
1918 O. Goetze: pneumoperitoneum needle
1920 Zollikofer (Switzerland) CO2
1934John C. Ruddock (Internist) : DIAGNOSTIC
LAPAROSCOPY, SUPERIOR TO LAPAROTOMY. 1938 Janos Veress (Hungary)
1944Raoul Palmer, (Paris) gynecologic
laparoscopy, Trendelenburg position
1953-9Rigid rod lens system: Hopkins (UK
physicist) Stortz acquires the patient
Laparoscopy: we have come a long way…….
1960Semm, (German gynecologist) :automatic insufflator
Steptoe (British Gynecologist ):sterilization technique
1982Clarke: laparoscopic suturing technique.
1st computer chip camera - Circon
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1898 Operative Gynecology (Kelly)1898
1912
1900 Pfannenstiel incision
1908
Stapler used for gastric and intestinal surgery
(Humor Hultl) 8#: 2 hours to assemble
(US Surgical 1964)
19011st abdominal “oscopy” (Ott)
U.S. Population: 62 million
1912 Basset describes Radical Vulvectomy
1900Uterine
hyperplasia (Cullen)
1902Suture
sterilization; Iodine
1911
1st Department of Urology
Bellevue
U.S. Population: 92 million
1913American College of Surgeons:
1st convocation
1912
1937
19161st Subspecialty Boards
Ophthalmology
1930American Board of
Obstetrics and Gynecology
1928PAPANICOLAOU’S
REPORT
U.S. Population: 92 million
1937- American Board of Surgery
- Catgut suture material
19131st EKG Chicago
Presbyterian
1929Penicillin
Fleming
U.S. Population: 110 million
1925Cushing & BovieElectrosurgery
1935 Foley catheter
1914-18 WW I
1933 Electron Microscope (Ruska)
1947Introduction of polyamide
Nylon
1947
1969
1953Obstetrics & Gynecology
(Green Journal)
1969SGO!
- Polypropolene
1948-Exenterative surgery
-Palliative care Cicely Saunders
1958 Mersilene (cerclage)
U.S. Population: 110 million
1968 TPN (Rhoads & Dudrick)
1953 Polio Vaccine (Salk)
1969 ARPAnet
1950Columbia : 1st
MSN
1964 Nurse Training Act
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1969
1979
1974 Polyglycolic Acid suture (Vicryl)
1976 Polyester suture (Ethibon)
U.S. Population: 110 million
1977Sentinel Node 1st reported (Penis)
1st Whole body MRI (Damadian)
1973 Computed Tomography (Cormack & Hounsfield)
1972Gynecologic
Oncology
1969 ARPAnet
1979 1st Nursing PhD (Case Western)
1980
1995
U.S. Population: 249 million
1980
Bayh–Dole Act or Patent and Trademark Law Amendments
Act
COI
• Ownership of inventions supported with federal funding
• Business interests influence the direction of cancer research and the adoption of new practices in therapy (Guidelines, CME)
• University projects which receive industry funding are more likely to produce research outcomes which favor their funders
• Pharmaceutical and medical device industry sponsored studies are more often favorable to the sponsor's product compared with studies with other sources of sponsorship
• “Funders” seek and court scientists to author papers and lend their person reputations to add credibility to research findings
• $13-18 meals influence prescribing habits
1982
- Polytetrafluoroethylene (PTEE suture)
- Polydioxanone Sulfate (PDS)
- 1st Lymphoscintigraphy
- 1st video camera chip!!!
1982
1995
1986-1st LSC cholecystectomy
-1st LSC hysterectomy (Reich)
1993Poliglecaprone 25
(Monocryl)
1992-1st LSC Radical hysterectomy
-SNL vulva (Barton)
1985- PET scan
- Polybutester (Novafil)
U.S. Population: 249 million
1994Polygloconate
(Maxon)
19931st use of
Morcellator!(FDA Advisory 2014)
1990BRCA 1
Mary-Claire King
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1996
2012
2000 HUMAN GENOME PROJECT
1996
EVIDENCE BASED MEDICINE(Sackett)
The conscientious and judicious integration of clinical expertise,
patient values, and the best evidence into the decision making
process for patient care.
1997FDA approves
daVinci
2001
CROSSING THE QUALITY CHASM: IOM
- ERAS
2010 Affordable Care Act
2006HPV
vaccine
2012Uterus
transplant
1998Herceptin approved:
“Targeted therapy”
2004NSQIP
“Outcomes based”
Where are we going????
Single site vs. Multiple?
Role of Mesh?
Transplant?
Sentinel node vs. Lymphadenectomy?
Cost?
Quality?
Doubled from 100 B.C. to 1700 (1800 years).Doubled from 1700-1900 (200 years).Doubled from 1900-1950 (50 years).Doubled from 1950-1970 (20 years).Doubled from 1970-1980 (10 years).Doubled from 1980-1988 (8 years).
Now doubles every 12 months.Soon it will double every 12 hours.
Knowledge
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“I think the biggest problem with healthcare today is not its cost or technology– which is a big problem – but for all that
money, it’s not an expression of our humanity.”
Jonathan Bush – CEO, athena health
James W. Orr, Jr. M.D. FACOG, FACSMedical Director
Florida Gynecologic Oncology
Regional Cancer Center
Past Chair, Florida Board of Medicine
Fort Myers
THE EVOLUTION OF SURGERY:A journey of opportunity,
invention and quality!
PROGRESS IN OB GYN2019