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Surgery: the story on HearLore | HearLore
Surgery
The first hole drilled into a human skull dates back to the Neolithic era, yet the survival rate of those ancient trepanation procedures remains a subject of intense archaeological debate. Evidence from prehistoric sites suggests that early surgeons were not merely experimenting with death but were attempting to relieve intracranial pressure caused by trauma or disease. The oldest known surgical text, the Edwin Smith Papyrus from ancient Egypt, dates to approximately 1600 BC but describes practices likely centuries older, detailing the examination and treatment of forty-eight cases of trauma and disease. These ancient practitioners used sutures to close wounds and applied honey to treat infections, a practice that modern science has confirmed possesses genuine antibacterial properties. In India, the Sushruta Samhita, written around the first millennium BCE, provided detailed instructions for cosmetic surgery and rhinoplasty, establishing a foundation for reconstructive techniques that would not be fully understood again until the twentieth century. The ancient Greek physician Galen performed audacious operations on the brain and eyes that were not attempted again for nearly two millennia, yet his anatomical errors persisted in medical teaching for over a thousand years until Andreas Vesalius challenged the status quo during the Renaissance. Vesalius, a professor of anatomy at the University of Padua, insisted that surgeons must engage in practical dissection themselves rather than relying on the testimonies of others, effectively dismantling the authority of Galen and laying the groundwork for empirical surgical science. The transition from ancient mysticism to modern science was not immediate, as the demand for surgeons to formally study for many years before practicing grew slowly across European universities like Montpellier, Padua, and Bologna. Barber-surgeons, who had long held a bad reputation, were eventually replaced by academic surgeons who viewed surgery as a specialty of medicine rather than an accessory field. The development of Halsteads principles established basic surgical principles for asepsis that remain relevant today, while the work of Ambroise Paré in the 1530s revolutionized military surgery. Paré, a French army surgeon, abandoned the practice of cauterizing gunshot wounds with boiling oil, which was extremely dangerous and painful, in favor of a less irritating emollient made of egg yolk, rose oil, and turpentine. He also described more efficient techniques for the ligation of blood vessels during amputation, saving countless lives on the battlefield. The legacy of these early pioneers set the stage for the dramatic transformations that would occur in the nineteenth century, when the very nature of surgery was about to change forever.
The Silence of the Operating Room
Before the mid-nineteenth century, surgery was a traumatically painful procedure where the speed of the surgeon was the only defense against the patient's suffering. Surgeons were encouraged to be as swift as possible to minimize the agony of the patient, which meant that operations were largely restricted to amputations and the removal of external growths. The discovery of effective and practical anesthetic chemicals in the 1840s changed the character of surgery dramatically, allowing for more intricate operations in the internal regions of the human body. Ether, first used by the American surgeon Crawford Long, and chloroform, discovered by Scottish obstetrician James Young Simpson and later pioneered by John Snow, physician to Queen Victoria, became the tools that liberated surgery from the tyranny of pain. In addition to relieving patient suffering, anesthesia allowed for the use of muscle relaxants such as curare, which enabled safer applications of complex procedures. The introduction of anesthetics inadvertently caused more dangerous patient post-operative infections, as the ability to perform longer surgeries meant that more tissue was exposed to the environment. The concept of infection was unknown until relatively modern times, and the first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis. Semmelweis noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives, and despite ridicule and opposition, he introduced compulsory handwashing for everyone entering the maternal wards. His efforts were rewarded with a plunge in maternal and fetal deaths, yet the Royal Society dismissed his advice, and he died in an asylum, his contributions largely ignored. It was not until the pioneering work of British surgeon Joseph Lister in the 1860s that the medical community began to understand the true cause of surgical infections. Lister became aware of the work of French chemist Louis Pasteur, who showed that rotting and fermentation could occur under anaerobic conditions if micro-organisms were present. Lister confirmed Pasteur's conclusions with his own experiments and decided to use his findings to develop antiseptic techniques for wounds. He experimented with spraying carbolic acid on his instruments, finding that this remarkably reduced the incidence of gangrene, and published his results in The Lancet. Five articles running from March 1867 to July 1867 detailed his findings, and on the 9th of August 1867, he read a paper before the British Medical Association in Dublin on the Antiseptic Principle of the Practice of Surgery. His work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern antiseptic operating theatres widely used within 50 years. Lister continued to develop improved methods of antisepsis and asepsis when he realized that infection could be better avoided by preventing bacteria from getting into wounds in the first place. This led to the rise of sterile surgery, and he introduced the Steam Steriliser to sterilize equipment, instituted rigorous hand washing, and later implemented the wearing of rubber gloves. These three crucial advances, the adoption of a scientific methodology toward surgical operations, the use of anesthesia, and the introduction of sterilized equipment, laid the groundwork for the modern invasive surgical techniques of today. The discovery of X-rays as an important medical diagnostic tool began with their discovery in 1895 by German physicist Wilhelm Röntgen, allowing the skeletal structure to be captured on a specially treated photographic plate and revolutionizing the ability to see inside the body without cutting.
Common questions
When was the first hole drilled into a human skull?
The first hole drilled into a human skull dates back to the Neolithic era. Evidence from prehistoric sites suggests that early surgeons were not merely experimenting with death but were attempting to relieve intracranial pressure caused by trauma or disease.
Who wrote the oldest known surgical text?
The oldest known surgical text is the Edwin Smith Papyrus from ancient Egypt, which dates to approximately 1600 BC but describes practices likely centuries older. This text details the examination and treatment of forty-eight cases of trauma and disease.
When did Joseph Lister publish his findings on antiseptic surgery?
Joseph Lister published his findings on antiseptic surgery in five articles running from March 1867 to July 1867. He read a paper before the British Medical Association in Dublin on the 9th of August 1867 on the Antiseptic Principle of the Practice of Surgery.
Who is considered the father of modern scientific surgery?
John Hunter is generally regarded as the father of modern scientific surgery. He brought an empirical and experimental approach to the science and reconstructed surgical knowledge from scratch by conducting his own surgical experiments.
When did Halfdan T. Mahler first highlight disparities in global surgical care?
Halfdan T. Mahler, the third Director-General of the World Health Organization, first brought attention to the disparities in surgery and surgical care in 1980. He stated in his address to the World Congress of the International College of Surgeons that the vast majority of the world's population has no access whatsoever to skilled surgical care.
What year did the Lancet Commission on Global Surgery publish its landmark report?
The Lancet Commission on Global Surgery published the landmark report titled Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development in 2015. The report described the large, pre-existing burden of surgical diseases in low- and middle-income countries and future directions for increasing universal access to safe surgery by the year 2030.
Modern surgical operations typically require a surgical team that typically consists of the surgeon, the surgical assistant, an anaesthetist, a scrub nurse, a circulating nurse, and a surgical technologist, while procedures that mandate cardiopulmonary bypass will also have a perfusionist. The duration of surgery can span from several minutes to tens of hours depending on the specialty, the nature of the condition, the target body parts involved, and the circumstance of each procedure. Most surgical procedures are designed to be one-off interventions that are typically not intended as an ongoing or repeated type of treatment, yet the complexity of the modern operating room demands a level of coordination that was unimaginable a century ago. The environment and procedures used in surgery are governed by the principles of aseptic technique, the strict separation of sterile things from unsterile or contaminated things. All surgical instruments must be sterilized, and an instrument must be replaced or re-sterilized if it becomes contaminated, such as when it is handled in an unsterile manner or allowed to touch an unsterile surface. Operating room staff must wear sterile attire, including scrubs, a scrub cap, a sterile surgical gown, sterile latex or non-latex polymer gloves, and a surgical mask, and they must scrub hands and arms with an approved disinfectant agent before each procedure. The choice of surgical method and anesthetic technique aims to solve the indicated problem, minimize the risk of complications, optimize the time needed for recovery, and limit the surgical stress response. In the operating room, the team will position the patient in an appropriate surgical position, and if hair is present at the surgical site, it is clipped instead of shaved. The skin surface within the operating field is cleansed and prepared by applying an antiseptic, typically chlorhexidine gluconate in alcohol, as this is twice as effective as povidone-iodine at reducing the risk of infection. Sterile drapes are then used to cover the borders of the operating field, and depending on the type of procedure, the cephalad drapes are secured to a pair of poles near the head of the bed to form an ether screen, which separates the anesthetist's working area from the surgical site. The work to correct the problem in the body then proceeds, involving excision, resection, reconnection of organs, reduction, ligation, grafts, insertion of prosthetic parts, creation of a stoma, and transplant surgery. Blood or blood expanders may be administered to compensate for blood lost during surgery, and once the procedure is complete, sutures or staples are used to close the incision. Once the incision is closed, the anesthetic agents are stopped or reversed, and the person is taken off ventilation and extubated if general anesthesia was administered. The postoperative period involves close monitoring in the post-anesthesia care unit, and when the person is judged to have recovered from the anesthesia, they are either transferred to a surgical ward elsewhere in the hospital or discharged home. During the post-operative period, the person's general function is assessed, the outcome of the procedure is assessed, and the surgical site is checked for signs of infection. There are several risk factors associated with postoperative complications, such as immune deficiency and obesity, which has long been considered a risk factor for adverse post-surgical outcomes. It has been linked to many disorders such as obesity hypoventilation syndrome, atelectasis, and pulmonary embolism, adverse cardiovascular effects, and wound healing complications. If removable skin closures are used, they are removed after 7 to 10 days post-operatively, or after healing of the incision is well under way. It is not uncommon for surgical drains to be required to remove blood or fluid from the surgical wound during recovery, and these drains stay in until the volume tapers off, then they are removed. Postoperative therapy may include adjuvant treatment such as chemotherapy, radiation therapy, or administration of medication such as anti-rejection medication for transplants. For postoperative nausea and vomiting, solutions like saline, water, controlled breathing placebo, and aromatherapy can be used in addition to medication. A recent post-operative care philosophy has been early ambulation, which is getting the patient moving around as early as possible to shorten the patient's length of stay. Through a retrospective analysis of national administrative data, the association between mortality and day of elective surgical procedure suggests a higher risk in procedures carried out later in the working week and on weekends, with the odds of death being 44% and 82% higher respectively when comparing procedures on a Friday to a weekend procedure. This weekday effect has been postulated to be from several factors including poorer availability of services on a weekend and a decrease in the number and level of experience over a weekend. Postoperative pain affects an estimated 80% of people who underwent surgery, and while pain is expected after surgery, there is growing evidence that pain may be inadequately treated in many people in the acute period immediately after surgery.
The Global Divide in Surgical Care
Halfdan T. Mahler, the third Director-General of the World Health Organization, first brought attention to the disparities in surgery and surgical care in 1980 when he stated in his address to the World Congress of the International College of Surgeons that the vast majority of the world's population has no access whatsoever to skilled surgical care and little is being done to find a solution. As such, surgical care globally has been described as the neglected stepchild of global health, a term coined by Paul Farmer to highlight the urgent need for further work in this area. Furthermore, Jim Young Kim, the former President of the World Bank, proclaimed in 2014 that surgery is an indivisible, indispensable part of health care and of progress towards universal health coverage. In 2015, the Lancet Commission on Global Surgery published the landmark report titled Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development, describing the large, pre-existing burden of surgical diseases in low- and middle-income countries and future directions for increasing universal access to safe surgery by the year 2030. The Commission highlighted that about 5 billion people lack access to safe and affordable surgical and anesthesia care and 143 million additional procedures were needed every year to prevent further morbidity and mortality from treatable surgical conditions, as well as a $12.3 trillion loss in economic productivity by the year 2030. This was especially true in the poorest countries, which account for over one-third of the population but only 3.5% of all surgeries that occur worldwide. It emphasized the need to significantly improve the capacity for Bellwether procedures, which are laparotomy, caesarean section, and open fracture care, considered a minimum level of care that first-level hospitals should be able to provide in order to capture the most basic emergency surgical care. In terms of the financial impact on the patients, the lack of adequate surgical and anesthesia care has resulted in 33 million individuals every year facing catastrophic health expenditure, the out-of-pocket healthcare cost exceeding 40% of a given household's income. In alignment with the Lancet Commission on Global Surgery call for action, the World Health Assembly adopted the resolution WHA68.15 in 2015 that stated, Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage. This not only mandated the World Health Organization to prioritize strengthening the surgical and anesthesia care globally, but also led to governments of the member states recognizing the urgent need for increasing capacity in surgery and anesthesia. Additionally, the third edition of Disease Control Priorities, published in 2015 by the World Bank, declared surgery as essential and featured an entire volume dedicated to building surgical capacity. Data from the World Health Organization and the World Bank indicate that scaling up infrastructure to enable access to surgical care in regions where it is currently limited or is non-existent is a low-cost measure relative to the significant morbidity and mortality caused by lack of surgical treatment. In fact, a systematic review found that the cost-effectiveness ratio, dollars spent per DALYs averted, for surgical interventions is on par or exceeds those of major public health interventions such as oral rehydration therapy, breastfeeding promotion, and even HIV/AIDS antiretroviral therapy. This finding challenged the common misconception that surgical care is financially prohibitive endeavor not worth pursuing in low- and middle-income countries. A key policy framework that arose from this renewed global commitment towards surgical care worldwide is the National Surgical Obstetric and Anesthesia Plan, which focuses on policy-to-action capacity building for surgical care with tangible steps including analysis of baseline indicators, partnership with local champions, broad stakeholder engagement, consensus building and synthesis of ideas, language refinement, costing, dissemination, and implementation. This approach has been widely adopted and has served as guiding principles between international collaborators and local institutions and governments. Successful implementations have allowed for sustainability in terms of long-term monitoring, quality improvement, and continued political and financial support. Access to surgical care is increasingly recognized as an integral aspect of healthcare and therefore is evolving into a normative derivation of human right to health, with the International Covenant on Economic, Social and Cultural Rights defining the human right to health as the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The United Nations Committee on Economic, Social and Cultural Rights interpreted this to mean the right to the enjoyment of a variety of facilities, goods, services, and conditions necessary for the realization of the highest attainable health. Surgical care can be thereby viewed as a positive right, an entitlement to protective healthcare, and woven through the International Human and Health Rights literature is the right to be free from surgical disease. The 1966 ICESCR Article 12.2a described the need for the provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child, which was subsequently interpreted to mean requiring measures to improve emergency obstetric services. Article 12.2d of the ICESCR stipulates the need for the creation of conditions which would assure to all medical service and medical attention in the event of sickness, and is interpreted in the 2000 comment to include timely access to basic preventative, curative services for appropriate treatment of injury and disability. Obstetric care shares close ties with reproductive rights, which includes access to reproductive health, and surgeons and public health advocates, such as Kelly McQueen, have described surgery as integral to the right to health.
The Future of the Scalpel
The discipline of surgery was put on a sound, scientific footing during the Age of Enlightenment in Europe, with the Scottish surgical scientist John Hunter generally regarded as the father of modern scientific surgery. He brought an empirical and experimental approach to the science and was renowned around Europe for the quality of his research and his written works. Hunter reconstructed surgical knowledge from scratch, refusing to rely on the testimonies of others, and conducted his own surgical experiments to determine the truth of the matter. To aid comparative analysis, he built up a collection of over 13,000 specimens of separate organ systems, from the simplest plants and animals to humans. He greatly advanced knowledge of venereal disease and introduced many new techniques of surgery, including new methods for repairing damage to the Achilles tendon and a more effective method for applying ligature of the arteries in case of an aneurysm. He was also one of the first to understand the importance of pathology, the danger of the spread of infection, and how the problem of inflammation of the wound, bone lesions, and even tuberculosis often undid any benefit that was gained from the intervention. He consequently adopted the position that all surgical procedures should be used only as a last resort. Other important 18th- and early 19th-century surgeons included Percival Pott, who described tuberculosis on the spine and first demonstrated that a cancer may be caused by an environmental carcinogen, as he noticed a connection between chimney sweep's exposure to soot and their high incidence of scrotal cancer. Astley Paston Cooper first performed a successful ligation of the abdominal aorta, and James Syme pioneered the Symes Amputation for the ankle joint and successfully carried out the first hip disarticulation. The use of X-rays as an important medical diagnostic tool began with their discovery in 1895 by German physicist Wilhelm Röntgen, allowing the skeletal structure to be captured on a specially treated photographic plate. Modern surgery has evolved to include a wide array of specialties, from general surgery and breast surgery to cardiothoracic surgery, colorectal surgery, craniofacial surgery, dental surgery, endocrine surgery, gynaecology, neurosurgery, ophthalmology, surgical oncology, oral and maxillofacial surgery, organ transplantation, orthopaedic surgery, hand surgery, otolaryngology, pediatric surgery, periodontal surgery, plastic surgery, podiatric surgery, skin surgery, trauma surgery, urology, and vascular surgery. Surgical procedures are commonly categorized by urgency, type of procedure, body system involved, the degree of invasiveness, and special instrumentation. Elective surgery is done to correct a non-life-threatening condition, and is carried out at the person's convenience, or to the surgeon's and the surgical facility's availability. Semi-elective surgery is one that is better done early to avoid complications or potential deterioration of the patient's condition, but such risk are sufficiently low that the procedure can be postponed for a short period time. Emergency surgery is surgery which must be done without any delay to prevent death or serious disabilities or loss of limbs and functions. Exploratory surgery is performed to establish or aid a diagnosis, while therapeutic surgery is performed to treat a previously diagnosed condition. Curative surgery is a therapeutic procedure done to permanently remove a pathology, and plastic surgery is done to improve a body part's function or appearance. Reconstructive plastic surgery is done to improve the function or subjective appearance of a damaged or malformed body part, and cosmetic surgery is done to subjectively improve the appearance of an otherwise normal body part. Bariatric surgery is done to assist weight loss when dietary and pharmaceutical methods alone have failed, and non-survival surgery, or terminal surgery, is where euthanasia is performed while the subject is under anesthesia so that the subject will not regain conscious pain perception, usually done in animal testing experiments. Amputation involves removing an entire body part, usually a limb or digit, and castration is the amputation of testes, while circumcision is the removal of prepuce from the penis or clitoral hood from the clitoris. Replantation involves reattaching a severed body part, and resection is the removal of all or part of an internal organ and/or connective tissue. A segmental resection specifically removes an independent vascular region of an organ such as a hepatic segment, a bronchopulmonary segment, or a renal lobe, and excision is the resection of only part of an organ, tissue, or other body part without discriminating specific vascular territories. Exenteration is the complete removal of all organs and soft tissue content, especially lymphoid tissues, within a body cavity, and extirpation is the complete excision or surgical destruction of a body part. Ablation is destruction of tissue through the use of energy-transmitting devices such as electrocautery, fulguration, laser, focused ultrasound, or freezing, and repair involves the direct closure or restoration of an injured, mutilated, or deformed organ or body part, usually by suturing or internal fixation. Reconstruction is an extensive repair of a complex body part, such as joints, often with some degrees of structural/functional replacement and commonly involves grafting and/or use of implants. Grafting is the relocation and establishment of a tissue from one part of the body to another, and a flap is the relocation of a tissue without complete separation of its original attachment, and a free flap is a completely detached flap that carries an intact neurovascular structure ready for grafting onto a new location. Bypass involves the relocation/grafting of a tubular structure onto another in order to reroute the content flow of that target structure from a specific segment directly to a more distal segment, and implantation is insertion of artificial medical devices to replace or augment existing tissue. Transplantation is the replacement of an organ or body part by insertion of another from a different human or animal into the person undergoing surgery, and harvesting is the resection of an organ or body part from a live human or animal, known as the donor, for transplantation into another patient, known as the recipient. Conventional open surgery requires a large incision to access the area of interest, and directly exposes the internal body cavity to the outside, while minimally-invasive surgery involves much smaller surface incisions or even natural orifices to insert miniaturized instruments within a body cavity or structure, as in laparoscopic surgery or angioplasty. Hybrid surgery uses a combination of open and minimally-invasive techniques, and may include hand ports or larger incisions to assist with performance of elements of the procedure. Laser surgery involves use of laser ablation to divide tissue instead of a scalpel, scissors, or similar sharp-edged instruments, and cryosurgery uses low-temperature cryoablation to freeze and destroy a target tissue. Electrosurgery involves use of electrocautery to cut and coagulate tissue, and microsurgery involves the use of an operating microscope for the surgeon to see and manipulate small structures. Endoscopic surgery uses optical instruments to relay the image from inside an enclosed body cavity to the outside, and the surgeon performs the procedure using specialized handheld instruments inserted through trocars placed through the body wall. Most modern endoscopic procedures are video-assisted, meaning the images are viewed on a display screen rather than through the eyepiece on the endoscope, and robotic surgery makes use of robotics such as the Da Vinci or the ZEUS robotic surgical systems to remotely control endoscopic or minimally-invasive instruments. Fetal surgery treats unborn children, pediatric surgery exclusively treats infants, toddlers, children, and adolescents, and geriatric surgery involves surgical treatment tailored to the specific needs of older adults. Resection and excisional procedures start with a prefix for the target organ to be excised and end in the suffix -ectomy, and procedures involving cutting into an organ or tissue end in -otomy. Minimally invasive procedures, involving small incisions through which an endoscope is inserted, end in -oscopy, and procedures for formation of a permanent or semi-permanent opening called a stoma in the body end in -ostomy. Plastic and reconstruction procedures start with the name for the body part to be reconstructed and end in -plasty, and procedures that involve cutting the muscular layers of an organ end in -myotomy. Repair of a damaged or abnormal structure ends in -orraphy, and reoperation, revision, or redo procedures refer to a planned or unplanned return to the operating theater after a surgery is performed to re-address an aspect of patient care. Unplanned reasons for reoperation include postoperative complications such as bleeding or hematoma formation, development of a seroma or abscess, anastomotic leak, tissue necrosis requiring debridement or excision, or in the case of malignancy, close or involved resection margins that may require re-excision to avoid local recurrence. Reoperation can be performed in the acute phase, or it can be also performed months to years later if the surgery failed to solve the indicated problem, and reoperation can also be planned as a staged operation where components of the procedure are performed or reversed under separate anesthesia. In 2011, of the 38.6 million hospital stays in U.S. hospitals, 29% included at least one operating room procedure, and these stays accounted for 48% of the total $387 billion in hospital costs. The overall number of procedures remained stable from 2001 to 2011, and in 2011, over 15 million operating room procedures were performed in U.S. hospitals. Data from 2003 to 2011 showed that U.S. hospital costs were highest for the surgical service line, with the surgical service line costs being $17,600 in 2003 and projected to be $22,500 in 2013. For hospital stays in 2012 in the United States, private insurance had the highest percentage of surgical expenditure, and in 2012, mean hospital costs in the United States were highest for surgical stays. Elderly people have widely varying physical health, and frail elderly people are at significant risk of post-surgical complications and the need for extended care. Assessment of older people before elective surgery can accurately predict the person's recovery trajectories, and one frailty scale uses five items: unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking speed. A healthy person scores 0, and a very frail person scores 5. Compared to non-frail elderly people, people with intermediate frailty scores are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes. People who are frail and elderly have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people. Surgery on children requires considerations that are not common in adult surgery, as children and adolescents are still developing physically and mentally, making it difficult for them to make informed decisions and give consent for surgical treatments. Bariatric surgery in youth is among the controversial topics related to surgery in children, and doctors perform surgery with the consent of the person undergoing surgery. Some people are able to give better informed consent than others, and populations such as incarcerated persons, people living with dementia, the mentally incompetent, persons subject to coercion, and other people who are not able to make decisions with the same authority as others have special needs when making decisions about their personal healthcare, including surgery. The use of topical antibiotics on surgical wounds to reduce infection rates has been questioned, as antibiotic ointments are likely to irritate the skin, slow healing, and could increase risk of developing contact dermatitis and antibiotic resistance. It has also been suggested that topical antibiotics should only be used when a person shows signs of infection and not as a preventative, and a systematic review published by Cochrane in 2016 concluded that topical antibiotics applied over certain types of surgical wounds reduce the risk of surgical site infections, when compared to no treatment or use of antiseptics. The review also did not find conclusive evidence to suggest that topical antibiotics increased the risk of local skin reactions or antibiotic resistance. Through a retrospective analysis of national administrative data, the association between mortality and day of elective surgical procedure suggests a higher risk in procedures carried out later in the working week and on weekends, with the odds of death being 44% and 82% higher respectively when comparing procedures on a Friday to a weekend procedure. This weekday effect has been postulated to be from several factors including poorer availability of services on a weekend and a decrease in the number and level of experience over a weekend. Postoperative pain affects an estimated 80% of people who underwent surgery, and while pain is expected after surgery, there is growing evidence that pain may be inadequately treated in many people in the acute period immediately after surgery. It has been reported that incidence of inadequately controlled pain after surgery ranged from 25.1% to 78.4% across all surgical disciplines, and there is insufficient evidence to determine if giving opioid pain medication pre-emptively reduces postoperative pain or the amount of medication needed after surgery. Postoperative recovery has been defined as an energy-requiring process to decrease physical symptoms, reach a level of emotional well-being, regain functions, and re-establish activities, and most people are discharged from the hospital or surgical center before they are fully recovered, with medical reasons including faster recovery and lowered risk of hospital-acquired infection. The recovery process may include complications such as postoperative cognitive dysfunction and postoperative depression, and the use of topical antibiotics on surgical wounds to reduce infection rates has been questioned. The future of surgery lies in the continued development of robotic systems, the refinement of minimally invasive techniques, and the expansion of access to surgical care globally, ensuring that the benefits of these life-saving procedures are available to all, regardless of their location or economic status.