Surgeons continue to have brilliant ideas and use amazing technology to bring safe and effective surgery to people all over the world, but it was not always so. The evolution of surgery to its present state has taken at least 200 years, and surgery is still evolving. Each of the many abdominal operations surgeons now performed has its own special history, from the idea that spawned it to the present state of its art. Abdominal operations were brought to fruition by innovative surgeons who carefully planned them and had the courage to perform them and the wisdom to modify and improve them.

Although the histories of all abdominal operations are interesting, a broader view of abdominal surgery puts those stories into perspective. The broader view is best obtained by asking: What enabled abdominal surgery to evolve to its present state? What were the barriers to the evolution of abdominal surgery? How were the barriers overcome, and who overcame them? Although recognizing the individuals who developed and perfected individual operations is important, the perspective of this chapter is on how modern abdominal surgery came about and how it was enabled.

Prior to the middle of the 19th century, few operations were done with the expectation that the patient would live and be cured of the disease for which it was performed. The fundamental barrier was the excruciating pain caused by opening the abdomen and manipulating its contents, even when tempered by the administration of alcohol or derivatives of opium such as laudanum and morphine. Patients often died from postoperative bleeding, dehydration, or malnutrition. But it was infection that was the bane of surgeons. Infections followed almost all operations. Wound infection and peritonitis were the killers of patients who had abdominal surgery. Without antibiotics or even standardized methods of dressing infected wounds, the consequences of infection were disastrous. Except in a few isolated instances, physicians knew that surgery was not a realistic therapeutic option until infection, hemorrhage, dehydration, and malnutrition could be alleviated or eliminated. Remarkable progress was made during the second half of the 19th century, enabling surgeons to bring hope to a large number of patients with diseases or conditions that swiftly became amenable to surgery.

The modernization of abdominal surgery was dependent on the patient’s loss of sensation, anesthesia, during the procedure. The development of anesthesia eliminated the cruelty of surgery and enabled surgeons to incise, manipulate, and suture tissue in a disciplined manner without the urgency and disorder that surrounded operations in the conscious patient.

Dr. Crawford Long was the first to use ether for general anesthesia, in 1842, but he did not report it until 1849.¹ Meanwhile, in 1846, the Boston dentist William T.G. Morton demonstrated the use of ether as a general anesthetic in the amphitheater of the Massachusetts General Hospital in a patient with a tumor of the neck, which was removed by Dr. John Collins Warren, former Dean of the Harvard Medical School (1816-1819).²

Louis Pasteur conducted experiments between 1860 and 1864 showing that “pyogenic vibrio” caused puerperal fever and that fermentation of wine and milk did not proceed in the absence of living organisms. Heating milk and wine, now called pasteurization, killed the bacteria, but not the yeast, and made them safe to drink.³

Robert Koch, the German physician and microbiologist who in 1876 identified Bacillus anthracis as the cause of anthrax, learned how to grow bacteria on media and, in 1884, isolated Vibrio cholerae, the agent that causes cholera. In 1882, Koch identified the slow-growing Mycobacterium tuberculosis as the cause of tuberculosis. Between 1879 and 1889, he also isolated the organisms that caused typhoid fever, diphtheria, pneumonia, tetanus, meningitis, and gonorrhea. He found organisms in wound infections. Koch proved that the germs in the germ theory of disease were organisms that could be isolated and identified.⁴

The English physician Joseph Lister, professor of surgery at the University of Glasgow, soaked surgical dressings in carbolic acid (phenol) and applied them to the open leg wound of a boy who had suffered a compound fracture (Fig. 1-1). No infection ensued, and to his surprise, the bones healed solidly together. He published the results in a series of articles in The Lancet in 1867. He returned to the University of Edinburgh in 1869 and continued to develop methods of asepsis and antisepsis. Soon, surgeons performed operations under a mist of dilute carbolic acid that was sprayed in the operating room, instruments were dipped in carbolic acid before use, and the surgical wound was covered in dressings saturated with it.⁵ This routine, with variations, became known as listerism, which Joseph Lister introduced to the United States during a visit in 1876.

Surgeons learned from listerism of the need to maintain sterile conditions at the operating table. Although the steam autoclave was invented in 1879, it was not used routinely for sterilization of instruments and supplies until early in the 20th century. Dr. William Halsted, who embraced listerism, introduced the use of surgical gloves at Johns Hopkins Hospital. However, the original use of the gloves made by the Goodyear Company was to protect the hands of the surgical team from the carbolic acid.⁶

Measures to control infection have been used routinely since the first half of the 20th century and affect hospital construction, all invasive procedures, interactions with patients, and behaviors in hospitals and other medical facilities.

The medicinal use of sulfa drugs in the late 1930s, the discovery of penicillin in 1928 by Fleming, and its clinical use by Florey and his colleagues in the early 1940s began the successful search for many other antibiotics to combat infections by almost all known bacteria. During the second half of the 20th century and beyond, surgical infections have been ameliorated or cured by the large array of antibiotics that became available, although antibiotic-resistant bacteria from antibiotic overuse have recently become a problem. In recent decades, the evidence-based prophylactic use of antibiotics in abdominal surgery has almost eliminated surgical site infections.

Hospitals were built to provide clinical material for the faculties and students of the country’s original medical schools. They included the Pennsylvania Hospital (1752), the New York Hospital (1771), and the Massachusetts General Hospital (1811), all of which became the workplaces of innovative physicians and surgeons who taught and conducted research (Fig. 1-2). However, most cities had no hospitals; instead, almshouses, poorhouses, and poor farms, living facilities for indigent people in the community were established by charitable organizations and wealthy individuals. Over time, many of them became hospitals for the sick and poor. Some physicians also established hospitals, often by converting a large home into a place for their sick patients. Many hospitals were dirty and poorly kept, and because some of the occupants had infectious diseases for which there were no cures, the other occupants also became infected and often died.