Surgery Encyclopedia

The advantages of the retropubic prostatectomy in- Open prostatectomy clude: clude a detailed history and physical examination; stan- dard blood tests; chest x ray; and electrocardiogram (EKG) to detect any possible preexisting conditions. • Direct visualization of the prostatic tumor. • Accurate incisions in the urethra, which will minimize Aftercare the complication of urinary continence. Open prostatectomy is a major surgical operation re- • Excellent anatomic exposure and visualization of the quiring an inpatient hospital stay of four to seven days. prostate. Blood transfusions are generally not required due to im- • Clear visualization to control bleeding after tumor re- provements in surgical technique. Immediately after the moval. operation, the surgeon must closely monitor urinary out- • Little or no surgical trauma to the urinary bladder. put and fluid status. On the first day after surgery, most patients are given a clear liquid diet and asked to sit up Suprapubic prostatectomy four times. Morphine sulfate, given via a patient con- trolled analgesic pump (IV), is used to control pain. Suprapubic prostatectomy (also called transvesical prostatectomy) is a procedure to remove the prostatic On the second postoperative day, the urethral cathe- overgrowth via a different surgical route. The suprapubic ter is removed if the urine does not contain blood. Oral approach utilizes an incision of the lower anterior (front) pain medications are begun if the patient can tolerate a bladder wall. The primary advantage over the retropubic regular diet. approach is that the suprapubic route allows for direct vi- On the third postoperative day, the pelvic drain is re- sualization of the bladder neck and bladder mucosa. Be- moved if drainage is less than 75ml/24 hr. The patient cause of this, the procedure is ideally suited for persons should gradually increase activity. Follow-up with the who have bladder complications, as well as obese men. surgeon is necessary following discharge from the hos- The major disadvantage is that visualization of the top pital. Full activity is expected to resume within four to part of the tumor is reduced. Additionally, with the sub- six weeks after surgery. rapubic approach, hemostasis (stoppage of bleeding dur- ing surgery) may be more difficult due to poor visualiza- Risks tion after removal of the tumor. Improvements in surgical technique have lowered Using a scalpel, a lower midline incision is made from blood loss to a minimal level. For several weeks after the umbilicus to the pubic area. A cystotomy (incision into open prostatectomy, patients may have urgency and urge the bladder) is made, and the bladder inspected. Using incontinence. The severity of bladder problems depends electrocautery (a special tool that produces heat at the tip, on the patient’s preoperative bladder status. Erectile dys- useful for hemostasis or tissue excision) and scissors, dis- function occurs in 3–5% of patients undergoing this pro- section proceeds until the prostatic tumor is identified and cedure. Retrograde (backward flow) ejaculation occurs removed. After maintaining hemostasis and arterial blood in approximately 50–80% of patients after open prostate- supply to the prostate, the incisions to the bladder and ab- ctomy. The most common non-urologic risks include dominal wall are closed. pulmonary embolism, myocardial infarction (heart at- tack), deep vein thrombosis, and cerebrovascular acci- Diagnosis/Preparation dent (stroke). The incidence of any one of these poten- The presence of symptoms is indicative of the dis- tially adverse effects is less than 1%. ease. Age also has an associated risk for an enlarged prostate, and can help establish diagnostic criteria. Normal results Men must have a special blood test called the Normally, patients will not have the adverse effects prostate specific antigen (PSA) and routine digital rectal of bleeding. Hematuria (blood in the urine) is typically examination (DRE) before surgery. If the PSA levels and resolved within two days after surgery. The patient DRE are suspiciously indicative of prostate cancer, a should begin a regular diet and moderate increases in ac- transrectal ultrasound guided needle biopsy of the tivity soon after surgery. His pre-surgical activity level prostate must be performed before open prostatectomy, should be restored within four to six weeks after surgery. to detect the presence of prostate cancer (carcinoma). Additionally, preoperative patients should have lower Morbidity and mortality rates urinary tract studies, including urinary flow rate and post The overall rate of morbidity and mortality is ex- void residual urine in the bladder. Because most patients tremely low. The overall mortality (death) rate for open are age 60 or older, preoperative evaluation should also in- prostatectomy is approximately zero. 1044 GALE ENCYCLOPEDIA OF SURGERY

it may be designed and equipped to provide specialized KEY TERMS care to patients with specific conditions. Bladder mucosa—Mucous coat of the bladder. Operating room Description Cerebrovascular accident—Brain hemorrhage, also known as a stroke. OR environment Cystoscopy—Examination of the bladder using a Operating rooms are sterile environments; all person- special instrument to visualize the organ. nel wear protective clothing called scrubs. They also wear Cystotomy—An incision in the bladder. shoe covers, masks, caps, eye shields, and other coverings Pulmonary embolus—A thrombi that typically de- to prevent the spread of germs. The operating room is taches from a deep vein of a lower extremity. brightly lit and the temperature is very cool; operating rooms are air-conditioned to help prevent infection. Trendelenburg—Position in which the head is low and the body and legs are on an inclined plane. The patient is brought to the operating room on a wheelchair or bed with wheels (called a gurney). The pa- tient is transferred from the gurney to the operating table, which is narrow and has safety straps to keep him Alternatives or her positioned correctly. For smaller prostates, treatment using medication The monitoring equipment and anesthesia used dur- may help to control abnormal prostatic growth. When the ing surgery are usually kept at the head of the bed. The prostate gland is large (75 grams and bigger), surgery is anesthesiologist sits here to monitor the patient’s condi- indicated. tion during surgery. Depending on the nature of the surgery, various Resources forms of anesthesia or sedation are administered. The sur- BOOKS gical site is cleansed and surrounded by a sterile drape. Walsh, P. Campbell’s Urology. 8th Ed. St. Louis: Elsevier Sci- The instruments used during a surgical procedure ence, 2002. are different for external and internal treatment; the same PERIODICALS tools are not used on the outside and inside of the body. Dull, P., R. Reagan, R. Bahnson, “Practical Therapeutics: Man- Once internal surgery is started, the surgeon uses small- aging Benign Prostatic Hyperplasia.” American Family er, more delicate devices. Physician 66 (July 1, 2002). Miles, B., et al.”Open Prostatectomy.” eMedicine.com [cited Operating room equipment July 7, 2003]. <http://www.emedicine.com/med/topic3041. htm>. An operating room has special equipment such as respiratory and cardiac support, emergency resuscitative Laith Farid Gulli, M.D., M.S. devices, patient monitors, and diagnostic tools. Alfredo Mori, M.B.B.S. Abraham F. Ettaher, M.D. Life support and emergency resuscitative equipment Bilal Nasser, M.D.,M.S. Equipment for life support and emergency resuscita- tion includes the following: • Heart-lung bypass machine, also called a cardiopul- monary bypass pump—takes over for the heart and lungs during some surgeries, especially heart or lung Operating room procedures. The heart-lung machine removes carbon Definition dioxide from the blood and replaces it with oxygen. A tube is inserted into the aorta to carry the oxygenated An operating room (OR), also called surgery center, blood from the bypass machine to the aorta for circula- is the unit of a hospital where surgical procedures are tion to the body. The heart-lung machine allows the performed. heart’s beating to be stopped during surgery. • Ventilator (also called a respirator)—assists with or Purpose controls pulmonary ventilation. Ventilators consist of a An operating room may be designed and equipped flexible breathing circuit, gas supply, heating/humidifi- to provide care to patients with a range of conditions, or cation mechanism, monitors, and alarms. They are mi- GALE ENCYCLOPEDIA OF SURGERY 1045

croprocessor-controlled and programmable, and regu- Diagnostic equipment Operating room • Infusion pump—device that delivers fluids intravenous- the operating room. Mobile x ray units are used for bed- late the volume, pressure, and flow of respiration. The use of diagnostic equipment may be required in ly or epidurally through a catheter. Infusion pumps em- side radiography, particularly of the chest. These ploy automatic, programmable pumping mechanisms to portable units use a battery-operated generator that pow- deliver continuous anesthesia, drugs, and blood infu- sions to the patient. The pump hangs from an intra- ers an x ray tube. Handheld portable clinical laboratory devices, called point-of-care analyzers, are used for venous pole that is located next to the patient’s bed. blood analysis at the bedside. A small amount of whole blood is required, and blood chemistry parameters can • Crash cart—also called resuscitation cart or code cart. be provided much faster than if samples were sent to the A crash cart is a portable cart containing emergency re- central laboratory. suscitation equipment for patients who are “coding” (i.e., vital signs are in a dangerous range). The emer- Other operating room equipment gency equipment includes a defibrillator, airway intu- bation devices, resuscitation bag/mask, and medication Disposable OR equipment includes urinary (Foley) box. Crash carts are strategically located in the operat- catheters to drain urine during surgery, catheters used for ing room for immediate accessibility if a patient experi- arterial and central venous lines to monitor blood pres- ences cardiorespiratory failure. sure during surgery or withdraw blood samples), Swan- Ganz catheters to measure the amount of fluid in the • Intra-aortic balloon pump—a device that helps reduce the heart and to determine how well the heart is functioning, heart’s workload and helps blood flow to the coronary ar- chest and endotracheal tubes, and monitoring electrodes. teries for patients with unstable angina, myocardial infarc- tion, or those awaiting organ transplants. Intra-aortic bal- loon pumps use a balloon placed in the patient’s aorta. The New surgical techniques balloon is on the end of a catheter that is connected to the Minimally invasive surgery, also called laparoscopic pump’s console, which displays heart rate, pressure, and surgery, is an operative technique performed through a electrocardiogram (ECG) readings. The patient’s ECG is few small incisions, rather than one large incision. used to time the inflation and deflation of the balloon. Through these small incisions, surgeons insert a laparo- scope (viewing instrument that displays the surgery on a Patient monitoring equipment computer screen for easier viewing) and endoscopic in- struments to perform the surgery. Patient monitoring equipment includes the following: Robot-assisted surgery allows surgeons to perform • Acute care physiologic monitoring system—compre- certain procedures through small incisions. In robotic hensive patient monitoring systems that can be config- surgery, a surgeon sits at a console several feet from the ured to continuously measure and display various para- operating table and uses a joystick, similar to that used meters via electrodes and sensors connected to the pa- for video games, to guide the movement of robotic arms tient. Parameters monitored may include the electrical that hold endoscopic instruments and an endoscope activity of the heart via an ECG, respiratory (breathing) (small camera). The robotic arms allow the surgeon to rate, blood pressure (noninvasive and invasive), body perform precise, fine hand movements, and provides ac- temperature, cardiac output, arterial hemoglobin oxy- cess to parts of the body that are difficult to reach manu- gen saturation (blood oxygen level), mixed venous ally. In addition, robotic surgery provides a three-dimen- oxygenation, and end-tidal carbon dioxide. sional image, and the surgical field can be magnified to a • Pulse oximeter—monitors the arterial hemoglobin oxy- greater extent than traditional or minimally invasive gen saturation (oxygen level) of the patient’s blood surgery. The goal of robotic surgery is to decrease inci- with a sensor clipped over the finger or toe. sion size and length of hospital stay, while improving pa- tient comfort and lessening recovery time. • Intracranial pressure monitor—measures the pressure of fluid in the brain in patients with head trauma or Lasers are “scalpels of light” that may offer a new other conditions affecting the brain (such as tumors, alternative for some surgical procedures. Lasers can be edema, or hemorrhage). Intracranial pressure monitors used to cut, burn, or destroy abnormal or diseased tis- are connected to sensors inserted into the brain through sue; shrink or destroy lesions or tumors; sculpt tissue; a cannula or bur hole. These devices signal elevated and seal blood vessels. Lasers may help surgeons per- pressure and record or display pressure trends. Intracra- form some procedures more effectively than other tra- nial pressure monitoring may be a capability included ditional methods. Because lasers cause minimal bleed- in a physiologic monitor. ing, the operative area may be more clearly viewed by 1046 GALE ENCYCLOPEDIA OF SURGERY

KEY TERMS Advance directives—Legal documents that in- Gastrointestinal tube—A tube surgically inserted Operating room crease a patient’s control over medical decisions. A into the stomach for feeding a patient who is un- patient may select medical treatment in advance, able to eat by mouth. in the event that he or she becomes physically or Infectious disease team—A team of physicians and mentally unable to communicate his or her wish- hospital staff who help control the hospital envi- es. Advance directives either state what kind of ronment to protect patients against harmful treatment the patient wants to receive (living will), sources of infection. or authorize another person to make medical deci- sions for the patient when he or she is unable to do Inpatient surgery—Surgery that requires an so (durable power of attorney). overnight stay of one or more days in the hospital. The number of days spent in the hospital after Anesthesiologist—A specially trained physician surgery depends on the type of procedure per- who administers anesthesia. formed. Arterial line—A catheter inserted into an artery Life support—Methods of replacing or supporting and connected to a physiologic monitoring system a failing bodily function, such as using mechanical to allow direct measurement of oxygen, carbon ventilation to support breathing. In treatable or dioxide, and invasive blood pressure. curable conditions, life support is used temporarily Catheter—A small, flexible tube used to deliver to aid healing until the body can resume normal fluids or medications. A catheter may also be used functioning. to drain fluid or urine from the body. Nasogastric tube—A tube inserted through the Central venous line—A catheter inserted into a nose and throat and into the stomach for directly vein and connected to a physiologic monitoring feeding the patient. system to directly measure venous blood pressure. NPO—Nothing by mouth. NPO refers to the time Chest tube—A tube inserted into the chest to drain after which the patient is not allowed to eat or fluid and air from around the lungs. drink prior to a procedure or treatment. Critical care—The multidisciplinary healthcare Outpatient surgery—Also called same-day or am- specialty that provides care to patients with acute, bulatory surgery. The patient arrives for surgery and life-threatening illness or injury. returns home on the same day. Outpatient surgery Edema—An abnormal accumulation of fluids in in- can take place in a hospital, surgical center, or out- tercellular spaces in the body; causes swelling. patient clinic. Endotracheal tube—A tube inserted through the Swan-Ganz catheter—Also called a pulmonary patient’s nose or mouth that functions as an airway artery catheter. This is a type of tubing inserted into and is connected to a ventilator. a large vessel in the neck or chest. It is used to Foley catheter—A tube inserted into the bladder to measure the amount of fluid in the heart, and to drain urine into an external bag. determine how well the heart is functioning. the surgeon. Lasers may also provide access to parts of care in health care facilities. There is also an accredita- the body that may not have been as easily reached man- tion option that is available for ambulatory surgery ually. centers. Choosing a surgery center with experienced staff is Surgery centers important. Here are some questions to consider when Freestanding surgery centers are available in many choosing a surgery center: communities, primarily for the purpose of providing • How many surgeries are performed annually and what outpatient surgical procedures. The patient should are the outcomes and survival rates for those proce- make sure that the surgery center has been accredited dures? by the Joint Commission on Accreditation of Health- care Organizations (JCAHO), a professionally spon- • How does the surgery center’s outcomes compare with sored program that stimulates a high quality of patient the national average? GALE ENCYCLOPEDIA OF SURGERY 1047

Ophthalmologic surgery • Does the surgery center offer procedures to treat a par- Surgical Procedures, Operative. (collection of links). <http:// www.mic.ki.se/Diseases/e4.html>. ticular disease? • Does the surgery center have experience treating pa- Angela M. Costello tients in certain age groups? • How much does surgery cost at this facility? • Is financial assistance available? • If the surgery center is far from the patient’s home, will accommodations be provided for caregivers? Ophthalmologic surgery Definition Resources BOOKS Ophthalmologic surgery is a surgical procedure per- Deardoff, Ph.D., William and John Reeves, Ph.D. Preparing formed on the eye or any part of the eye. for Surgery: A Mind-Body Approach to Enhance Healing and Recovery. New Harbinger Publications, Oakland, CA: Purpose June 1997. (800) 748-6273. <http://www.newharbinger. com/>. Surgery on the eye is routinely performed to repair Furlong, Monica Winefryck. Going Under: Preparing Yourself retinal defects, remove cataracts or cancer, or to repair for Anesthesia: Your Guide to Pain Control and Healing eye muscles. The most common purpose of ophthalmo- Techniques Before, During and After Surgery. Autonomy logic surgery is to restore or improve vision. Publishing Company, November 1993. Goldman, Maxine A. Pocket Guide to the Operating Room 2nd Edition. F.A. Davis Col, January 1996. Demographics PERIODICALS Patients from the very young to very old have ocular “Recommended practices for managing the patient receiving conditions that warrant eye surgery. Two of the most com- anesthesia.” AORN Journal 75, no.4 (April 2002): 849. mon procedures are phacoemulsification for cataracts ORGANIZATIONS and elective refractive surgeries. American Board of Surgery. 1617 John F. Kennedy Boulevard, Cataract surgery is the most common ophthalmic pro- Suite 860, Philadelphia, PA 19103. (215) 568-4000. cedure. More than 1.5 million cataract surgeries are per- <http://www.absurgery.org/>. formed in the United States each year. The National Eye American College of Surgeons. 633 N. Saint Clair Street, Institute (NEI) recently reported that more than half of all Chicago, IL 60611-3211. (312) 202-5000. <http://www. United States residents age 65 and older have a cataract. facs.org/>. American Society of Anesthesiologists. 520 N. Northwest Elective refractive surgeries, especially laser in-situ Highway, Park Ridge, IL 60068-2573. (847) 825-5586. E- keratomileusis (LASIK), attract younger patients in mail: [email protected]. <http://www.asahq.org/>. their thirties and forties. Recently, the American Acade- Association of Perioperative Registered Nurses (AORN, Inc.). my of Ophthalmology (AAO) estimated that 95% of the 2170 South Parker Road. Suite 300, Denver, CO 80231. 1.8 million refractive surgery procedures performed in a (800) 755-2676 or (303) 755-6304. <http://www.aorn. year were LASIK. org/>. National Heart, Lung and Blood Institute. Information Center. P.O. Box 30105, Bethesda, MD 20824-0105. (301) 251- Description 2222. <http://www.nhlbi.nih.gov >. National Institutes of Health. U.S. Department of Health and The surgeon, operating room nurses, and an anes- Human Services, 9000 Rockville Pike, Bethesda, MD thesiologist are present for ophthalmologic surgery. For 20892. (301) 496-4000. <http://www.nih.gov>. many eye surgeries, only a local anesthetic is used, and the patient is awake but relaxed. The patient’s eye area is OTHER scrubbed prior to surgery, and sterile drapes are placed preSurgery.com. <http://www.presurgery.com>. over the shoulders and head. Heart rate and blood pres- Reports of the Surgeon General. National Library of Medicine. <http://sgreports.nlm.nih.gov/NN/>. sure are monitored throughout the procedure. The patient is required to lie still and for some surgery, especially re- SurgeryLinx. (surgery medical news and newsletters from top medical journals). MDLinx, Inc. 1025 Vermont Avenue, fractive surgery, he or she is asked to focus on the light NW, Suite 810, Washington, DC 20005. (202) 543-6544. of the operating microscope. A speculum is placed in the <http://sgreports.nlm.nih.gov/NN/>. eye to hold it open throughout surgery. 1048 GALE ENCYCLOPEDIA OF SURGERY

Common ophthalmologic surgery tools include scalpels, blades, forceps, speculums, and scissors. Many WHO PERFORMS ophthalmologic surgeries now use lasers, which decrease THE PROCEDURE AND the operating time as well as recovery time. WHERE IS IT PERFORMED? Surgeries requiring suturing can take as long as two Ophthalmologic surgery to three hours. These intricate surgeries sometimes re- Ophthalmologists and optometrists may detect quire the skill of a corneal or vitreo-retinal specialist, and ophthalmic problems; however, only an oph- require the patient to be put under general anesthesia. thalmologist can perform surgery. An ophthal- mologist has received specialized training in dis- eases of the eye and their surgical treatment. Refractive surgeries Some ophthalmologists further specialize in cer- Refractive surgeries use an excimer laser to reshape tain areas of the eye, such as corneal or vitreo- the cornea. The surgeon creates a flap of tissue across the retinal specialists. Depending on the severity of cornea with an instrument called a microkeratome, ab- the disease, the general ophthalmologist may lates the cornea for about 30 seconds, and then replaces refer the patient to a specialist for treatment. the flap. The laser allows this surgery to take only min- An anesthesiologist may be on hand during utes, without the use of stitches. surgery to administer the local anesthetic. Sur- gical nurses will assist the ophthalmologist in Trabeculectomy the operating room, and assist the patient pre- Trabeculectomy surgery uses a laser to open the operatively and postoperatively. drainage canals or make an opening in the iris to increase Most ophthalmic surgery is performed on outflow of aqueous humor. The purpose is to lower in- an outpatient basis. Ambulatory surgery cen- traocular pressure in the treatment of glaucoma. ters designed for ophthalmologic surgery are commonly used. Surgery may also be per- Laser photocoagulation formed in hospital operating rooms designed for outpatient surgeries. Laser photocoagulation is used to treat some forms of wet age-related macular degeneration. The procedure stops leakage of abnormal blood vessels by burning them to slow the progress of the disease. The patient’s overall health must also be considered. Poor general health will affect the ophthalmologic Diagnosis/Preparation surgery outcome. Surgeons may request a complete physical examination, in addition to the eye examina- Patients complaining of any ocular problem that re- tion, prior to surgery. quires surgery will receive a similar initial examination. A complete patient history is taken, including the chief Pre-surgery preparation complaint. The patient needs to disclose any allergies, Patients having ophthalmologic surgery usually medication usage, family eye and medical histories, and must stop taking aspirin, or aspirin-like products, 10 vocational and recreational vision requirements. days before surgery unless directed otherwise by the sur- The diagnostic exam should include measurement of geon. Patients taking blood thinners also must check visual acuity under both low and high illumination, biomi- with their physician to find out when they should stop croscopy with pupillary dilation, stereoscopic fundus ex- taking the medication before surgery. A number of pain amination with pupillary dilation, assessment of ocular relievers may affect outcomes, making it important for motility and binocularity, visual fields, evaluation of patients to disclose all medication. The patient might pupillary responses to rule out afferent pupillary defects, have to ask about alternative medications if the surgeon refraction, and measurement of intraocular pressure (IOP). requires that he or she stops taking the usual regime be- fore the procedure. Some prescription medicines have Other examination procedures include corneal map- been known to cause postsurgical scarring or flecks ping, a keratometer reading to determine the curvature of under the corneal flap after LASIK. the central part of the cornea, and a slit lamp exam to de- termine any damage to the cornea and evidence of glau- To reduce the chance of infection, the surgeon may coma and cataracts. A fundus exam also will be per- request that the patient begin using antibiotic drops be- formed to check for retinal holes, and macular degenera- fore surgery. Depending on the procedure, the patient tion and disease. may also be advised to discontinue contact lens wear and GALE ENCYCLOPEDIA OF SURGERY 1049

Ophthalmologic surgery • If both eyes are diseased, will they be treated formed under a local anesthetic, and patients remain QUESTIONS awake but in a relaxed state. TO ASK THE DOCTOR Aftercare After surgery, the patient is monitored in a recovery simultaneously? area. For most outpatient procedures, the patient is ad- • Will the eyes need to rest after surgery? Will vised to rest for at least 24 hours until he or she returns to protective lenses be required following the the surgeon’s office for follow-up care. Over-the-counter procedure? medications are usually advised for pain relief, but pa- • Will eyeglasses be needed eyeglasses? tients should check with their doctor to see what is recom- • How many times has the surgeon performed mended. Some pain relievers interfere with surgical out- this specific procedure? comes. Patients may also use ice packs to help ease pain. • Should the physician be contacted if pain de- Some patients may experience slight drooping or velops after the surgery? bruising of the eye. This condition improves as the eye • When can normal activities be resumed? heals. Severe pain, nausea, or vomiting should be report- What about driving? ed to the surgeon immediately. After surgery, patients may be advised not to stoop, lift heavy objects, exercise vigorously, or swim. Patients may also be required to wear an eye shield while sleep- stop using creams, lotions, make-up, or perfume. Pa- ing, and sunglasses or some type of protective lens dur- tients may also be asked to scrub their eyelashes for a pe- ing the day to avoid injury. Wearing make-up may be riod of time to remove any debris. prohibited for weeks after surgery. The patient may be Patients are advised not to drink alcoholic beverages restricted from driving and air travel. at least 24 hours before and after the ophthalmic proce- Patients usually have their first postoperative visit dure. the day after the eye surgery. Subsequent exams are Patients must usually avoid eating or drinking any- commonly scheduled at one, three, and six to eight thing after midnight on the day before the surgery; how- weeks following surgery. This schedule depends on the ever, some patients may be allowed to have clear liquids patient’s healing, and any complications he or she might in the morning. It is important for patients to ask their experience. physician for a list of foods and medications permitted on Some patients will be required to instill eye drops for the morning of surgery. Some patients may take morning a number of weeks after surgery to prevent infection, medications (with physician approval) with the exclusion pain, and to lessen inflammation. Eye drops also are used of diuretics, insulin, or diabetes pills. Patients are ad- to lower intraocular pressure. In some cases, correct eye vised to dress comfortably for the surgery, and wear but- drop usage is critical to a successful surgery outcome. ton-down shirts that will not have to pass over the head. Presurgical tests sometimes are administered when Risks the patient arrives for surgery. For refractive surgeries, this Complications may occur during any surgery. Oph- ensures the laser is set for the correct refractive error. Be- thalmologic surgery, however, is usually very safe. fore cataract surgery, measurements help determine the re- fractive power of the intraocular lens (IOL). Other tests Some risks include: such as a chest x ray, blood work, or urinalysis may also • Undercorrection or overcorrection in refractive surgery. be requested depending on the patient’s overall health. Undercorrected refractive surgery patients usually can Most ophthalmic surgeries are done on an outpatient be treated with an enhancement, but overcorrected pa- basis, and patients must arrange for someone to take tients will need to use eyeglasses or contact lenses. them home after the procedure. • Debilitating symptoms. These include glare, halos, double vision, and poor nighttime vision. Some pa- Before surgery, doctors will review the presurgical tients may also lose contrast sensitivity. These symp- tests and instill any dilating eye drops, antibiotic drops, toms may be temporary or permanent. and a corticosteriod or nonsteroidal anti-inflammatory drops as needed. Anesthetic eye drops also will be ad- • Dry eye. Some patients are treated with artificial tears ministered. Many ophthalmologic surgeries are per- or punctal plugs. 1050 GALE ENCYCLOPEDIA OF SURGERY

• Retinal detachment. The retina can become detached by the surgery if this part of the eye has any weakness KEY TERMS when the procedure is performed. This may not occur Orchiectomy for weeks or months. Ablation—During LASIK, the vaporization of eye tissue. • Endophthalmitis. An infection in the eyeball is a com- plication that is less common today because of newer Cornea—The clear, curved tissue layer in front of surgery techniques and antibiotics. the eye. It lies in front of the colored part of the eye (iris) and the black hole in the center of the Other serious complications that may occur are blindness, glaucoma, or hemorrhage. iris (pupil). Glaucoma—Disease of the eye characterized by Normal results increased pressure of the fluid inside the eye. Un- treated, glaucoma can lead to blindness. Normal results include restored or improved vision, Macular degeneration—A condition usually asso- and a much improved quality of life. Specific improve- ciated with age in which the area of the retina ments depend on the type of ophthalmologic surgery called the macula is impaired due to hardening of performed, and the type of ocular ailment being treated. the arteries (arteriosclerosis). This condition inter- feres with vision. Morbidity and mortality rates Retina—The inner, light-sensitive layer of the eye Death from ophthalmologic surgery is rare. However, containing rods and cones; transforms the images complications can still arise from the use of general anes- it receives into electrical messages sent to the thesia. With most ophthalmic surgeries requiring only brain via the optic nerve. local anesthetic, that risk has been widely eliminated. Blindness, which was sometimes caused by serious infection, has also been reduced because of more effec- tive antibiotics. National Eye Institute. 2020 Vision Place Bethesda, MD 20892-3655. (301) 496-5248. <www.nei.nih.gov>. Alternatives University of Michigan Kellogg Eye Center Department of Ophthalmology and Visual Sciences. 1000 Wall Street, Some medications can be used to treat certain oph- Ann Arbor, MI 48105. (734) 763-1415. <www.kellogg. thalmic conditions. For example, surgery for glaucoma is umich.edu>. performed only in patients who do not respond to med- OTHER ication. Patients with myopia (nearsightedness), hyper- “Conditions.” Vision Channel. [cited April 12, 2003] <www.vi- opia (farsightedness), or presbyopia, can wear contact sionchannel.net> lenses or eyeglasses instead of having refractive surgery “Surgical Procedures for Glaucoma.” Your Medical Source. to improve their refractive errors. [cited April 12, 2003] <www.yourmedicalsource.com/ library/glaucoma/GLC_surgery.html> Resources BOOKS Mary Bekker Berkow, Robert, ed. The Merck Manual of Medical Informa- tion. Whitehorse Station, NJ: 1997. Columbia University College of Physicians & Surgeons Com- Opioid analgesics see Analgesics, opioid plete Home Medical Guide 3rd Edition. New York, NY: Crown Publishers, 1995. Optional surgery see Elective surgery Daly, Stephen, ed. Everything You Need to Know About Medical Treatments. Springhouse, PA: Springhouse Corp., 1996. ORGANIZATIONS American Academy of Ophthalmology. PO Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. <www.aao. Orchiectomy org>. American Optometric Association. 243 North Lindbergh Blvd., Definition St. Louis, MO 63141. (314) 991-4100. <www.aoanet.org>. American Society of Cataract and Refractive Surgery. 4000 Orchiectomy is the surgical removal of one or both Legato Road, Suite 850, Fairfax, VA 22033-4055. (703) testicles, or testes, in the human male. It is also called an 591-2220. E-mail: [email protected]; <www.ascrs.org>. orchidectomy, particularly in British publications. The GALE ENCYCLOPEDIA OF SURGERY 1051

Orchiectomy Orchiectomy Incision Sutures Spermatic cord Testis A. B. C. D. Scrotum In an orchiectomy, the scrotum is cut open (A).Testicle covering is cut to expose the testis and spermatic cord (B).The cord is tied and cut, removing the testis (C), and the wound is repaired (D). (Illustration by GGS Inc.) removal of both testicles is known as a bilateral orchiec- considered controversial in some parts of the legal sys- tomy, or castration, because the person is no longer able tem. A small number of men with very strong sex dri- to reproduce. Emasculation is another word that is some- ves request an orchiectomy for religious reasons; it times used for castration of a male. Castration in women should be noted, however, that official Roman Catholic is the surgical removal of both ovaries (bilateral teaching is opposed to the performance of castration for oophorectomy). spiritual purity. Purpose Demographics An orchiectomy is done to treat cancer or, for other Cancer reasons, to lower the level of testosterone, the primary Cancers in men vary widely in terms of both the male sex hormone, in the body. Surgical removal of a numbers of men affected and the age groups most likely testicle is the usual treatment if a tumor is found within to be involved. Prostate cancer is the single most com- the gland itself, but an orchiectomy may also be per- mon malignancy affecting American men over the age of formed to treat prostate cancer or cancer of the male 50; about 220,000 cases are reported each year. Accord- breast, as testosterone causes these cancers to grow and ing to the Centers for Disease Control and Prevention metastasize (spread to other parts of the body). An or- (CDC), 31,000 men in the United States die every year chiectomy is sometimes done to prevent cancer when an from prostate cancer. African-American men are almost undescended testicle is found in a patient who is beyond 70% more likely to develop prostate cancer than either the age of puberty. Caucasian or Asian-American men; the reasons for this A bilateral orchiectomy is commonly performed as difference are not yet known. Other factors that increase one stage in male-to-female (MTF) gender reassignment a man’s risk of developing prostate cancer include a diet surgery. It is done both to lower the levels of male hor- high in red meat, fat, and dairy products, and a family mones in the patient’s body and to prepare the genital history of the disease. Men whose father or brother(s) area for later operations to construct a vagina and exter- had prostate cancer are twice as likely as other men to nal female genitalia. develop the disease themselves. Today, however, there are still no genetic tests available for prostate cancer. Some European countries and four states in the United States (California, Florida, Montana, and Texas) Testicular cancer, on the other hand, frequently oc- allow convicted sex offenders to request surgical cas- curs in younger men; in fact, it is the most common tration to help control their sexual urges. This option is cancer diagnosed in males between the ages of 15 and 1052 GALE ENCYCLOPEDIA OF SURGERY

34. The rate of new cases in the United States each year is about 3.7 per 100,000 people. The incidence of tes- WHO PERFORMS ticular cancer has been rising in the developed coun- THE PROCEDURE AND Orchiectomy tries at a rate of about 2% per year since 1970. It is not WHERE IS IT PERFORMED? yet known whether this increase is a simple reflection of improved diagnostic techniques or whether there are Orchiectomy performed as part of cancer ther- other causes. There is some variation among racial and apy may be done in a hospital under general ethnic groups, with men of Scandinavian background anesthesia, but is most often done as an outpa- having higher than average rates of testicular cancer, tient procedure in a urology clinic or similar fa- and African-American men having a lower than aver- cility. Most surgeons who perform orchiec- age incidence. Testicular cancer occurs most often in tomies to treat cancer are board-certified urolo- males in one of three age groups: boys 10 years old or gists or general surgeons. younger; adult males between the ages of 20 and 40; Orchiectomies performed as part of gender and men over 60. reassignment surgery are usually done in clin- Other risk factors for testicular cancer include: ics that specialize in genital surgery. The stan- • Cryptorchidism, which is a condition in which a boy’s dards of care defined by the Harry Benjamin testicles do not move down from the abdomen into the International Gender Dysphoria Association scrotum at the usual point in fetal development. It is stipulate that the surgeon should be a board- also called undescended testicle(s). Ordinarily, the tes- certified urologist, gynecologist, plastic sur- ticles descend before the baby is born; however, if the geon, or general surgeon, and that he or she baby is born prematurely, the scrotal sac may be empty must have undergone supervised training in at the time of delivery. About 3–4% of full-term male genital reconstruction. infants are born with undescended testicles. Men with a history of childhood cryptorchidism are three to 14 times more likely to develop testicular cancer. • Family history of testicular cancer. however, maintains that a more accurate estimation is 1:11,900 males and 1:30,400 females. In any case, the • A mother who took diethylstilbestrol (DES) during number of surgical procedures is lower than the number pregnancy. DES is a synthetic hormone that was pre- of patients diagnosed with gender identity disorders. scribed for many women between 1938 and 1971 to prevent miscarriage. It has since been found to increase the risk of certain types of cancer in the offspring of Description these women. There are three basic types of orchiectomy: simple, • Occupational and environmental factors. Separate subcapsular, and inguinal (or radical). The first two types groups of researchers in Germany and New Zealand re- are usually done under local or epidural anesthesia, and ported in 2003 that firefighters have an elevated risk of take about 30 minutes to perform. An inguinal orchiecto- testicular cancer compared to control subjects. The spe- my is sometimes done under general anesthesia, and cific environmental trigger is not yet known. takes between 30 minutes and an hour to complete. Gender reassignment Simple orchiectomy Statistics for orchiectomies in connection with gen- A simple orchiectomy is performed as part of gen- der reassignment surgery are difficult to establish be- der reassignment surgery or as palliative treatment for cause most patients who have had this type of surgery advanced cancer of the prostate. The patient lies flat on prefer to keep it confidential. Persons undergoing the an operating table with the penis taped against the ab- hormonal treatments and periods of real-life experience domen. After the anesthetic has been given, the surgeon as members of the other sex that are required prior to makes an incision in the midpoint of the scrotum and genital surgery frequently report social rejection, job dis- cuts through the underlying tissue. The surgeon removes crimination, and other negative consequences of their de- the testicles and parts of the spermatic cord through the cision. Because of widespread social disapproval of sur- incision. The incision is closed with two layers of sutures gical gender reassignment, researchers do not know the and covered with a surgical dressing. If the patient de- true prevalence of gender identity disorders in the gener- sires, a prosthetic testicle can be inserted before the inci- al population. Early estimates were 1:37,000 males and sion is closed to give the appearance of a normal scrotum 1:107,000 females. A recent study in the Netherlands, from the outside. GALE ENCYCLOPEDIA OF SURGERY 1053

Orchiectomy TO ASK THE DOCTOR transrectal ultrasound (TRUS), or from elevated levels of prostate-specific antigen (PSA) in the patient’s blood. QUESTIONS PSA is a tumor marker, or chemical, in the blood that can be used to detect cancer and monitor the results of • How effective is an orchiectomy in prevent- er, requires a tissue biopsy. The tissue sample can usual- ing a recurrence of my cancer? therapy. A definite diagnosis of prostate cancer, howev- ly be obtained with the needle technique. Testicular can- • What side effects of this procedure am I most cer is suspected when the doctor feels a mass in the pa- likely to experience? tient’s scrotum, which may or may not be painful. In • How many orchiectomies have you per- order to perform a biopsy for definitive diagnosis, how- formed? ever, the doctor must remove the affected testicle by • Can you recommend a local men’s network radical orchiectomy. or support group? GENDER REASSIGNMENT. Patients requesting gen- der reassignment surgery must undergo a lengthy process of physical and psychological evaluation before receiving approval for surgery. The Harry Benjamin In- Subcapsular orchiectomy ternational Gender Dysphoria Association (HBIGDA), A subcapsular orchiectomy is also performed for which is presently the largest worldwide professional treatment of prostate cancer. The operation is similar to a association dealing with the treatment of gender identi- simple orchiectomy, with the exception that the glandu- ty disorders, has published standards of care that are lar tissue is removed from the lining of each testicle followed by most surgeons who perform genital rather than the entire gland being removed. This type of surgery for gender reassignment. HBIGDA stipulates orchiectomy is done primarily to keep the appearance of that a patient must meet the diagnostic criteria for gen- a normal scrotum. der identity disorders as defined by either the Diagnos- tic and Statistical Manual of Mental Disorders, fourth Inguinal orchiectomy edition (DSM-IV) or the International Classification of Diseases–10 (ICD-10). An inguinal orchiectomy, which is sometimes called a radical orchiectomy, is done when testicular cancer is Preparation suspected. It may be either unilateral, involving only one testicle, or bilateral. This procedure is called an inguinal All patients preparing for an orchiectomy will have orchiectomy because the surgeon makes the incision, standard blood and urine tests before the procedure. which is about 3 in (7.6 cm) long, in the patient’s groin They are asked to discontinue aspirin-based medications area rather than directly into the scrotum. It is called a for a week before surgery and all non-steroidal anti-in- radical orchiectomy because the surgeon removes the en- flammatory drugs (NSAIDs) two days before the proce- tire spermatic cord as well as the testicle itself. The rea- dure. Patients should not eat or drink anything for the son for this complete removal is that testicular cancers eight hours before the scheduled time of surgery. frequently spread from the spermatic cord into the lymph Most surgeons ask patients to shower or bathe on nodes near the kidneys. A long non-absorbable suture is the morning of surgery using a special antibacterial soap. left in the stump of the spermatic cord in case later They should take extra time to lather, scrub, and rinse surgery is necessary. their genitals and groin area. After the cord and testicle have been removed, the Patients who are anxious or nervous before the pro- surgeon washes the area with saline solution and closes cedure are usually given a sedative to help them relax. the various layers of tissues and skin with various types CANCER. Patients who are having an orchiectomy as of sutures. The wound is then covered with sterile gauze treatment for testicular cancer should consider banking and bandaged. sperm if they plan to have children following surgery. Although it is possible to father a child if only one testi- Diagnosis/Preparation cle is removed, some surgeons recommend banking sperm as a precaution in case the other testicle should Diagnosis develop a tumor at a later date. CANCER. The doctor may suspect that a patient has GENDER REASSIGNMENT. Most males who have re- prostate cancer from feeling a mass in the prostate in the quested an orchiectomy as part of male-to-female gender course of a rectal examination, from the results of a reassignment have been taking hormones for a period of 1054 GALE ENCYCLOPEDIA OF SURGERY

several months to several years prior to surgery, and have Risks had some real-life experience dressing and functioning Some of the risks for an orchiectomy done under as women. The surgery is not performed as an immediate Orchiectomy general anesthesia are the same as for other procedures. response to the patient’s request. They include deep venous thrombosis, heart or breathing Because the standards of care for gender reassign- problems, bleeding, infection, or reaction to the anesthe- ment require a psychiatric diagnosis as well as a physi- sia. If the patient is having epidural anesthesia, the risks cal examination, the surgeon who is performing the or- include bleeding into the spinal canal, nerve damage, or chiectomy should receive two letters of evaluation and a spinal headache. recommendation by mental health professionals, prefer- Specific risks associated with an orchiectomy in- ably one from a psychiatrist and one from a clinical psy- clude: chologist. • loss of sexual desire (This side effect can be treated Aftercare with hormone injections or gel preparations.) • impotence Patients who are having an orchiectomy in an ambu- latory surgery center or other outpatient facility must • hot flashes similar to those in menopausal women, con- have a friend or family member to drive them home after trollable by medication the procedure. Most patients can go to work the follow- • weight gain of 10–15 lb (4.5–6.8 kg) ing day, although some may need an additional day of rest at home. Even though it is normal for patients to feel • mood swings or depression nauseated after the anesthetic wears off, they should start • enlargement and tenderness in the breasts eating regularly when they get home. Some pain and • fatigue swelling is also normal; the doctor will usually prescribe a pain-killing medication to be taken for a few days. • loss of sensation in the groin or the genitals Other recommendations for aftercare include: • osteoporosis (Men who are taking hormone treatments for prostate cancer are at greater risk of osteoporosis.) • Drinking extra fluids for the next several days, except for caffeinated and alcoholic beverages. An additional risk specific to cancer patients is re- currence of the cancer. • Avoiding sexual activity, heavy lifting, and vigorous ex- ercise until the follow-up appointment with the doctor. • Taking a shower rather than a tub bath for a week fol- Normal results lowing surgery to minimize the risk of absorbable Cancer stitches dissolving prematurely. Normal results depend on the location and stage of • Applying an ice pack to the groin area for the first the patient’s cancer at the time of surgery. Most prostate 24–48 hours. cancer patients, however, report rapid relief from cancer • Wearing a jock strap or snug briefs to support the scro- symptoms after an orchiectomy. Patients with testicular tum for two weeks after surgery. cancer have a 95% survival rate five years after surgery Some patients may require psychological counsel- if the cancer had not spread beyond the testicle. Metasta- ing following an orchiectomy as part of their long-term tic testicular cancer, however, has a poorer prognosis. aftercare. Many men have very strong feelings about any procedure involving their genitals, and may feel de- Gender reassignment pressed or anxious about their bodies or their relation- Normal results following orchiectomy as part of a ships after genital surgery. In addition to individual psy- sex change from male to female are a drop in testos- chotherapy, support groups are often helpful. There are terone levels with corresponding decrease in sex drive active networks of prostate cancer support groups in and gradual reduction of such masculine characteristics Canada and the United States as well as support groups as beard growth. The patient may choose to have further for men’s issues in general. operations at a later date. Long-term aftercare for patients with testicular can- cer includes frequent checkups in addition to radiation Morbidity and mortality rates treatment or chemotherapy. Patients with prostate cancer may be given various hormonal therapies or radiation Orchiectomy by itself has a very low rate of morbid- treatment. ity and mortality. Patients who are having an orchiecto- GALE ENCYCLOPEDIA OF SURGERY 1055

Orchiectomy Androgen—Any substance that promotes the de- Inguinal—Referring to the groin area. KEY TERMS velopment of masculine characteristics in a per- son. Testosterone is one type of androgen; others Metastasis—A process in which a malignant tumor transfers cells to a part of the body not directly are produced in the adrenal glands located above connected to its primary site. A cancer that has the kidneys. spread from its original site to other parts of the Bilateral—On both sides. A bilateral orchiectomy body is said to be metastatic. is the removal of both testicles. Oophorectomy—Removal of one or both ovaries Capsule—A general medical term for a structure in a woman. that encloses another structure or body part. The capsule of the testicle is the membrane that sur- Orchiectomy—Surgical removal of one or both tes- rounds the glandular tissue. ticles in a male. It is also called an orchidectomy. Castration—Removal or destruction by radiation of Scrotum—The pouch of skin on the outside of the both testicles (in a male) or both ovaries (in a fe- male body that holds the testes. male), making the individual incapable of repro- ducing. Spermatic cord—A tube-like structure that extends from the testicle to the groin area. It contains blood Cryptorchidism—A developmental disorder in vessels, nerves, and a duct to carry spermatic fluid. which one or both testes fail to descend from the abdomen into the scrotum before birth. Subcapsular—Inside the outer tissue covering of Emasculation—Another term for castration of a the testicle. A subcapsular orchiectomy is a proce- male. dure in which the surgeon removes the inner glan- dular tissue of the testicle while leaving the outer Epidural—A type of regional anesthetic delivered capsule intact. by injection into the area around the patient’s lower spine. An epidural numbs the body below Testis (plural, testes)—The medical term for a testi- the waist but allows the patient to remain con- cle. scious throughout the procedure. Testosterone—The major male sex hormone, pro- Gender identity disorder (GID)—A mental disor- duced in the testes. der in which a person strongly identifies with the other sex and feels uncomfortable with his or her Tumor marker—A circulating biochemical com- biological sex. It occurs more often in males than pound that indicates the presence of cancer. Tumor in females. markers can be used in diagnosis and in monitor- ing the effectiveness of treatment. Gender reassignment surgery—The surgical alter- ation and reconstruction of a person’s sex organs to Urology—The branch of medicine that deals with resemble those of the other sex as closely as possi- disorders of the urinary tract in both males and fe- ble; it is sometimes called sex reassignment surgery. males, and with the genital organs in males. my as part of cancer therapy have a higher risk of dying chemotherapy are considered follow-up treatments from the cancer than from testicular surgery. rather than alternatives. The morbidity and mortality rates for persons hav- There are, however, several alternatives to orchiec- ing an orchiectomy as part of gender reassignment tomy in the treatment of prostate cancer: surgery are about the same as those for any procedure in- • watchful waiting volving general or epidural anesthesia. • hormonal therapy (The drugs that are usually given for Alternatives prostate cancer are either medications that oppose the action of male sex hormones [anti-androgens, usually Cancer flutamide or nilutamide] or medications that prevent There is no effective alternative to radical orchiecto- the production of testosterone [goserelin or leuprolide my in the treatment of testicular cancer; radiation and acetate].) 1056 GALE ENCYCLOPEDIA OF SURGERY

• radiation treatment Landen, M., et al. “Done Is Done—and Gone Is Gone. Sex Re- assignment is Presently the Best Cure for Transsexuals.” • chemotherapy [in Swedish] Lakartidningen, 98 (July 25, 2001): Orchiectomy 3322–3326. Gender reassignment Papanikolaou, Frank, and Laurence Klotz. “Orchiectomy, Rad- ical.” eMedicine,, October 3, 2001 [March 30, 2003]. The primary alternative to an orchiectomy for gen- <http://www.emedicine.com/med/topic3063.htm>. der reassignment is hormonal therapy. Most patients Roberts, L. W., M. Hollifield, and T. McCarty. “Psychiatric seeking MTF gender reassignment begin taking female Evaluation of a ‘Monk’ Requesting Castration: A Patient’s hormones (estrogens) for three to five months minimum Fable, with Morals.” American Journal of Psychiatry, 155 before requesting genital surgery. Some persons post- (March 1998): 415–420. pone surgery for a longer period of time, often for finan- Smith, M. R. “Osteoporosis and Other Adverse Body Compo- cial reasons; others choose to continue on estrogen thera- sition Changes During Androgen Deprivation Therapy for py indefinitely without surgery. Prostate Cancer.” Cancer and Metastasis Reviews, 21 (2002): 159–166. See also Orchiopexy. Stang, A., K. H. Jockel, C. Baumgardt-Elms, and W. Ahrens. “Firefighting and Risk of Testicular Cancer: Results from Resources a German Population-Based Case-Control Study.” Ameri- can Journal of Industrial Medicine, 43 (March 2003): BOOKS 291–294. “Breast Disorders: Breast Cancer in Men.” Section 18, Chapter Stone, T. H., W. J. Winslade, and C. M. Klugman. “Sex Of- 242 in The Merck Manual of Diagnosis and Therapy, edit- fenders, Sentencing Laws and Pharmaceutical Treatment: ed by Mark H. Beers and Robert Berkow. Whitehouse Sta- A Prescription for Failure.” Behavioral Sciences and the tion, NJ: Merck Research Laboratories, 1999. Law, 18 (2000): 83–110. “Congenital Anomalies: Renal and Genitourinary Defects.” Volm, M. D. “Male Breast Cancer.” Current Treatment Options Section 19, Chapter 261 in The Merck Manual of Diagno- in Oncology, 4 (April 2003): 159–164. sis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Labo- ORGANIZATIONS ratories, 1999. American Board of Urology (ABU). 2216 Ivy Road, Suite 210, Morris, Jan. Conundrum. New York: Harcourt Brace Jovanovich, Charlottesville, VA 22903. (434) 979-0059. <http://www. Inc., 1974. abu.org>. “Principles of Cancer Therapy: Other Modalities.” Section 11, American Cancer Society (ACS). (800) ACS-2345. <http:// Chapter 144 in The Merck Manual of Diagnosis and Ther- www.cancer.org>. apy, edited by Mark H. Beers and Robert Berkow. White- American Prostate Society. P. O. Box 870, Hanover, MD house Station, NJ: Merck Research Laboratories, 1999. 21076. (800) 308-1106. <http://www.ameripros.org>. “Sexual and Gender Identity Disorders.” In Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text Canadian Prostate Cancer Network. P. O. Box 1253, Lakefield, revision. Washington, DC: American Psychiatric Associa- ON K0L 2H0 Canada. (705) 652-9200. <http://www. tion, 2000. cpcn.org>. Centers for Disease Control and Prevention (CDC) Cancer Pre- PERIODICALS vention and Control Program. 4770 Buford Highway, NE, Berruti, A., et al. “Background to and Management of Treat- MS K64, Atlanta, GA 30341. (888) 842-6355. <http:// ment-Related Bone Loss in Prostate Cancer.” Drugs and www.cdc.gov/cancer/comments.htm>. Aging, 19 (2002): 899–910. Harry Benjamin International Gender Dysphoria Association, Dawson, C. “Testicular Cancer: Seek Advice Early.” Journal of Inc. (HBIGDA). 1300 South Second Street, Suite 180, Family Health Care, 12 (2002): 3. Minneapolis, MN 55454. (612) 625-1500. <http://www. Elert, A., K. Jahn, A. Heidenreich, and R. Hofmann. “The Fa- hbigda.org>. milial Undescended Testis.” [in German] Klinische Padia- National Cancer Institute (NCI). NCI Public Inquiries Office. trie, 215 (January–February 2003): 40–45. Suite 3036A, 6116 Executive Boulevard, MSC8332, Geldart, T. R., P. D. Simmonds, and G. M. Mead. “Orchidecto- Bethesda, MD 20892-8322. (800) 4-CANCER or (800) my after Chemotherapy for Patients with Metastatic Tes- 332-8615 (TTY). <http://www.nci.nih.gov>. ticular Germ Cell Cancer.” BJU International, 90 (Sep- tember 2002): 451–455. OTHER Incrocci, L., W. C. Hop, A. Wijnmaalen, and A. K. Slob. Harry Benjamin International Gender Dysphoria Association “Treatment Outcome, Body Image, and Sexual Function- (HBIGDA). Standards of Care for Gender Identity Disor- ing After Orchiectomy and Radiotherapy for Stage I-II ders, 6th version, February, 2001 [April 1, 2003]. <http:// Testicular Seminoma.” International Journal of Radiation www.hbigda.org/socv6.html>. Oncology, Biology, Physics, 53 (August 1, 2002): National Cancer Institute (NCI) Physician Data Query (PDQ). 1165–1173. Male Breast Cancer: Treatment, December 9, 2002 GALE ENCYCLOPEDIA OF SURGERY 1057

[March 29, 2003]. <http://www.nci.nih.gov/cancerinfo/ Orchiopexy NCI PDQ. Testicular Cancer: Treatment, February 20, 2003 at the time of orchiopexy and whether both testicles are pdq/treatment/malebreast/healthprofessional>. affected. Men with one undescended testicle have a 40% chance of being infertile; this figure rises to 70% {March 29, 2003]. <http://www.nci.nih.gov/cancerinfo/ in men with bilateral cryptorchidism. pdq/treatment/testicular/healthprofessional>. • To lower the risk of testicular cancer. The incidence of Rebecca Frey, PhD malignant tumors in undescended testes has been esti- mated to be 48 times the incidence in normal testes. Men with cryptorchidism have a 10% chance of even- tually developing testicular cancer. • To lower the risk of traumatic injury to the testicle. Un- Orchiopexy descended testicles that remain in the patient’s groin area are vulnerable to sports injuries and pressure from Definition car seat belts. • To prevent the development of an inguinal hernia. An Orchiopexy is a procedure in which a surgeon fas- inguinal hernia is a disorder that occurs when a portion tens an undescended testicle inside the scrotum, usually of the contents of the abdomen pushes through an ab- with absorbable sutures. It is done most often in male in- normal opening in the abdominal wall. It is likely to fants or very young children to correct cryptorchidism, occur in a male infant with cryptorchidism because a which is the medical term for undescended testicles. Or- sac known as the processus vaginalis, which connects chiopexy is also occasionally performed in adolescents the scrotum and the abdominal cavity, remains open or adults, and may involve one or both testicles. In after birth. In normal development, the processus vagi- adults, orchiopexy is most often done to treat testicular nalis closes shortly after the testes descend into the torsion, which is a urologic emergency resulting from scrotum. If the sac remains open, a section of the the testicle’s twisting around the spermatic cord and los- child’s intestine can extend into the sac. It may be- ing its blood supply. come trapped (incarcerated) in the sac, forming what Other names for orchiopexy include orchidopexy, is called a strangulated hernia. The portion of the in- inguinal orchiopexy, repair of undescended testicle, testine that is trapped in the sac may die, which is a cryptorchidism repair, and testicular torsion repair. medical emergency. • To prevent testicular torsion in adolescence. Purpose • To maintain the appearance of a normal scrotum. Or- To understand the reasons for performing an or- chiopexy is considered a necessary procedure for psy- chiopexy in children, it is helpful to have an outline of chological reasons, as boys with only one visible testi- the normal pattern of development of the testes in a cle are frequently subjected to teasing and ridicule after male infant. The gubernaculum is an embryonic cord- they start school. like ligament that attaches the testes within the in- The primary reason for performing an orchiopexy in guinal (groin) region of a male fetus up through the an adolescent or adult male is treatment of testicular tor- seventh month of pregnancy. Between the 28th and the sion, rather than cryptorchidism. Testicles that have not 35th week of pregnancy, the gubernaculum migrates descended by the time a boy reaches puberty are usually into the scrotum and creates space for the testes to de- removed by a complete orchiectomy. scend. In normal development, the testes have fol- lowed the gubernaculum downward into the scrotum by the time the baby is born. The normal pattern may Demographics be interrupted by several possible factors, including in- Cryptorchidism adequate androgen (male sex hormone) secretion, Cryptorchidism is the most common abnormality of structural abnormalities in the boy’s genitals, and de- the male genital tract, affecting 3–5% of full-term male fective nerves in the genital region. infants and 30–32% of premature male infants. In most Orchiopexy is performed in children for several rea- cases, the condition resolves during the first few months sons: after delivery; only 0.8% of infants over three months of • To minimize the risk of infertility. Adult males with age still have undescended testicles. Because of the po- cryptorchidism typically have lower sperm counts and tentially serious consequences of cryptorchidism, how- produce sperm of poorer quality than men with normal ever, doctors do not advise watchful waiting once the testicles. The risk of infertility rises with increasing age child is over six months old. Undescended testicles 1058 GALE ENCYCLOPEDIA OF SURGERY

Orchiopexy Orchiopexy Testis Abdominal Abdominal incision incision Scrotal incision Electrocautery tool A. B. Retractor Abdominal incision C. Testis Scrotal incision D. E. Testis descended in scrotum An orchiopexy is used to repair an undescended testicle in childhood. An incision is made into the abdomen, the site of the undescended testicle, and another is made in the scrotum (A).The testis is detached from surrounding tissues (B) and pulled out of the abdominal incision attached to the spermatic cord (C).The testis is then pulled down into the scrotum (D) and stitched into place (E). (Illustration by Argosy.) rarely come down into the scrotum of their own accord No variation in the incidence of cryptorchidism after that age. among different racial and ethnic groups has been reported. Cryptorchidism is a frequent occurrence in prune Testicular torsion belly syndrome (PBS) and a few other genetic disorders characterized by structural abnormalities of the geni- Most American males suffering from testicular tor- tourinary tract. sion are below age 30, with the majority between the GALE ENCYCLOPEDIA OF SURGERY 1059

Orchiopexy THE PROCEDURE AND testicle completely from its present location and re-im- plants it in the scrotum by reattaching its surrounding tis- WHO PERFORMS sues and blood vessels to nearby blood vessels. This technique minimizes the risk of an inadequate blood sup- WHERE IS IT PERFORMED? ply to the re-implanted testicle. A pediatric surgeon or pediatric urologist is the specialist most likely to perform an orchiopexy Testicular torsion in an infant or small child. In an adult patient, An orchiopexy done to treat testicular torsion is usu- the procedure is usually performed by a urolo- ally done under general or epidural anesthesia. The sur- gist after referral from the patient’s primary geon makes an incision in the patient’s scrotum and un- physician or the emergency care physician. twists the spermatic cord. The affected testicle is inspect- An orchiopexy can be performed in the ed for signs of necrosis, or tissue death. If too much tis- surgical unit of a children’s hospital or an am- sue has died due to loss of blood supply, the surgeon will bulatory surgical center. Most orchiopexies in remove the entire testicle. If the tissue appears to be adults are performed as outpatient procedures. healthy, the surgeon sutures the testicle to the wall of the scrotum and then closes the incision. In most cases, the surgeon will also attach the unaffected testicle to the scrotal wall as a preventive measure. ages of 12 and 18. The peak ages for an acute episode of testicular torsion are the first year of life and age 14. Tes- Diagnosis/Preparation ticular torsion occurs on the left side of the body slightly more often than on the right side, about 52% versus 48% Cryptorchidism of cases. The diagnosis of cryptorchidism is usually made when a pediatrician examines the newborn baby, al- Description though the condition can occur at any time before the boy reaches puberty. The first stage in diagnosis is an Cryptorchidism external physical examination of the child’s genitals. Some orchiopexies in children are relatively simple If either testicle does not appear to be in the scrotum, procedures; however, others are complicated by the loca- the doctor will palpate, or touch, the groin area and ab- tion of the undescended testicle. In general, an or- domen to determine whether a testicle can be felt in chiopexy for an undescended testicle that lies in front of any of those locations. If the testicle can be felt, the the scrotum or just above it is a less complicated opera- doctor will decide on the basis of its location whether tion than one done to treat a non-palpable testicle. The it is an undescended testicle, a so-called ectopic testi- procedure is usually done under general anesthesia. cle, or a retractile testicle. An ectopic testicle is one that has developed in a location outside the normal If the undescended testis is in the groin area, the sur- path of development in the inguinal canal. Ectopic tes- geon will make a small incision in the groin and a sec- ticles are most often discovered along the inner part of ond small incision in the scrotum. The testis is moved the thigh near the groin, at the base of the penis, or downward from the groin without complete separation below the scrotum in the perineum (the area between from the gubernaculum. It is then placed inside a small the scrotum and the rectum). A retractile testicle is one pouch created by the surgeon between the skin of the that is readily pulled back out of the scrotum by an scrotum and a layer of muscle in the scrotum called the overly sensitive reflex called the cremasteric reflex; it dartos muscle. The testicle is held in place with sutures is not a genuinely undescended testicle. It is important that are eventually absorbed by the body. for the doctor to distinguish a retractile testicle from The Fowler-Stephens technique is often used when genuine cryptorchidism because retractile testicles do the undescended testicle is located high above the scrotum not need surgical treatment. At this point in the diag- or in the abdomen. It may be done in two stages scheduled nostic workup, a general pediatrician will often consult several months apart. In the first stage, the surgeon moves a specialist in pediatric urology. the testicle downward and attaches it temporarily to the in- In about 20% of male infants with cryptorchidism, side of the thigh. In the second stage, the testicle is trans- the missing testicle cannot be felt at all. It is known as a ferred into the scrotum itself and sutured into place. non-palpable testicle. The child may be given a hormone A third type of orchiopexy is called testicular auto- challenge test to help determine whether the testicle is transplantation. The surgeon removes the undescended located in the abdomen or whether it has failed to devel- 1060 GALE ENCYCLOPEDIA OF SURGERY

op fully. If the testosterone level in the blood rises in re- sponse to the test, the doctor knows that there is a testis QUESTIONS present somewhere in the child’s body. In other cases, TO ASK THE DOCTOR Orchiopexy the testis has atrophied, or shriveled up due to an inade- quate blood supply before birth. If neither testicle can be • How often have you treated a child for cryp- felt, the child should be examined further for evidence of torchidism? inter-sexuality. The doctor may order an ultrasound to • What are the chances that the treatment will check for the presence of a uterus, particularly if the be successful? child’s external genitals are ambiguous in appearance. • What should I tell my son about the opera- Surgery is the next step in searching for a non-palpa- tion? ble testicle. The surgeon may perform either an open in- • Are there likely to be any long-term afteref- guinal procedure or a laparoscopic approach. In an open fects? inguinal exploration, the surgeon makes an incision in the child’s groin; if nothing is found, the incision may be ex- tended into the lower abdomen. In a laparoscopic ap- proach, the surgeon uses an instrument that looks like a find a non-palpable testicle before performing the or- small telescope with a light attached in order to see inside chiopexy, the child may remain in the hospital for two or the groin or the abdominal cavity through a much smaller three days. The doctor will usually prescribe a pain med- incision. If the surgeon is able to find the testicle, he or ication for the first few days after the procedure. she may then proceed directly to perform an orchiopexy. After the child returns home, he should not bathe Testicular torsion until the day after surgery. In addition, he should not ride Testicular torsion is usually diagnosed in the emer- a bicycle, climb trees, or do anything else that requires gency room. The doctor will usually suspect testicular straddling for two or three weeks. An older boy should torsion on the basis of sudden onset of severe pain on one avoid sports or rough games that might result in injury to side of the scrotum; it is unusual for pain to develop grad- the genitals until he has a post-surgical checkup. ually in this disorder. The patient’s history often indicates Most surgeons will schedule the child for a checkup recent hard physical work, vigorous exercise, or trauma one or two weeks after the orchiopexy, with a second to the genital area; however, testicular torsion can also checkup three months later. occur without any apparent reason. Other symptoms may include swelling of the scrotum, blood in the semen, nau- Testicular torsion sea and vomiting, pain in the abdomen, and fever. A few patients feel the need to urinate frequently. When the doc- Aftercare is similar to that for orchiopexy in a child. tor examines the patient’s scrotum, the affected testicle is The area around the incision should be washed very gen- usually enlarged and is painful when the doctor touches tly the next day and a clean dressing applied. Medication it. It usually lies higher in the scrotum than the unaffected will be prescribed for postoperative pain. The patient is testicle and may be lying in a horizontal position. advised to rest at home for several days after surgery, to Since testicular torsion is a medical emergency, remain in bed as much as possible, to drink extra fluids, most doctors will not risk permanent damage to the testi- and to elevate the scrotum on a small pillow to ease the cle by taking the time to perform imaging studies. If the discomfort. Vigorous physical and sexual activity should diagnosis is unclear, however, the doctor may order a ra- be avoided until the pain and swelling go away. dionuclide scan or a color Doppler ultrasound to deter- mine whether the blood flow to the testicle has been cut Risks off. The patient will be given a mild pain medication and referred to a urologist for surgery as soon as possible. Cryptorchidism The risks of orchiopexy in treating cryptorchidism Aftercare include: Cryptorchidism • infection of the incision Aftercare in children depends partly on the com- • bleeding plexity of the procedure. If the child has an uncomplicat- ed orchiopexy, he can usually go home the same day. If • damage to the blood vessels and other structures in the the surgeon had to make an incision in the abdomen to spermatic cord, leading to eventual loss of the testicle GALE ENCYCLOPEDIA OF SURGERY 1061

Orchiopexy KEY TERMS Cremasteric reflex—A reflex in which the cremas- testicles in a male; also called an orchidectomy. ter muscle, which covers the testes and the sper- Orchiectomy—Surgical removal of one or both matic cord, pulls the testicles back into the scro- tum. It is important for a doctor to distinguish be- Perineum—The area between the scrotum and the tween an undescended testicle and a hyperactive anus. cremasteric reflex in small children. Peritoneum—The smooth, colorless membrane Cryptorchidism—A developmental disorder in that lines the inner surface of the abdomen. which one or both testes fail to descend from the Prune belly syndrome (PBS)—A genetic disorder abdomen into the scrotum before birth. It is the associated with abnormalities of human chromo- most common structural abnormality in the male somes 18 and 21. Male infants with PBS often have genital tract. cryptorchidism along with other defects of the gen- Ectopic—Located in an abnormal site or tissue. An itals and urinary tract. PBS is also known as triad ectopic testicle is one that is located in an unusual syndrome and Eagle-Barrett syndrome. position outside its normal line of descent into the scrotum. Scrotum—The pouch of skin on the outside of the male body that holds the testes. Gonadotropins—Hormones that stimulate the ac- tivity of the ovaries in females and testes in males. Spermatic cord—A tube-like structure that extends Hernia—The protrusion of a loop or piece of tissue from the testicle to the groin area. It contains blood through an incision or abnormal opening in other vessels, nerves, and a duct to carry spermatic fluid. tissues. Testicular torsion—Twisting of the testicle around Inguinal—Referring to the groin area. the spermatic cord, cutting off the blood supply to Laparoscope—An instrument that allows a surgeon the testicle. It is considered a urologic emergency. to look inside the abdominal cavity. Testis (plural, testes)—The medical term for a testi- Non-palpable—Unable to be detected through the cle. sense of touch. A non-palpable testicle is one that is located in the abdomen or other site where the Urology—The branch of medicine that deals with doctor cannot feel it by pressing gently on the disorders of the urinary tract in both males and fe- child’s body. males, and with the genital organs in males. • failure of the testicle to remain in the scrotum (This successful, there is no damage to the blood vessels sup- problem can be repaired by a second operation.) plying the testicle, no loss of fertility, and no recurrence • difficulty urinating for a few days after surgery of torsion. Testicular torsion Morbidity and mortality rates The risks of orchiopexy as a treatment for testicular Cryptorchidism torsion include: Orchiopexy is most likely to be successful in chil- • infection of the incision dren when the undescended testicle is relatively close to • bleeding the scrotum. The rate of failure for orchiopexy per- formed as a treatment for cryptorchidism is 8% if the • loss of blood circulation in the testicle leading to loss testicle lies just above the scrotum; 10–20% if the testi- of the testicle cle is located in the inguinal canal; and 25% if the testi- • reaction to anesthesia cle lies within the abdomen. Normal results Testicular torsion In a normal orchiopexy, the testicle remains in the The mortality rate for orchiopexy in adults is very scrotum without re-ascending. If the procedure has been low because almost all patients are young males in good 1062 GALE ENCYCLOPEDIA OF SURGERY

health. The procedure has a 99% rate of success in sav- Dogra, Vikram S., and Hamid Mojibian. “Cryptorchidism.” ing the testicle when the diagnosis is made promptly and eMedicine, June 21, 2002 [April 4, 2003]. <www.emedi- treated within six hours. After 12 hours, however, the cine.com/radio/topic201.htm>. rate of success in saving the testicle drops to 2%. The av- Franco, Israel. “Prune Belly Syndrome.” eMedicine, August 24, Orthopedic surgery 2001 [April 4, 2003]. <www.emedicine.com/med/topic erage rate of testicular atrophy following orchiopexy for 3055.htm>. testicular torsion is about 27%. Jawdeh, Bassam Abu, and Samir Akel. “Cryptorchidism: An Update.” American University of Beirut Surgery, (Summer Alternatives 2002) [April 3, 2003]. <www.staff.aub.edu.lb/~websurgp/ Cryptorchidism sc0a.html>. Nair, S. G., and B. Rajan. “Seminoma Arising in Cryptorchid Hormonal therapy using gonadotropins to stimulate Testis 25 Years After Orchiopexy: Case Report.” American the production of more testosterone is effective in some Journal of Clinical Oncology, 25 (June 2002): 287–288. children in causing the testes to descend into the scrotum Rupp, Timothy J., and Mark Zwanger. “Testicular Torsion.” without surgery. This approach, however, is usually suc- eMedicine, March 25, 2003 [April 4, 2003]. <www.e cessful only with undescended testes that are already medicine.com/EMERG/topic573.htm>. close to the scrotum; its rate of success ranges from Sessions, A. E., et al. “Testicular Torsion: Direction, Degree, Duration, and Disinformation.” Journal of Urology, 169 10–50%. Undescended testes that are located higher al- (February 2003): 663–665. most never respond to hormonal therapy. In addition, Shekarriz, B., and M. L. Stoller. “The Use of Fibrin Sealant in treatment with hormones has several undesirable side ef- Urology.” Journal of Urology, 167 (March 2002): fects, including aggressive behavior. 1218–1225. Some surgeons will, however, prescribe hormonal Tsujihata, M., et al. “Laparoscopic Diagnosis and Treatment of treatment before an orchiopexy in order to increase the Nonpalpable Testis.” International Journal of Urology, 8 size of the undescended testis and make it easier to iden- (December 2001): 692–696. tify during surgery. ORGANIZATIONS American Academy of Pediatrics (AAP). 141 Northwest Point Testicular torsion Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. Pain caused by testicular torsion can be relieved tem- <http://www.aap.org>. porarily by manual detorsion. To perform this maneuver, American Board of Urology (ABU). 2216 Ivy Road, Suite 210, Charlottesville, VA 22903. (434) 979-0059. <http://www. the doctor stands at the patient’s feet and gently rotates abu.org>. the affected testicle toward the outside of the patient’s National Organization for Rare Disorders (NORD). 55 Kenosia body in a sidewise direction. Manual detorsion is effec- Avenue, P. O. Box 1968, Danbury, CT 06813-1968. (203) tive in relieving pain in 30–70% of patients; however, it is 744-0100. <http://www.rarediseases.org>. not considered an alternative to orchiopexy in preventing Prune Belly Syndrome Network. P. O. Box 2125, Evansville, a recurrence of the torsion or loss of the testicle. IN 47728-0125. <http://www.prunebelly.org>. See also Orchiectomy; Urologic surgery. Rebecca Frey, PhD Resources BOOKS “Congenital Anomalies: Renal and Genitourinary Defects.” Section 19, Chapter 261 in The Merck Manual of Diagno- sis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Labo- Orthopedic surgery ratories, 1999. Definition PERIODICALS Orthopedic (sometimes spelled orthopedic) surgery Baker, L. A., et al. “A Multi-Institutional Analysis of Laparo- is an operation performed by a medical specialist such as scopic Orchidopexy.” BJU International, 87 (April 2001): 484–489. an orthopedist or orthopedic surgeon, who is trained to Chang, B., L. S. Palmer, and I. Franco. “Laparoscopic Orchi- assess and treat problems that develop in the bones, dopexy: A Review of a Large Clinical Series.” BJU Inter- joints, and ligaments of the human body. national, 87 (April 2001): 490–493. Docimo, S. G., R. I. Silver, and W. Cromie. “The Undescended Purpose Testicle: Diagnosis and Management.” American Family Physician, 62 (November 1, 2000): 2037–2044, 2047– Orthopedic surgery addresses and attempts to cor- 2048. rect problems that arise in the skeleton and its attach- GALE ENCYCLOPEDIA OF SURGERY 1063

Orthopedic surgery Orthopedic surgery is performed by a physician amputation, hand reconstruction, spinal fusion, and joint replacements. They also treat strains and sprains, WHO PERFORMS broken bones, and dislocations. Some specific proce- THE PROCEDURE AND WHERE IS IT PERFORMED? dures performed by orthopedic surgeons are listed as separate entries in this book, including arthroplasty, arthroscopic surgery, bone grafting, fasciotomy, frac- with specialized training in orthopedic surgery. It is most commonly performed in operating room ture repair, kneecap removal, and traction. In general, orthopedists are employed by hospitals, of a hospital. Very minor procedures such as set- medical centers, trauma centers, or free-standing surgical ting a broken bone may be performed in a profes- centers where they work closely with a surgical team, sional office or an emergency room of a hospital. including an anesthesiologist and surgical nurse. Ortho- pedic surgery can be performed under general, regional, or local anesthesia. ments, the ligaments and tendons. It may also include Much of the work of an orthopedic surgeon involves some problems of the nervous system, such as those that adding foreign material to the body in the form of arise from injury of the spine. These problems can occur screws, wires, pins, tongs, and prosthetics to hold dam- at birth, through injury, or as the result of aging. They aged bones in their proper alignment or to replace dam- may be acute, as in an accident or injury, or chronic, as aged bone or connective tissue. Great improvements in many problems related to aging. have been made in the development of artificial limbs and joints, and in the materials available to repair dam- Orthopedics comes from two Greek words, ortho, age to bones and connective tissue. As developments meaning straight, and pais, meaning child. Originally, or- occur in the fields of metallurgy and plastics, changes thopedic surgeons treated skeletal deformities in children, will take place in orthopedic surgery that will allow sur- using braces to straighten the child’s bones. With the de- geons to more nearly duplicate the natural functions of velopment of anesthesia and an understanding of the im- bones, joints, and ligaments, and to more accurately re- portance of aseptic technique in surgery, orthopedic sur- store damaged parts to their original ranges of motion. geons extended their role to include surgery involving the bones and related nerves and connective tissue. Diagnosis/Preparation The terms orthopedic surgeon and orthopedist are used interchangeably today to indicate a medical doctor Persons are usually referred to an orthopedic sur- with special training and certification in orthopedics. geon by a primary care physician, emergency room physician, or other doctor. Prior to any surgery, candi- Many orthopedic surgeons maintain a general prac- dates undergo extensive testing to determine appropriate tice, while some specialize in one particular aspect of or- corrective procedures. Tests may include x rays, comput- thopedics such as hand surgery, joint replacements, or ed tomography (CT) scans, magnetic resonance imag- disorders of the spine. Orthopedists treat both acute and ing (MRI), myelograms, diagnostic arthroplasty, and chronic disorders. Some orthopedic surgeons specialize blood tests. The orthopedist will determine the history of in trauma medicine and can be found in emergency the disorder and any treatments that were previously rooms and trauma centers, treating injuries. Others find tried. A period of rest to the injured part may be recom- their work overlapping with plastic surgeons, geriatric mended before surgery is undertaken. specialists, pediatricians, or podiatrists (foot care spe- cialists). A rapidly growing area of orthopedics is sports Surgical candidates undergo standard blood and medicine, and many sports medicine doctors are board urine tests before surgery and, for major procedures, certified in orthopedic surgery. may be given an electrocardiogram or other diagnostic tests prior to the operation. Individuals may choose to Demographics donate some of their own blood to be held in reserve for The American Academy of Orthopedic Surgeons re- their use in major surgery such as knee replacement, ports that in 2003, there are 15,853 active fellows, 1,829 during which heavy bleeding is common. resident members, and 2,240 candidate members, for a total of 19,922 orthopedic surgeons in the United States. Aftercare Rehabilitation from orthopedic injuries can require Description long periods of time. Rehabilitation is usually physically The range of treatments provided by orthopedists is and mentally taxing. Orthopedic surgeons will work extensive. They include procedures such as traction, closely with physical therapists to ensure that patients re- 1064 GALE ENCYCLOPEDIA OF SURGERY

ceive treatment that will enhance the range of motion and return function to all affected body parts. QUESTIONS TO ASK THE DOCTOR Risks Orthopedic surgery • What tests will be performed prior to surgery? As with any surgery, there is always the risk of ex- cessive bleeding, infection, and allergic reaction to anes- • How will the procedure affect daily activities thesia. Risks specifically associated with orthopedic after recovery? surgery include inflammation at the site where foreign • Where will the surgery be performed? materials (pins, prostheses, or wires) are introduced into • What form of anesthesia will be used? the body, infection as the result of surgery, and damage • What will be the resulting appearance and to nerves or to the spinal cord. level of function after surgery? Normal results • Is the surgeon board certified by the Ameri- can Academy of Orthopedic Surgeons? Thousands of people have successful orthopedic • How many similar procedures has the sur- surgery each year to recover from injuries or to restore lost geon performed? function. The degree of success in individual recoveries depends on an individual’s age and general health, the • What is the surgeon’s complication rate? medical problem being treated, and a person’s willingness to comply with rehabilitative therapy after the surgery. Abnormal results from orthopedic surgery include Townsend, C., K. L. Mattox, R. D. Beauchamp, B. M. Evers, persistent pain, swelling, redness, drainage or bleeding and D. C. Sabiston. Sabiston’s Review of Surgery, 3rd Edi- in the surgical area, surgical wound infection resulting in tion. Philadelphia: Saunders, 2001. slow healing, and incomplete restoration of pre-surgical function. PERIODICALS Caprini, J. A., J. I. Arcelus, D. Maksimovic, C. J. Glase, J. G. Morbidity and mortality rates Sarayba, and K. Hathaway. “Thrombosis Prophylaxis in Orthopedic Surgery: Current Clinical Considerations.” Mortality from orthopedic surgical procedures is not Journal of the Southern Orthopedic Association 11, no.4 common. The most common causes for mortality are ad- (2002): 190–196. verse reactions to anesthetic agents or drugs used to con- O’Brien, J. G. “Orthopedic Surgery: A New Frontier.” Mayo trol pain, post-surgical clot formation in the veins, and Clinic Proceedings 78, no.3 (2003): 275–277. post-surgical heart attacks or strokes. Ribbans, W. J. “Orthopedic Care in Haemophilia.” Hospital Medicine 64, no.2 (2003): 68–69. Alternatives Showstack, J. “Improving Quality of Care in Orthopedic For the removal of diseased, non-functional, or non- Surgery.” Arthritis and Rheumatism 48, no.2 (2003): vital tissue, there is no alternative to orthopedic surgery. 289–290. Alternatives to orthopedic surgery depend on the condi- ORGANIZATIONS tion being treated. Medications, acupuncture, or hypno- sis are used to relieve pain. Radiation is an occasional al- American Academy of Orthopedic Surgeons. 6300 North River Road Rosemont, IL 60018-4262. (847) 823-7186 or (800) ternative for shrinking growths. Chemotherapy may be 346-2267. <http://www.aaos.org/wordhtml/home2.htm>. used to treat bone cancer. Some foreign bodies may re- American College of Sports Medicine. 401 West Michigan main in the body without harm. Street, Indianapolis, IN 46202-3233 (Mailing Address: See also Elective surgery; Finding a surgeon. P.O. Box 1440, Indianapolis, IN 46206-1440). (317) 637- 9200, Fax: (317) 634-7817. <http://www.acsm.org>. Resources American College of Surgeons. 633 North Saint Claire Street, BOOKS Chicago, IL 60611. (312) 202-5000. <http://www.facs. org/>. Bland, K. I., W. G. Cioffi, and M. G. Sarr. Practice of General Surgery. Philadelphia: Saunders, 2001. American Society for Bone and Mineral Research 2025 M Canale, S. T. Campbell’s Operative Orthopedics. St. Louis: Street, NW, Suite 800, Washington, DC 20036-3309. Mosby, 2003. (202) 367-1161. <http://www.asbmr.org/>. Schwartz, S. I., J. E. Fischer, F. C. Spencer, G. T. Shires, and J. Orthopedic Trauma Association. 6300 N. River Road, Suite M. Daly. Principles of Surgery, 7th Edition. New York: 727, Rosemont, IL 60018-4226. (847) 698-1631. <http:// McGraw Hill, 1998. www.ota.org/links.htm>. GALE ENCYCLOPEDIA OF SURGERY 1065

Otoplasty KEY TERMS • To reconstruct an external ear in children who are born with a partially or completely missing auricle (the visi- ble part of the external ear). This type of birth defect is Arthroplasty—The surgical reconstruction or re- placement of a joint. called microtia; it occurs in such disorders as hemifa- cial microsomia and Treacher Collins syndrome. Most Prosthesis—A synthetic replacement for a missing cases of microtia, however, involve only one ear. part of the body such as a knee or a hip. • To correct the appearance of protruding or prominent Range of motion—The normal extent of move- ears. This procedure is also known as setback otoplasty ment (flexion and extension) of a joint. or pinback otoplasty. • To correct major disparities in the size or shape of a pa- tient’s ears. OTHER • To reshape deformed ears. One congenital type of defor- American Osteopathic Association. [cited April 7, 2003] mity is known as Stahl’s ear, which is characterized by a <http://www.aoa-net.org/Certification/orthopedsurg.htm>. pointed upper edge produced by the flattening of the ear Brigham and Woman’s Hospital (Harvard University School of rim and folding of the cartilage. Stahl’s deformity is also Medicine). [cited April 7, 2003] <http://splweb.bwh.har- known as Vulcan ear or Spock ear because it resembles vard.edu:8000/pages/projects/ortho/ortho.html>. the ears of the well-known Star Trek character. Martindale’s Health Science Guide, 2003. [cited April 7, 2003] <http://www-sci.lib.uci.edu/HSG/MedicalSurgery.html>. • To repair or reconstruct the auricle after traumatic in- Thomas Jefferson University Hospital. [cited April 7, 2003] juries or cancer surgery. <http://www.jeffersonhospital.org/e3front.dll?durki= Otoplasty is considered reconstructive rather than 4529>. cosmetic surgery. Consequently, it is often covered by University of Maryland College of Medicine. [cited April 7, health insurance. People who are considering otoplasty for 2003] <http://www.umm.edu/surg-ortho/>. themselves or their children should check with their insur- L. Fleming Fallon, Jr, MD, DrPH ance carrier about coverage. The average surgeon’s fee for an otoplasty in the United States in 2001 was $2,168. Otoplasty is not done to correct hearing difficulties Orthopedic x rays see Bone x rays related to the structures of the middle and inner ear. Orthotopic transplantation see Liver Hearing problems are treated surgically by otolaryngolo- gists (physicians who specialize in ear, nose, and throat transplantation procedures). Osteotomy, hip see Hip osteotomy Osteotomy, knee see Knee osteotomy Demographics Otolaryngologic surgery see Ear, nose, and Statistics for congenital deformities of the external throat surgery ear are difficult to obtain because the causes are so di- verse. Such genetic disorders as Treacher Collins syn- drome and hemifacial microsomia affect between one in 3,500 and one in 10,000 children. In addition, microtia has been associated with certain medications taken dur- ing pregnancy—particularly anticonvulsants, which are Otoplasty drugs given to treat epilepsy, and isotretinoin, a drug pre- scribed for severe acne. Definition Stahl’s deformity is found more often among Asian Otoplasty refers to a group of plastic surgery proce- Americans than among Caucasian or African Americans. dures done to correct deformities of or disfiguring injuries As of 2003, it is thought to be a hereditary disorder. to the external ear. It is the only type of plastic surgery that is performed more often in children than adults. Setback or pinback otoplasty is the most frequently performed procedure for reconstruction of prominent or protruding ears. According to the American Society of Purpose Plastic Surgeons, 33,107 setback otoplasties were per- Otoplastic surgery may done for the following rea- formed in the United States in 2001. This figure repre- sons: sents about 2% of all plastic surgical procedures. There 1066 GALE ENCYCLOPEDIA OF SURGERY

Otoplasty Otoplasty Incision is made to expose ear cartilage A. B. Permanent sutures pull the ear back Incision is closed C. D. Dressing is applied During a setback otoplasty, an incision is made in the back of the ear, exposing cartilage (A). Permanent sutures in the carti- lage pull the ear back closer to the skull (B).The incision is closed (C), and dressings are applied (D). (Illustration by GGS Inc.) are no exact statistics on the incidence of protruding and 25. Most cases of auricular avulsion in children, ears in the general population, although about 8% of pa- however, are caused by dog bites, which are likely to tients treated for this deformity have a family history of cause crushing as well as tearing of the tissues. Although it. Large or protruding ears appear to be equally com- statistics cover bites on all parts of the body, it is still mon in males and females; however, it is easier for girls noteworthy that plastic surgeons in the United States per- and women to avoid social discomfort by styling their formed 43,687 operations to repair injuries caused by hair to cover their ears. This factor may explain why a animal bites in 2001. slight majority (53%) of setback otoplasties is done on boys. Although most setback otoplasties are performed Description in children between the ages of four and 14, the second Otoplasty in children is performed under general largest group of patients in this category is women in anesthesia; in adults, it may be done under either general their 20s and 30s. anesthesia or local anesthesia with sedation. Most oto- plasties take about two or three hours to complete. Many The most common cause of trauma requiring oto- plastic surgeons prefer to use absorbable sutures when plasty is human and animal bites. Although exact figures performing an otoplasty in order to minimize the risk of are not known because many bite cases are not reported, disturbing the shape of the ear by removing stitches later. a large percentage of dog and human bites cause wounds on the head and neck. With regard to human bites, the Otoplasty for microtia single most common injury requiring medical treatment is auricular avulsion, or tearing of the external ear. In the Otoplasty for microtia requires a series of three or United States, 93% of patients treated for ear injuries four separate operations. In the first operation, a piece of caused by human bites are males between the ages of 15 cartilage is removed from the child’s rib cage on the side GALE ENCYCLOPEDIA OF SURGERY 1067

Otoplasty THE PROCEDURE AND movable sutures. Removal of cartilage is sometimes re- ferred to as a conchal resection. WHO PERFORMS Another procedure for protruding ears involves the WHERE IS IT PERFORMED? removal of skin and suturing the cartilage back on itself. This technique reshapes the ear without the need to re- Otoplasties for microtia and prominent or de- move cartilage; it is sometimes called a cartilage-sparing formed ears are specialized procedures per- otoplasty. formed only by qualified plastic surgeons. Plas- After the surgeon has finished reshaping the ear and tic surgeons are doctors who have completed carefully drying the area, the incision is closed. The sur- three years of general surgical training, fol- geon covers the ear with a cotton dressing moistened lowed by two to three years of specialized with mineral oil or other soft dressing. training in plastic surgery. There are, however, relatively few plastic surgeons who perform otoplasties for microtia. Diagnosis/Preparation Ear molding as an alternative to surgery is Congenital abnormalities of the ear performed by a plastic surgeon as an outpatient or office procedure. Diagnosis of microtia is made by the obstetrician or Traumatic injuries of the external ear are pediatrician at the time of the child’s birth. The diagnosis treated initially by an emergency physician, of prominent or protruding ears, however, is somewhat trauma surgeon, or plastic surgeon; in most more complex because the deformity is a matter of shape cases, an otolaryngologist is consulted to deter- and proportion rather than the absence or major malfor- mine whether the inner structures of the ear mation of a body part. The head of a newborn infant is have also been injured. Revision plastic surgery larger in proportion to its body than is the case in adults, may be performed later to remove scar tissue. and as a result, the shape of the ears may not concern the parents until the child is two or three years old. Otoplasty to correct microtia is usually started when the child is at least five years old. The surgeon must re- opposite the affected ear, so that the surgeon can use the move a portion of rib cartilage in order to construct a natural curve of the cartilage in fashioning the new ear. framework for the missing ear, and children younger than The surgeon works from a template derived from pho- five may not have enough cartilage. In addition, it is easi- tographs and computer models when he or she carves the er for the surgeon to use the child’s normal ear as a model cartilage into the desired shape. The cartilage is then for the size and shape of the reconstructed ear when the carefully positioned under the skin on the side of the child is five or seven years old. Otoplasty for microtia is face. The skin will shape itself to fit the cartilage frame- preceded by consultations between the surgeon and the work of the new ear. The second and third operations are child’s parents. Following the diagnosis, a comprehensive done to shape the ear lobe and to raise the new ear into treatment plan is made that includes long-term psychoso- its final position. cial as well as surgical follow-up. The reconstruction of a missing ear must be done in several stages because the Otoplasty for protruding ears surgeon must allow for changes in the proportions of the child’s face and skull as he or she matures as well as at- There is no universally accepted single technique tempt to make the new ear look as normal as possible. for performing a setback otoplasty. Variations in the pro- As of 2003, there is some debate among plastic sur- cedure are due partly to the different causes of ear pro- geons concerning the best age for performing a setback trusion. The patient’s ear may have a large concha (the otoplasty. Many recommend the operation when the child shell-like hollow of the external ear); the angle of the is between five and seven years old. One reason is that the fold in the ear cartilage may cause the ear to protrude; or human ear has attained 85–90% of its adult size by this the ear lobe may be unusually large. age, and therefore the surgeon can estimate the final size After the patient has been anesthetized, the surgeon and shape of the ear with considerable accuracy. In addi- makes an incision behind the ear in the fold of skin tion, the cartilage in the ear is still relatively soft and easi- where the ear meets the head. In one technique, the sur- er for the surgeon to reshape. Another reason for perform- geon exposes the ear cartilage beneath the skin and re- ing an otoplasty in children in the early elementary shapes it or removes a small piece. The cartilage is bent school years is psychological; name-calling and teasing back toward the head and secured in place with non-re- by peers can be emotionally destructive for children in 1068 GALE ENCYCLOPEDIA OF SURGERY

this age bracket. On the other hand, some surgeons have reported performing setback otoplasties on children as QUESTIONS Otoplasty young as nine months with no disturbances in the growth TO ASK THE DOCTOR of the ear or recurrence of the problem. • How long will it take for the ear to assume its Preparation for otoplasty in children should include final shape? an assessment of the child’s feelings about the proce- dure. Some surgeons consider opposition on the child’s • How much change in the shape of the ear part to be a contraindication for surgery, as well as unre- can be reasonably expected? alistic expectations on the part of the parents. In general, • Would my child benefit from ear molding a positive attitude is associated with faster recovery and rather than surgery? better overall results. • How many otoplasties have you performed? Preparation for otoplasty in adults includes a physi- cal examination and standard blood tests. Patients are usually advised to discontinue taking aspirin and any Patients should also avoid contact sports for at least other medications that thin the blood for two weeks prior three months after otoplasty. An anti-inflammatory med- to surgery. Plastic surgeons strongly urge adult patients ication (Kenalog) can be applied to the ear in the event to quit smoking before the surgery, because smoking de- of abnormal scar formation. lays and complicates the healing process. Adult patients are also asked to shower and shampoo their hair thor- oughly on the morning of the procedure. Men should Risks have a haircut or trim a day or two before surgery; Some risks associated with otoplasties are common women should braid or pin their hair close to the head. to all operations performed under general anesthesia. They include bleeding or infection of the incision; Trauma numbness or loss of feeling in the area around the inci- sion; and a reaction to the anesthesia. Avulsion injuries caused by bites, thermal or chemi- cal burns resulting from industrial accidents, and other Specific risks associated with otoplasties include the traumatic injuries of the auricle are diagnosed by emer- following: gency physicians. • Formation of abnormal scar tissue. This complication can usually be corrected later; plastic surgeons advise Plastic surgery for traumatic injuries of the auricle is waiting at least six months for revision surgery. preceded by thorough cleansing of the wound and de- bridement of damaged tissue. It is important to treat ear • Hematoma, which is a collection of blood within a body injuries promptly because the ears are not well supplied organ or tissue caused by leakage from broken blood with blood vessels. This characteristic makes it easier for vessels. In the case of the ear, a hematoma can damage infection to develop in parts of the auricle where the skin the results of plastic surgery because it creates tension has been torn open or crushed. In some cases, plastic and pressure that distort the final shape of the ear. Care- surgery is postponed for a few days and the patient is ful drying of the ear at the end of the procedure and ap- given oral penicillin to prevent infection. plication of a pressure bandage can reduce the risk of a hematoma. In the event that one develops, it is treated by reopening the incision and draining the collected blood. Aftercare • Distortion of the shape of the ear caused by overcorrec- After an otoplasty, the patient’s head is wrapped tion of deformed features. with a turban-type bandage that is worn for four or five • Reappearance of ear protrusion (in setback otoplasty). days following surgery. The patient is instructed to wear This complication is most likely to occur in the first six a ski-type headband over the ears continuously for about months after surgery. a month after the turban is removed, and then at night for an additional two months. Warm compresses should be Normal results applied to the ears two or three times a day for two The normal result of an otoplasty is a reconstructed weeks after the turban is removed. or reshaped ear that resembles a normal ear (or the pa- Patients should follow the surgeon’s instructions tient’s other ear) more closely. In a setback otoplasty, the about washing their hair, and avoid holding hot-air blow normal result is an ear that lies closer to the patient’s dryers too close to the ear. head without an overcorrected, “pinned-back” look. GALE ENCYCLOPEDIA OF SURGERY 1069

Otoplasty KEY TERMS Auricle—The portion of the external ear that is not contained inside the head. It is also called the Microtia—The partial or complete absence of the auricle of the ear. pinna. Pinna—Another name for the auricle; the visible Avulsion—A type of injury caused by ripping or portion of the external ear. tearing. Most ear injuries requiring otoplasty are avulsion injuries. Setback otoplasty—A surgical procedure done to reduce the size or improve the appearance of large Concha—The hollow shell-shaped portion of the or protruding ears; it is also known as pinback oto- external ear. plasty. Congenital—Present at the time of birth. Stahl’s deformity—A congenital deformity of the Ear molding—A non-surgical method for treating ear ear characterized by a flattened rim and pointed deformities shortly after birth with the application of upper edge caused by a fold in the cartilage; it is a mold held in place by tape and surgical glue. also known as Vulcan ear or Spock ear. Hematoma—A localized collection of blood in an Treacher Collins syndrome—A disorder that affects organ or tissue due to broken blood vessels. facial development and hearing, thought to be Hemifacial microsomia (HFM)—A term used to de- caused by a gene mutation on human chromo- scribe a group of complex birth defects character- some 5. Treacher Collins syndrome is sometimes ized by underdevelopment of one side of the face. called mandibulofacial dysostosis. Morbidity and mortality rates There are no effective alternatives to otoplasty in treating ear deformities or injuries in adults; however, The mortality rate in otoplasty is extremely low and some plastic surgeons use custom-made silicone molds is almost always associated with anesthesia reactions. to help maintain the position of the ears in adult patients The most common complication reported is asymmetri- for several weeks after surgery. cal ears (18.4%), followed by skin irritation (9.8%); in- creased sensitivity to cold (7.5%); soreness when the ear See also Craniofacial reconstruction; Pediatric sur- is touched (5.7%); abnormal shape to the ear (4.4%); gery. loss of feeling in the ear (3.9%); bleeding (2.6%); and hematoma (0.4%). Resources Alternatives BOOKS “Chromosomal Abnormalities.” Section 19, Chapter 261 in The Some ear deformities in children, including protrud- Merck Manual of Diagnosis and Therapy, edited by Mark ing ears and Stahl’s deformity, can be treated with ear H. Beers and Robert Berkow. Whitehouse Station, NJ: molding in the early weeks of life, when the cartilage in Merck Research Laboratories, 1999. the ear can be reshaped by the application of splints and “Drugs in Pregnancy.” Section 18, Chapter 249 in The Merck Steri-Strips. One technique involves making a mold in Manual of Diagnosis and Therapy, edited by Mark H. the shape desired for the child’s ear from dental com- Beers and Robert Berkow. Whitehouse Station, NJ: Merck pound and attaching it to the ear with methylmethacry- Research Laboratories, 1999. late glue. The ear and the mold are held in place with “External Ear: Trauma.” Section 7, Chapter 83 in The Merck surgical tape and covered with a tubular bandage or ear Manual of Diagnosis and Therapy, edited by Mark H. wrap for reinforcement. The mold and tape must be worn Beers and Robert Berkow. Whitehouse Station, NJ: Merck constantly for six weeks, with a change of dressing every Research Laboratories, 1999. two weeks. Ear molding is reported to be about 85% ef- Sargent, Larry. The Craniofacial Surgery Book. Chattanooga, fective when it is started within six weeks after the TN: Erlanger Health System, 2000. baby’s birth. It costs less than surgery—about $600— PERIODICALS and is considerably less painful. The chief disadvantage Aygit, A. C. “Molding the Ears After Anterior Scoring and of ear molding is its ineffectiveness in treating ear defor- Concha Repositioning: A Combined Approach for Pro- mities characterized by the absence of skin and cartilage truding Ear Correction.” Aesthetic Plastic Surgery, 27 rather than distorted shape. (March 14, 2003) [e-publication ahead of print]. 1070 GALE ENCYCLOPEDIA OF SURGERY

Bauer, B. S., D. H. Song, and M. E. Aitken. “Combined Oto- plasty Technique: Chondrocutaneous Conchal Resection Outpatient surgery as the Cornerstone to Correction of the Prominent Ear.” Plastic and Reconstructive Surgery, 110 (September 15, Definition Outpatient surgery 2002): 1033–1040. Outpatient surgery, also referred to as ambulatory Caouette-Laberge, L., N. Guay, P. Bortoluzzi, and C. surgery, is surgery that does not require an overnight Belleville. “Otoplasty: Anterior Scoring Technique and Results in 500 Cases.” Plastic and Reconstructive hospital stay. Patients may go home after being released Surgery, 105 (February 2000): 504–515. following surgery and time spent in the recovery room. Furnas, D. W. “Otoplasty for Prominent Ears.” Clinics in Plas- tic Surgery, 29 (April 2002): 273–288. Purpose Gosain, A. K., and R. F. Recinos. “Otoplasty in Children Less than Four Years of Age: Surgical Technique.” Journal of Mounting pressure to keep hospitalization costs Craniofacial Surgery, 13 (July 2002): 505–509. down and improved technology have increased the fre- McNamara, Robert M. “Bites, Human.” eMedicine, April 25, quency of outpatient surgery, with shorter medical pro- 2001 [April 7, 2003]. <www.emedicine.com/emerg/topic cedure duration, fewer complications, and less cost. 61.htm>. Manstein, Carl H. “Ear, Congenital Deformities.” eMedicine, June 20, 2002 [April 6, 2003]. “www.emedicine.com/ Description plastic/topic207.htm>. Due to improved pain control, advanced medical Peker, F., and B. Celikoz. “Otoplasty: Anterior Scoring and techniques—including those that reduce recovery time— Posterior Rolling Technique in Adults.” Aesthetic Plastic and cost-cutting considerations, more and more surgeries Surgery, 26 (July–August 2002): 267–273. are being performed on an outpatient basis. Surgeries Vital, V., and A. Printza. “Cartilage-Sparing Otoplasty: Our Ex- suited to a non-hospital setting generally are those with a perience.” Journal of Laryngology and Otology, 116 (Sep- low percentage of postoperative complications, which tember 2002): 682–685. Yugueros, P., and J. A. Friedland. “Otoplasty: The Experience would require serious attention by a physician or nurse. of 100 Consecutive Patients.” Plastic and Reconstructive Outpatient surgery continues to mushroom: in 1984, Surgery, 108 (September 15, 2001): 1045–1051. roughly 400,000 outpatient surgeries were performed. By 2000, the number had risen to 8.3 million. A 2002 ORGANIZATIONS study reports that 65% of all surgical procedures did not American Academy of Facial Plastic and Reconstructive involve a hospital stay. This statistic also reflects the fact Surgery (AAFPRS). 310 South Henry Street, Alexandria, that many patients (especially children) prefer to recover VA 22314. (703) 299-9291. <www.facemd.org>. American Society of Plastic Surgeons (ASPS). 444 East Algo- at home or in a familiar setting. nquin Road, Arlington Heights, IL 60005. (847) 228- With increased technological advances in instru- 9900. <www.plasticsurgery.org>. ments such as the arthroscope and laparoscope, more FACES: The National Craniofacial Association. P. O. Box physicians are performing surgery in their offices or in 11082, Chattanooga, TN 37401. (800) 332-2373. <www. other outpatient settings, primarily ambulatory clinics faces-cranio.org>. and surgical centers, or surgicenters. Among the most National Organization for Rare Disorders (NORD). 55 Kenosia Avenue, P. O. Box 1968, Danbury, CT 06813-1968. (203) frequently performed outpatient surgeries are tonsillec- 744-0100. tomies, arthroscopy, cosmetic surgery, removal of cataracts, gynecological, urological and orthopedic pro- OTHER cedures, wound and hernia repairs, and gallbladder re- American Academy of Facial Plastic and Reconstructive movals. Even such procedures as microscopically con- Surgery. 2001 Membership Survey: Trends in Facial Plas- tic Surgery. Alexandria, VA: AAFPRS, 2002. trolled surgery under local anesthesia (Mohs) for skin American Academy of Facial Plastic and Reconstructive cancer have been recommended on an outpatient basis. Surgery. Procedures: Understanding Otoplasty Surgery, [April 6, 2003]. <www.facial-plastic-surgery.org/patient/ Preparation procedures/otoplasty.html>. American Society of Plastic Surgeons. Procedures: Otoplasty, While many outpatient surgeries are covered by in- [April 5, 2003]. <www.plasticsurgery.org/public_educa surance plans, many are not. Candidates for such surg- tion/procedures/Otoplasty.cfm>. eries should check in advance with their insurance carri- er concerning whether their procedures are covered on Rebecca Frey, PhD an outpatient basis. Preparing for outpatient surgery varies, of course, Otosclerosis surgery see Stapedectomy with the surgical procedure to be performed. There are, GALE ENCYCLOPEDIA OF SURGERY 1071

Oxygen therapy however, guidelines common to most outpatient surg- Ambulatory surgery—Surgery done on an outpa- KEY TERMS eries. Patients should be in good health before undergo- ing ambulatory surgery. Colds, fever, chills, or flu symp- toms are all reasons to postpone a procedure, and surgi- tient basis; the patient goes home the same day. cal candidates should notify their primary health care physicians if such conditions exist. ty with at least two operating rooms, either con- Patients should check with their physician for all in- Ambulatory surgery center—An outpatient facili- formation covering preparation for outpatient proce- nected or not connected to a hospital. dures. A near-universal requirement is to have a family Outpatient procedures—Surgery that is per- member or friend take charge of delivering the outpatient formed on an outpatient basis, involving less re- to surgery, either to wait there or to arrive in time to pick covery time and fewer expected complications. up the patient on release from recovery. The evening be- fore, a light meal is recommended to preoperative pa- tients, with no alcohol taken for a full day before surgery. Nothing is to be taken by mouth after midnight Joint Commission on Accreditation of Healthcare Or- of the day preceding surgery. Smokers should stop or cut ganizations. back on smoking prior to surgery. Loose-fitting clothing Among problems encountered during outpatient is recommended, and it is advised to bring enough surgery are those concerning anesthesia administration, money along to cover postoperative prescription drugs. infection, bleeding that calls for a transfusion, and res- This same information applies if the outpatient is a piratory and resuscitation events. child. If children are permitted clear liquids on the day of outpatient surgery, parents will be told when the child Resources must stop taking them. Surgery will be cancelled or de- PERIODICALS layed if these requirements are not met. Lewis, C. “Sizing up Surgery.” FDA Consumer Magazine (No- vember–December, 1998). <http://www.fda.gov/fdac/fea- tures/1998/698_surg.html>. Results ORGANIZATIONS The benefits of outpatient surgery include lower Joint Commission on Accreditation of Healthcare Organiza- medical costs (one study sets them at 60–75% lower than tions. (630) 792-5000. <http://www.jcaho.org/>. comparable hospital procedures), tighter scheduling— Questions To Ask Your Doctor Before You Have Surgery. because patients are not subject to the potential delays Agency for Health Care Research and Quality. encountered in hospital operating rooms—and what <http://www.ahcpr.gov/consumer/surgery.htm#head2/>. many patients would consider a less stressful environ- OTHER ment than a hospital setting. Recovery time spent in Wax, C. M. Preparation for Surgery. <http://www.HealthIs- one’s own home, either with familiar caregivers or home NumberOne.com>. nurses, is a choice many postoperative patients prefer. Complications related to surgery occur less than Nancy McKenzie, PhD 1% of the time in outpatient settings. However, in terms of patient safety, non-hospital settings are not as regu- lated as are hospitals, so patients should inquire about Ovary and fallopian tube removal see potential risks concerning outpatient surgery that arise Salpingo-oophorectomy in ambulatory clinics, surgical centers, and physicians’ offices. There are guidelines for surgery in outpatient Ovary removal see Oophorectomy settings, but oversight and enforcement may vary. In 2002, though 20 states required ambulatory surgical fa- cilities to be accredited by one of three existing accred- itation organizations, only half of these 20 states issued regulations on office-based procedures, and fewer still have established a system for reporting events in outpa- Oxygen therapy tient settings. Patients may wish to find out whether Definition their outpatient center is licensed or certified as a med- ical facility, or is accredited, in the states that require Oxygen may be classified as an element, a gas, and this. The latter may be accomplished by contacting the a drug. Oxygen therapy is the administration of oxygen 1072 GALE ENCYCLOPEDIA OF SURGERY

at concentrations greater than that in room air to treat or extra work of the heart, and decreases shortness of breath. Oxygen therapy prevent hypoxemia (not enough oxygen in the blood). Oxygen therapy is frequently ordered in the home care Oxygen delivery systems are classified as stationary, setting, as well as in acute (urgent) care facilities. portable, or ambulatory. Oxygen can be administered by Some of the conditions oxygen therapy is used to nasal cannula, mask, and tent. Hyperbaric oxygen thera- treat include: py involves placing the patient in an airtight chamber • documented hypoxemia with oxygen under pressure. • severe respiratory distress (e.g., acute asthma or pneu- monia) Purpose • severe trauma The body is constantly taking in oxygen and releas- • chronic obstructive pulmonary disease (COPD, includ- ing carbon dioxide. If this process is inadequate, oxygen ing chronic bronchitis, emphysema, and chronic asthma) levels in the blood decrease, and the patient may need supplemental oxygen. Oxygen therapy is a key treatment • pulmonary hypertension in respiratory care. The purpose is to increase oxygen sat- • cor pulmonale uration in tissues where the saturation levels are too low • acute myocardial infarction (heart attack) due to illness or injury. Breathing prescribed oxygen in- creases the amount of oxygen in the blood, reduces the • short-term therapy, such as post-anesthesia recovery GALE ENCYCLOPEDIA OF SURGERY 1073

Oxygen may also be used to treat chronic lung dis- Oxygen therapy ease patients during exercise. • Compressed oxygen—oxygen that is stored as a gas in a tank. A flow meter and regulator are attached to the oxygen tank to adjust oxygen flow. Tanks vary in size Hyperbaric oxygen therapy is used to treat the fol- from very large to smaller, portable tanks. This system lowing conditions: is generally prescribed when oxygen is not needed con- • gas gangrene physical activity). • decompression sickness stantly (e.g., when it is only needed when performing • air embolism • Liquid oxygen—oxygen that is stored in a large sta- tionary tank that stays in the home. A portable tank is • smoke inhalation available that can be filled from the stationary tank for • carbon monoxide poisoning trips outside the home. Oxygen is liquid at very cold temperatures. When warmed, liquid oxygen changes to • cerebral hypoxic event a gas for delivery to the patient. Helium-oxygen therapy is a treatment that may be • Oxygen concentrator—electric oxygen delivery system used for patients with severe airway obstruction. The approximately the size of a large suitcase. The concen- combination of helium and oxygen, known as heliox, re- trator extracts some of the air from the room, separates duces the density of the delivered gas, and has been the oxygen, and delivers it to the patient via a nasal can- shown to reduce the effort of breathing and improve ven- nula. A cylinder of oxygen is provided as a backup in tilation when an airway obstruction is present. This type the event of a power failure, and a portable tank is avail- of treatment may be used in an emergency room for pa- able for trips outside the home. This system is generally tients with acute, severe asthma. prescribed for patients who require constant supplemen- tal oxygen or who must use it when sleeping. Description • Oxygen conserving device, such as a demand inspirato- Oxygen delivery (other than mechanical ry flow system or pulsed-dose oxygen delivery sys- ventilators and hyperbaric chambers) tem—uses a sensor to detect when inspiration (inhala- tion) begins. Oxygen is delivered only upon inspiration, In the hospital, oxygen is supplied to each patient thereby conserving oxygen during exhalation. These room via an outlet in the wall. Oxygen is delivered from systems can be used with either compressed or liquid a central source through a pipeline in the facility. A flow oxygen systems, but are not appropriate for all patients. meter attached to the wall outlet accesses the oxygen. A valve regulates the oxygen flow, and attachments may be connected to provide moisture. In the home, the oxygen Preparation source is usually a canister or air compressor. Whether in A physician’s order is required for oxygen therapy, home or hospital, plastic tubing connects the oxygen except in emergency use. The need for supplemental source to the patient. oxygen is determined by inadequate oxygen saturation, Oxygen is most commonly delivered to the patient indicated in blood gas measurements, pulse oximetry, or via a nasal cannula or mask attached to the tubing. The clinical observations. The physician will prescribe the nasal cannula is usually the delivery device of choice specific amount of oxygen needed by the patient. Some since it is well tolerated and doesn’t interfere with the pa- patients require supplemental oxygen 24 hours a day, tient’s ability to communicate, eat, or drink. The concen- while others may only need treatments during exercise tration of oxygen inhaled depends upon the prescribed or sleep. No special patient preparation is required to ad- flow rate and the ventilatory minute volume (MV). minister oxygen therapy. Another delivery option is transtracheal oxygen therapy, which involves a small flexible catheter inserted Patient education in the trachea or windpipe through a tracheostomy tube. SELECTING AN OXYGEN SYSTEM. A health care In this method, the oxygen bypasses the mouth, nose, provider will meet with the patient to discuss the oxygen and throat, and a humidifier is required at flow rates of 1 systems available. A system recommendation will be liter (2.1 pt) per minute and above. Other oxygen deliv- made, based on the patient’s overall condition and per- ery methods include tents and specialized infant oxygen sonal needs, as well as the system’s ease of use, reliabili- delivery systems. ty, cost, range of oxygen delivery, and features. The TYPES OF OXYGEN DELIVERY SYSTEMS. The types of health care provider can give the patient a list of medical oxygen delivery systems include: supply companies that stock home oxygen equipment 1074 GALE ENCYCLOPEDIA OF SURGERY

and supplies. The patient can meet with home care repre- Travel guidelines sentatives from these companies to evaluate the product Traveling with oxygen requires advanced planning. lines that best fit his or her needs. Patients in the home The patient needs to obtain a letter from his or her health Oxygen therapy setting are directed to notify the vendors when replace- care provider that verifies all medications, including ment oxygen supplies are needed. oxygen. In addition, a copy of the patient’s oxygen pre- OXYGEN SAFETY. Patients will receive instructions scription must be shown to travel personnel. Home about the safe use of oxygen in the home. Patients must health care companies can help the patient make travel be advised not to change the flow rate of oxygen unless plans, and can arrange for oxygen when the patient ar- directed to do so by the physician. rives at his or her destination. Patients cannot bring or use their own oxygen tanks on an airplane; therefore the Oxygen supports combustion, therefore no open patient must leave his or her portable oxygen tank at the flame or combustible products should be permitted when airport before boarding. Oxygen suppliers can pick up oxygen is in use. These include petroleum jelly, oils, and the oxygen unit from the airport if necessary, or a family aerosol sprays. A spark from a cigarette, electric razor, or member can take it home. other electrical device could easily ignite oxygen-satu- rated hair or bedclothes around the patient. Explosion- proof plugs should be used for vaporizers and humidifier Aftercare attachments. The patient should be sure to have a func- Once oxygen therapy is initiated, periodic assess- tioning smoke detector and fire extinguisher in the home ment and documentation of oxygen saturation levels is at all times. required. Follow-up monitoring includes blood gas mea- surements and pulse oximetry tests. If the patient is Care must be taken with oxygen equipment used in using a mask or a cannula, gauze can be tucked under the the home or hospital. The oxygen system should be kept tubing to prevent irritation of the cheeks or the skin be- clean and dust-free. Cylinders should be kept in carts, or hind the ears. Water-based lubricants can be used to re- have collars for safe storage. If not stored in a cart, lieve dryness of the lips and nostrils. smaller canisters may be lain on the floor. Knocking cylinders together can cause sparks, so bumping them should be avoided. In the home, the oxygen source must Risks be placed at least 6 ft (1.8 m) away from flames or other Oxygen is not addictive and causes no side effects sources of ignition, such as a lit cigarette. Oxygen tanks when used as prescribed. Complications from oxygen should be kept in a well–ventilated area. Oxygen tanks therapy used in appropriate situations are infrequent. should not be kept in the trunk of a car. “No Smoking— Respiratory depression, oxygen toxicity, and absorption Oxygen in Use” signs should be used to warn visitors atelectasis are the most serious complications of oxygen not to smoke near the patient. overuse. Special care must be given when administering oxy- A physician should be notified and emergency ser- gen to premature infants because of the danger of high vices may be required if the following symptoms develop: oxygen levels causing retinopathy of prematurity, or con- • frequent headaches tributing to the construction of ductus arteriosis. PaO 2 • anxiety (partial pressure of oxygen) levels greater than 80 mm Hg should be avoided. • cyanotic (blue) lips or fingernails • drowsiness Patients who are undergoing a laser bronchoscopy should receive concurrent administration of supplemen- • confusion tal oxygen to avoid burns to the trachea. • restlessness • slow, shallow, difficult, or irregular breathing Insurance clearance Oxygen delivery equipment may present other prob- The patient should check with his or her insurance lems. Perforation of the nasal septum as a result of using provider to determine if the treatment is covered and a nasal cannula and non–humidified oxygen has been re- what out-of-pocket expenses may be incurred. Oxygen ported. In addition, bacterial contamination of nebulizer therapy is usually fully or partially covered by most in- and humidification systems can occur, possibly leading surance plans, including Medicare, when prescribed ac- to the spread of pneumonia. High-flow systems that em- cording to specific guidelines. Usually test results indi- ploy heated humidifiers and aerosol generators, especial- cating the medical necessity of the supplemental oxygen ly when used by patients with artificial airways, also are needed before insurance clearance is granted. pose a risk of infection. GALE ENCYCLOPEDIA OF SURGERY 1075

Oxygen therapy Arterial blood gas test—A blood test that measures Pulmonary rehabilitation—A program that helps KEY TERMS oxygen and carbon dioxide in the blood. patients learn how to breathe easier and improve Atelectasis—Partial or complete collapse of the cludes treatment, exercise training, education, and lung, usually due to a blockage of the air passages their quality of life. Pulmonary rehabilitation in- with fluid, mucus or infection. counseling. Breathing rate—The number of breaths per minute. Pulmonologist—A physician who specializes in Cannula—Also called nasal cannula. A small, light- caring for people with lung diseases and breathing weight plastic tube with two hollow prongs that fit problems. just inside the nose. Nasal cannulas are used to supply supplemental oxygen through the nose. Pulse oximetry—A non-invasive test in which a de- vice that clips onto the finger measures the oxygen Cyanosis—Blue, gray, or dark purple discoloration of the skin caused by a deficiency of oxygen. level in the blood. Ductus arteriosis—A fetal blood vessel that con- Residual volume—The volume of air remaining in nects the pulmonary artery to the aorta; normally the lungs, measured after a maximum expiration. closes at birth. Respiratory failure—The sudden inability of the Flow meter—Device for measuring the rate of a gas (especially oxygen) or liquid. lungs to provide normal oxygen delivery or normal carbon dioxide removal. Hypoxemia—Oxygen deficiency, defined as an oxygen level less than 60 mm Hg or arterial oxy- Respiratory therapist—A health care professional gen saturation of less than 90%. Different values who specializes in assessing, treating, and educat- are used for infants and patients with certain lung ing people with lung diseases. diseases. Oxygenation—Saturation with oxygen. Total lung capacity test—A test that measures the amount of air in the lungs after a person has Peak expiratory flow rate—A test used to measure breathed in as much as possible. how fast air can be exhaled from the lungs. Pulmonary function tests—A series of tests that Vital capacity—Maximal breathing capacity; the measure how well air is moving in and out of the amount of air that can be expired after a maximum lungs and carrying oxygen to the bloodstream. inspiration. Normal results 2nd ed. Philadelphia: Lippincott Williams and Wilkins Publishers, 2003. A normal result is a patient that demonstrates ade- Wilkins, Robert, et al. Clinical Assessment in Respiratory quate oxygenation through pulse oximetry, blood gas Care, 2nd ed. St. Louis: Mosby, 2000. tests, and clinical observation. Signs and symptoms of in- Wilkins, Robert, et al. Egan’s Fundamentals of Respiratory adequate oxygenation include cyanosis, drowsiness, con- Care, 8th ed. St. Louis: Mosby, 2003. fusion, restlessness, anxiety, or slow, shallow, difficult, or Yutsis, Pavel I. Oxygen to the Rescue: Oxygen Therapies and irregular breathing. Patients with obstructive airway dis- How They Help Overcome Disease, Promote Repair, and ease may exhibit “aerophagia” (air hunger) as they work Improve Overall Function. Basic Health Publications, to pull air into the lungs. In cases of carbon monoxide in- Inc., 2003. halation, the oxygen saturation can be falsely elevated. PERIODICALS Resources Crockett, A. J., J.M. Cranston, et al. “A Review of Long-term BOOKS Oxygen Therapy for Chronic Obstructive Pulmonary Dis- Branson, Richard, et al. Respiratory Care Equipment 2nd. ed. ease.” Respiratory Medicine 95 (June 2001): 437-43. Philadelphia: Lippincott Williams and Wilkins Publishers, Eaton, T.E., et al. “An Evaluation of Short-term Oxygen Thera- 1999. py: The Prescription of Oxygen to Patients with Chronic Hyatt, Robert E., Paul D. Scanlon, Masao Nakamura,. Interpre- Lung Disease Hypoxic at Discharge.” Respiratory Medi- tation of Pulmonary Function Tests: A Practical Guide, cine 95 (July 2001): 582-7. 1076 GALE ENCYCLOPEDIA OF SURGERY

Kelly, Martin G., et al. “Nasal Septal Perforation and Oxygen National Heart, Lung and Blood Institute. Information Center. Cannulae.” Hospital Medicine 62, no.4 (April 2001): 248. P.O. Box 30105, Bethesda, Maryland 20824. (301) 251- Ruiz-Bailen M, M.C. Serrano-Corcoles, J.A. Ramos-Cuadra 2222. <http://www.nhlbi.nih.gov/nhlbi/>. “Tracheal Injury Caused by Ingested Paraquat.” Chest National Jewish Medical and Research Center. Lung-Line. Oxygen therapy 119, no.6 (June 2001): 1956-7. 14090 Jackson Street, Denver, Colorado 80206. <http:// www.nationaljewish.org>. ORGANIZATIONS American Association for Cardiovascular and Pulmonary Re- OTHER habilitation (AACVPR). 7600 Terrace Avenue, Suite 203, Daily Lung. <http://www.dailylung.com>. A full-feature maga- Middleton, Wisconsin 53562. (608) 831-6989. E-mail: zine covering lung disease and related health topics. [email protected]. <http://www.aacvpr.org>. National Lung Health Education Program. <http://www.nlhep. American Association for Respiratory Care. 11030 Ables Lane, org>. Dallas, Texas 75229. (972) 243-2272. E-mail: info@aarc. The Pulmonary Paper. P.O. Box 877, Ormond Beach, Florida org. <http://www.aarc.org>. 32175. (800) 950-3698. <http://www.pulmonarypaper. American College of Chest Physicians. 3300 Dundee Road, org>. Not-for-profit newsletter supporting people with Northbrook, Illinois 60062-2348. (847) 498-1400. <http:// chronic lung problems. www.chestnet.org>. American Lung Association and American Thoracic Society. Maggie Boleyn, R.N., B.S.N. 1740 Broadway, New York, NY 10019-4374. (800) Angela M. Costello LUNG-USA or (800) 586-4872. <http://www.lungusa. org>. Oxytocin see Uterine stimulants GALE ENCYCLOPEDIA OF SURGERY 1077