Surgical Philosophy

Concepts of Modern Surgery Paralleled to Sun Tzu's 'Art of War'

Hutan Ashrafian

• Publisher: CRC Press
• Year: 2015
• ISBN:
  9780429586422
• Edition: 1
• Topic: Business
• Subtopic: Service Industry
• Index: Business

Treating disease can be considered a combat between curative therapies and pathological afflictions. As such, the action of achieving a cure can be likened to successfully waging war on sickness and bodily disorders. Surgical Philosophy applies the core principles derived from Sun Tzu's timeless book Art of War to combating disease through surgery.

1 The Aims of Operative Surgery

1. Sun Tzu said: The art of war is of vital importance to the State.

1. The art of surgery is of vital importance to modern medicine and is a key component of modern healthcare.

2. It is a matter of life and death, a road either to safety or to ruin. Hence it is a subject of inquiry which can on no account be neglected.

2. It is a matter of life and death; a path to successful outcomes and patient satisfaction or medical complications, poor outcomes and death. As a result it should be studied and on no account can it be neglected by doctors and health practitioners.

3. The art of war, then, is governed by five constant factors, to be taken into account in one’s deliberations, when seeking to determine the conditions obtaining in the field.

3. The art of surgery is governed by five constant factors; these require consideration in one’s thoughts, analyses and decision making when reflecting on a surgical problem or assessing a patient.

4. These are: (1) The Moral Law; (2) Heaven; (3) Earth; (4) The Commander; (5) Method and discipline.

4. These are (1) Patient Safety and Ethics; (2) Science, Anatomy and Research; (3) Operating Environment and Staff; (4) The Surgeon; and (5) Surgical Training (Figure 1.1).

Figure 1.1 The five constant factors.

5, 6. The Moral Law causes the people to be in complete accord with their ruler, so that they will follow him regardless of their lives, undismayed by any danger.

5, 6. Patient Safety and Ethics allows doctors and health practitioners to be in complete accord with their fundamental values, so that they will follow these regardless of their careers, undismayed by complex pathologies and dangerous diseases.

7. Heaven signifies night and day, cold and heat, times and seasons.

7. Science, Anatomy and Research represents the knowledge of the human body, its diseases and treatments. Surgery cannot take place without a deep-rooted understanding of anatomy and surgical practice cannot occur without scientific principles and methods. The advancement of surgery can only take place through the objectivity and lack of bias offered by the scientific method in the practice of surgical research. This includes characterizations (definitions, observations, measurements), hypothesis development, predictions from the hypotheses (logical deduction and reasoning), experiments (testing), evaluation and improvement and confirmation. These processes have come to us from luminaries including Aristotle (384–322 BCE), Alhazen (c. 965–1040), Francis Bacon (1561–1626), Galileo Galilei (1564–1642) and Karl Popper (1902–1994, father of critical rationalism) but have been increasingly adopted by surgeons in the nineteenth, twentieth and twenty-first centuries.

All surgical practice should be based on the best evidence so that all surgeons should adhere to evidence-based surgery. Research data is required to support surgical decisions and actions, and the raw knowledge of research (molecular data, individual case data, clinical trial data, epidemiological data and policy data) is delivered into surgical practice through evidence synthesis. This offers the ability to combine all raw data from experiments whether quantitative or qualitative. Evidence synthesis techniques include a vast array of models and mathematical tools (including statistical tests and meta-analyses) to offer answers for surgical questions posed by individual surgeons, healthcare institutions, policymakers and even members of the public. This allows the practice of personalized evidence-based surgery and precision medicine. In patient care both research and audit are important elements of clinical governance and they have specific meanings. Research is related to the generation of new knowledge whereas audit is focussed on identifying how to improve certain practices and outcomes. There is clearly an overlap although the two concepts are distinct and are readily applied in patient care. Surgery cannot proceed without the application of the scientific method as this allows the appropriate translation of new knowledge. Whether it reflects the design of a new surgical robot, novel surgical molecular therapy or even psychological support of surgical patients, the application of science offers new knowledge to enhance patients’ treatments in a way that decreases inherent researcher biases but provides an environment of healthy generation of new surgical concepts.

8. Earth comprises distances, great and small; danger and security; open ground and narrow passes; the chances of life and death.

8. Operating environment and staff comprises the whole context in which operations take place. This includes the precision of operating instruments (from scalpel and diathermy to surgical robot). What is the patient pathway leading to the patient coming for an operation? What is the design and condition of the operating space or theatre? Is there for example conventional (mixing), plenum, laminar airflow (LAF or vertical parallel flow), directed airflow or combined ventilation? Who are the other theatre staff (assistant surgeon, anaesthetists, operating room practitioners)? What is their expertise and experience? What are their work and nonwork relationships with each other, the room, the patient and the surgeon? All these factors relate to the technical and nontechnical skills of all theatre members and if all these interactions are enhanced then patient safety and patient outcomes can be optimized.

9. The Commander stands for the virtues of wisdom, sincerity, benevolence, courage and strictness.

9. The surgeon stands for the virtues of leadership, wisdom, sincerity, benevolence, courage and strictness. The role of the surgeon is to completely know the patient, understand the disease process and guide the patient through the patient pathway. This includes actually operating on the patient, but also encompasses the broader role of supporting disease diagnosis and management while also guiding or contributing to nonoperative patient care where necessary. The surgeon is regularly considered to be a leader in the patient pathway, and consequently the role of the surgeon is fundamentally central in decision making, team management, pathway regulation, communication and the development of patient management policies.

10. By method and discipline are to be understood the marshaling of the army in its proper subdivisions, the graduations of rank among the officers, the maintenance of roads by which supplies may reach the army, and the control of military expenditure.

10. The art of surgery cannot exit or grow without surgical training. Surgeons need to be trained not only to operate but to perform all the technical and nontechnical elements of surgery. The application of simulators and surgical learning curves has relevance in direct surgical training but these concepts carry a wider resonance in terms of patient management experience, team iteration and the role of the surgeon in wider society. The provenance of simulation in surgical training is typically considered to be a modern phenomenon largely as an offshoot of simulation first developed in nonmedical fields (such as the airline industry and simulators for pilots). In reality, however, surgical simulation dates back to before the eighth century BCE. In the ancient Zoroastrian text of the Vendidad translated by James Darmesteter (Sacred Books of the East, Volume 4, 1880, Oxford University Press) the following text from Chapter 7, Verses 36 to 40 relates to surgeons (Kard-pezeshks or knife-doctors) operating on True-Worshipers and Demon-Worshipers:

[36.] O Maker of the material world, thou Holy One! If a True-Worshiper wants to practice the art of healing, on whom shall he first prove his skill? On True-Worshiper or Demon-Worshipers? [37.] The Lord answered: ‘Demon-Worshipers shall he first prove himself, rather than on True-Worshipers. If he treat with the knife a Demon-Worshiper and he die; if he treat with the knife a second Demon-Worshiper and he die; if he treat with the knife for the third time a Demon-Worshiper and he die, he is unfit for ever and ever. [38.] ‘Let him therefore never attend any True-Worshiper; let him never treat with the knife a True-Worshiper, nor wound him with the knife. If he shall ever attend any True-Worshiper, if he shall ever treat with the knife any True-Worshiper, and wound him with the knife, he shall pay for his wound the penalty for wilful murder. [39.] ‘If he treat with the knife a Demon-Worshiper and he recover; if he treat with the knife a second Demon-Worshiper and he recover; if for the third time he treat with the knife a Demon-Worshiper and he recover; then he is fit for ever and ever. [40.] ‘He may henceforth at his will attend True-Worshipers; he may at his will treat with the knife True-Worshipers, and heal them with the knife.’

This segment alludes that ‘simulation’ by surgery on three ‘non-believers’ with success would then allow a surgeon the right to operate on ‘believers’. Modern simulation techniques apply computer-based technologies, artificial tissue and models and virtual worlds. Each surgical situation (whether technical or nontechnical) can ultimately be replicated by a simulated scenario, to offer an appropriate surgical training environment. Enhanced surgical training can offer higher quality surgeons, improved patient outcomes and ultimately enriched patient well-being.

11. These five heads should be familiar to every general: he who knows them will be victorious; he who knows them not will fail.

11. These five factors should be familiar to every surgeon: he or she who knows them will succeed in treating his or her patients; he or she who knows them not will fail.

12. Therefore, in your deliberations, when seeking to determine the military conditions, let them be made the basis of a comparison, in this wise:

12. Therefore, in your deliberations, when seeking to determine and treat the surgical conditions of your patient(s), let them be made the basis of the following comparison:

13. (1) Which of the two sovereigns is imbued with the Moral law? (2) Which of the two generals has most ability? (3) With whom lie the advantages derived from Heaven and Earth? (4) On which side is discipline most rigorously enforced? (5) Which army is stronger? (6) On which side are officers and men more highly trained? (7) In which army is there the greater constancy both in reward and punishment?

13. (1) Which of the two hospitals (or healthcare institutions) offer the most rigorous patient safety and ethics?

(2) Which of the two surgeons has the most ability?

(3) With whom lie the advantages derived from Science, Anatomy and Research, and which healthcare institute offers the best operating environment and staff, who offers the best value and quality of care with the most safety?

(4) On which side is adherence to national/international guidelines most rigorously enforced?

(5) Which healthcare institute offers the strongest professional staff, surgeons and researchers?

(6) On which side are the surgeons and surgical trainees more highly trained?

(7) In which healthcare institution is there the greater constancy in reward, incentivisation and support (or training) for failing staff?

14. By means of these seven considerations I can forecast victory or defeat.

14. By means of these seven considerations I can forecast surgical treatment success or failure.

15. The general that hearkens to my counsel and acts upon it, will conquer: let such a one be retained in command! The general that hearkens not to my counsel nor acts upon it, will suffer defeat: let such a one be dismissed!

15. The surgeon who reflects on this advice and acts upon it will conquer disease: Individuals such as these should be kept and promoted as surgeons! Surgeons who do not consider these elements and who do not act upon them will fare poorly in the face of disease – such individuals should not receive support in a career in surgery.

16. While heading the profit of my counsel, avail yourself also of any helpful circumstances over and beyond the ordinary rules.

16. While contemplating the benefits of my advice, expose yourself also to other useful sources of healthcare environments, centres and knowledge over and above the ordinary lessons.

17. According as circumstances are favorable, one should modify one’s plans.

17. In surgery one needs to be both pragmatic and flexible. When operative circumstances are favourable, one should modify one’s decisions and actions to offer the patient the best gains and outcomes.

18. All warfare is based on deception.

18. All surgery can benefit from biological deception. Many disease processes contain elements of molecular deception or molecular mimicry where pathogens and disease processes utilize common molecular structures (genes-DNA, RNA or proteins) with healthy tissues to evade natural biological defences. For example cancer typically hijacks inherent biological structures and systems to generate cancer products, activating the phosphatidylinositide-3-OH kinase/3-phos-pho-inositide-dependent protein kinase-1 (PDK1)/Akt and the Raf/mitogen-activated protein kinase (MAPK/ERK) kinase (MEK)/mitogen-activated protein kinase (MAPK) pathways. Alternatively, pathogens utilize immune marker epitopes resembling natural human epitopes such as human leukocyte antigens (HLAs) of the major histocompatibility (MHC) molecule system to go ‘under the immune radar’. As a result auto-immunity can result where the body unwittingly attacks itself in order to exterminate pathogens carrying these immune recognition molecules. Retroviruses such as the human immunodeficiency virus (HIV) hijack and therefore ‘deceive’ host cells to utilize the cells’ own reverse transcriptase enzymes to produce DNA from its RNA genome to replicate and multiply this pathogenic lentivirus.

Surgeons, however, can also apply bio-deception tools in many guises to treat their patients.

The most common form of biological deception in surgery includes antibiotics such as those of the large β-lactam antibiotic family. Examples include the famous penicillin derivatives, cephalosporins, monobactams and carbapenems. These antibiotics all contain β-lactam segments, which are structural analogues to the D-alanyl-D-ala amino acid residues of the precursor NAM/NAG-peptide subunits of the peptidoglycan layer of the bacterial cell wall. When they are exposed to bacteria, antibiotics irreversibly bind to penicillin-binding proteins (PBPs) in competition with the reversible D-alanyl-D-alanine residues. As the PBPs regulate the final transpeptidation step in the synthesis of the peptidoglycan layer of the bacterial cell wall, further transpeptidation is limited and bacterial cell wall synthesis is disrupted and exposed. Consequently bacterial structural integrity and subsequent division is halted so that the bacteria cannot survive. As a result, β-lactam antibiotics are considered bactericidal and have saved millions of patient lives through bio-deception.

All forms of reconstructive techniques rely on deceiving the body’s healing process to heal a surgical man-made construct. Whether two segments of bowel are anastomosed with sutures or anastomotic gun after the surgical resection of cancer or a coronary artery is bypassed with a surgical conduit (typically ve...