Surgical Services History
Surgery plays major role in development of Central Maine Medical Center
When Central Maine General Hospital opened on July 1, 1891, records show the first patient was a 27-year-old “Welchville woman with abdominal troubles." Other than noting that her doctor was Edward H. Hill, M.D., the hospital’s founder, the record offers no further detail.
On the following day, an 18-year-old man was admitted for surgery. But unlike the case of the anonymous Oxford County woman, Charles Teague’s admission generated considerable interest. He "suffered with white swelling of the knee" and had decided that living without a leg was preferable to living with pain. Dr. Hill was engaged to do the amputation.
When Mr. Teague was raised by a hand-operated elevator to the attic of the original CMG building for his surgery, he was met by a group of onlookers. In a photograph that one of the doctors took of the scene, the dimly lit room seems crowded.
The attention paid to Mr. Teague’s operation shows the importance then placed on surgery as a way of treating health problems. Scarcely 50 years earlier, voluntarily submitting to the surgeon’s knife would have been considered the act of an unsound mind. But with improvements in anesthesia and more refined surgical techniques, surgeons were no longer associated in the public eye with barbers and butchers. They had emerged as healers in their own right.
In the many years since young Charles Teague abandoned his fear to faith in his surgeon at Central Maine General, thousands upon thousands of others have availed themselves of the tremendous health benefits offered through surgery at Central Maine Medical Center.
More than a century of extraordinary advances in surgery are today nowhere more evident than at Central Maine Medical Center, where an operating room in the attic of a wood-framed house has evolved into a spacious, high-tech facility serving dozens of surgeons and thousands of patients annually.
CMMC's surgical services facility was dedicated in 1993 as the Andre P. Marcotte, M.D., Surgical Suites in memory of the late Dr. Marcotte, an orthopedic surgeon who practiced at CMMC for some 25 years. Dr. Marcotte established a $500,000 charitable remainder trust for the benefit of CMMC.
CMMC’s Surgical Services Department is now comprised of 11 surgical suites and a cysto room. Two of the suites are dedicated to the Central Maine Heart and Vascular Institute’s (CMHVI) cardiac surgery program. Another suite is used for trauma surgery and a fourth suite is reserved for the neurosurgeons who practice at CMMC. The remaining suites are used for general, vascular, gynecological, and orthopedic procedures. The cysto room was developed for urologic procedures and contains special x-ray equipment.
The CMHVI operating suites are equipped with high-definition monitors that project images captured by cameras in the cardiac surgeon’s headlamp and in an overhead surgical light. These images help CMHVI’s cardiac surgeons better visualize their work. The CMHVI suites are also equipped with heart-lung machines used to maintain patients during cardiac surgery. Furthermore, these "smart ORs" are outfitted with special cabling, data connections, light booms, and display screens that can be upgraded to accommodate emerging technologies, including voice recognition and robotics.
CMMC’s surgical suites are located in a restricted area. Each suite is located next to a substerile room where instruments and equipment can be sterilized. Each suite is equipped with an airflow system that minimizes the chance of airborne contaminants compromising sterility. Many procedures done in CMMC’s surgical suites require specialized equipment, including microscopes, lasers, fiber optic scopes, video equipment, cautery units, irrigation systems, tourniquets, and specialized beds.
Patients who undergo surgery at CMMC are in skilled hands. The number of surgical or surgery-related specialists working at CMMC and its affiliated hospitals Bridgton Hospital and Rumford Hospital now encompasses dozens of highly-trained physicians whose practices range from anesthesia to vascular surgery. What draws these talented doctors to the area is CMMC itself: a regional referral center with a fine surgical services facility, intensive care unit, radiology and laboratory support, and a broad range of primary and specialty care physicians.
Better tools, advancing techniques
Better tools for diagnosis, advances in anesthesia and surgical techniques, and improved post-operative care have all advanced the art and science of surgery, minimizing physical intrusion on the patient and reducing recovery time, discomfort, scarring, and cost.
Anesthesia, in particular, has made tremendous strides since the early days when ether was the principal anesthetic agent and doctors administered it by dropping the liquid on a gauze cloth draped over the patient’s mouth and nose.
Many years ago, Central Maine General Hospital physician Wedgewood Webber, M.D., recalled how his father, surgeon Wallace Webber, M.D., and his associates performed surgery. In the early 1900s, the elder Dr. Webber worked with Sam Sawyer, M.D., one of the first physicians in Maine to limit his practice to anesthesiology. The pair was later joined by Gard Twaddle, M.D., a doctor who became so popular that years later some 6,000 people attended his retirement party at the Lewiston Armory.
"Dr. Sawyer was usually the anesthetist when Dr. Webber or Twaddle did surgery. I remember hearing them tell stories of how [Dr. Sawyer] would be pouring ether and all of a sudden Dr. Twaddle would holler at him because he'd etherized himself he'd fallen asleep during surgery,” Wedgewood Webber recalled.
The late M.S.F. Greene, M.D., another CMG physician from the first half of the 20th century, described having to physically restrain patients while anesthesia was being administered. “We used to have to strap [patients] down. The operating table had these wide leather straps that buckled across the chest and legs to hold them down. I remember one man who actually got up off the table and ran out of the room. We had to go after him," said Dr. Greene, who seemed amused by the recollection of the fleeing patient.
CMMC's Anesthesiology Department in the 21st century has access to various technologies and a variety of anesthetic agents that make anesthesia safer and much more easily tolerated by patients. By fine-tuning the delivery of anesthesia and analgesics, physicians at CMMC can offer the same quality of services available at larger specialty hospitals, says Anthony Miller, M.D., a CMMC anesthesiologist.
"What we are often doing now is giving general anesthesia for surgery and giving a regional anesthetic for pain relief afterward," Dr. Miller says. Patients appreciate this one-two punch because it means less pain and fewer after-effects during the recovery process most notoriously, nausea.
"People fear nausea more than pain," Dr. Miller says. "Anesthesiologists are starting to use some of the potent anti-nausea drugs used by oncologists" to control nausea in other patients, he says.
Dr. Miller notes that the anesthesiology field continues to change rapidly. "Fifty to 75 percent of the anesthetics I use every day now were not commonly used when I completed my residency in 1990," he says.
Other frequently used techniques include the epidural catheter, which delivers painkillers directly to nerves near the spine to deaden pain signals, and patient controlled analgesic (PCA) systems that allow patients to control their pain-relief dosage by pressing a button connected to a computer. Patient controlled medication can be delivered through an intravenous or epidural catheter.
Miniaturization pays off big
In the 1980s surgery was revolutionized by laparoscopy, an approach to some procedures that uses a fiberoptic video camera to visualize the inner body without the need for long incisions. This approach results in a shorter, less painful recovery for most patients.
During a laparoscopic procedure, a slender illuminating laparoscope equipped with a small camera is inserted through a small incision, giving the surgeon a view of the inner body through the scope and on a video monitor. Miniaturized surgical instruments are then passed through other small incisions and manipulated within the body. The patient often goes home the same day with the incisions covered by small bandages.
Many surgical tasks can be performed with the aid of the laparoscope. In addition to imaging parts of the body for examination, tissue can be vaporized, cut, cauterized, or removed for biopsy. Among the most common laparoscopic procedures are removal of the gallbladder, called a cholecystectomy, appendectomies, and hernia repairs. A laparoscopic procedure called a Nissen fundoplication is now used to treat chronic heartburn. Orthopedic procedures, such as those commonly done on knees and shoulders, are often done with an arthroscope. Procedures that once involved an extended inpatient stay are now often performed on an outpatient basis, with the patient ready to go home just hours later.
In December 2003, Carmine Frumiento, M.D., a cardiothoracic surgeon at the Central Maine Heart and Vascular Institute, performed Maine’s first minimally invasive esophagectomy, a recently innovated procedure for removing a diseased esophagus and creating a new passage from the throat to the stomach
“Surgical removal of the esophagus is associated with significant risk of complications and death. Recent data presented to the Society of Thoracic Surgeons reveals a complication rate as high as 49.5 percent and a morality rate of 9.8 percent. Other studies show hospital stays of over 10 days in 47 percent of esophagectomy patients,” says Dr. Frumentio.
Conventional surgical approaches for esophagectomy involve a large abdominal incision, a chest incision and/or a small neck incision. Alternatively, an abdominal incision is combined with a neck incision. The high morbidity and mortality rate for these open procedures led surgeons to consider if a minimally invasive approach might reduce complication rates.
The new procedure begins with the placement of four thoracoports into the right side of the chest. Working through these ports, the surgeon mobilizes the esophagus and removes surrounding lymph nodes. Once the esophagus is mobilized the ports are removed and a small chest tube is positioned within the right chest to drain any fluid and help the lung re-expand. Five laparoscopic ports are then placed in the abdomen and through these ports the stomach is freed from surrounding tissue and fashioned into a tube with a special stapling devices. This tube will act as the “replacement esophagus.”
The surgeon’s attention then turns to the left side of the neck where a small incision is made and the esophagus is identified and freed. Since the esophagus is no longer attached to surrounding tissue, it can be pulled up through the neck incision and transected from its proximal attachment to the throat. The remaining short segment of esophagus is then attached to the stomach tube. The incision is closed in the neck and the ports are removed from the abdomen.
Post-anesthesia care system relatively new development in surgical management
Surgical recovery units emerged when the use of ether as an anesthetic created the need for special nursing units for post-anesthesia patients. The actual emergence of dedicated recovery rooms began in the 1940s.
Early recovery rooms were actually overnight special care units before many of the duties of this type of nursing evolved into intensive care nursing. Recovery room nursing gradually assumed its own identity, and in 1986 the American Society of Post-Anesthesia Nurses began offering an accreditation program for post-anesthesia nurses. Recovery rooms later became know as post-anesthesia care units, or PACUs.
The post-anesthesia nurse's job is the care of surgical patients who are emerging from anesthesia. Once surgical patients are stabilized, they are transported to appropriate nursing care units. Because they deal with anesthetized patients, the post-anesthesia nurse must be skilled in patient assessment. They must rely on objective data gained through monitoring and observation, while taking into account the patient’s medical history. They must also be proficient in the use of high-tech patient monitoring equipment, and able to intervene to stabilize patients experiencing respiratory and cardiovascular difficulties.
CMMC's Post-Anesthesia Care Unit (PACU) staff cares for 20 to 30 patients per day, and the average post-anesthesia stay for each patient is about 60 minutes. About 60 percent of CMMC’s PACU patients are same-day surgery patients who are discharged the same day they have surgery.
Whether a patient has same-day surgery or is admitted for an overnight stay depends on a number of factors, the most important being the type of surgery required and the patient’s general health. If a patient, with the counsel of his physician, decides to have same-day surgery, the doctor arranges a date for surgery. A week to 10 days before the operation, the patient visits CMMC for any necessary tests and for an interview with a nurse. On the day of the operation, the patient reports to the Same-Day Surgery Unit.
Once in the Same-Day Surgery Unit, the patient is prepared for surgery much like a conventional surgical patient, and is then transferred to the Surgical Services Department for their procedure. After surgery, the patient is moved first to the Post-Anesthesia Care Unit and then back to the Same-Day Surgery Unit for discharge later the same day.
The keeper of all things sterile
An essential support service for any hospital-based surgical facility is the department responsible for cleaning, processing, sterilizing, storing and distributing supplies and equipment. At Central Maine Medical Center, this department is called Sterile Processing and Distribution (SPD).
A core task of the SPD technician is the proper cleaning and care of instruments and equipment. Since healthcare facilities have a large financial investment in medical instrumentation and devices, it’s important that these materials be well maintained. Meeting this responsibility requires technicians to learn countless details regarding the care of a large variety of items.
SPD technicians at CMMC must pass a national certification exam, learn medical terminology and the names and functions of all the instruments used in the operating room. An understanding of anatomy and physiology, the mechanisms of disease transmission and infection control, and the principles of disinfection and sterilization are also essential knowledge for SPD technicians.
Critical Care Unit is essential to surgical services program
The depth of CMMC’s surgical services program is enhanced by its Critical Care Unit, a specialized nursing unit that provides expert care for seriously-ill or -injured patients.
CMMC’s Critical Care Unit consists of two separate but interlinked nursing units. The Intensive Care Unit (ICU) provides care for patients with a wide range of health issues. Only steps away from the ICU is the Cardiac Care Unit, which primarily serves those recovering from a heart attack or other cardiac event. A major focus of the Critical Care Unit is assisting surgical patients, particularly trauma patients who have had extensive procedures following an accident.
Both units are staffed with specially-trained nurses and technicians. Michael J. Sterling, M.D., the region’s only hospital-based critical care specialist, serves as medical director of the Critical Care Unit.
Patients on CMMC’s Critical Care Unit are cared for by a skilled team of healthcare professionals that has at its disposal high-tech equipment and sophisticated medications that can be essential in helping critically ill patients recover from sickness or injury.
Surgical nurses, surgical technologists
Two important members of the surgical services team are surgical nurses, who assist with a wide range of activities while sharing responsibility for patient care, and surgical technologists, who assist with operating room duties ranging from assuring sterility in the operating room to maintaining equipment and providing hands-on assistance with surgical procedures.
The surgical nurse assists in preparing an operating room for a procedure and maintaining sterility throughout the surgical case, is responsible for assessing the patient during the preoperative phase, and helps assure the patient’s safety throughout the operation. Surgical nurses are responsible for the documentation of patient information during the entire perioperative phase.
Surgical technologists prepare the operating room prior to a procedure and assist the surgeon during the operation. They prepare the equipment needed for each case. They also set up the operating environment required by the surgeon and communicate the doctor's needs for equipment and materials to the circulating nurses during a procedure.
Surgical technologists are knowledgeable in the function, care and maintenance of surgical instruments. They assist with stocking, rotating and maintaining supplies, and are responsible for assembling the surgical instrument kits necessary to undertake a particular operation.
For surgical patients who have procedures requiring more extensive follow-up care, CMMC supports a dedicated medical-surgical nursing unit.
Most commonly referred to as T1 because of its location on the first floor of the Medical Center’s Thompson Wing, CMMC’s medical-surgical nursing unit is unique primarily because of its skilled professional staff. T1’s cadre of registered nurses has extensive experience assisting patients who have undergone a wide variety of surgical procedures.
Integral to the work of CMMC’s medical-surgical nurses is not only their technical care-giving skills, but also their facility as educators. When a surgery patient is discharged from the T1 Nursing Unit, it’s important that they know how to care for themselves at home and how to recognize potential problems. Teaching self-care to patients is a primary responsibility of the medical-surgical nurse.
Continuing growth and advancement
The variety of surgical specialties continues to grow with advancements in medical science and medical-surgical technology. Click here to learn about the surgical specialties now available at Central Maine Medical Center.