A Century of Surgical Innovation at a Boston Hospital

Enhancing Surgical Safety and Expanding the Boundaries of Resectability with Electrosurgery

When the Peter Bent Brigham Hospital was formed in 1913, surgery was in the throes of revolution. The previous 75 years had witnessed the ascent of anesthetic administration, aseptic technique, early antibiosis, and radiography. Meticulous hemostasis had evolved as one of the most critical pillars of surgery outlined by Dr. William Stewart Halsted, the “father of modern surgery.”^1,2 The application of thermal energy to achieve hemostasis was a technique that had been in use for millennia and was even described in the Hippocratic Corpus. ³ However, the imprecision of historic heat sources (direct thermal contact from heated stones, oil, or iron, for example) violated an important Halstedian principle—of minimizing tissue trauma—by causing uncontrolled collateral injury. ⁴ Hemorrhage was a major cause of morbidity and mortality in surgery during this era, and hemostatic techniques, which are now considered basic, were still under development until the emergence of the work of William T. Bovie—which transformed direction of surgical intervention across the globe.^5,6

William T. Bovie was born in rural Augusta, Michigan, the son of a general practitioner. He would ultimately complete his formal education in Boston, where he was awarded his Ph.D. in plant physiology from Harvard University. He took his first faculty position at the affiliated Huntington Hospital for Cancer Research. ⁷ It was here that Bovie engineered his diathermy device, which channeled high frequency electrical current through an electrode (“cutting loop”) in a targeted manner to the patient's tissues before dissipating the current through the surrounding tissue.

Not far from Huntington Hospital stood the Peter Bent Brigham Hospital, where Dr. Harvey Cushing had provided clinical care and carried on his research as the institution's surgeon-in-chief for some years. Cushing, also the son of a physician, obtained his medical degree in 1895 from Harvard Medical School. He went on to complete an internship at Massachusetts General Hospital and surgery residency under the instruction of renowned surgeon Dr. William Halstead of the Johns Hopkins Hospital. By age 32, Cushing ascended to the position of Associate Professor of Surgery at Johns Hopkins, during which time he wrote comprehensively on the spine and became the first to describe various other medical topics, including the now eponymous Cushing's disease, Cushing reflex, Cushing's ulcer, and the “third circulation” of cerebrospinal fluid. Cushing was a dynamic steward of noteworthy discoveries and innovations—too numerous to catalog here—which earned him esteem as one of the first modern endocrinologists and the “father of modern neurosurgery.”^7,8

At age 42, Cushing was appointed Surgeon-in-Chief at the Peter Bent Brigham Hospital in 1911. Two years later, he was a part of the first surgical procedure to be completed in the hospital; by 1926, he had a steady high volume practice. Cushing recognized the limitations of bone wax, cotton pledgets, his own newly invented silver clips, the tree sap product gutta percha, and other hemostatic techniques of the day and wrote of them in his 1911 publication.^5,9–11 These limitations forced him to adopt staged operations for the resection of larger intracranial neoplasms in some circumstances or precluded operation altogether. In 1926, Bovie, then an assistant professor of biophysics at Harvard, presented his new device at a staff meeting to which Cushing was in attendance.^12,13 This exchange ultimately led to a prominent milestone in surgical innovation. On September 28, 1926, Cushing was forced to abort the resection of an enlarging intracranial vascular myeloma in a 64-year-old patient due to hemorrhage. Remembering Bovie's demonstration, he visited the physicist's laboratory to inquire on the potential for use of the device in neurosurgery. On October 1, 1926, Cushing successfully employed Bovie's device to resect the tumor.^4,10 In his operative note, Cushing noted that “with Dr. Bovie's help, I proceeded to take off most satisfactorily the remaining portion of tumor with practically none of the bleeding which was occasioned in the preceding operation. The loop acted perfectly and blood stilling was almost complete.…” ¹⁴ Inspired by this success, in the ensuing years, Cushing recalled patients who had previously been deemed inoperable to reattempt excision of their tumors with the new electrosurgical device. He later noted an improvement in his personal surgical mortality rates from 22% before the introduction of Bovie's electrosurgical device to 12% thereafter. ¹¹

Although a registered trademark of the Bovie Medical Corporation, Bovie's name has become synonymous with monopolar electrosurgery, and the device he cocreated with Cushing has become so pervasive, it is used in operating theaters worldwide. As surgical approaches evolved to include minimally invasive approaches such as laparoscopy, robotic surgery, and endoluminal therapies, the principle of electrosurgery, which met early success application in Bovie's invention, has now been extended to these techniques through the evolution of advanced energy devices. However, the success and widespread dissemination of Bovie's invention cannot be wholly attributed to its novelty. Reports and even patents for other devices, which used electricity to divide tissues by first heating them, predate Bovie's.^4,7,15–18 In fact, this would later lead to some controversy following publication of the use of his invention. The adoption and spread of Bovie's electrosurgical device, however, almost certainly can be attributed to the championship of a leader in the field of the device's potential clinical end users. Cushing described the successful October 1, 1926, first in human demonstration of the device as “a perfect circus—many ringed” with numerous attendants, including those from the New England Surgical Association. In addition to those observing his operations with the use of the electrocautery device (with Bovie himself frequently present in the operating room) and personal correspondences, the world further came to know of the device and its use in surgery through Cushing's 1928 manuscript outlining the experience. ¹⁹ Interest in the technique increased rapidly; although Bovie left Harvard, Cushing continued to collaborate with those at the Liebel-Flarsheim Company (to whom Bovie had sold the patent rights for $1) to make further developments on the device. ¹⁶ Without this relationship with Harvey Cushing, Bovie's name might not have lived on in our day to day efforts in the operating theater nearly a century after the first-in-human use of the device at the Peter Bent Brigham Hospital in 1926.

The Birth of Solid Organ Transplantation

Similar to the introduction of Bovie, solid organ transplantation made its debut at the Brigham with the work of a remarkably productive surgeon–scientist—Dr. Joseph Edward Murray. Born and raised in Milford Massachusetts as a star athlete in virtually every sport, Murray went to college at the College of Holy Cross, where he studied philosophy and English. Murray went on to attend Harvard Medical School and began his internship at the Peter Bent Brigham Hospital. During that time, Murray was inducted into the Medical Corps of the U.S. Army, where he served in the plastic surgery unit at Valley Forge General Hospital in Pennsylvania. ²⁰ Here, Murray worked for an esteemed plastic surgeon, Dr. Bradford Cannon—whom many attributed Murray's initial introduction to plastic surgery. In this unit, Murray cared for thousands of soldiers wounded in World War II, working to reconstruct their disfigured hands and faces. Not long did an interest in transplantation arise, influenced by the work done on these injured burn patients. Murray and his colleagues carefully observed trends of rejection among unrelated donors, sparking interest in understanding the properties of skin grafting and, later, the possibility of solid organ grafts and transplantation.

Following conclusion of his military obligation, Murray completed general surgery training at the Peter Bent Brigham Hospital and joined its surgical staff. He then trailed this experience with further training in plastic surgery at the New York and Memorial Hospitals. Murray returned to Brigham as a member of its surgical staff in 1951, where he began to further explore his interest in transplantation. On December 23, 1954, the left kidney from a healthy 24-year-old, Ronald Herrick, was transplanted to his monozygotic twin brother suffering from end-stage renal disease, Richard, by Dr. Murray and his surgical team at the Peter Bent Brigham Hospital. This was a landmark case of the first long-term successful renal transplantation in humans with homograft viability noted up to 8 years. ²¹ Until then, the longest documented survival of human homotransplantations was up to five and a half months. ²² The undertaking of the Herrick twin transplantation took place amidst an environment of censure for what was viewed by critics from both inside and outside the profession of organ transplantation as empiric surgery and of no benefit. ²³ William Dempster, a prominent researcher in the field of transplantation from the Hammersmith Hospital in London then, was noted to comment “it is quite out of the question that kidneys should be homo-transplanted in man just in case a permanent survival might be obtained.” ²⁴ This reproach arrived at a time following decades of unsuccessful attempts at homo- and heterotransplantation, including cadaveric and xenotransplants, with the exception of a kidney transplant between dizygotic cattle twins noted to have survived 9 months. ²¹

Murray and his team's methods, however, were beyond trial and error and guided by developments of the immunologic basis of graft rejection at the time. He was aware of the permanent survival of skin grafts between identical twins, although that had not been extended to solid organs in the two decades since the case was described. ²⁵ Murray and his team were also aware of the long-term viability of autotransplanted kidneys in dogs from their own studies, which combined with the knowledge of acquired tolerance of tissues in identical twins from common placental circulation and led them to proceed with the Herrick twin's homotransplantation with optimism. ²⁶ As part of the preoperative work-up, Murray exchanged 2.5 × 2.5 cm full-thickness skin graft between the Herrick brothers, with survival confirmed using gross and histopathological analysis, as a predictive tool before renal transplantation. ²¹

The outcome of the Herrick twin case, although remarkable, would have been of limited utility unless long-term viability of nonmonozygotic twin grafts could be achieved. Dr. Murray and team were cognizant of this limitation and expanded their work to first investigate extension of graft viability through total body irradiation-mediated recipient immunosuppression, with limited success, and then 6-MP and azathioprine treatments to prolong graft survival. This led to one of the first cases of extended survival of an unrelated human kidney recipient using chemical immunosuppression only. ²⁷ The culmination of his contribution to the advancement of transplantation eventually won him the honor of the Nobel Prize in Physiology and Medicine in 1990.

The support and resources that were made available to Dr. Murray under leadership of Dr. Francis D. Moore, Chairman of Surgery at the Peter Bent Brigham Hospital, made these ground-breaking advances possible at a time when organ transplantation and its future were under scrutiny in light of multiple disappointing results. Perhaps the significance of this mentorship is best immortalized in Dr. Starzl's account of the Herrick twin case, who is a Distinguished University Professor of Surgery in the University of Pittsburg School of Medicine for his multiple innovations in surgery and immunology, where he notes, “The ruling board and administrative structure of that hospital did not falter in their support of the quixotic objective of treating end-stage renal disease despite a long list of tragic failures that resulted from these early efforts—leavened only by occasional encouraging notations such as those in the identical twin case. Those who were there at the time have credited Dr. George Thorn, Chairman of Medicine and Dr. Francis D. Moore, Chairman of Surgery, with the qualities of leadership, creativity, courage, and unselfishness that made the Peter Bent Brigham Hospital a unique world resource for that moment of history.” ²⁸

The Integration of the Surgical Checklist

Beyond solid organ transplantation and the advent of Bovie, the Department of Surgery at BWH has continued to clutch an unyielding lead as one of the foremost medical institutions in surgical innovation, creating breakthroughs that recurrently change the scope of surgery even today. However, the institution has not limited its discovery to just product and item design, but rather it has also embraced key areas of innovation with broad-reaching efforts such as those relating to the impact of changing healthcare delivery systems and the practices of surgery as well as the viability of academic medical centers. Dr. Atul Gawande, department surgical resident and later faculty member, who now practices general and endocrine surgery at Brigham and Women's Hospital, is among the most notable examples of surgical innovators, who have led the Brigham into the 21st century with new ways of understanding and executing innovations in surgical care.

Gawande was born in Brooklyn, New York, to Indian immigrants to the United States, both doctors. His family moved to Athens, Ohio, where he and his sister grew up, and he graduated from Athens High School in 1983. Thereafter, he earned an undergraduate degree in biology and political science from Stanford University in 1987. As a Rhodes Scholar, Gawande earned an M.A. in Philosophy, Politics, and Economics (PPE) from Balliol College, Oxford, in 1989. He went on to attend Harvard Medical School, graduating in 1995, and earned a Master of Public Health from the Harvard School of Public Health in 1999. Gawande completed his general surgical residency training at the BWH from 1995 to 2003, and it was during this time that he began documenting his personal accounts of patient encounters. These snapshots into the intimate lives of his patients soon morphed into his first bestselling book—Complications, which was penned while still a resident in general surgery. Now a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. Gawande is also the executive director of Ariadne Labs, a joint center of BWH and the Harvard School of Public Health, launched to foster innovation to drive better care at the most critical moments in people's lives, everywhere. He additionally serves as the chairman of Lifebox, a nonprofit that works on reducing deaths in surgery globally. ²⁹ During his tenure, Gawande has written extensively on medicine and public health for The New Yorker and Slate and is the author of the books Complications, Better, The Checklist Manifesto, and Being Mortal—all highly acclaimed pieces, which have provided a daring glimpse into the medical profession, bridging the gap between the surgical community and public's awareness and understanding of major issues in surgical quality and safety issues. ²⁹

In addition to his writing, Gawande has been the steward of a new kind of surgical innovation, which regards patient safety and outcomes. He has also spearheaded compelling research in maternal/infant mortality that has created significant pause and has prompted health delivery systems around the world to refocus how they deliver care. Since 2007, Atul has headed the WHO work to improve surgical safety worldwide, leading the Safe Surgery Saves Lives program. This program has led to the creation of the WHO Surgical Safety Checklist, which in a yearlong pilot study in eight hospitals worldwide has reduced deaths and complications following surgery by up to a third. Today, the use of standardized checklists has emerged as an important tool to address these issues. In the ensuing years, the impact of implementation of checklists nationwide and worldwide in operating rooms and other care settings has been extensively studied, demonstrating the Surgical Checklist as one of the single most powerful tools available that is proven to reduce operative mortality. In 2013, BWH researchers found that checklists in the operating room improve performance during crisis. Teams using checklists were 74% less likely to omit key lifesaving steps in care during emergency situations than those working from memory alone. ³⁰

Moving Innovation Forward as a Part of Institutional Culture

Indeed, the surgical checklist driven by the work of Gawande, Murray's pioneering efforts in transplantation, and Bovie's exemplary ambition with the creation of his device have all set the stage for innovation and discovery to thrive at BWH. Still other innovations continue to file down the pipeline that impacts the direction of surgery worldwide in varying ways that go beyond the scope of product design or task efficiency and look toward outcomes and creation of opportunity of innovation sustainability. A key example includes the establishment of the first-of-its kind research institution committed to the development of surgical innovation and research in 2005—the Center for Surgery and Public Health (CSPH), a collaboration between the Harvard Medical School (through the BWH Department of Surgery) and the Harvard School of Public Health. The center's focus is on healthcare, quality, safety, effectiveness, and global surgical care. Hosting medical professionals and research specialists across disciplines, CSPH has served as a contemporary think-tank for ongoing innovations among a multitude of academic genres. The CSPH has mentored and supported the career interests of many leading surgeons across the globe that have and continue to engage Brigham's commitment to surgical innovation.

Moving forward, the Brigham has continued to blaze trails with a number of firsts, each of which has set the pace for rapid progression of innovation at the institution and beyond. In 2010, a comprehensive thoracic surgery team performed ex vivo human lung perfusion for the first time in the United States. Building off the rich history of transplant surgery at BWH, a multidisciplinary group of both medical and surgical specialists began performing hand transplants. In March 2011, a plastic surgery team, led by Dr. Bohdan Pomahac, performed the first full face transplant in the country. Less than a month later, the team performed the nation's second full face transplant. In February 2012, a team at BWH implanted the first total artificial heart in New England. In April 2014, BWH performed its first transcatheter aortic valve replacement without general anesthesia. In the same year, the first double arm transplant was placed. In summary, Brigham has been the site of significant achievement, especially during the latter years where there has been a fusion of creativity and surgical innovation.

Understanding Why These Innovations Occurred at BWH

The development of each of these innovations was multifactorial. However, they all seem to have had three critical elements in common: (1) they rested on multidisciplinary collaboration between surgical innovators and individuals in fields outside of surgery, (2) such collaboration was facilitated by a rich institutional environment that sustained many fields of study in close proximity, and (3) they all occurred under the departmental leadership of individuals who promoted the primary innovators themselves and incentivized such personal success rather than seeking prestige and financial gain for themselves or their departments alone.

Multidisciplinary collaboration was critical to each innovation. Their personal correspondence suggests the collegial relationship between Cushing and Bovie, with the neurosurgeon once writing, “…I shall hope to see you over here often, and we may make a brain surgeon of you yet. I only wish you were here so that we could tap your ventricles and get some of your ideas more often” ¹⁰ Bovie assisted in the oversight and operation of the device during surgeries. Indeed, Bovie's presence in the operating room may have helped bridge the gap between the electrophysics laboratory where his tools were developed and the hospital where care was delivered. Bovie even described himself as a “sort of a middle man …watching operations on the one hand and studying electrical currents on the other” through which he “managed to learn a little bit of both ends of the problem.” ¹⁰

A necessary element that made such collaboration possible was a clinical and scientific setting, which was diversified in its expertise. Cushing, a neurosurgeon, and Bovie, a physicist, were both associated with Harvard affiliates and met fortuitously through this connection. Murray, who trained at Brigham with the support of the hospital's leadership with whom he shared common scientific interests, enabled solid organ transplant to become a part of our current surgical armamentarium. Similarly, Gawande's forward thinking to capture the essence of the patient–doctor relationship in his books is hugely underscored by the support of his surgical chairman, Dr. Michael Zinner, who himself is known for having revolutionized the way we think of surgical leadership and how to incorporate innovation at a major academic medical center. Gawande readily admits that he would not have gotten a public health degree had Zinner not suggested it, which is what likely ignited much of his career in policy and public health.

Together, these and other innovators have created a fertile culture of innovative thought that only fosters further innovation. Now, however, the new challenges lie in understanding how to capture the best ideas not only within the walls of BWH but beyond and to harness them to create larger more meaningful impact. One advantage that exists today that supplants the barriers of prior efforts is the progression of modern information technology that has now reduced the geographic barriers to collaboration and communication. Information technology permits the creation of a virtual environment, meeting these criteria of inclusion, collaboration, and generalizability where geography falls short.

Challenges to Sustainability of Innovation at BWH

Even with the advantage of modern technology and progressive designs, innovation sustainability and its preservation within the culture of BWH is fraught with a number of challenges. Foremost is the increasing emphasis on clinical efficiency and cost containment. All areas of research, particularly those funded by federal agencies, have felt the tightening of support and incentives, which make it difficult to propagate further developments or create innovations. In addition, margins of resources are shrinking such that would-be innovators are finding it challenging to find available resources to support their burgeoning ideas. However, the advantage of a parsimonious economic climate is the yield of more efficient high-impact innovations that look to expand accountability as well as optimize value extracted from each new innovation. These challenges have also led innovators to become more creative with identifying funding streams outside of federal agencies through avenues like start-ups and industry. These novel relationships are now the nidus of a new era of sophisticated collaboration that portends for an exciting future for surgical innovation.

Leadership and Dedication for All

The genesis of surgical innovation is occasionally inspired by the pursuit of alternative solutions to complex medical problems that frequently evolve into novel therapies that inform the way in which we approach modern medicine. At the BWH, surgical innovation—which has evolved through deliberate application of information, imagination, and initiative to effect meaningful change—thrives as its central focus and positions the institution at the forefront of revolutionary breakthroughs in almost every discipline of medicine. Extraordinary leadership and dedication has led to the creation of a rich landscape that fosters a sustained legacy of surgical innovation for this hospital organization. To that end, BWH has not only defined surgical innovation but it has created a comprehensive template for others to follow.