Medicine and Society Curriculum Contents

Section Three: When Is Surgery Unnecessary?

Every year, millions of Americans are subjected to surgical procedures based not on medical necessity, but on convenience, tradition, ease, or lack of awareness that other methods might obviate the need for surgery. A woman “fails to progress” after only a few hours of labor and is given a cesarean section. Marginal fibroids discovered in a woman’s uterus lead to a hysterectomy. An infant undergoes a painful circumcision for primarily cosmetic reasons. When are these and other elective procedures justified? Doctors have to sort out these issues and their roles every day.

What constitutes unnecessary surgery is extremely controversial among physicians. This section aims not to take a concrete stance on these issues, but to present the concerns raised by patients and in medical literature for purposes of discussion.

Circumcision

According to the American Academy of Pediatrics, more than 60 percent of male infants born in the U.S. are circumcised. Once steeped in religious tradition, circumcision today is more closely associated with familial and societal norms than either religious or medical concerns. While Jews, Muslims, and other groups continue to practice ritual circumcision, the most powerful influences in determining circumcision are whether the father is circumcised and concerns about the attitude of peers and the boy’s self-concept.¹

There is little argument that circumcision offers benefits. There is some disagreement, however, as to whether the potential benefits outweigh the risks and whether it is appropriate to operate on a perfectly healthy child.

Circumcision as a Preventive Measure

While circumcision is believed to reduce the risks of certain diseases, some believe the evidence is less than conclusive. Proponents of circumcision hold that the procedure reduces the risks of the following diseases:

Penile Cancer. A number of authors believe circumcision virtually eliminates the threat of penile cancer. In fact, only 10 of the 60,000 cases of penile cancer reported in the U.S. since 1930 involved circumcised men.²

Cancer of the Cervix. The human papilloma virus, believed to contribute to cervical cancer, is found more often in uncircumcised men. However, there is no association between exposure to uncircumcised men and an increase in the rate of cervical cancer among their sexual partners.²

Sexually Transmitted Diseases. According to the American Academy of Family Physicians, virtually all sexually transmitted diseases occur more frequently among uncircumcised men. It is believed that uncircumcised men are at greater risk for HIV infection, genital herpes, syphilis, chancroid, and condyloma acuminatum.

Penile Problems. Balanitis (inflammation of the penile glans), posthitis (inflammation of the prepuce), and phimosis (constriction of the preputial orifice so that the prepuce cannot be retracted back over the glans) are more common among uncircumcised children. However, there have been reports to the contrary, noting that meatitis solely affects circumcised boys.²

Urinary Tract Infections (UTIs). Experts agree that circumcision helps prevent urinary infections. A 1987 study found the rate to be ten times greater among uncircumcised boys.³ Because the rate of UTI among male infants is low (1 to 2 percent),¹ some argue that circumcision is unnecessary. Proponents, however, point to the dangers associated with urinary infection, which include renal damage. It must be noted that UTI infection and other afflictions are often a result of the lack of clean water, plumbing, and sanitation among populations subjected to poor living conditions.

Complications

The rate of complications appears to be extremely low, from 0.2 to 0.6 percent.³ The most common problems are bleeding and local infection. Less common problems include partial or complete penile amputations, degloving injuries, urethrocutaneous fistulas, formation of skin bridges, and staphylococcal scaled skin syndrome.³

Pain

Most neonatal circumcisions are performed without anesthesia, a practice attributing to concerns about the significant risks of anesthesia in a tiny infant as well as the mistaken belief that infants do not feel pain. In fact, neonates respond to painful stimuli with cardiovascular, hormonal, and behavioral changes. A recent study in the New England Journal of Medicine included 38 babies who received topical analgesia and 30 who got no analgesia prior to circumcision. The medicated group cried half as much and had heart-rate increases of ten beats per minute less than those who got nothing. There can be little doubt that circumcision is a painful, traumatic procedure.

Making a Choice

Despite the fact that many parents choose circumcision based on social considerations, it is important to provide parents with as much information as possible on its risks and benefits.

Hysterectomy

A hysterectomy is the removal of the uterus, sometimes along with the ovaries. Of the approximately 570,000⁴ hysterectomies performed in the United States each year, most are either necessary or strongly advised for relieving symptoms. Many, however, fall into a category where medical necessity is less clear.

The following life-threatening conditions generally require hysterectomy:

• Invasive cancer of the uterus, cervix, vagina, fallopian tubes, and/or ovaries;
• Severe, uncontrollable bleeding;
• Life-threatening blockage of the urinary tract or intestines by the uterus or growth in the uterus;
• Conditions associated with rare but serious complications during childbirth, including rupture of the uterus.

The following conditions, although not life-threatening, may justify a hysterectomy in some cases:

• Precancerous changes of the endometrium (hyperplasia);
• Severe, recurring pelvic infections;
• Extensive endometriosis, causing debilitating pain and/or involving other organs;
• Fibroid tumors that are extensive, large, involve other organs or cause debilitating bleeding;
• Pelvic relaxation (uterine prolapse).

Non-surgical treatments are available for many of these cases, and newer techniques, such as laparoscopy, can reduce the need for hysterectomies. Some gynecologists, however, argue that laparoscopy is not necessarily safer than hysterectomy.

The following conditions generally do not indicate hysterectomy:

• Small fibroids that are not causing problems;
• Abortion (during first and second trimesters);
• Sterilization;
• Cervicitis;
• Mild dysfunctional uterine bleeding.

Hysterectomies are performed more frequently on women who fit one or more of the following characteristics:⁵

• African-American;
• Between 30 and 54 years old;
• Living in the southern U.S.;
• Less educated;
• Suffering from severe menstrual bleeding;
• Have a history of previous surgery.

A 1997 report by Kramer and Reiter showed that surgeons most likely to utilize hysterectomy are:

• Male;
• Trained several years earlier, as opposed to more recent graduates;
• Not affiliated with a teaching hospital.

Recently trained physicians and those associated with teaching hospitals are more likely to use alternative treatments.

Cost

The average cost of a hysterectomy including surgeon and hospital fees is between $3,000 and $6,000.

Surgical Complications

Women who have hysterectomies often experience some of the following complications:

• Infection;
• Urinary tract complications. Half of all women who have hysterectomies will develop a post-surgical kidney or bladder infection. Most are not serious, but some may require additional surgery. A radical hysterectomy, while necessary in certain cancer cases, can result in sensory nerves being cut, leading the woman to lose the sensation of having to urinate or the ability to control bladder function.
• Hemorrhage.

Less frequent complications include:

• Bowel problems, resulting from damage during surgery. Two percent of all women who undergo the procedure require additional surgery to remove scar tissue from the bowel.
• Blood clots that travel to the lungs or brain;
• The potential for death or paralysis from anesthesia;
• Postsurgical complications, including infection, abnormal bleeding, heavy discharge, and a narrowing of the vagina.

If established criteria for hysterectomy are followed, frequency of procedures may be reduced by as much as 30 percent.^6,7

Cesarean Sections

Between 1970 and 1991, the number of cesarean sections performed in the U.S. increased 350 percent.⁸ In 1995, cesarean sections accounted for 20.8 percent of all births in the U.S., a slight decline from 23.5 percent in 1991.^8,9 While Canada and the U.S. have similar rates, European nations range between 10 and 14 percent.¹⁰ There is growing sentiment in the medical community that many of these operations are unnecessary. According to a report by the National Institutes of Health, between 33 and 75 percent of all cesareans performed over the last decade “were not necessary, having been performed as a result of current medical procedures and attitudes alone.”¹¹ However, many women prefer cesarean delivery, as do their physicians in certain circumstances.

Cesarean Indicators

There are times when a cesarean section is a life-saving procedure. Medical conditions that usually require a cesarean include:

• Severe preeclampsia
• Severe diabetes
• Malpresentation incompatible with a safe vaginal delivery, such as transverse lie of the baby
• Failure of the baby to descend
• Cord prolapse
• Placenta privia
• Baby much too large
• Active herpes lesions
• Sudden unexplained fetal distress

In addition, cesarean sections obviate the unpredictability of labor pain of normal birth.

Reasons Cited for Performing Cesarean Sections

Following are the most common indications for cesarean sections, all of which are controversial in some circumstances:¹²

• A scar from a previous cesarean (known as the “once-a-cesarean-always-a cesarean” policy). An estimated 35 percent of all cesareans are repeat procedures based on the belief that a rupture in the uterine scar may occur if vaginal birth is attempted. Evidence suggests that vaginal births are as safe, or even safer, in all but 1 percent of such cases. A vaginal birth after cesarean (VBAC) cannot be entertained if the prior section had used a longitudinal or an upper uterine segment incision. To offer the VBAC, there must be confirmed evidence that the prior incision was transverse and in the lower uterine segment. If that is established, the indication for the second or successive section is only an obstetric one for the current labor.
• Dystocia. Also called “failure to progress,” this condition is cited in 30 percent of all cesareans. While there are cases in which a women’s pelvis is too small or the delivery too slow, some cases are amenable to natural delivery.
• Breech presentation. This condition occurs when the baby presents buttocks or feet first, and accounts for 12 percent of all cesarean sections. However, there is still some debate as to whether cesareans are more effective than vaginal breech deliveries. According to the National Institute of Child Health and Human Development, “Neonatal mortality among full term breeches in New York City did not fall during a decade in which the cesarean rate for breech more than doubled. One institution reported its incidence of poor breech outcomes did not decline while its cesarean rate for breech increased from 22 to 94 percent.”
• Fetal distress. This condition is identified through changes in the fetal heart rate that indicate that the fetus may not be receiving enough oxygen through the placenta. While fetal distress is often a justification for cesarean section, what constitutes distress in not always clear. Fetal monitoring sometimes produces false alarms. Some have opined that many cases of “fetal or maternal distress” may be more accurately termed “obstetrician distress.” Some physicians feel that the implementation of a cesarean section will afford them legal protection in the delivery of a child with disabilities.

Patient and Physician Variables in Cesarean Use

Women who have cesareans tend to be better insured, healthier, and more affluent than women who have vaginal births.¹⁰ Mothers who undergo cesarean sections also tend to receive private care rather than public services. Older women are more likely than their younger counterparts to have cesarean sections. This may be a result of either a real or perceived inability and/or unwillingness on the part of the older women to endure prolonged labor when given the option of a relatively quick cesarean section. Finally, some women believe that natural childbirth is essential to the bond between mother and child, whereas other women may view the experience as best carried out with as little time and pain as necessary.

Physicians most likely to perform cesareans tend to be young and/or are more often graduates of foreign medical schools than those who perform fewer cesareans.⁸

Private Versus Public Care

Recent studies suggest private physicians are more likely to use cesarean sections than general service physicians for the following reasons:¹⁰

• Efficiency. Studies suggest physicians sometimes perform cesareans to better manage their time. Private physicians have greater time constraints due to the need to maintain regular office hours, whereas house-staff provide care during rotating shifts. Cesarean sections are most often performed late in the day or evening, and after the office has closed. They are less likely to be done past midnight.
• Patients’ preferences. Private physicians develop and maintain close ties to their patients and believe that care perceived as “high-tech” is preferable.
• Reduced liability. Private physicians, believing cesareans reduce the risk of liability, use the procedure to protect themselves from malpractice suits, which can destroy a private practice. In contrast, it is not the physician alone in public care who bears the brunt of such suits, but also the institution for which he or she works.

Cost

In 1993, the average cost of a cesarean was $11,000 compared to $6,430 for a vaginal delivery. The average hospital stay for a cesarean was 3.4 days, whereas it was 1.0 for vaginal delivery.¹³

Risks

There are a number of risks, for both mother and infant, associated with cesarean sections. These are often risks inherent in giving birth, not simply of cesarean section, but it must be noted that a cesarean section is a major surgical procedure and, therefore, carries risks and complications associated with such an event.

For the mother, they include:¹²

• The risk of death is very small, but is 2 to 11 times greater than that of vaginal delivery.
• Postpartum infection (urinary and wound infections)
• Pulmonary embolism
• Anesthesia accidents
• Hemorrhage

For the infant they include:

• Iatrogenic prematurity and lung disease
• Low Apgar scores
• Fetal hypoxia caused by regional anesthesia
• Injuries such as accidental lacerations

The risks of iatrogenic prematurity and lung disease are dramatically higher for those infants delivered by elective cesarean before labor (30 percent), than those born by cesarean after labor begins (11 percent). However, premature babies are more likely to require birth by cesarean section.¹²

Limiting Use of Cesarean Sections

Responding to the high number of cesareans performed in the U.S., some hospitals have implemented “active management of labor” (AML) programs. Such programs place the emphasis on achieving vaginal birth within 12 hours of hospital labor, using explicit criteria for ascertaining that a women is in labor, artificially rupturing membranes, artificially augmenting labor with synthetic oxytocin, repeated vaginal exams to monitor cervical dilation, and reserving cesareans for cases where labor extends beyond 12 hours.¹⁰

A Broader Look at “Unnecessary” Procedures

Some surgical interventions, while necessary at times, may not be needed if physicians and patients implement effective, preventive measures in a timely manner. With much of physician training focusing on diagnosis and treatment, it is sometimes easy to lose sight of the power of prevention.

Heart disease, for example, is the leading killer of North Americans and a major cause for surgery. In 1992, surgeons performed more than one million coronary artery bypass grafts and 399,000 procedures to remove coronary artery obstructions. The cost of treating heart disease totaled $40.4 billion.

A coronary artery bypass graft uses either a portion of the saphenous vein or a mammary artery to provide blood flow around a coronary artery that is blocked with atherosclerotic plaque. Without an adequate blood supply, a portion of the heart muscle dies (myocardial infarction).

In 1990, a young Harvard-trained physician named Dean Ornish, M.D., showed that blockages in coronary arteries can begin to regress on their own without surgery. Using a low-fat, vegetarian diet, exercise, stress management, and no smoking, 82 percent of research subjects showed angiographic evidence of reversal of their blockages within one year.¹⁴

Although many doctors initially felt that a low-fat, vegetarian diet was too austere for most patients, it has been shown to meet no more resistance among patients than a more typical heart diet relying on poultry, fish, and “lean” meats.¹⁵ In fact, acceptance of a vegetarian diet may be better than less stringent diets, because its clinical effect is much more rewarding.¹⁶

Many insurance companies now reimburse physicians for providing the Ornish lifestyle treatment, because it is cheaper than surgery and more lasting in its effects. While vessels used in coronary bypass typically become blocked within six to eight years, necessitating a repeat bypass procedure, the diet and lifestyle changes can be maintained indefinitely.

Many doctors, however, prescribe no diet changes at all for their heart patients. A 1994 review found that 51 percent of physicians prescribed cholesterol-lowering drugs without first recommending dietary changes in patients with high cholesterol levels.¹⁷

Counseling patients on dietary changes takes time. However, it need not be done by the physician. The physician can refer patients to nutrition and cooking classes conducted by a dietitian or educator, either individually or in groups. Such an intervention is far less labor-intensive than surgery, post-operative recovery, and rehabilitation, and often yields other significant benefits, such as weight loss and a reduced need for medications to control diabetes or hypertension.

However, to effectively advocate for diet and lifestyle changes, it helps if doctors have experienced such a diet and lifestyle change themselves and can help patients through the natural hesitancy they may have about changing habits.

<< back to Medicine and Society contents | top | next section >>

References
1. Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996;154(6):769-80.
2. Anonymous. Fact sheet for physicians regarding neonatal circumcision. Am Fam Physician 1995;52(2):523-6.
3. Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol North Am 1995;22(1):57-65.
4. Graves EJ. Detailed diagnoses and procedures: National Hospital Survey, 1992. Vital Stat 1994;(118):1-281.
5. Kramer MG, Reiter RC. Hysterectomy: indications, alternatives, and predictors. Am Fam Physician 1997;55(3):827-34.
6. Gambone JC, Reiter RC, Hagey S. Clinical outcomes in gynecology: hysterectomy. Curr Prob Obstet Gynecol Fertil 1993;16:141-66.
7. Gambone JC, Reiter RC, Lench JB, Moore JG. The impact of a quality assurance process on the frequency and confirmation rate of hysterectomy. Am J Obstet Gynecol 1990;163:545-50.
8. Burns LR, Geller SE, Wholey DR. The effect of physician factors on the cesarean section decision. Med Care 1995;33(4):365-82.
9. National Center for Health Statistics, October 1997.
10. Sakala C. Medically unnecessary cesarean section births: introduction to a symposium. Soc Sci Med 1993;37(10):1177-98.
11. National Institutes of Health. Marieskind H. Cesarean childbirth: an evaluation of cesarean section.
12. Shearer EL. Cesarean section: medical benefits and costs. Soc Sci Med 1993;37(10):1223-31.
13. Metropolitan Life Insurance, 1997.
14. Ornish D, Brown SE, Scherwitz LW. Can lifestyle change reverse coronary heart disease? Lancet 1990;336:129-33.
15. Barnard ND, Scherwitz LW, Ornish D. Adherence and acceptability of a low-fat, vegetarian diet among patients with cardiac disease. J Cardiopul Rehabil 1992;12:423-31.
16. Barnard ND, Akhtar A, Nicholson A. Factors that facilitate compliance to lower fat intake. Arch Fam Med 1995;4:153:58.
17. Second report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel II). Circulation 1994;89:1330-44.