Prior to  Hippocrates , physicians largely based their anatomical conceptions of the eye on speculation, rather than  empiricism . [ 2 ]  They recognized the sclera and transparent cornea running flushly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by  Alcamaeon  (fifth century BC) and others, that this fluid was the medium of vision and flowed from the eye to the brain by a tube.  Aristotle  advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He and his contemporaries further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull.


The Greek physician  Rufus of Ephesus  (first century AD) recognised a more modern concept of the eye, with  conjunctiva , extending as a fourth epithelial layer over the eye. [ 2 ]  Rufus was the first to recognise a two-chambered eye, with one chamber from cornea to lens (filled with water), the other from lens to retina (filled with a substance resembling egg whites).


Celsus  the Greek philosopher of the second century AD gave a detailed description of cataract surgery by the  couching  method.


The Greek physician  Galen  (second century AD) remedied some mistaken descriptions, including about the curvature of the cornea and lens, the nature of the optic nerve, and the existence of a  posterior chamber . Although this model was a roughly correct modern model of the eye, it contained errors. Still, it was not advanced upon again until after  Vesalius . A  ciliary body  was then discovered and the sclera, retina, choroid, and cornea were seen to meet at the same point. The two chambers were seen to hold the same fluid, as well as the lens being attached to the choroid. Galen continued the notion of a central canal, but he dissected the optic nerve and saw that it was solid. He mistakenly counted seven optical muscles, one too many. He also knew of the  tear ducts .


The Indian surgeon  Sushruta  wrote the  Sushruta Samhita  in  Sanskrit  in approximately the sixth century BC, [ 16 ]  which describes 76 ocular diseases (of these, 51 surgical) as well as several ophthalmological surgical instruments and techniques. [ 17 ] [ 18 ]  His description of  cataract surgery  was compatible with the method of  couching . [ 19 ]  He has been described as one of the first cataract surgeons. [ 20 ] [ 21 ]


Medieval Islamic Arabic and Persian scientists (unlike their classical predecessors) considered it normal to combine theory and practice, including the crafting of precise instruments, and therefore, found it natural to combine the study of the eye with the practical application of that knowledge. [ 22 ]   Hunayn ibn Ishaq , and others beginning with the medieval Arabic period, taught that the crystalline lens is in the exact center of the eye. [ 23 ]  This idea was propagated until the end of the 1500s. [ 23 ]


Ibn al-Nafis , an Arabic native of Damascus, wrote a large textbook,  The Polished Book on Experimental Ophthalmology , divided into two parts,  On the Theory of Ophthalmology  and  Simple and Compounded Ophthalmic Drugs . [ 24 ]


Avicenna  wrote in his Canon "rescheth", which means "retiformis", and  Gerard of Cremona  translated this at approximately 1150 into the new term "retina". [ 25 ]


In the seventeenth and eighteenth centuries,  hand lenses  were used by  Malpighi ,  microscopes  by  Leeuwenhoek , preparations for fixing the eye for study by  Ruysch , and later the freezing of the eye by  Petit . This allowed for detailed study of the eye and an advanced model. Some mistakes persisted, such as: why the pupil changed size (seen to be vessels of the iris filling with blood), the existence of the  posterior chamber , and the nature of the retina. Unaware of their functions,  Leeuwenhoek  noted the existence of photoreceptors, [ 26 ]  however, they were not properly described until  Gottfried Reinhold Treviranus  in 1834.


Jacques Daviel  performed the first documented planned primary cataract extraction on Sep. 18, 1750 in Cologne. [ 27 ]
 Georg Joseph Beer  (1763–1821) was an Austrian ophthalmologist and leader of the First Viennese School of Medicine. He introduced a flap operation for treatment of  cataract  (Beer's operation), as well as having popularized the instrument used to perform the surgery (Beer's knife). [ 28 ]


In North America, indigenous healers treated some eye diseases by rubbing or scraping the eyes or eyelids. [ 29 ]


The first ophthalmic surgeon in the UK was  John Freke , appointed to the position by the governors of  St. Bartholomew's Hospital  in 1727. A major breakthrough came with the appointment of Baron de Wenzel (1724–90), a German who became the oculist to  King George III  of Great Britain in 1772. His skill at removing cataracts legitimized the field. [ 30 ]  The first dedicated ophthalmic hospital opened in 1805 in London; it is now called  Moorfields Eye Hospital .  Clinical developments at Moorfields and the founding of the Institute of Ophthalmology (now part of the  University College London ) by  Sir Stewart Duke-Elder  established the site as the largest eye hospital in the world and a nexus for ophthalmic research. [ 31 ]


In Berlin, ophthalmologist  Albrecht von Graefe  introduced  iridectomy  as a treatment for glaucoma and improved cataract surgery, he is also considered the founding father of the German Ophthalmological Society.


Numerous ophthalmologists fled Germany after 1933 as the Nazis began to persecute those of Jewish descent. A representative leader was  Joseph Igersheimer  (1879–1965), best known for his discoveries with arsphenamine for the treatment of syphilis. He fled to  Turkey  in 1933. As one of eight emigrant directors in the Faculty of Medicine at the  University of Istanbul , he built a modern clinic and trained students. In 1939, he went to the United States, becoming a professor at  Tufts University . [ 32 ]  German ophthalmologist,  Gerhard Meyer-Schwickerath  is widely credited with developing the predecessor of laser coagulation, photocoagulation.


In 1946, Igersheimer conducted the first experiments on light coagulation. In 1949, he performed the first successful treatment of a retinal detachment with a light beam (light coagulation) with a self-constructed device on the roof of the ophthalmic clinic at the  University of Hamburg-Eppendorf . [ 33 ] [ 34 ]


Polish ophthalmology dates to the thirteenth century. The Polish Ophthalmological Society was founded in 1911. A representative leader was  Adam Zamenhof  (1888–1940), who introduced certain diagnostic, surgical, and nonsurgical eye-care procedures. He was executed by the German Nazis in 1940. [ 35 ]


Zofia Falkowska (1915–93) head of the Faculty and Clinic of Ophthalmology in Warsaw from 1963 to 1976, was the first to use lasers in her practice.


The prominent physicists of the late nineteenth and early twentieth centuries included  Ernst Abbe  (1840–1905), a co-owner of at the Zeiss Jena factories in Germany, where he developed numerous optical instruments.  Hermann von Helmholtz  (1821–1894) was a polymath who made contributions to many fields of science and invented the  ophthalmoscope  in 1851. They both made theoretical calculations on image formation in optical systems and also had studied the optics of the eye.


Ophthalmologists are  physicians  ( MD/DO in the U.S. or MBBS in the UK and elsewhere  or  DO /DOMS/DNB, who typically complete an undergraduate degree, general medical school, followed by a residency in ophthalmology. Ophthalmologists typically perform optical, medical and surgical eye care.


In  Australia  and  New Zealand , the FRACO or FRANZCO is the equivalent postgraduate specialist qualification. The structured training system takes place over five years of postgraduate training. Overseas-trained ophthalmologists are assessed using the pathway published on the RANZCO website. Those who have completed their formal training in the UK and have the CCST or CCT, usually are deemed to be comparable.


In  Bangladesh  to be an ophthalmologist the basic degree is an MBBS. Then they have to obtain a postgraduate degree or diploma in an ophthalmology specialty. In Bangladesh, these are diploma in ophthalmology, diploma in community ophthalmology, fellow or member of the College of Physicians and Surgeons in ophthalmology, and Master of Science in ophthalmology.


In  Canada , after medical school an ophthalmology residency is undertaken. The residency typically lasts five years, which culminates in fellowship of the Royal College of Surgeons of Canada (FRCSC). Subspecialty training is undertaken by approximately 30% of fellows (FRCSC) in a variety of fields from  anterior segment ,  cornea ,  glaucoma ,  vision rehabilitation ,  uveitis ,  oculoplastics , medical and surgical retina,  ocular oncology ,  Ocular pathology , or  neuro-ophthalmology . Approximately 35 vacancies open per year for ophthalmology residency training in all of Canada. These numbers fluctuate per year, ranging from 30 to 37 spots. Of these, up to ten spots are at French-speaking universities in Quebec. At the end of the five years, the graduating ophthalmologist must pass the oral and written portions of the  Royal College  exam in either English or French.


In  India , after completing MBBS degree, postgraduate study in ophthalmology is required. The degrees are doctor of medicine, master of surgery, diploma in ophthalmic medicine and surgery, and diplomate of national board. The concurrent training and work experience are in the form of a junior residency at a medical college, eye hospital, or institution under the supervision of experienced faculty. Further work experience in the form of fellowship, registrar, or senior resident refines the skills of these eye surgeons. All members of the India Ophthalmologist Society and various state-level ophthalmologist societies hold regular conferences and actively promote continuing medical education.


In  Nepal , to become an ophthalmologist, three years of postgraduate study is required after completing an MBBS degree. The postgraduate degree in ophthalmology is called medical doctor in ophthalmology. Currently, this degree is provided by Tilganga Institute of Ophthalmology, Tilganga, Kathmandu, BPKLCO, Institute of Medicine, TU, Kathmandu, BP Koirala Institute of Health Sciences, Dharan, Kathmandu University, Dhulikhel, and National Academy of Medical Science, Kathmandu. A few Nepalese citizens also study this subject in Bangladesh, China, India, Pakistan, and other countries. All graduates have to pass the Nepal Medical Council Licensing Exam to become a registered ophthalmologists in Nepal. The concurrent residency training is in the form of a PG student (resident) at a medical college, eye hospital, or institution according to the degree providing university's rules and regulations. Nepal Ophthalmic Society holds regular conferences and actively promotes continuing medical education.


In  Ireland , the  Royal College of Surgeons of Ireland  grants membership (MRCSI (Ophth)) and fellowship (FRCSI (Ophth)) qualifications in conjunction with the Irish College of Ophthalmologists. Total postgraduate training involves an intern year, a minimum of three years of basic surgical training, and a further 4.5 years of higher surgical training. Clinical training takes place within public,  Health Service Executive -funded hospitals in  Dublin ,  Sligo ,  Limerick ,  Galway ,  Waterford , and  Cork . A minimum of 8.5 years of training is required before eligibility to work in  consultant  posts. Some trainees take extra time to obtain  MSc ,  MD  or  PhD  degrees and to undertake clinical fellowships in the UK, Australia, and the United States.


In  Pakistan , after MBBS, a four-year full-time residency program leads to an exit-level FCPS examination in ophthalmology, held under the auspices of the College of Physicians and Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani and eminent international ophthalmic consultants. As a prerequisite to the final examinations, an intermediate module, an optics and refraction module, and a dissertation written on a research project carried out under supervision is also assessed.


Moreover, a two-and-a-half-year residency program leads to an MCPS while a two-year training of DOMS is also being offered. [ 36 ]  For candidates in the military, a stringent two-year graded course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute in Rawalpindi.


The M.S. in ophthalmology is also one of the specialty programs. In addition to programs for physicians, various diplomas and degrees for allied eyecare personnel are also being offered to produce competent optometrists, orthoptists, ophthalmic nurses, ophthalmic technologists, and ophthalmic technicians in this field. These programs are being offered, notably by the  College of Ophthalmology and Allied Vision Sciences , in  Lahore  and the Pakistan Institute of Community Ophthalmology in Peshawar. [ 37 ]  Subspecialty fellowships also are being offered in the fields of  pediatric ophthalmology  and vitreoretinal ophthalmology.  King Edward Medical University , Al Shifa Trust Eye Hospital Rawalpindi, and Al- Ibrahim Eye Hospital Karachi also have started a degree program in this field.


In the Philippines, Ophthalmology is considered a medical specialty that uses medicine and surgery to treat diseases of the eye. There is only one professional organization in the country that is duly recognized by the PMA and the PCS: the Philippine Academy of Ophthalmology (PAO). [ 38 ]  PAO and the state-standard Philippine Board of Ophthalmology (PBO) regulates ophthalmology residency programs and board certification. To become a general ophthalmologist in the Philippines, a candidate must have completed a doctor of medicine degree (MD) or its equivalent (e.g. MBBS), have completed an internship in Medicine, have passed the physician licensure exam, and have completed residency training at a hospital accredited by the Philippine Board of Ophthalmology (accrediting arm of PAO). [ 39 ]  Attainment of board certification in ophthalmology from the PBO is essential in acquiring privileges in most major health institutions. Graduates of residency programs can receive further training in ophthalmology subspecialties, such as neuro-ophthalmology, retina, etc. by completing a fellowship program that varies in length depending on each program's requirements.


In the  United Kingdom , three colleges grant postgraduate degrees in ophthalmology. The  Royal College of Ophthalmologists  (RCOphth) and the  Royal College of Surgeons of Edinburgh  grant MRCOphth/FRCOphth and MRCSEd/FRCSEd, (although membership is no longer a prerequisite for fellowship), the  Royal College  of Glasgow grants FRCS. Postgraduate work as a  specialist registrar  and one of these degrees is required for specialization in  eye diseases . Such clinical work is within the NHS, with supplementary private work for some consultants.


Only 2.3 ophthalmologists exist per 100,000 population in the UK – fewer  pro rata  than in any nations in the European Union. [ 40 ]


Ophthalmologists typically complete four years of undergraduate studies, four years of medical school and four years of eye-specific training (residency). Some pursue additional training, known as a fellowship - typically one to two years. Ophthalmologists are physicians who specialize in the eye and related structures. They perform medical and surgical eye care and may also write prescriptions for corrective lenses. They often manage late stage eye disease, which typically involves surgery. [ 41 ]


Ophthalmologists must complete the requirements of  continuing medical education  to maintain licensure and for recertification.


The following is a list of physicians who have significantly contributed to the field of ophthalmology:


1. LeFort I
2. Bilateral Sagittal Split
3. Genioplasty
4. IMDO
5. GenioPaully
6. Custom PEEK
7. SARME
8. Custom BIMAX


Orthognathic surgery  ( / ˌ ɔːr θ ə ɡ ˈ n æ θ ɪ k / ), also known as  corrective jaw surgery  or simply  jaw surgery , is  surgery  designed to correct conditions of the  jaw  and lower  face  related to structure, growth, airway issues including  sleep apnea ,  TMJ  disorders,  malocclusion  problems primarily arising from skeletal disharmonies, and other  orthodontic  dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics  [ 1 ]  and self-esteem.


The origins of orthognathic surgery belong in oral surgery, and the basic operations related to the surgical removal of impacted or displaced teeth – especially where indicated by orthodontics to enhance dental treatments of malocclusion and dental crowding. One of the first published cases of orthognathic surgery was the one from Dr.  Simon P. Hullihen  in 1849.


Originally coined by Harold Hargis, it was more widely popularised first in Germany and then most famously by Hugo Obwegeser who developed the bilateral sagittal split osteotomy (BSSO). This surgery is also used to treat congenital conditions such as  cleft palate . [ 2 ]  Typically surgery is performed via the mouth, where jaw bone is cut, moved, modified, and realigned to correct malocclusion or  dentofacial deformity . The word "osteotomy" means the division of bone by means of a surgical cut.


The "jaw osteotomy", either to the upper jaw or lower jaw (and usually both) allows (typically) an oral and maxillofacial surgeon to surgically align an arch of teeth, or the segment of a dental arch with its associated jawbone, relative to other segments of the dental arches. Working with orthodontists, the coordination of dental arches has primarily been directed to create a working occlusion. As such, orthognathic surgery is seen a secondary procedure supporting a more fundamental orthodontic objective.


It is only recently, and especially with the evolution of oral and maxillofacial surgery in establishing itself as a primary medical specialty – as opposed to its long term status as a dental speciality – that orthognathic surgery has increasingly emerged as a primary treatment for obstructive sleep apnoea, as well as for primary facial proportionality or symmetry correction.


The primary use of surgery to correct jaw disproportion or malocclusion is rare in most countries due to private health insurance and public hospital funding and health access issues. A small number of mostly heavily socialist funded countries report that jaw correction procedures occur in some form or other in about 5% of a general population, but this figure would be at the extreme end of service  [ 3 ] [ 4 ] [ 5 ]  presenting with dentofacial  deformities  like maxillary prognathisms, mandibular prognathisms, open bites, difficulty chewing, difficulty swallowing,  temporomandibular joint dysfunction  pains, excessive wear of the teeth, and receding chins.


Increasingly, as people are more able to self-fund surgery, 3D facial diagnostic and design systems have emerged, as well as new operations that enable for a broad range of jaw correction procedures that have become readily accessible; in particularly in private maxillofacial surgical practice. These procedures include IMDO, SARME, GenioPaully, custom BIMAX, and custom PEEK procedures. These procedures are replacing the traditional role of certain orthognathic surgery operations that have for decades served wholly and primarily orthodontic or dental purposes. [ 6 ]  Another development in the field is the new index called the index of orthognathic functional treatment need (IOFTN) that detects patients with the greatest need for orthognathic surgery as a part of their comprehensive treatment. [ 7 ]  IOFTN has been validated internationally and detected over 90% of patients with greatest need for orthognathic surgery. [ 8 ]


It is estimated that nearly 5% of the UK or US population present with dentofacial deformities that are not amenable to orthodontic treatment requiring orthognathic surgery as a part of their definitive treatment. [ 9 ] [ 4 ] [ 5 ]  Orthognathic surgery can be used to correct:


A disproportionately grown upper or lower jaw causes dentofacial deformities. Chewing becomes problematic, and may also cause pain due to straining of the jaw muscle and bone. Deformities range from  micrognathia , which is when the mandible does not grow far forward enough (over bite), and when the mandible grows too much, causing an under bite; all of which are uncomfortable. Also, a total  maxilla  osteotomy is used to treat the "long face syndrome", known as the skeptical open bite, idiopathic long face, hyper divergent face, total maxillary alveolar hyperplasia, and vertical maxillary excess. Prior to surgery, surgeons should take  x-rays  of the patient's jaw to determine the  deformity , and to make a plan of procedures. [ 11 ]   Mandible  osteotomies, or corrective jaw surgeries, benefit individuals who have difficulty chewing, swallowing,  TMJ  pains, excessive wear of the teeth, open bites,  overbites ,  underbites , or a receding chin. [ citation needed ]  The deformities listed above can be perfected by an osteotomy surgery of either the maxilla or mandible (whichever the deformity calls for), which is performed by an oral surgeon who is specialized in the working with both the upper and lower jaws. [ 12 ]  Orthognathic surgery is also available as a very successful treatment (90–100%) for obstructive sleep apnea. [ 13 ]


Orthognathic surgery is a well established and widely used treatment option for insufficient growth of the  maxilla  in patients with an  orofacial cleft . [ 14 ]  There is some debate regarding the timing of orthognathic procedures, to maximise the potential for natural growth of the facial skeleton. [ 15 ]  Patient reported aesthetic outcomes of orthognathic surgery for cleft lip and palate appear to be of overall satisfaction, [ 16 ] [ 17 ]  despite complications that may arise. A potentially significant long-term outcome of orthognathic surgery is impaired maxillary growth, due to scar tissue formation. [ 18 ]  A 2013 systematic review comparing traditional orthognathic surgery with maxillary  distraction osteogenesis  found that the evidence was of low quality; it appeared that both procedures might be effective, but suggested distraction osteogenesis might reduce the incidence of long-term relapse. [ 19 ]  The most common causes of cleft lip and palate are genetic and environmental factors. Clefts are known to occur due to folic acid deficiency, iron and iodine deficiency [ 20 ]


Although infrequent, there can be complications such as bleeding, swelling, infection, nausea and vomiting. [ 21 ]  Infection rates of up to 7% are reported after orthognathic surgery; antibiotic prophylaxis reduces the risk of surgical site infections when the antibiotics are given during surgery and continued for longer than a day after the operation. [ 22 ]


There can also be some post operative facial numbness due to nerve damage. [ 23 ]  Diagnostics for nerve damage consist of: brush-stroke directional discrimination (BSD), touch detection threshold (TD), warm/cold (W/C) and sharp/blunt discrimination (S/B), electrophysiological tests (mental nerve blink reflex (BR), nerve conduction study (NCS), and cold (CDT) and warm (WDT) detection thresholds. [ 24 ]  The  inferior alveolar nerve , which is a branch of the  mandibular nerve , must be identified during surgery and worked around carefully in order to minimize  nerve  damage. The numbness may be either temporary, or more rarely, permanent. [ 25 ]  Recovery from the nerve damage typically occurs within three months after repair. Some 3D movements are considered riskier than other ones, such as maxillary impaction.  [ 26 ]


Orthognathic surgery is performed by maxillofacial or an  oral surgeon  or a plastic surgeon in collaboration with an  orthodontist . It often includes braces before and after surgery, and retainers after the final removal of braces. Orthognathic surgery is often needed after reconstruction of cleft palate or other major  craniofacial  anomalies. Careful coordination between the surgeon and orthodontist is essential to ensure that the teeth will fit correctly after the surgery.


Planning for the surgery usually involves input from a multidisciplinary team, including oral and maxillofacial surgeons, orthodontists, and occasionally a speech and language therapist. Although it depends on the reason for surgery, working with a speech and language therapist in advance can help minimize potential relapse. The surgery usually results in a noticeable change in the patient's face; a psychological assessment is occasionally required to assess patient's need for surgery and its predicted effect on the patient.
Radiographs and photographs are taken to help in the planning. There is also advanced software that can predict the shape of the patient's face after surgery, [ 27 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ]  which is useful for the planning and also explaining the surgery to the patient and the patient's family. [ 32 ]  Great care needs to be taken during the planning phase to maximize airway patency.


Orthodontics are a critical component of orthognathic surgery. Traditionally the presurgical orthodontic phase can take as long as one year and undertaken with conventional metal braces. [ 33 ]  However, these days new approaches and paradigms exist including surgery-first  [ 34 ]  And using clear aligner orthodontia (like Invisalign) [ 35 ] [ 36 ]


This procedure is used to correct  mandible  retrusion and  mandibular prognathism  (over and under bite).
First, a  horizontal  cut is made on the inner side of the  ramus mandibulae , extending anterally to the  anterior  portion of the ascending  ramus . The cut is then made inferiorly on the ascending ramus to the descending ramus, extending to the lateral border of the mandible in the area between the first and  second molar . At this time, a  vertical  cut is made extending inferior to the body of the mandible, to the inferior border of the mandible.
All cuts are made into the middle of the bone, where  bone marrow  is present. Then, a chisel is inserted into the pre existing cuts and tapped gently in all areas to split the mandible of the left and right side. From here, the mandible can be moved either forwards or backwards. If sliding backwards, the distal segment must be trimmed to provide room in order to slide the mandible backwards. Lastly, the jaw is stabilized using stabilizing screws that are inserted extra-orally. The jaw is then wired shut for approximately 4–5 weeks. [ 37 ]


This procedure is used for the advancement (movement forward) or retraction (movement backwards) of the chin.
First, incisions are made from the  first bicuspid  to the first bicuspid, exposing the  mandible . Then, soft tissue of the mandible is detached from the bone; done by stripping attaching tissues. A horizontal incision is then made inferior to the first bicuspids, bilaterally, where bone cuts (osteotomies) are made vertically inferior, extending to the inferior border of the mandible, thereby detaching the bony segments of the mandible. The bony segments are stabilized with titanium plates; no fixation (binding of the jaw) necessary. If advancement is indicated for the chin, there are inert products available to implant onto the mandible, utilizing titanium screws, bypassing bone cuts. [ 38 ] [ 39 ]


When a patient has a constricted (oval shape)  maxilla , but normal  mandible , many  orthodontists  request a rapid  palatal  expansion.
This consists of the surgeon making horizontal cuts on the lateral board of the maxilla, extending anterally to the inferior border of the  nasal cavity . At this time, a chisel designed for the  nasal septum  is utilized to detach the maxilla from the  cranial  base. Then, a pterygoid chisel, which is a curved chisel, is used on the left and right side of the maxilla to detach the pterygoid palates. Care must be taken as to not injure the inferior palatine artery. Prior to the procedure, the orthodontist has an  orthopedic  appliance attached to the maxilla teeth, bilaterally, extending over the  palate  with an attachment so the surgeon may use a hex-like screw to place into the device to push from anterior to posterior to start spreading the bony segments. [ 37 ]  The expansion of the maxilla may take up to eight weeks with the surgeon advancing the expander hex lock, sideways (← →), once a week.


After orthognathic surgery, patients are often required to adhere to an all-liquid diet for a time. Weight loss due to lack of appetite and the liquid diet is common. Normal recovery time can range from a few weeks for minor surgery, to up to a year for more complicated surgery. For some surgeries, pain may be minimal due to minor nerve damage and lack of feeling. Doctors will prescribe pain medication and prophylactic antibiotics to the patient. There is often a large amount of swelling around the jaw area, and in some cases bruising. Most of the swelling will disappear in the first few weeks, but some may remain for a few months.


All dentofacial osteotomies require an initial healing time of 2–6 weeks with secondary healing (complete bony union and bone remodeling) taking an additional 2–4 months. The jaw is sometimes immobilized (movement restricted by wires or elastics) for approximately 1–4 weeks. However, the jaw will still require two to three months for proper healing. Lastly, if screws were inserted in the jaw, bone will typically grow over them during the two to three month healing period. Patients also may not drive or operate vehicles or large machinery during the consumption of painkillers, which are typically taken for six to eight days after the surgery, depending on the pain experienced. Immediately after surgery, patients must adhere to certain infection preventing instructions such as daily cleaning, and the consumption of  antibiotics . Cleaning of the mouth should always be done regardless of surgery to ensure healthy, strong teeth. Patients are able to return to work 2–6 weeks after the surgery, but must follow the specific rules for recovery for ~8 weeks. [ 40 ]


Mandible  and  maxilla  osteotomies date to the 1940s. They were used to correct dentofacial  deformities  like a  malocclusion , and a  prognathism . [ 41 ]  Advances have been made in the procedures, and in the  anesthesia  used. In 1985, mandible and maxilla osteotomies were effectively used to correct more extreme deformities like receding chins, and to relieve pain from  temporomandibular joint disorder  (TMJ).


Prior to 1991, some patients undergoing a dentofacial osteotomy still had  third molars  (wisdom teeth), and had them removed during surgery. An extensive study done by Dr. M Lacy and Dr. R Colcleugh, was used to identify threats of combining the two surgeries used 83 patients from the time span of 1987 and 1991. Patients were reviewed, and divided into two groups; those who had, and those who did not have their third molars extracted during the dentofacial Osteotomy. The study showed that 73% of patients developed an infection of the hardware inserted into the jaw when having their third molars removed during an osteotomy. The data indicated that getting the osteotomy and the  third molar   extraction  at the same time highly increases the chances of infection development. [ 42 ]


Advances in the surgical techniques allow surgeons to perform the surgery under  local anesthesia  with assistance from  intravenous  sedation. Dr. Raffaini introduced this technique in 2002 after a four-year study done with local anesthesia and assistance from intravenous sedation. Prior to this, surgeons would fully  sedate  patients, hospitalizing them shortly after the surgery for a 2–3 day recovery, specifically from the  anesthesia . Advancements allow surgeons to expand the use of an osteotomy on more parts of the jaws with faster recovery time, less pain, and no hospitalization, making the surgery more effective with respect to time and recovery. [ 43 ]
The procedure, which is strictly used for a mandibular (jaw) deformity and mobilization, has advanced from similar, very effective procedures performed since 1985. The original mandible and maxilla osteotomy procedure still remains almost unchanged, as it is the simplest and still the most effective for dentofacial deformity correction.


Prophylactic surgery  (also known as  preventive surgery  or  risk-reducing surgery ) is a form of  surgery  most commonly intended to minimize or eliminate the risk of the patient developing cancer in an organ or  gland  before development occurs. This can be a life-saving procedure for those at high risk of developing cancer in certain organs. [ 1 ] [ 2 ] [ 3 ]  This category of surgery may include  mastectomies ,  oophorectomies ,  colectomies  and surgical corrections for conditions that include  cryptorchidism   ( undescended testis) . [ 4 ]  Another, less common use of prophylactic surgery is in the prevention of other  diseases  or to seek better health outcomes. [ 5 ] [ 6 ]


Throughout most of history, preventive medical techniques have been largely ignored and mostly only relegated to scarce occurrences. Despite the prevalence of diseases such as  syphilis ,  leprosy  and the  black plague  throughout the  late Middle Ages , the concepts of preventive medicine was largely ignored despite advancements in  quarantining  and  sanitary techniques . [ 7 ]  Furthermore, the high  mortality rate  of surgeries both during operation and post-operation deemed these procedures to be too high of a risk to take for a preventive measure. [ 8 ]  This changed however with the introduction of  anesthesia , advancements in  anatomy  and with the introduction  antiseptic  or  aseptic techniques  alongside further advancements in sanitary techniques in the 19th to 20th century allowed surgeons to consider prophylactic surgeries without running the high risks previously experienced. [ 9 ]


One may choose to undergo prophylactic surgery if they believe that it is within their best interest to undergo a procedure in order to remove a high-risk  organ  or  gland . There are several types of preventable surgeries that are known to substantially decrease the risk of future disease. Since prophylactic surgeries are usually permanent and  irreversible , the pros and cons must be carefully weighed by individuals considering the procedure. There are a  myriad  of  ethical ,  physiological,   and  psychological  considerations to be made before taking such a procedure.


There are both physical and mental implications that come with committing to a prophylactic surgery; often, alongside the initial disadvantages that are associated with any procedure, such as cost, time lost, recovery, and more, there are other reasons for opting out of an operation. Ethical and religious reasons are commonly considered, especially when in regard to the  reproductive system  and its function. Concerns about sexual and reproductive function and self-image are rather common on clear external surgeries or sexual/ reproductive related surgeries. [ 10 ]  Furthermore, depending on the surgery, there may be certain unknown or unique risks attached depending on the cancer or surgical area. Additionally, undertaking a prophylactic surgery does not guarantee that the patient will never develop cancer later. [ 11 ]  Ultimately, it is a very complex and personal question when it comes to making the decision on whether to operate. Individuals whom do request prophylactic surgeries can be under the influence of  anxiety ,  uncertainty  and  irrational fear  as a result of a test or  hereditary disease  may incite these fears in the individual. It is important to consider the person's opinion, as well as those of their families and surgeon's first before committing to a prophylactic surgery. [ 4 ]


Prophylactic surgery in children has largely been justified through two grounds, the best interest of the child and  public health . Since children are unlikely to be able to provide a meaningfully informed  consent , it is an  ethical  subject discussed and heavily contested by various  bioethics  committees and the public. [ 6 ]


Depending on the situation, the type of prophylactic surgery performed may be relegated to match with relevant primary, secondary or tertiary  preventive measures . A primary prevention's goal is to prevent a disease or injury before it has occurred, secondary prevention's goal is to minimize the effects of an illness after it has occurred, and tertiary prevention aims to manage the effects of an illness in the long term. [ 12 ]  Depending on the stage of the illness or whether the patient has had an illness, a different type of procedure may be required. If a cancer has not appeared already then a preventive surgery including the considerations of issues associated with  metastatic breast cancer  will not be considered, instead operations that conserve tissue can be discussed without considerations in case of  metastasis  and the patient may choose, under the context of breast cancer, may undergo a skin sparing or  nipple sparing mastectomy  instead of a  total mastectomy . [ 13 ]


Mastectomies, especially under the context of cancer, are the most well-known form of prophylactic surgery, however there are still a multitude of other forms of surgery used to prevent other diseases. Prophylactic surgery is not only restricted to the prevention of cancer but can also include surgery whose intended purpose is to prevent any disease or unwanted consequence surgically. [ 5 ]  These can include prophylactic  appendectomy ,  circumcision  and even cosmetic surgeries as forms of prophylactic surgery. However, the terms usage is largely associated and most commonly interpreted as the prevention of cancer surgically. [ 11 ] [ 3 ]
There are several examples and types of prophylactic surgery, for both cancer related and cancer unrelated diseases. In cancer related prophylactic surgeries, most individuals required to do these surgeries have either already been effected by a related cancer or have an inherited cancer. These  hereditary cancer syndromes  contribute to 5-10 percent of all cancers. [ 14 ]


Prophylactic  mastectomy  is the surgical removal of breast tissue to remove cells that are at risk of developing cancer. These are most commonly done in women whom have  BRCA1  or  BRCA2  mutations discovered from gene testing, have already had cancer in one breast, have a family history of breast cancer or have undergone radiation therapy to their chest, increasing their risk of developing breast cancer. Instances of post-surgery complications are common, with two-thirds of women experiencing at least one complication post-surgery. However, women whom have opted for simultaneous reconstruction after surgery have shown a slightly significant lower risk of  complication at 64%. [ 15 ]


Prophylactic  salpingectomy  is the surgical removal of the  Fallopian tube  which, when done as a preventive measure, may be done to prevent pregnancies as a form of  contraception , or as a method to prevent cancer. Women who underwent prophylactic salpingectomy have shown to have a lower incidence of ovarian cancer compared to women who have not undergone the procedure, from 2.2% to 13% and from 4.75% to 24.4%. Furthermore, it has been shown that salpingectomy may reduce 29.2% to up to 64% of ovarian cancer incidence. [ spelling? ]  For most women, it has been shown to have no significant effect on ovarian function, quality of life, sexuality, and its cost-effective profile. [ 16 ]


Prophylactic  oophorectomy  is the removal of the ovaries and is either done as a planned response to the genetic risk of ovarian or breast cancer, especially among women whom have a hereditary family history of ovarian cancer, have the BRCA1 or BRCA2 mutations,  [ 17 ]  or have developed breast cancer in the past. [ 18 ]  Oophorectomy when done alongside salpingectomy as a bilateral  salpingo-oophorectomy ,  [ 17 ]  or alongside  hysterectomy  or all together, have shown to significant decrease instances of ovarian cancer if the individual has a known history of  BRCA1 or BRCA2  mutations and if they have an identified genetic risk of breast and ovarian cancer. However, hormone replacement therapy and less invasive methods of treating  menorrhagia  and  fibroids  have become more common, making prophylactic oophorectomy a less common choice in unaffected women without a hereditary history of breast or ovarian cancer. [ 19 ]


Prophylactic  Colectomy  is the removal of part or all of the colon in an effort to prevent cancer in the colon. [ 20 ]  This is especially prevalent in individuals with hereditary colorectal cancer syndromes like  hereditary non-polyposis colorectal cancer [ 4 ]  or  familial adenomatous polyposis . [ 21 ]   Individuals affected by these inherited cancers can carry a risk of 80% to up to nearly 100% in some cases within their lifetime. Prophylactic Colectomy have shown to greatly minimize this risk with minimal disturbance to the  bowel . [ 22 ]


Prophylactic  appendectomy  is the removal of the  appendix  in order to remove the chances of developing  appendicitis  as the leading cause of acute intra-abdominal disease in more than 50% of all cases. [ 23 ]  Prophylactic Appendectomy is one of the most common preventive surgeries and is the most common emergency surgery performed in the  USA . [ 24 ]  The procedure is very safe when performed safely under optimal conditions with little to no  adverse effects  on the operated individuals. [ 25 ]


In  medicine ,  traumatology  (from Greek  trauma , meaning injury or wound) is the study of  wounds  and  injuries  caused by  accidents  or  violence  to a person, and the  surgical therapy  and repair of the damage. Traumatology is a branch of  medicine . It is often considered a subset of  surgery  and in countries without the specialty of  trauma surgery  it is most often a sub-specialty to  orthopedic surgery . Traumatology may also be known as  accident surgery .


Branches of traumatology include medical traumatology and  psychological traumatology . Medical traumatology can be defined as the study of specializing in the treatment of wounds and injuries caused by violence or general accidents. This type of traumatology focuses on the surgical procedures and future  physical therapy  a patient needs to repair the damage and recover properly. Psychological traumatology is a type of damage to one's mind due to a  distressing  event. This type of trauma can also be the result of overwhelming amounts of stress in one's life. Psychological trauma usually involves some type of physical trauma that poses as a threat to one's sense of security and survival. Psychological trauma often leaves people feeling overwhelmed,  anxious , and threatened. [ 1 ]
Trauma can also be classified as:


Secondary or vicarious trauma, is another form of trauma in which a person develops trauma symptoms from close contact with someone who has experienced a traumatic event. [ 2 ]


When it comes to types of trauma, medical and psychological traumatology go hand in hand. Types of trauma include  car accidents ,  gunshot wounds ,  concussions ,  PTSD  from incidents, etc. Medical traumas are repaired with surgeries; however, they can still cause psychological trauma and other stress factors. For example, a teenager in a car accident who broke his  wrist  and needed extensive surgery to save his arm may experience  anxiety  when driving in a car post-accident. PTSD can be diagnosed after a person experiences one or more intense and traumatic events and react with fear with complaints from three categorical symptoms lasting one month or longer. These categories are: re-experiencing the traumatic event, avoiding anything associated with the trauma, and increased symptoms of increased psychological  arousal . [ 3 ] : 555


Airway management , monitoring, and management of injuries are all key guidelines when it comes to medical trauma care. Airway management is a key component of emergency on-scene care. Using a systematic approach, first responders must assess that a patient's airway is not blocked in order to ensure the patient gets enough  circulation  and remain as calm as they can. [ 4 ] : 19   Monitoring patients and making sure their body does not go into  shock  is another essential guideline when it comes to medical trauma care. Nurses are required to watch over patients and check  blood pressure ,  heart rate , etc. to make sure that patients are doing well and are not  crashing . When it comes to managing injuries, head and neck injuries require the most care post surgery.  Head injuries  are one of the major causes of trauma related death and disabilities worldwide. It is important for patients of head trauma to get  CT scans  post surgery to insure that there are no problems. [ 4 ] : 28–30


There is a range of approaches to assist victims to overcome the anxiety and stress that follows  psychological trauma . Affected persons can also follow  self-care  such as exercise and socializing with familiar and safe associates and family members. Trauma disturbs the body's natural equilibrium by putting it in a state of fear and hyper-arousal. [ 1 ]  Exercising for thirty minutes a day facilitated the nervous system to "unfreeze" from a traumatic state. Being surrounded by a good support system is a powerful factor in treating psychological trauma. Participating in social activities, volunteering, and making new friends are all ways to help forget about or cope with traumatic events. Coming to terms with  childhood trauma  is especially challenging. [ citation needed ]


Factors in the  assessment of wounds  are: [ citation needed ]


Forensic physicians, as well as pathologists may also be required to examine ( traumatic ) wounds on people.


Urogynecology  or  urogynaecology  is a surgical sub-specialty of  urology  and  gynecology .


In 1893,  Howard Kelly , a gynecologist and pioneering urogynecologist, invented an air  cystoscope  which was simply a handheld, hollow tube with a glass partition. [ 1 ]  When the American Surgical Society, later the  American College of Surgeons , met in Baltimore in 1900, a contest was held between  Howard Kelly  and  Hugh Hampton Young , who is often considered the father of modern urology. [ 2 ]  Using his air cystoscope, Kelly inserted ureteral catheters in a female patient in just 3 minutes. Young equaled this time in a male patient. [ 3 ]  So began the friendly competitive rivalry between gynecologists and urologists in the area of female urology and urogynecology. This friendly competition continued for decades. In modern times, the mutual interest of obstetricians, gynecologists, and urologists in pelvic floor problems in women has led to a more collaborative effort.


Urogynecologists are medical professionals who have been to medical school and achieved their basic medical degree, followed by postgraduate training in Obstetrics and Gynaecology (OB-GYN).  They then undertake further training in Urogynecology to achieve accreditation/board certification in this subspecialty. Training programme requirements and duration varies from country to country but usually tend to be around 2–3 years in most places. Urogynaecology fellowship programmes are available in some countries, but not all and the levels of formal accreditation and certification vary from country to country.


The International Urogynecological Association (IUGA) is a global body for professionals practising in the field of urogynaecology and female pelvic medicine and reconstructive surgery.  IUGA facilitates training for physicians from countries which do not have formal training programmes by maintaining and publishing a directory of fellowship programmes. IUGA also  provides educational opportunities for urogynecologists both online and in-person, develops terminology and standardization for the field. The International Continence Society (ICS) is another global organization which strives to improve the quality of life for people affected by urinary, bowel and pelvic floor disorders through education, and research.


Urogynecology is a sub-specialty of Gynecology, and in some countries is also known as Female Pelvic Medicine and Reconstructive Surgery.  A urogynecologist manages clinical problems associated with dysfunction of the pelvic floor and bladder.  Pelvic floor disorders affect the bladder, reproductive organs, and bowels.  Common pelvic floor disorders include urinary incontinence, pelvic organ prolapse and fecal incontinence.  Increasingly, Urogynecologists are also responsible for the care of women who have experienced trauma to the perineum during childbirth.


There is some crossover with the subspecialty of Female Urology - these doctors are urologists who undergo additional training to be able to manage female urinary incontinence, pelvic organ prolapse and interstitial cystitis/PBS.  In addition, there are colorectal surgeons who have a special interest in anal incontinence and pelvic floor dysfunction related to rectal function.  Contemporary urogynecological practice encourages multidisciplinary teams working in the care of patients, with collaborative input from urogynecologists, urologists, colorectal surgeons,  elderly care  physicians, and physiotherapists.  This is especially important in the care of patients with complex problems, e.g. those who have undergone previous surgery or who have combined incontinence and prolapse, or combined urinary and bowel problems.  Multidisciplinary team meetings are an important part of the management pathway of these women.


Urogynaecologists manage women with urinary incontinence and pelvic floor dysfunction.  The clinical conditions that a urogynecologist may see include stress incontinence, overactive bladder, voiding difficulty, bladder pain, urethral pain, vaginal or uterine prolapse, obstructed defecation, anal incontinence, and perineal injury.  They may also care for women with  vesicovaginal  or rectovaginal fistulae with specialist training, and in conjunction with other specialties.


Patients will usually be assessed using a combination of history taking, examination (including pelvic examination and assessment of prolapse using validated systems such as the  Pelvic Organ Prolapse Quantification System  and assessment of quality of life impact using validated questionnaires, including the assessment of sexual function, using Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA- Revised [PISQ-IR].  A bladder diary is often used to quantify an individual's fluid intake, and the number of voids per day and night, as well as the volume the bladder can hold on a day-to-day basis.  Further investigations might include urodynamics or a cystoscopy.  Treatment usually starts with conservative measures such as pelvic floor muscle training, fluid and food modification or bladder training.  Drug therapies can be used for overactive bladder, which may include antimuscarinic drugs or beta 3 receptor agonists - both of these help to control the urgency that is the key component of overactive bladder. If medications fail, more invasive options such as injections of botulinum toxin into the bladder muscle, or neuromodulation are other options for symptom relief.  Surgical treatments can be offered for stress incontinence and/or uterovaginal prolapse if pelvic floor muscle training is unsuccessful.


Urogynecological problems are seldom life-threatening, but they do have a major impact on the quality of life of affected individuals.  Urogynecologists will usually use quality of life improvement as a treatment goal, and there is a major focus on optimising symptoms using conservative measures before embarking on more invasive treatments.


Some conditions treated in urogynecology practice include: [ 4 ]


Diagnostic tests and procedures performed include: [ 4 ]


Specialty treatments available include: [ 4 ]


Urology  (from  Greek   οὖρον   ouron  "urine" and  -λογία   -logia  "study of"), also known as  genitourinary surgery , is the branch of  medicine  that focuses on surgical and medical diseases of the  urinary system  and the  reproductive organs . Organs under the domain of urology include the  kidneys ,  adrenal glands ,  ureters ,  urinary bladder ,  urethra , and the male reproductive organs ( testes ,  epididymides ,  vasa deferentia ,  seminal vesicles ,  prostate , and  penis ).


The urinary and reproductive tracts are closely linked, and disorders of one often affect the other. Thus a major spectrum of the conditions managed in urology exists under the domain of  genitourinary disorders . Urology combines the management of medical (i.e., non-surgical) conditions, such as  urinary-tract infections  and  benign prostatic hyperplasia , with the management of surgical conditions such as bladder or  prostate cancer ,  kidney stones , congenital abnormalities, traumatic injury, and  stress incontinence . [ 1 ]


Urological techniques include minimally invasive  robotic  and  laparoscopic surgery , laser-assisted surgeries, and other scope-guided procedures. Urologists receive training in open and minimally invasive surgical techniques, employing real-time ultrasound guidance, fiber-optic endoscopic equipment, and various lasers in the treatment of multiple benign and malignant conditions. [ 2 ] [ 3 ]  Urology is closely related to (and urologists often collaborate with the practitioners of)  oncology ,  nephrology ,  gynaecology ,  andrology ,  pediatric surgery ,  colorectal surgery ,  gastroenterology , and  endocrinology .


Urology is one of the most competitive and highly sought surgical specialties for  physicians , with new urologists comprising less than 1.5% of United States medical-school graduates each year. [ 4 ] [ 5 ]


Urologists are physicians which have specialized in the field after completing their general degree in medicine. Upon successful completion of a residency program, many urologists choose to undergo further advanced training in a subspecialty area of expertise through a fellowship lasting an additional 12 to 36 months. Subspecialties may include: urologic surgery, urologic oncology and urologic oncological surgery, endourology and endourologic surgery,  urogynecology  and urogynecologic surgery, reconstructive urologic surgery (a form of  reconstructive surgery ), minimally-invasive urologic surgery,  pediatric urology  and pediatric urologic surgery (including adolescent urology, the treatment of premature or delayed puberty, and the treatment of congenital urological syndromes, malformations, and deformations),  transplant  urology (the field of transplant medicine and surgery concerned with transplantation of organs such as the kidneys, bladder tissue, ureters, and, recently, penises),  voiding dysfunction ,  paruresis ,  neurourology , and androurology and  sexual medicine . Additionally, some urologists supplement their fellowships with a master's degree (2–3 years) or with a Ph.D. (4–6 years) in related topics to prepare them for academic as well as focused clinical employment.


As of 2022, there are 146  residency  programs that offered 356 categorical positions. [ 6 ]  Urology is one of the early match programs, with results given to applicants by early February (6 weeks before NRMP match). Applications are accepted starting Sep 1, with some programs accepting applications until early Jan. [ 7 ]


It is a relatively competitive specialty to match into, with only 65.6% of US seniors matching in the 2022 match cycle. [ 8 ]  The number of positions has grown from 278 in 2012 to 356 in 2022. Matching is significantly more difficult for IMGs and students who have a year or more off before residency - match rates were 27% and 55% respectively in 2012. [ 9 ]


The medical school environment may also be a factor. A study in 2012 also showed after an analysis of match rates from schools between 2005 and 2009 that 20 schools sent more than 15 students into urology (1  standard deviation  above the  median ), with Northwestern University sending 44 students over those five years. [ 10 ]


After urology residency, there are seven subspecialties recognized by the AUA (American Urological Association):


Training is completed through the  Royal Australasian College of Surgeons [ 12 ]  (RACS). The program requires six years of full-time training (for those who commenced prior to 2016), or five years for those who commenced after 2016. [ 13 ]  The program is accredited by the  Australian Medical Council . [ 12 ] [ 14 ]


In Nepal, the formal urologist degree awarded is MCh (Magister Chirurgiae). [ 15 ]  This is a three years course post masters and includes thesis and a mandatory publication. This degree is awarded after completing MBBS (four and half year plus a one-year rotatory internship) and MS (Mastery of surgery) in general surgery (three years course). Till now [ when? ]  two universities Tribhuvan University and Kathmandu University as well as two Autonomous institutes BP Koirala Institute of health sciences and National Academy of Medical Sciences (Bir Hospital) run the MCh Urology programme. [ 16 ] [ 17 ]  This degree is equivalent to Clinical PhD and called as "Chikitsa Bidhyabaridhi" by Tribhuvan University (Government University) and is considered to be the highest degree among the surgical discipline degrees.


In Ethiopia, in 2001, there were only five qualified urologists. All trained abroad, in countries like India, Tanzania and Hungary. Before this chapter all urology cases were managed by general surgeons. The only urological unit in the country was at Tikur Anbessa Tertiary Hospital. The services provided included  ESWL  and endo-urology. The urology training program was started in 2009 with a curriculum for general surgeons which had a three-year training program. Up to 2019, six urologists have graduated by this program for general surgeons. The first residency program started accepting general practitioners in 2010 for a five-year program. [ 18 ]  The first two years were trainings in general surgery, the next three years were dedicated urology training program, which included the same three-year training as of the general surgeons three year curriculum. It started with two residents who graduated in 2015 with a certificate in specialty of urology. Up to 2019, seventeen urologists have graduated from this five-year residency program. From the start these programs in 2009 up to 2019, a total of 23 urologists have been trained in Tikur Anbessa Tertioary Hospital. As of 2020, there were 26 trainees in the programme. All of the urologists who graduated from Tikur Anbessa Tertioary Hospital were as of 2020 working in different parts of the country. [ 18 ]


As a medical discipline that involves the care of many organs and physiological systems, urology can be broken down into several subdisciplines. At many larger academic centers and university hospitals that excel in patient care and clinical research, urologists often specialize in a particular sub discipline.


Endourology is the branch of urology that deals with the closed manipulation of the urinary tract. [ 19 ]  It has lately grown to include all minimally invasive urologic surgical procedures. As opposed to open surgery, endourology is performed using small cameras and instruments inserted into the urinary tract. Transurethral surgery has been the cornerstone of endourology. Most of the urinary tract can be reached via the urethra, enabling prostate surgery, surgery of tumors of the  urothelium , stone surgery, and simple urethral and ureteral procedures. Recently, the addition of laparoscopy and robotics has further subdivided this branch of urology.


Laparoscopy  is a rapidly evolving branch of urology and has replaced some open surgical procedures.  Robot-assisted surgery  of the prostate, kidney, and ureter has been expanding this field. Today, many prostatectomies in the United States are carried out by so-called robotic assistance. This has created controversy, however, as robotics greatly increase the cost of surgery and the benefit for the patient may or may not be proportional to the extra cost. Moreover, current (2011) market situation for robotic equipment is a de facto monopoly of one publicly held corporation [ 20 ]  which further fuels the cost-effectiveness controversy.


Urologic oncology concerns the surgical treatment of malignant genitourinary diseases such as cancer of the prostate, adrenal glands, bladder, kidneys, ureters, testicles, and penis, as well as the skin and subcutaneous tissue and muscle and fascia of those areas (that particular subspecialty overlaps with dermatological oncology and related areas of oncology). The treatment of genitourinary cancer is managed by either a urologist or an oncologist, depending on the treatment type (surgical or medical). Most urologic oncologists in Western countries use minimally invasive techniques (laparoscopy or endourology, robotic-assisted surgery) to manage urologic cancers amenable to surgical management.


Neurourology concerns  nervous system  control of the genitourinary system, and of conditions causing abnormal  urination . Neurological diseases and disorders such as a stroke,  multiple sclerosis ,  Parkinson's disease , and  spinal cord injury  can disrupt the lower urinary tract and result in conditions such as  urinary incontinence ,  detrusor  overactivity,  urinary retention , and  detrusor sphincter dyssynergia .  Urodynamic studies  play an important diagnostic role in neurourology. Therapy for nervous system disorders includes clean intermittent self-catheterization of the bladder, anticholinergic drugs, injection of Botulinum toxin into the bladder wall and advanced and less commonly used therapies such as sacral  neuromodulation .
Less marked neurological abnormalities can cause urological disorders as well—for example, abnormalities of the sensory nervous system are thought by many researchers to play a role in disorders of painful or frequent urination (e.g. painful bladder syndrome also known as  interstitial cystitis ).


Pediatric  urology concerns urologic disorders in  children . Such disorders include  cryptorchidism  (undescended testes), congenital abnormalities of the genitourinary tract,  enuresis , underdeveloped genitalia (due to delayed growth or delayed puberty, often an endocrinological problem), and  vesicoureteral reflux .


Andrology  is the medical specialty that deals with male health, particularly relating to the problems of the male reproductive system and urological problems that are unique to men such as prostate cancer, male fertility problems, and surgery of the male reproductive system. It is the counterpart to gynaecology, which deals with medical issues that are specific to female health, especially reproductive and urologic health.


Reconstructive urology is a highly specialized field of male urology that restores both structure and function to the genitourinary tract.  Prostate procedures, full or partial hysterectomies, trauma (auto accidents, gunshot wounds, industrial accidents, straddle injuries, etc.), disease, obstructions, blockages (e.g., urethral strictures), and occasionally, childbirth, can necessitate reconstructive surgery. The urinary bladder, ureters (the tubes that lead from the kidneys to the urinary bladder) and genitalia are other examples of reconstructive urology.


Female urology is a branch of urology dealing with  overactive bladder ,  pelvic organ prolapse , and  urinary incontinence . Many of these physicians also practice neurourology and reconstructive urology as mentioned above. Female urologists (many of whom are men) complete a 1–3-year fellowship after completion of a 5–6-year urology residency. [ 21 ]  Thorough knowledge of the female pelvic floor together with intimate understanding of the physiology and pathology of voiding are necessary to diagnose and treat these disorders. Depending on the cause of the individual problem, a medical or surgical treatment can be the solution. Their field of practice heavily overlaps with that of urogynecologists, physicians in a sub-discipline of gynecology, who have done a three-year fellowship after a four-year OBGYN residency. [ 21 ]


There are a number of peer-reviewed journals and publications about urology, including  The Journal of Urology ,  European Urology , the  African Journal of Urology ,  British Journal of Urology International ,  BMC Urology ,  Indian Journal of Urology ,  Nature Reviews Urology , and  Urology .


There are national organizations such as the  American Urological Association , the American Association of Clinical Urologists, [ 22 ]   European Association of Urology , the Large Urology Group Practice Association (LUGPA), [ 22 ]  and  The Society for Basic Urologic Research . Urology is also included under the auspices of the  International Continence Society .


Teaching organizations include the  European Board of Urology , as well as the  Vattikuti Urology Institute  in  Detroit , which also hosts an annual  International Robotic Urology Symposium  devoted to new technologies. The American non-profit  IVUMed  teaches urology in  developing countries .


Veterinary surgery  is  surgery  performed on non-human animals by  veterinarians , whereby the procedures fall into three broad categories: orthopaedics (bones, joints, muscles), soft tissue surgery (skin, body cavities, cardiovascular system, GI/urogenital/respiratory tracts), and neurosurgery.  Advanced surgical procedures such as joint replacement (total hip, knee and elbow replacement), fracture repair, stabilization of cranial cruciate ligament deficiency, oncologic (cancer) surgery, herniated disc treatment, complicated gastrointestinal or urogenital procedures, kidney transplant, skin grafts, complicated wound management, and minimally invasive procedures ( arthroscopy ,  laparoscopy ,  thoracoscopy ) are performed by veterinary surgeons (as registered in their jurisdiction). Most general practice veterinarians perform routine surgeries such as  neuters  and minor mass excisions; some also perform additional procedures.


The goal of veterinary surgery may be quite different in  pets  and in  farm animals . In the former, the situation is more close to that with human beings, where the benefit to the patient is the important factor. In the latter, the economic benefit is more important.


In the United States, Canada and  Europe , veterinary surgery is one of 22  veterinary specialties  recognized by the  American Veterinary Medical Association [ 1 ]  respectively the European Board of Veterinary Specialisation. [ 2 ]  Those wishing to become board certified must undergo a one-year clinical internship program followed by three years of intensive training in a residency program under direct supervision of board certified veterinary surgeons, including performance of a large number of surgical procedures in such categories as  abdominal surgery , surgical treatment of angular limb deformities,  arthroscopic surgery , surgery of the foot, fracture fixation,  ophthalmic surgery , urogenital surgery, and upper respiratory surgery, etc. Once the minimum requirements of training are met, residents are required to pass a rigorous certification examination before being admitted as members (diplomates) of the  American College of Veterinary Surgeons [ 3 ]  or European College of Veterinary Surgeons. [ 4 ]


Anesthesia  in animals has many similarities to human anesthesia, but some differences as well.   Local anesthesia  is primarily used for wound closure and removal of small tumors.  Lidocaine ,  mepivacaine , and  bupivacaine  are the most commonly used  local anesthetics  used in veterinary medicine. [ 5 ]   Sedation  without general anesthesia is used for more involved procedures. Sedatives commonly used include  acepromazine ,  hydromorphone ,  midazolam ,  diazepam ,  xylazine , and  medetomidine .  α2   agonists  like xylazine and medetomidine are especially useful because they can be reversed, xylazine by  yohimbine  and medetomidine by  atipamezole .  Xylazine is approved for use in dogs, cats, horses,  deer , and  elk  in the United States, while medetomidine is only approved for dogs. [ 6 ]   Most surgeries in  ruminants  can be performed with  regional anesthesia .


General anesthesia  is commonly used in animals for major surgery. Animals are often premedicated intravenously or intramuscularly with a sedative,  analgesic , and  anticholinergic  agent (dogs frequently receive  buprenorphine  and acepromazine). The next step is induction, usually with an  intravenous  drug.  Dogs and cats commonly receive  thiopental  (no longer allowed in the UK),  ketamine  with diazepam,  tiletamine  with  zolazepam  (usually just in cats), and/or  propofol .  Alfaxalone  is a  steroid  anaesthetic used in many practices in the UK to induce anaesthesia in  cats  and sometimes  dogs . It is similar in physiological effect but different in composition to the now withdrawn  Saffan . [ 7 ]   Horses commonly receive thiopental and  guaifenesin . [ 5 ]   Following induction, the animal is  intubated  with an  endotracheal tube  and maintained on a gas anesthetic.  The most common gas anesthetics in use in veterinary medicine are  isoflurane ,  enflurane , and  halothane , although  desflurane  and  sevoflurane  are becoming more popular due to rapid induction and recovery. [ 8 ]


Elective procedures are those performed on a non-emergency basis, and which do not involve immediately life-threatening conditions. These are in contrast to  emergency  procedures.


One of the most common elective surgical procedures in animals are those that render animals incapable of reproducing.  Neutering in animals describes  spaying or castration  (also please see  castration ).  To spay (medical term:  ovariectomy  or ovario-hysterectomy) is to completely remove the  ovaries  and often the  uterus  of a female animal.  In a  dog , this is accomplished through a  ventral  midline incision into the  abdomen . In a  cat , this is accomplished either by a  ventral  midline abdominal incision, or by a flank incision (more common in the UK). With an  ovariectomy ,  ligatures  are placed on the blood vessels above and below the ovary and the organ is removed. With an ovariohysterectomy, the ligaments of the uterus and ovaries are broken down and the blood vessels are  ligated  and both organs are removed.  The body wall,  subcutis , and skin are  sutured .  To castrate (medical term:  orchiectomy ) is to remove the  testicles  of a male animal.  Different techniques are used depending on the type of animal, including ligation of the  spermatic cord  with suture material, placing a rubber band around the cord to restrict blood flow to the testes, or crushing the cord with a specialized instrument like the  Burdizzo .


Neutering is usually performed to prevent breeding, prevent unwanted behavior, or decrease risk of future medical problems.  Neutering is also performed as an emergency procedure to treat certain reproductive diseases, like  pyometra  and  testicular torsion , and it is used to treat  ovarian ,  uterine , and  testicular cancer .  It is also recommended in cases of  cryptorchidism  to prevent torsion and  malignant transformation  of the testicles. Please see  spaying and neutering  for more information on the advantages and disadvantages of this procedure.


Laser surgery  offers a number of benefits, [ 9 ] [ 10 ]  including reduced risk of  infection , less post-operative pain and  swelling , reduced  bleeding  and improved visibility of the surgical field. Better  hemostasis  and visibility can in some cases minimize the need for  anesthesia  and/or reduce overall surgical time.


Other common elective surgical procedures in the United States are declawing in cats ( onychectomy ),  ear-cropping  in dogs,  tail docking  in dogs,  horses , and dairy cattle, and  livestock dehorning  in cattle, sheep, and goats.  These procedures have been controversial and recently debated among breeders, veterinary organizations, and animal welfare scientists. The controversy is different for each procedure, but issues arise based on reasons to perform the procedure, differing opinions on techniques and methods, perceived long-term benefits in individual animals, and the development of alternatives. Declawing, for example, consists of removal of the  distal phalanges  using either a  scalpel ,  scissors  or  laser . It is typically performed to prevent property damage in house cats, but may also be performed in purebred dogs to meet certain show requirements. Some procedures are illegal in some countries (in the UK, declawing is illegal and tail docking is only allowed in working dogs) and face ethical challenges in others.


Common dental surgical procedures:


In older dogs and cats  tumors  are a common occurrence, and may involve any or multiple body systems: skin, musculoskeletal, gastrointestinal tract, urogenital tract, reproductive tract, cardiovascular system, spinal cord and peripheral nerves, the spleen and the lining of body cavities.  Common skin tumors include  lipomas ,  mast cell tumors ,  melanomas ,  squamous cell carcinomas ,  basal cell carcinomas ,  fibrosarcomas , and  histiocytomas .  Skin tumors are removed through either simple excisions or through excisions needing reconstructive  plastic  surgery.  Common oral tumors include melanomas, fibrosarcomas, and squamous cell carcinomas, which are removed with as much surrounding tissue as possible, including parts of the  mandible  and  maxilla .  Other types of cancer requiring surgery include  osteosarcomas , stomach and intestinal tumors,  splenic masses , and  urinary bladder  tumors.


Common ophthalmic surgeries in animals include:


Common orthopedic surgeries in animals include:


Common cardiology surgeries in animals include:


Caesarean sections  are commonly performed in dogs, cats, horses, sheep, and cattle. Usually it is done as an emergency surgery due to difficulties in the birthing process. Certain dog breeds such as  Bulldogs  often need to have this surgery because of the size of the puppy's head relative to the width of the bitch's birth canal.


Gastric dilatation volvulus  (bloat) is a common condition in dogs in which the stomach fills with gas, and can become torsed. This requires immediate surgical intervention to prevent  necrosis  of the stomach wall and death of the dog. During surgery, the stomach is deflated and put back into its normal position. A  gastropexy  may be performed, whereby the stomach is attached to the body wall to prevent this condition from recurring. A  splenectomy  or partial  gastrectomy  may also be required.


A  cystotomy  is a surgical opening of the  urinary bladder . It is commonly performed in dogs and cats to remove  bladder stones  or tumors.


Bite wounds from other animals (and rarely humans) are a common occurrence.  Wounds from objects that the animal may step on or run into are also common.  Usually these wounds are simple  lacerations  that can be easily cleaned and sutured, sometimes using a  local anesthetic .  Bite wounds, however, involve compressive and tensile forces in addition to shearing forces, and can cause separation of the skin from the underlying tissue and  avulsion  of underlying muscles.  Deep puncture wounds are especially prone to infection.  Deeper wounds are assessed under  anesthesia  and explored,  lavaged , and  debrided .  Primary wound closure is used if all remaining tissue is healthy and free of contamination.  Small puncture wounds may be left open, bandaged, and allowed to  heal  without surgery.  A third alternative is delayed primary closure, which involves bandaging and reevaluation and surgery in three to five days. [ 17 ]


Wounds occurring in the  udder  and  teats  of  cows  are more difficult to repair, due to the difficult access and sensitivity of the organ, and because deep anaesthesia may not be applied to cows. [ 18 ]


A variety of non-edible objects are commonly swallowed by dogs, cats, and cattle.  These  foreign bodies  can cause obstruction of the  gastrointestinal tract  causing severe vomiting and resulting  electrolyte  imbalances.  The stomach (gastrotomy) or intestine (enterotomy) can be surgically opened to remove the foreign body.  Necrotic intestine can be removed (enterectomy) and repaired with  intestinal anastomosis .  Foreign bodies can also be removed by  endoscopy , which although requires general anesthesia does not require surgery and significantly decreases recovery time. [ 19 ]  However, endoscopic foreign body retrieval is anatomically limited to objects lodged in the esophagus, the stomach or the colon. The condition in cattle is known as  hardware disease .


Advanced trauma life support  ( ATLS ) is a training program for medical providers in the management of acute  trauma  cases, developed by the  American College of Surgeons . Similar programs exist for immediate care providers such as paramedics. The program has been adopted worldwide in over 60 countries, [ 2 ]  sometimes under the name of  Early Management of Severe Trauma , especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in  trauma centers . The premise of the ATLS program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most  time-critical  interventions performed early. [ 2 ]


The American College of Surgeons Committee on Trauma has taught the ATLS course to over 1 million doctors in more than 80 countries. ATLS has become the foundation of care for injured patients by teaching a common language and a common approach. [ 3 ]  However, there is no high-quality evidence to show that ATLS improves patient outcomes as it has not been studied. If it were studied, this would be known. [ 4 ] [ 5 ]


The first and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and simultaneously  resuscitation  is begun. A simple mnemonic,  ABCDE , is used as a  mnemonic  for the order in which problems should be addressed.


Cervical spine stabilization is the first step, after that follow ABCD. The first stage of the primary survey is to  assess the airway . If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or  jaw thrust . Airway adjuncts may be required. If the airway is blocked (e.g., by blood or vomit), the fluid must be cleaned out of the patient's mouth by the help of suctioning instruments. In the case of obstruction, pass an  endotracheal tube . [ citation needed ]


The chest must be examined by inspection,  palpation ,  percussion  and  auscultation .  Subcutaneous emphysema  and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions as  Airway Obstruction , Tension  Pneumothorax , Massive  Haemothorax ,  Open Pneumothorax ,  Flail chest  segment with  Pulmonary Contusion  and  Cardiac Tamponade .  Flail chest , tracheal deviation, penetrating injuries and bruising can be recognized by inspection.  Subcutaneous emphysema  can be recognized by palpation. Tension  Pneumothorax  and  Haemothorax  can be recognized by percussion and auscultation.


Hemorrhage  is the predominant cause of preventable post-injury deaths.  Hypovolemic shock  is caused by significant blood loss. Two large-bore intravenous lines are established and  crystalloid solution  may be given. If the person does not respond to this, type-specific blood, or  O-negative  if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones. [ citation needed ]


During the primary survey a basic neurological assessment is made, known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. This establishes the patient's level of consciousness, pupil size and reaction,  lateralizing signs , and  spinal cord injury  level.


The  Glasgow Coma Scale  is a quick method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status.  Hypoglycemia  and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to  traumatic brain injury  until proven otherwise.


The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent  hypothermia  in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.


When the primary survey is completed, resuscitation efforts are well established, and the vital signs are normalizing, the secondary survey can begin. The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete  history  and physical examination, including the reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination are obtained. If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present. The person should be removed from the hard  spine board  and placed on a firm mattress as soon as reasonably feasible as the spine board can rapidly cause  skin breakdown  and pain while a firm mattress provides equivalent stability for potential spinal fractures. [ 6 ]


A careful and complete examination followed by serial assessments help recognize missed injuries and related problems, allowing a definitive care management. The rate of delayed diagnosis may be as high as 10%. [ 7 ]


Mannequin surgical simulators are widely used in the United States as alternatives to the use of live animals in ATLS courses. In 2014,  PETA  announced that it was donating surgical simulators to ATLS training centers in 9 countries that agreed to switch from animal use to training on the simulators. [ 8 ]


Additionally, Anaesthesia Trauma and Critical Care (ATACC) is an international trauma course based in the United Kingdom that teaches an advanced trauma course and represents the next level for trauma care and trauma patient management post ATLS certification. Accredited by two  Royal Colleges  and numerous emergency services, the course runs numerous times per year for candidates drawn from all areas of medicine and trauma care. [ 9 ]  Specific injuries, such as major  burn  injury, may be better managed by other more programs.


In military medicine, the ATLS protocol has been modified to the Battlefield Advanced Trauma Life Support (BATLS) protocol. The treatment procedure is cABCDE. Added c = Catastrophic bleeding (massive external bleeding). [ 10 ]


ATLS has its origins in the United States in 1976, when  James K. Styner , an  orthopedic surgeon  piloting a light aircraft, crashed his plane into a field in  Nebraska . His wife Charlene was killed instantly and three of his four children, Ken, Randy, and Kim sustained critical injuries. His son Chris suffered a broken arm. He carried out the initial  triage  of his children at the crash site. Styner had to flag down a car to transport him to the nearest hospital in  Hebron ; upon arrival, he found it closed. Even once the hospital was opened and a doctor called in, he found that the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate. [ 11 ]  Upon returning to  Lincoln , Styner declared: "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed." [ 12 ]


Upon returning to work, he set about developing a system for saving lives in medical trauma situations. Styner and his colleague Paul 'Skip' Collicott, with assistance from  advanced cardiac life support  personnel and the Lincoln Medical Education Foundation, produced the initial ATLS course which was held in 1978. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began US and international dissemination of the course. Styner himself recently recertified as an ATLS instructor, teaching his Instructor Candidate course in Nottingham in the UK, July 2007, [ 13 ]  and then in the Netherlands. [ 12 ]


Since its inception, ATLS has become the standard for trauma care in American emergency departments and advanced paramedical services. Since emergency physicians, paramedics and other advanced practitioners use ATLS as their model for trauma care it makes sense that programs for other providers caring for trauma would be designed to interface well with ATLS. The Society of Trauma Nurses has developed the Advanced Trauma Care for Nurses (ATCN) course for  registered nurses . ATCN meets concurrently with ATLS and shares some of the lecture portions. This approach allows for medical and nursing care to be well-coordinated with one another as both the medical and nursing care providers have been trained in essentially the same model of care. Similarly, the  National Association of Emergency Medical Technicians  has developed the Prehospital Trauma Life Support (PHTLS) course for basic Emergency Medical Technicians (EMT)s and a more advanced level class for Paramedics. The International Trauma Life Support committee publishes the ITLS-Basic and ITLS-Advanced courses for prehospital professionals as well. This course is based around ATLS and allows the PHTLS-trained EMTs to work alongside paramedics and to transition smoothly into the care provided by the ATLS and ATCN-trained providers in the hospital. On March 22, 2013, the American College of Surgeons Committee on Trauma renamed their annual Award for Meritorious Service in ATLS to the James K. Styner Award for Meritorious Service in honor of Styner's contributions to trauma care. [ 14 ]


The  Australasian Trauma Society  (ATS) [ 1 ]  is a medical specialist interest group for  medical  and  paramedical  individuals working in the area of  traumatic injury .  It was begun in 1997 by a group of health professionals from  Australia  and  New Zealand  involved in  trauma  care. In 2022 the ATS was renamed the Australian and New Zealand Trauma Society (ANZTS).


The stated aims of the ATS are:


Membership of the Society is open to  doctors ,  nurses  and  paramedical personnel  from both Australia and New Zealand. Associate membership is open to others outside of those categories.


The ATS runs an annual scientific meeting either alone or in combination with other organisations such as the Trauma Association of Canada. [ 2 ]  It also provides financial and other support for the  Australasian  National Trauma Registry consortium. [ 3 ]


An annual travelling fellowship is offered to a member to allow them to further their  trauma  care knowledge.


The medical journal  Injury [ 4 ]  is the journal for both the ATS and the British Trauma Society. [ 5 ]


Battle's sign , also known as  mastoid ecchymosis , is an indication of  fracture  of  middle cranial fossa  of the  skull . These fractures may be associated with underlying  brain trauma . Battle's sign consists of bruising over the  mastoid process  as a result of  extravasation  of blood along the path of the  posterior auricular artery . [ 1 ]  The sign is named after  William Henry Battle . [ 2 ]


Battle's sign takes at least one day to appear after the initial traumatic  basilar skull fracture , similar to  raccoon eyes . [ 3 ]  It is usually seen after head injuries resulting in injury to mastoid process leading to bruising.


Battle's sign may be confused with a spreading  hematoma  from a  fracture of the mandibular condyle , [ 4 ]   which is a less serious injury.


Complex post-traumatic stress disorder  ( CPTSD ,  cPTSD , or hyphenated  C-PTSD ) is a  stress-related   mental  and  behavioral   disorder  generally occurring in response to  complex traumas [ 1 ]  (i.e., commonly prolonged or repetitive exposures to a series of  traumatic events , from which one sees little or no chance to escape). [ 2 ] [ 3 ] [ 4 ]


In the  ICD-11  classification, C-PTSD is a category of  post-traumatic stress disorder  (PTSD) with three additional clusters of significant symptoms:  emotional dysregulation , negative self-beliefs (e.g., shame, guilt, failure for wrong reasons), and interpersonal difficulties. [ 5 ] [ 6 ] [ 3 ]  C-PTSD's symptoms include prolonged feelings of terror, worthlessness, helplessness, distortions in identity or  sense of self , and  hypervigilance . [ 5 ] [ 6 ] [ 3 ]  Although early descriptions of CPTSD specified the type of trauma (i.e. prolonged, repetitive), in the  ICD-11  there is no requirement of a specific trauma type. [ 7 ]


The  World Health Organization  (WHO)'s  International Statistical Classification of Diseases  has included C-PTSD since its eleventh revision that was published in 2018 and came into effect in 2022 ( ICD-11 ). The previous edition ( ICD-10 ) proposed a diagnosis of  Enduring Personality Change after Catastrophic Event  ( EPCACE ), which was an ancestor of C-PTSD. [ 3 ] [ 2 ] [ 8 ]   Healthdirect Australia  (HDA) and the British  National Health Service  (NHS) have also acknowledged C-PTSD as mental disorder. [ 9 ] [ 10 ]  However, the  American Psychiatric Association  (APA) has not included C-PTSD in the  Diagnostic and Statistical Manual of Mental Disorders . The related disorder,  Disorders of Extreme Stress – not otherwise specified  ( DESNOS ) was studied for inclusion in the  DSM-IV , but not ultimately included. Instead, the symptoms of PTSD were expanded in the DSM-IV and then DSM-5 to better capture the range of symptoms that can follow from all types of trauma. [ 11 ]


The diagnosis of  PTSD  was originally given to adults who had suffered because of a trauma (e.g., during a  war ,  rape ). [ 12 ]  However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver. [ 13 ]  In many cases, it is the child's caregiver who causes the trauma. [ 12 ]  The diagnosis of PTSD does not take into account how the  developmental stages  of children may affect their symptoms and how trauma can affect a child's development. [ 12 ] [ 14 ]


The term  developmental trauma disorder  ( DTD ) has been proposed as the childhood equivalent of C-PTSD. [ 13 ]  This developmental form of trauma places children at risk for developing psychiatric and medical disorders. [ 13 ] [ 14 ]   Bessel van der Kolk  explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame. [ 15 ]


Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. [ 15 ]  Cook and others describe symptoms and behavioral characteristics in seven domains: [ 16 ] [ 1 ]


Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or other siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon. [ 17 ] [ 18 ]


Earlier descriptions of CPTSD suggested six clusters of symptoms: [ 19 ] [ 20 ]


Experiences in these areas may include: [ 4 ] : 199–122


C-PTSD was considered for inclusion in the  DSM-IV  but was excluded from the 1994 publication. [ 4 ]  It was also excluded from the  DSM-5 , which lists post-traumatic stress disorder. [ 22 ]  The  ICD-11  has included C-PTSD since its initial publication in 2018 and a validated self-report measure exists for assessing the ICD-11 C-PTSD, [ 2 ]  which is the International Trauma Questionnaire (ITQ). [ 23 ]


In the ICD-11, there are two paired diagnoses, PTSD and CPTSD. A person can only be diagnosed with one or the other. A diagnosis of PTSD is made if a person has experienced a trauma and also experiences 1) re-experiencing the event in the form of intrusive memories, nightmares, or flashbacks, 2) avoidance of memories of the event or of people, places, and situations that remind them of it, and 3) perceptions of heightened current threat (e.g., hypervigilance, enhanced startle reaction). These symptoms must cause impairment in important areas of functioning.


In contrast, a diagnosis of CPTSD is made if the person meets all of the above criteria in addition to 1) difficulties in regulating emotions, 2) changes in beliefs about oneself such as feeling worthless with significant shame, and 3) difficulties in maintaining close relationships with important people. Again, these symptoms must cause significant impairment to be considered CPTSD.


In the DSM-5, many of the symptoms of complex PTSD are now captured in the symptoms of PTSD, which are much broader than the PTSD symptoms in the ICD-11. Moreover, the DSM-5 also includes a dissociative symptom subtype. [ 11 ]


Earlier descriptions of CPTSD were broader but may no longer apply clinically:For instance, CPTSD was described to include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be  revictimized . Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD. [ 4 ] : 199–122   C-PTSD has also been characterized by  attachment disorder , particularly the  pervasive insecure , or  disorganized-type attachment . [ 24 ]   Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested.


Continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker in 1987, [ 25 ]  differs from C-PTSD. [ citation needed ] [ how? ]  It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with  civil conflict  and  political repression . The term is applicable to the effects of exposure to contexts in which  gang violence  and  crime  are endemic as well as to the effects of ongoing exposure to life threats in  high-risk occupations  such as  police, fire and emergency services . It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence. [ 26 ]


Traumatic grief [ 27 ] [ 28 ] [ 29 ] [ 30 ]  or complicated mourning [ 31 ]  are conditions [ 32 ]  where trauma and  grief  coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. [ 33 ]  If a traumatic event was  life-threatening , but did not result in a  death , then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence. [ 34 ] [ 35 ]


For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of  stepchildren  is referred to as the  Cinderella effect .


C-PTSD may share some symptoms with both PTSD and borderline personality disorder (BPD). [ 36 ] [ 37 ]  However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder. [ 38 ]


It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of  Bessel A. van der Kolk  together with an understanding drawn from a description of BPD:


Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently  harass , beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional,  physiologic , and  neuroendocrinologic  levels. Repetition on these different levels causes a large variety of individual and social suffering.